Kevin L. Kirk

Evaluation of orthopaedic injuries in Operation Enduring Freedom.

Summary: Orthopaedic injuries constitute a majority of the combat casualties in recent U.S. military conflicts. Orthopaedic injuries sustained in Operation Enduring Freedom from December 2001 to January 2003 that were treated in forward-deployed military medical facilities and evacuated to a U.S. army medical center were reviewed. The spectrum of injuries included open fractures, amputations, neurovascular, and soft-tissue injuries. Forty-four patients (85%) received treatment beyond local wound care prior to arrival at a military medical center. Debridement and irrigation was the most commonly performed procedure due to the contaminated nature of these combat injuries. There were no infections among patients with open fractures, and no patients with external fixators had pin tract infections. None of the open fracture patients underwent primary internal fixation or primary wound closure. The average time from injury to wound coverage of the open fracture wounds was 12 days. Two amputations were infected and were treated with revision and delayed wound closure. There were no primary amputations done at our institution due to infection or ischemia. All arterial injuries underwent urgent revascularization in a field hospital. None of the arterial repairs required revision after evacuation to a medical center. Operation Enduring Freedom has been an excellent example of how early and aggressive intervention in a forward-deployed area has a significant effect on rehabilitative and reconstructive efforts at a rear echelon tertiary care center.

Prevalence of Late Amputations During the Current Conflicts in Afghanistan and Iraq

During the current conflicts, over 950 soldiers have sustained a combat-related amputation. The majority of these are acute, but an unknown number are performed months to years after the initial injury. The goal of this study is to determine the prevalence of late amputations in our combat wounded. Electronic medical records and radiographs of all soldiers who had a combat-related, lower extremity injury that resulted in amputation were reviewed to confirm demographic, injury, and amputation information. Time to amputation was defined as a late amputation when it occurred more than 12 weeks following the date of injury. There were 348 major limb amputees that met inclusion criteria. Fifty-three (15.2%) amputees had a late amputation (range = 12 wk-5.5 yr). While the majority of combat-related amputations occur acutely, more than 15% occur late. This study demonstrates that further research is needed to identify predictive factors and outcomes of the late amputation.

Incidence of Osteochondral Lesions of the Talus in the United States Military

Background: Osteochondral lesion of the talus (OCLT) is frequently described as an uncommon diagnosis; however, little is known of its incidence. In light of increased awareness combined with the continued evolution of radiologic and treatment modalities, more attention has been given to this diagnosis. Serving a young, athletic population with unique occupational requirements, we have perceived an increase in the diagnosis of OCLTs. The goal of this study was to determine the incidence of OCLTs in an active duty military population, as well as demographic risk factors for OCLTs. Methods: We performed a query of the Defense Medical Epidemiology Database (DMED) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for OCLTs which in the Armed Forces Health Longitudinal Technology Application (AHLTA) system is uniquely assigned the code 732.5. An overall injury incidence was calculated, in addition to multivariate analysis to determine independent risk factors among the following demographic considerations: gender, race, rank, branch of military service, and age. Year of diagnosis was also considered. Results: The overall incidence rate for the 10-year period (1999 to 2008) was 27 OCLTs per 100,000 person-years. Significant demographic risk factors were female gender, white race, enlisted rank, service in the Army and Marines, and age greater than 20 years. Incidence rate was 16 per 100,000 in 2002, with steady annual increases resulting in an incidence rate of 56 per 100,000 person-years in 2008, corresponding to the years of active involvement in global combat operations. Conclusion: The incidence of OCLTs in the active duty military population was higher with female gender, white race, enlisted rank, increased age, and Army or Marine service. Level of Evidence: IV, Retrospective Series

Orthopedic Injuries during Operation Enduring Freedom

ABSTRACT Orthopedic injuries comprise a majority of combat injuries seen in recent U.S. military conflicts. Interventions in the forward deployed area have played an important role in improving mortality rates of soldiers as well as outcome at a medical center level. A retrospective review was conducted on orthopedic injuries from Operation Enduring Freedom evaluated at Walter Reed Army Medical Center (WRAMC). Patients were grouped into one of five injury categories (open fracture, amputation, arterial injuries, neurological injuries, and soft tissue injury) with evacuation time (days from time of injury to arrival at WRAMC) and procedures performed before arrival at WRAMC evaluated. The average evacuation time for all orthopedic casualties was 7.9 days. There was an average of 2.6 procedures performed per patient before arrival at WRAMC. There was no difference in evacuation time among the injury groups. Those with only soft tissue injuries underwent fewer procedures than the other injury groups; however...

Lateral Talar Dome Access Utilizing Temporary Invasive Distraction

Background: Autogenous osteochondral grafting is an operative option for the treatment of osteochondral lesions of the talus (OLT). Graft implantation often requires an osteotomy to gain perpendicular access to the recipient site. The purpose of this study was to determine the relative contributions of soft tissue releases, osteotomies, and invasive distraction on perpendicular access to the lateral talar dome. We hypothesized that temporary invasive distraction (TID) would provide greater perpendicular access than anterolateral arthrotomy alone and similar access compared to an anterolateral tibial osteotomy. Materials and Methods: Eight fresh frozen cadaveric limb specimens were utilized. An anterolateral arthrotomy was performed and an osteochondral plug was harvested as far posterior as allowed. An additional two Kirschner wires were placed to mark the borders of the area of access. This process was then repeated utilizing: 1) an external fixator for distraction alone, 2) an anterolateral tibial osteotomy alone (with distraction released), and 3) an anterolateral tibial osteotomy (with distraction reapplied). The area accessible as well as the anterior to posterior (AP) access was measured and recorded for each approach. Results: The approach utilizing TID provided greater access than arthrotomy with regard to AP access (p = 0.0007) as well as area (p = 0.003). The approach utilizing TID alone was equivalent to the anterolateral tibial osteotomy with regard to AP access as well as area. TID combined with osteotomy provided greater access than the TID or osteotomy approaches alone with regard to AP access (p = 0.01 and p = 0.02, respectively) and greater access than the external fixator alone with regard to area (p = 0.02). Conclusion: Temporary distraction utilizing external fixation provides greater perpendicular access than anterolateral arthrotomy and access equivalent to anterolateral osteotomy alone. Clinical Relevance: Utilizing TID may obviate the morbidity and possible complications associated with osteotomy and may prove to be a valuable tool in the treatment of osteochondral lesions of the talus.

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.

Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies.

OBJECTIVESnThe purpose of this study was to investigate the amount of fluid required and the sensitivity of the saline load test to identify an intra-articular arthrotomy of the elbow.nnnMETHODSnA cadaveric study was conducted using 36 thawed, fresh-frozen forequarter amputations. An elbow arthrotomy was made in the posterocentral arthroscopic portal site with a 4.5-mm trochar. To confirm intra-articular location of the arthrotomy, the trochar was trapped in the ulnohumeral joint. The elbow joint was then loaded with saline mixed with methylene blue. During the injection, the known arthrotomy site was observed for leakage. If no leakage occurred after loading 20 mL of fluid, the elbow was taken through a range of motion. If still no leakage was appreciated at the arthrotomy site, the elbow was again infused with fluid in 2 mL increments until outflow. All injections were confirmed as intra-articular by demonstrating methylene blue staining of the anterior joint by open exploration.nnnRESULTSnA positive result was obtained in 26 of the 36 elbows (72% sensitivity) with injection of 20 mL of fluid, and with the addition of range of motion, another 5 elbows demonstrated leakage, raising the sensitivity to 86%. However, to identify 95% of arthrotomies, a total of 40 mL of fluid had to be injected.nnnCONCLUSIONSnOur results demonstrate that 40 mL of fluid must be injected to identify the majority of traumatic arthrotomies about the elbow. Moreover, adding range of motion after the injection increases the detection rate.

Functional Outcome of Multiligamentous Knee Injuries Treated Arthroscopically in Active Duty Soldiers

PURPOSEnTo evaluate variables unique to our military population to determine whether we can be better predict functional outcome and return to duty of active duty military soldiers with multiligament knee disruption following arthroscopically assisted reconstruction.nnnMATERIALS AND METHODSnTwenty-four active duty Army personnel who underwent arthroscopically assisted reconstruction of multiple ligament disruption by the same surgeon were enrolled in this study. Postoperatively, a standardized knee joint questionnaire was administered and current vocational and recreational status was evaluated. Demographic data as well as military-specific factors to include rank, military occupation specialty, associated injuries, and retention on active duty were reviewed for these patients to determine their correlation with outcome.nnnRESULTSnOverall, 13 (54%) remained on active duty following surgical reconstruction of their knee. There was a positive correlation between military rank and return to military duty. We were unable to correlate physical job demand to postinjury duty status. The Cincinnati Knee Ligament Rating Scale indicated that most soldiers were able to perform sports at half speed, with some limits in daily living function scores.nnnCONCLUSIONnArthroscopically assisted multiligament knee reconstruction enabled only a slight majority of active duty soldiers to return to duty following reconstruction and rehabilitation of this devastating injury.

Minimally Invasive Shortening Humeral Osteotomy to Salvage a Through-Elbow Amputation

OBJECTIVEnDetermine the efficacy of a novel surgical technique to salvage a through-elbow amputation and avoid revision transhumeral amputation.nnnMETHODSnA 23-year-old soldier presented after sustaining a through-elbow amputation in a close-range blast injury with inadequate soft tissues to obtain closure over the distal humerus. A 2-cm anterior incision was made and a shortening osteotomy with percutaneous submuscular osteosynthesis was done. A myodesis was performed and a tension-free primary closure of the soft tissue envelope obtained.nnnRESULTSnAt 3 months postoperatively the osteotomy and soft tissue envelope were healed. At 2-year follow-up the patient reports using a body-powered prosthesis for ADLs and recreational hobbies, citing excellent rotational control and ease of prosthetic suspension.nnnCONCLUSIONnMinimally invasive shortening humeral osteotomy in the setting of a through-elbow amputation is a safe and effective procedure, which allows primary soft tissue closure, prevents the need for more proximal amputation, and allows for ease of prosthetic fitting and suspension.

Comparative Study of Mobility and Perceived Exertion for the Wheeled Knee Walker and Axillary Crutches in Healthy Participants

Category: Other Introduction/Purpose: Functional limitations are common after lower extremity surgery and often require the use of an assistive device for ambulation during rehabilitation and recovery. There is no known data evaluating the wheeled knee walker (WKW) as an assistive device for postoperative protected ambulation. The purpose of this study is to compare mobility and perceived exertion in the WKW and the axillary crutch (AC) in healthy volunteers. Methods: This is a cross sectional study of the WKW and the AC that was performed on 24 healthy volunteers utilizing the Six- Minute Walk Test (6MWT). The participants were randomized into two separate arms, one starting with the AC (N=12) and one starting with the WKW (N=12). A modified version of the American Thoracic Society (ATS) Guidelines for the 6MWT was performed for both assistive devices on all subjects. Pre-activity and post-activity heart rates were recorded for both events. From the 6MWT data the values for the Self Selected Walking Velocity (SSWV) were calculated and the subjects rating of perceived exertion was recorded using the OMNI Rating of Perceived Exertion (OMNI-RPE). Patients preference for assistive device was identified. Results: The 6MWT, SSWV and the Omni-RPE were evaluated using paired T-tests and was determined to be statistically significant for the WKW when compared to the AC (p < 0.001). The confounding effect of the sequences were measured utilizing a mixed-model 2x2 ANOVA and was determined to have no significant 3 way (time x device x sequence) interaction (p = 0.968). Factorial 2 x 2 repeated measures ANOVA was used to evaluate the pre-activity and post-activity heart rates and demonstrated a statistically significant difference for the WKW when compared to the AC (p < 0.001). 87.5% of subjects preferred the WKW to the AC. Conclusion: The WKW provided increased mobility and had a lower rating of perceived exertion than the AC on level surfaces in healthy participants