Jeanne C. Patzkowski

Adjacent vertebral body osteolysis with bone morphogenetic protein use in transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT Recent studies have demonstrated cases of adjacent vertebral body osteolysis when assessing the effect of bone morphogenetic protein (BMP) on fusion rates. However, no study to date has evaluated the course of osteolysis at different periods. PURPOSE To determine the incidence and resolution of osteolysis associated with BMP used in transforaminal lumbar interbody fusions (TLIF). STUDY DESIGN Retrospective review. PATIENT SAMPLE All TLIF cases using BMP performed at one institution with routine postoperative computed tomography (CT) scans at defined intervals. OUTCOME MEASURES Area of osteolysis and fusion as determined by CT scan. METHODS We performed a retrospective analysis of all patients at our facility who underwent TLIF with BMP. Included were all patients who had obtained a CT scan within 48 hours of surgery, 3 to 6 months postoperatively, and 1 to 2 years postoperatively. Areas of osteolysis were defined as lucency within the vertebral body communicating with the interbody spacer that was not present on the immediately postoperative CT scan. Areas of osteolysis were measured in all three planes and the volume used for comparison of the 3 to 6 months CT scans with the greater than 1 year CT scan. RESULTS Twenty-three patients who underwent TLIF with BMP had obtained CT scans at all time periods required for evaluation. Seventy-eight vertebral bodies/end plates were assessed for osteolysis (39 levels). The incidence of osteolysis 3 to 6 months postoperatively in the adjacent vertebral bodies was 54% compared with 41% at 1 to 2 years. The mean volume of osteolysis was at 0.216 cm(3) at 1 to 2 years compared with 0.306 cm(3) at 3 to 6 months (p=.082). The area/rate of osteolysis did not appear to significantly affect the rate of fusion or final outcome with an overall union rate of 83%. CONCLUSIONS The rate of osteolysis decreased at 1 year compared with 3 to 6 months, but only 24% of the vertebral bodies with evidence of osteolysis at 3 to 6 months completely resolved by 1 year.

Comparative effect of orthosis design on functional performance.

BACKGROUND High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hypothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace. METHODS Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it. RESULTS Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation. CONCLUSIONS Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention.

Spinal Column Injuries Among Americans in the Global War on Terrorism

BACKGROUND While combat spinal injuries have been documented since the fourth century BC, a comprehensive analysis of such injuries has not been performed for any American military conflict. Recent literature has suggested that spinal injuries account for substantial disability in wounded service members. METHODS The Joint Theater Trauma Registry was queried to identify all American military personnel who sustained injuries to the back, spinal column, and/or spinal cord in Iraq or Afghanistan from October 2001 to December 2009. Spinal injuries were categorized according to anatomic location, neurological involvement, mechanism of injury, and concomitant wounds. RESULTS Of 10,979 evacuated combat casualties, 598 (5.45%) sustained 2101 spinal injuries. Explosions accounted for 56% of spinal injuries, motor vehicle collisions for 29%, and gunshots for 15%. Ninety-two percent of all injuries were fractures, with transverse process, compression, and burst fractures the most common. Spinal cord injuries were present in 17% (104) of the 598 patients. Concomitant injuries frequently occurred in the abdomen, chest, head, and face. CONCLUSIONS The incidence of spine trauma sustained by military personnel in Iraq and Afghanistan is higher than that reported for previous conflicts, and the nature of these injuries may be similar to those in severely injured civilians. Further research into optimal management and rehabilitation is critical for military service members and severely injured civilians with spine trauma.

Return to Running and Sports Participation After Limb Salvage

BACKGROUND The ability to return to running and sports participation after lower extremity limb salvage has not been well documented previously. Although the ability to ambulate without pain or assistive devices is generally a criteria for a good limb salvage outcome, many patients at our institution have expressed a desire to return to a more athletic lifestyle to include running and sports participation. The purpose of this study was to investigate the types of athletic endeavors our high-energy lower extremity trauma patients were able to pursue after limb salvage. METHODS We retrospectively analyzed lower extremity limb salvage patients who were at least 12 weeks status after external fixation removal and participated in our limb salvage return-to-running clinical pathway. Patients were rehabilitated to their highest functional level through a sports medicine-based approach. A custom energy-storing ankle-foot orthosis was implemented to help augment plantarflexion strength in conjunction with running gait retraining. RESULTS The first 10 patients to complete the clinical pathway were identified. All patients were treated at the same institution by the same orthopedic surgeon and physical therapist. Eight patients have returned to running, and 10 patients have returned to weight-lifting. Seven patients have returned to cycling, three have returned to golf, three to basketball, and two to softball. Two patients have completed a mini-triathlon. CONCLUSION Aggressive rehabilitation, an energy-storing ankle-foot orthosis, and running gait retraining can restore an active recreational lifestyle to patients who have undergone lower extremity limb salvage.

Can an Integrated Orthotic and Rehabilitation Program Decrease Pain and Improve Function After Lower Extremity Trauma

BackgroundPatients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown.Questions/purposes(1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation?MethodsWe prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation.ResultsBy 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks.ConclusionsWe found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation.Level of EvidenceLevel II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Are spine injuries sustained in battle truly different

BACKGROUND CONTEXT The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research. PURPOSE Compare the severity and prognosis of battle and nonbattle injuries to the spine. STUDY DESIGN Retrospective study. PATIENT SAMPLE American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR). METHODS The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs). RESULTS Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p=.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p<.0001), were injured by high-energy injury mechanisms at a significantly greater rate (p<.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p=.16). CONCLUSIONS Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not.

Return to duty after integrated orthotic and rehabilitation initiative.

Objectives: To determine the return to active duty rate of military service members undergoing lower extremity limb salvage while using a novel custom orthosis and specialized rehabilitation compared with those receiving a novel custom orthosis alone. Design: Retrospective cohort study. Setting: Military level I trauma center and tertiary referral center for limb salvage. Patients/Participants: All active duty service members enrolled in our institutions Return to Run Clinical Pathway were analyzed retrospectively. Service members were enrolled if they sustained injuries with residual disability below the knee. Injuries typically involved substantial motor and/or nerve deficit, and the overwhelming majority was secondary to high-energy injuries. Intervention: Service members were fitted with a customized orthosis, an Intrepid Dynamic Exoskeletal Orthosis (IDEO), for use during rehabilitation. Service members were divided into 2 groups: those who had participated in the Return to Run Clinical Pathway with an IDEO (group 1) and those who only were fitted with an IDEO only (group 2). Main Outcome Measure: Return to military active duty rate. Results: One hundred forty-six service members met the inclusion criteria. Group 1 consisted of 115 service members and group 2 consisted of 31 service members. Of those in group 1, 59 (51.3%) returned to active duty compared with 4 (12.9%) in group 2 (P = 0.0001). Mechanisms of injury were significant factors for return to duty (RTD), and those sustaining explosive mechanisms of injury or gunshot wounds had significantly lower RTD rates across both groups. Conclusions: Active duty service members participating in an integrated orthotic and rehabilitation initiative after a lower extremity injury have a higher rate of RTD than previous reports, and it is significantly higher than the orthotic device alone. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multiple associated injuries are common with spine fractures during war

BACKGROUND CONTEXT The nature of concomitant injuries associated with spine fractures in American military personnel engaged in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been poorly documented in the literature. PURPOSE To characterize the incidence and epidemiology of associated injuries (AIs) in American military personnel with spine fractures sustained during OEF and OIF from 2001 to 2009. STUDY DESIGN Retrospective study. PATIENT SAMPLE American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR). OUTCOME MEASURES Not applicable. METHODS The JTTR was queried using International Statistical Classification of Disease, Ninth Revision codes to identify all individuals who sustained spine injuries in OEF or OIF from October 2001 to December 2009. Medical records of all identified service members were abstracted to ensure accuracy and avoid duplication. Demographic information, including sex, age, and military rank, were obtained for all patients. Information regarding fracture type, spine region, mechanism of injury, and the presence of AIs was collected for all patients. RESULTS Seventy-eight percent of patients with a spine fracture sustained at least one AI, with an average of 3.4 AIs per patient. Musculoskeletal injuries were most common, followed by chest, abdomen, and traumatic brain injuries. Most patients were injured by an explosive mechanism (62%). Head and face traumas were more common with cervical fractures, chest with thoracic injuries, and abdominopelvic injuries with lumbosacral fractures. Pelvis and acetabulum fractures were common after helicopter crashes, tibia/fibula injuries after explosions, thoracoabdominal injuries after gunshot wounds, and traumatic brain injuries after falls. Most patients (76%) sustained multiple spine fractures. CONCLUSION Spine fractures sustained in OEF and OIF have high rates of AIs. Musculoskeletal AIs are the most common, but visceral injuries adjacent to the spine fracture frequently occur. Multiple spine injuries are more prevalent after military trauma.

Management of posttraumatic osteoarthritis with an integrated orthotic and rehabilitation initiative.

&NA; Posttraumatic osteoarthritis affects approximately 5.6 million Americans annually. Those affected are typically younger and more active than persons with primary osteoarthritis. Arthrodesis is the typical management option for persons with end‐stage ankle and subtalar posttraumatic arthritis. Arthroplasty is typically reserved for elderly persons. The functional limitations resulting from any of these strategies make treatment of this young population challenging. Combat wounds frequently lead to severe lower extremity injuries. We present a series of patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint after combat trauma. They were treated at our institution with an integrated orthotic and rehabilitation initiative called the Return To Run clinical pathway. This clinical pathway may serve as an alternative or adjunct to arthrodesis and arthroplasty for young patients with severe posttraumatic osteoarthritis of the ankle and subtalar joint.

Quantification of Posterior Ankle Exposure through an Achilles Tendon-Splitting versus Posterolateral Approach:

Background: The optimal surgical exposure to the posterior ankle for trauma and reconstruction is a source of debate. We hypothesized that the Achilles tendon-splitting approach would provide greater exposure to the posterior ankle than the posterolateral approach. Methods: Forty surgical approaches were performed from twenty fresh-frozen cadavers. Achilles tendon-splitting and posterolateral approaches were performed using a randomized crossover design for surgical sequence. Six landmarks (medial malleolus, ankle joint, subtalar joint, incisura fibularis, lateral malleolus and medial gutter) were identified by direct visualization or palpation. A calibrated digital photograph was taken and Image J (http://rsb.info.nih.gov/ij/) was used to calculate the surface area of the distal tibia and talus exposed in neutral and dorsiflexion. Results: Using a posterolateral approach, the average distal tibia exposed was 11.3cm2 in neutral and 10.2 cm2 in dorsiflexion. The average talus exposed was 2.0 cm2 in neutral and 2.4 cm2 in dorsiflexion. Using an Achilles tendon-splitting approach, the average exposed distal tibia was 33% more (15.0 cm2) in neutral and 43% more (14.6 cm2) in dorsiflexion. The average talus exposed was 47% more (3.0 cm2) in neutral and 76% more (4.2 cm2) in dorsiflexion. All increases in exposure were statistically significant. The medial malleolus was visualized in 19 tendon-splitting and six posterolateral approaches. The medial gutter was visualized in 20 tendon-splitting and 13 posterolateral approaches. These differences were statistically significant. All other landmarks could be visualized through both approaches. Conclusion: The Achilles tendon-splitting approach provided significantly greater exposure of the posterior distal tibia and talus compared to the posterolateral approach. Clinical Relevance: Prospective studies will help determine if the tendon-splitting approach is a safe and clinically useful approach for surgeries in which direct access to the entire posterior ankle and subtalar joint are required.