Kevin M. Kuhn

Acetabular Retroversion in Military Recruits with Femoral Neck Stress Fractures

Acetabular retroversion (AR) alters load distribution across the hip and is more prevalent in pathologic conditions involving the hip. We hypothesized the abnormal orientation and mechanical changes may predispose certain individuals to stress injuries of the femoral neck. We retrospectively reviewed the anteroposterior (AP) pelvic radiographs of 54 patients (108 hips) treated for a femoral neck stress fracture (FNSF) and compared these radiographs with those for a control group of patients with normal pelvic radiographs. We determined presence of a crossover sign (COS), femoral neck abnormalities, and neck shaft angle. The prevalence of a positive COS was greater in patients with stress fractures than in the control subjects (31 of 54 [57%] versus 17 of 54 [31%], respectively) and higher than for control subjects reported in the literature. Thirteen patients had radiographic changes of the femoral neck consistent with femoroacetabular impingement (FAI). These radiographic abnormalities were seen more commonly in retroverted hips. A greater incidence of AR was noted in patients with FNSF. Potential implications include more aggressive screening of military recruits with AR and the new onset of hip pain. Finally, we present an algorithm we use to diagnose and treat these relatively rare FNSFs.Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

THERMAL NECROSIS COMPLICATING REAMED INTRAMEDULLARY NAILING OF A CLOSED TIBIAL DIAPHYSIS FRACTURE: A CASE REPORT

A case report of thermal necrosis of the tibia after reamed intramedullary nailing is presented. Given the consequences of this complication, the proper use of reaming technique and equipment is emphasized.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies.

Objectives: To determine whether methylene blue dye significantly improves the sensitivity of the saline load test for detection of a traumatic arthrotomy of the knee. Design: Randomized, prospective. Setting: Orthopaedic department, tertiary care medical center. Patients/Participants: Subjects scheduled for elective outpatient knee arthroscopy were prospectively enrolled and randomized to a normal saline group or a methylene blue group. A total of 58 subjects were enrolled (methylene blue 29, normal saline 29). Intervention: In the course of routine elective knee arthroscopy, a standard inferior lateral arthrotomy was created and then normal saline or methylene blue solution was injected while observing for fluid outflow from the arthrotomy site. Main Outcome Measurements: The volume of fluid injected at the time of outflow was recorded with 180 mL set as the maximum injection volume. Results: The false-negative rate was 67% (methylene blue 69%, normal saline 66%). In patients with a positive test, mean volume of injected fluid at outflow was 105 mL in the methylene blue group and 95 mL in the normal saline group (P = 0.61). Conclusions: The sensitivity of the saline load test is unacceptably low. The addition of methylene blue does not improve the diagnostic value of the saline load test. Therefore, these results indicate that the saline load test, regardless of the inclusion of methylene blue, is not an accurate test for diagnosing small traumatic knee arthrotomies. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Heterotopic Ossification: A Review of Current Understanding, Treatment, and Future

Summary: Heterotopic ossification is the formation of bone at extraskeletal sites. The incidence of heterotopic ossification in military amputees from recent operations in Iraq and Afghanistan has been demonstrated to be as high as 65%. Heterotopic ossification poses problems to wound healing, rehabilitation, and prosthetic fitting. This article details the current evidence regarding its etiology, prevention, management, and research strategies.

Primary Arthrodesis versus Open Reduction and Internal Fixation for Low-Energy Lisfranc Injuries in a Young Athletic Population.

Background: There are 2 Level I studies comparing open reduction and internal fixation (ORIF) and primary arthrodesis (PA) in high-energy Lisfranc injuries. There are no studies comparing ORIF and PA in young athletic patients with low-energy injuries. Methods: All operatively managed low-energy Lisfranc injuries sustained by active duty military personnel at a single institution were identified from 2010 to 2015. The injury pattern, method of treatment, and complications were reviewed. Implant removal rates, fitness test scores, return to military duty rates, and Foot and Ankle Ability Measure (FAAM) scores were compared. Thirty-two patients were identified with the average age of 28 years. PA was performed in 14 patients with ORIF in 18. Results: The PA group returned to full duty at an average of 4.5 months whereas the ORIF group returned at an average of 6.7 months (P = .0066). The PA group ran their fitness test an average of 9 seconds per mile slower than their preoperative average whereas the ORIF group ran it an average of 39 seconds slower per mile (P = .032). There were no differences between the 2 groups in the FAAM scores at an average of 35 months. Implant removal was performed in 15 (83%) in the ORIF group and 2 (14%) in the PA group (P = .005). Conclusions: Low-energy Lisfranc injuries treated with primary arthrodesis had a lower implant removal rate, an earlier return to full military activity, and better fitness test scores after 1 year, but there was no difference in FAAM scores after 3 years. Level of Evidence: Level III, comparative cohort study.

Operative and Nonoperative Management of Achilles Tendon Ruptures in Active Duty Military Population.

Background: The optimal management of Achilles tendon ruptures continues to be a subject of debate in orthopedics. These injuries are common in the active duty military population. The purpose of this study was to retrospectively compare the results of operative and nonoperative management of Achilles tendon ruptures in the active duty military population following the publication of a landmark level I study that has influenced practice patterns. Methods: All Achilles tendon injuries in active duty patients were identified at a single military institution from January 1, 2011, to January 1, 2014. Inclusion and exclusion criteria were applied and charts were reviewed. Demographic and treatment information were recorded along with return to duty status, deep vein thrombosis (DVT), rerupture, and other complication data. Rates of DVT, rerupture, other complications, and return to duty (including time to return) were then compared. Demographic data were described. Fifty-seven male patients met inclusion criteria with an average age of 31 years. There were 27 in the operative group and 30 in the nonoperative group. There were no significant differences in group demographics. Results: There were no DVTs in either treatment group. There were no wound complications in the operative group. There were no significant differences in the rates of rerupture, return to duty, or other complications. There were 2 reruptures in the nonoperative group. Both were treated nonoperatively. There was one rerupture in the operative group that was treated nonoperatively. All reruptures were partial tears. Two patients underwent repair with flexor hallucis longus augmentation. Both of these patients were initially managed nonoperatively. When available data on time to return to duty was analyzed, patients who underwent operative management returned to duty on average approximately one and a half months earlier (6.7 vs 8.2 months) than nonoperative patients (P = .04). In 2011, 12% of injuries were treated nonoperatively; in 2012, 57%; and in 2013, 84%. Conclusions: Similar to previously published work, this retrospective analysis found no significant difference in complication, DVT, or rerupture rates. The rate of rerupture in this study was slightly higher than previously published work in the era of functional rehabilitation, but the sample size was small. The data were limited with respect to functional outcome for comparison; however, the rate of return to active duty was not significantly different. The data also demonstrate a shift in institutional treatment pattern for Achilles injuries in this population over the 3-year study period. Operatively treated patients did have a statistically significant reduction in the time required to return to active duty of approximately one and a half months, which may represent a clinically significant difference in highly active workers or highly active people. Level of Evidence: Level III, retrospective comparative series.

Challenges in definitive fracture management of blast injuries

The United States military remains engaged in the longest armed conflict in this nation’s history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.

Antegrade versus retrograde intramedullary nailing of proximal third femur fractures.

The purpose of this study is to retrospectively review the results of proximal third femur fractures treated with retrograde nailing (RGN) and compare those results to a cohort from the same period treated with antegrade nailing (AGN). Adult patients with femur fractures within 10 cm of the lesser trochanter who were treated with intramedullary nails were reviewed. Two groups, patients treated with AGN (n = 35) and RGN (n = 34), were compiled. Demographic information, comorbidities, associated injuries, radiographic outcomes, complications, and secondary procedures were compared. There were two malunions in the AGN group and three in the RGN group. The AGN group had two nonunions while the RGN group had one. Subgroup analysis demonstrated that a higher body mass index (BMI) (p = .011) and a higher AO/OTA fracture classification (p = .019) were the only factors predictive of malunion. Regardless of starting point, there were no differences between groups in the number of secondary procedures, nonunions, malunions, or time until union.

Injury Characteristics of Low-Energy Lisfranc Injuries Compared With High-Energy Injuries

Background: Lisfranc injuries result from high- and low-energy mechanisms though the literature has been more focused on high-energy mechanisms. A comparison of high-energy (HE) and low-energy (LE) injury patterns is lacking. The objective of this study was to report injury patterns in LE Lisfranc joint injuries and compare them to HE injury patterns. Methods: Operative Lisfranc injuries were identified over a 5-year period. Patient demographics, mechanism of injury, injury pattern, associated injuries, missed diagnoses, clinical course, and imaging studies were reviewed and compared. HE mechanism was defined as motor vehicle crash, motorcycle crash, direct crush, and fall from greater than 4 feet and LE mechanism as athletic activity, ground level twisting, or fall from less than 4 feet. Thirty-two HE and 48 LE cases were identified with 19.3 months of average follow-up. Results: There were no differences in demographics or missed diagnosis frequency (21% HE vs 18% LE). Time to seek care was not significantly different. HE injuries were more likely to have concomitant nonfoot fractures (37% vs 6%), concomitant foot fractures (78% vs 4%), cuboid fractures (31% vs 6%), metatarsal base fractures (84% vs 29%), displaced intra-articular fractures (59% vs 4%), and involvement of all 5 rays (23% vs 6%). LE injuries were more commonly ligamentous (68% vs 16%), with fewer rays involved (2.7 vs 4.1). Conclusions: LE mechanisms were a more common cause of Lisfranc joint injury in this cohort. These mechanisms generally resulted in an isolated, primarily ligamentous injury sparing the lateral column. Both types had high rates of missed injury that could result in delayed treatment. Differences in injury patterns could help direct future research to optimize treatment algorithms. Level of Evidence: Level III, comparative series.