Steven J. Svoboda

Characterization of Extremity Wounds in Operation Iraqi Freedom and Operation Enduring Freedom

Objectives: Extremity wounds and fractures traditionally comprise the majority of traumatic injuries in US armed conflicts. Little has been published regarding the extremity wounding patterns and fracture distribution in the current conflicts in Iraq and Afghanistan. The intent of this study was to describe the distribution of extremity fractures during this current conflict. Design: Descriptive epidemiologic study. Methods: The Joint Theater Trauma Registry was queried for all US service members receiving treatment for wounds (ICD-9 codes 800-960) sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) from October 2001 through January 2005. Returned-to-duty and nonbattle injuries were excluded. Wounds were classified according to region and type. Extremity wounds were analyzed in detail and compared to published results from previous conflicts. Results: A total of 1281 soldiers sustained 3575 extremity combat wounds. Fifty-three percent of these were penetrating soft-tissue wounds and 26% were fractures. Of the 915 fractures, 758 (82%) were open fractures. The 915 fractures were evenly distributed between the upper (461, 50%) and lower extremities (454, 50%). The most common fracture in the upper extremity was in the hand (36%) and in the lower extremity was the tibia and fibula (48%). Explosive munitions accounted for 75% of the mechanisms of injury. Conclusions: The burden of wounds sustained in OIF/OEF is extremity injuries, specifically soft-tissue wounds and fractures. These results are similar to the reported casualties from previous wars.

Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy

Background: There is recent evidence that use of allograft tendons for anterior cruciate ligament (ACL) reconstruction in young patients may result in increased failure rates compared with autologous grafts. Hypothesis: Allograft ACL reconstruction will result in higher failure rates in young athletes compared with autograft reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort study of cadets at the United States Military Academy (USMA) was performed to assess performance of ACL reconstructions performed before entrance to service. Members of the classes of 2007 through 2013 who had undergone prior ACL reconstruction were identified through the Department of Defense Medical Evaluation Review Board reporting and waiver process and evaluated on the first day of matriculation. These participants were followed during their tenure at the academy with revision ACL reconstruction as the primary outcome measure of interest. Kaplan-Meier survival analysis was performed for all graft types using STATA with significance set as P < .05. Results: A total of 120 cadets underwent 122 ACL reconstructions (2 bilateral) before matriculation and compose the prospective cohort. This cohort included 30 female and 90 male cadets. Of these 122 knees with prior ACL reconstructions, the grafts used were 61 bone–patellar tendon–bone (BTB), 45 hamstring, and 16 allograft. A total of 20 failures occurred among this cohort at an average of 545 days from matriculation. Of the failures requiring revision, 7 were BTB (11% of all BTB), 7 were allograft (44% of all allograft), and 6 were hamstring (13% of all hamstring). There was no significant difference in the graft failure between the BTB and hamstring autograft groups. In contrast, those who entered the USMA with an allograft were 7.7 times more likely to experience a subsequent graft failure during the follow-up period when compared with the BTB autograft group (hazard ratio = 7.74; 95% confidence interval [CI], 2.67-22.38; P < .001). When allografts were compared with all autografts combined, a similar increase failure was noted in the allograft group (hazard ratio = 6.71; 95% CI, 2.64-17.06; P < .001). Conclusion: In this young active cohort, individuals having undergone an allograft ACL reconstruction were significantly more likely to experience clinical failure requiring revision reconstruction compared with those who underwent autologous graft reconstruction. The authors recommend the use of autograft in ACL reconstruction in young athletes.

Epidemiology of Acromioclavicular Joint Injury in Young Athletes

Background: Acromioclavicular (AC) joint injuries, particularly sprains, are common in athletic populations and may result in significant time lost to injury. However, surprisingly, little is known of the epidemiology of this injury. Purpose: To define the incidence of AC joint injuries and to determine the risk factors for injury. Study Design: Descriptive epidemiological study. Methods: A longitudinal cohort study was performed to determine the incidence and characteristics of AC joint injury at the United States Military Academy between 2005 and 2009. All suspected AC joint injuries were reviewed by an independent orthopaedic surgeon using both chart reviews as well as assessments of radiological imaging studies. Injuries were graded according to the modified Rockwood classification system as well as dichotomized into low-grade (Rockwood types I and II) and high-grade (Rockwood types III, IV, V, and VI) injuries for analysis. Injury mechanisms, return-to-play timing, and athlete-exposures were documented and analyzed. χ2 and Poisson regression analyses were performed, with statistical significance set at P < .05. Results: During the study period, 162 new AC joint injuries and 17,606 person-years at risk were documented, for an overall incidence rate of 9.2 per 1000 person-years. The majority of the AC joint injuries were low-grade (145 sprains, 89%) injuries, with 17 high-grade injuries. Overall, male patients experienced a significantly higher incidence rate for AC joint injuries than female patients (incidence rate ratio [IRR], 2.18; 95% confidence interval [CI], 1.21-4.31). An AC joint injury occurred most commonly during athletics (91%). The incidence rate of AC joint injury was significantly higher in intercollegiate athletes than intramural athletics when using athlete-exposure as a measure of person-time at risk (IRR, 2.11; 95% CI, 1.31-3.56). Similarly, the incidence rate of AC injury was significantly higher among male intercollegiate athletes when compared to female athletes (IRR, 3.56; 95% CI, 1.74-8.49) when using athlete-exposure as the denominator. The intercollegiate sports of men’s rugby, wrestling, and hockey had the highest incidence rate of AC joint injury. Acromioclavicular injuries resulted in at least 1359 total days lost to injury and an average of 18.4 days lost per athlete. The average time lost to injury for low-grade sprains was 10.4 days compared with high-grade injuries at 63.7 days. Of the patients with high-grade injuries, 71% elected to undergo coracoclavicular/AC reconstructions. The rate of surgical intervention was 19 times higher for high-grade AC joint injuries than for low-grade injuries (IRR, 19.2; 95% CI, 7.64-48.23; P < .0001). Conclusion: Acromioclavicular separations are relatively common in young athletes. Most injuries occur during contact sports such as rugby, wrestling, and hockey. Male athletes are at greater risk than female athletes. Intercollegiate athletes are at greater risk than intramural athletes. The average time lost to sport due to AC joint injury was 18 days, with low-grade injuries averaging 10 days lost. High-grade injuries averaged 64 days lost to sport, and 71% elected to undergo surgical repair/reconstruction.

Risk Factors for Syndesmotic and Medial Ankle Sprain Role of Sex, Sport, and Level of Competition

Background: Syndesmotic and medial ankle sprains constitute up to 15% of all ankle sprains in athletic populations and can result in significant time lost to injury and long-term disability. Purpose: The objective of this study was to estimate the rate of syndesmotic and medial ankle sprain injuries and identify risk factors associated with these injuries within the physically active cadet population at the United States Military Academy (USMA). Study Design: Cohort study; Level of evidence, 2. Methods: The Cadet Illness and Injury Tracking System (CIITS) database at USMA was queried for all ankle injuries between 2005 and 2009. Sex, level of competition, and exposure to sport were among risk factors analyzed. Results: Among 20 336 person-years, 1206 cadets sustained ankle sprain. Syndesmotic (6.7%) and medial (5.1%) ankle sprains had an incidence rate (IR) of 4.8 and 3.5 per 1000 person-years, respectively. Compared with women, men were 3 times more likely to experience medial ankle sprain (IR ratio [IRR] 3.37; 95% confidence interval [CI]: 1.05, 10.74], but there was no difference in rate of syndesmotic sprains by sex (IRR 1.06; 95% CI: 0.58, 1.95). Athletics accounted for 81% of syndesmotic sprains and 64% of medial sprains. Sprint football (52.3), team handball (men’s, 34.7), soccer (men’s, 30.5; women’s, 6.5), and basketball (men’s, 24.8; women’s, 6.7) had the highest syndesmotic IR per 100 000 athlete-exposures. Medial sprain IR was highest in men’s rugby (16.6) and gymnastics (14.0). When analyzed by athlete-exposure, male intercollegiate athletes had a greater risk of syndesmotic sprain than their female counterparts (3.53; 95% CI: 1.26, 9.83). Furthermore, intercollegiate level of competition had an increased risk of syndesmotic sprain when compared with intramural level (IRR 2.41; 95% CI: 1.03, 5.65). Conclusion: Male athletes have an over threefold greater risk of medial ankle sprain. Male sex and higher level of competition are risk factors for syndesmotic ankle sprain during athletics.

Return to Play and Recurrent Instability After In-Season Anterior Shoulder Instability A Prospective Multicenter Study

Background: There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play. Purpose: To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability. Results: Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury. Conclusion: In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Incidence and Risk Factors Associated with Meniscal Injuries Among Active-Duty US Military Service Members

CONTEXT Few population-based studies have examined the incidence of meniscal injuries, and limited information is available on the influence of patients demographic and occupational factors. OBJECTIVE To examine the incidence of meniscal injuries and the influence of demographic and occupational factors among active-duty US service members between 1998 and 2006. DESIGN Cohort study. SETTING Using the International Classification of Diseases (9th revision) codes 836.0 (medial meniscus), 836.1 (lateral meniscus), and 836.2 (meniscus unspecified), we extracted injury data from the Defense Medical Surveillance System to identify all acute meniscal injuries among active-duty military personnel. PATIENTS OR OTHER PARTICIPANTS Active-duty military personnel serving in all branches of military service during the study period. MAIN OUTCOME MEASURE(S) Incidence rate (IR) per 1000 person-years at risk and crude and adjusted rates by strata for age, sex, race, rank, and service. RESULTS During the study period, 100201 acute meniscal injuries and 12115606 person-years at risk for injury were documented. The overall IR was 8.27 (95% confidence interval [CI] = 8.22, 8.32) per 1000 person-years. Main effects were noted for all demographic and occupational variables (P < .001), indicating that age, sex, race, rank, and service were associated with the incidence of meniscal injuries. Men were almost 20% more likely to experience an acute meniscal injury than were women (incidence rate ratio = 1.18, 95% CI = 1.15, 1.20). The rate of meniscal injury increased with age; those older than 40 years of age experienced injuries more than 4 times as often as those under 20 years of age (incidence rate ratio = 4.25, 95% CI=4.08,4.42). CONCLUSIONS The incidence of meniscal injury was substantially higher in this study than in previously reported studies. Male sex, increasing age, and service in the Army or Marine Corps were factors associated with meniscal injuries.

Association Between Previous Meniscal Surgery and the Incidence of Chondral Lesions at Revision Anterior Cruciate Ligament Reconstruction

Background: Knees undergoing revision anterior cruciate ligament (ACL) reconstruction typically have more intra-articular injuries than do knees undergoing primary reconstruction. Hypothesis: Previous partial meniscectomy (PM) is associated with a higher rate of chondral lesions at revision ACL reconstruction, whereas previous meniscal repair (MR) is not associated with a higher rate of chondral lesions at revision ACL reconstruction, compared with knees undergoing revision ACL with no previous meniscal surgery. Study design: Cohort study (Prevalence); Level of evidence, 2. Methods: Data from a multicenter cohort was reviewed to determine the history of prior meniscal surgery (PM/MR) and the presence of grade II/III/IV chondral lesions at revision ACL reconstruction. The association between previous meniscal surgery and the incidence of chondral lesions was examined. Patient age was included as a covariate to determine if surgery type contributes predictive information independent of patient age. Results: The cohort included 725 ACL revision surgeries. Chondrosis was associated with patient age (P < .0001) and previous meniscal surgery (P < .0001). After adjusting for patient age, knees with previous PM were more likely to have chondrosis than knees with previous MR (P = .003) or no previous meniscal surgery (P < .0001). There was no difference between knees without previous meniscal surgery and knees with previous MR (P = .7). Previous partial meniscectomy was associated with a higher rate of chondrosis in the same compartment compared with knees without previous meniscal surgery (P < .0001) and knees with previous MR (P ≤ .03). Conclusion: The status of articular cartilage at the time of revision ACL reconstruction relates to previous meniscal surgery independent of the effect of patient age. Previous partial meniscectomy is associated with a higher incidence of articular cartilage lesions, whereas previous meniscal repair is not. Although this association may reflect underlying differences in the knee at the time of prior surgery, it does suggest that meniscal repair is preferable when possible at the time of ACL reconstruction.

Changes in Serum Biomarkers of Cartilage Turnover After Anterior Cruciate Ligament Injury

Background: Biomarkers of cartilage turnover and joint metabolism have a potential use in detecting early degenerative changes after a traumatic knee joint injury; however, no study has analyzed biomarkers before an anterior cruciate ligament (ACL) injury and again after injury or in comparison with a similar group of uninjured controls. Hypothesis: Changes in serum biomarker levels and the ratio of cartilage degradation to synthesis, from baseline to follow-up, would be significantly different between ACL-injured patients and uninjured controls. Study Design: Case-control study; Level of evidence, 3. Methods: This case-control study was conducted to examine changes in serum biomarkers of cartilage turnover following ACL injury in a young athletic population. Specifically, 2 markers for type II collagen and aggrecan synthesis (CPII and CS846, respectively) and 2 markers of types I and II degradation and type II degradation only (C1,2C and C2C, respectively) were studied. Preinjury baseline serum samples and postinjury follow-up samples were obtained for 45 ACL-injured cases and 45 uninjured controls matched for sex, age, height, and weight. Results: Results revealed significant decreases in C1,2C (P = .042) and C2C (P = .006) over time in the ACL-injured group when compared with the controls. The change in serum concentrations of CS846 from baseline to follow-up was also significantly different between the ACL-injured patients and uninjured controls (P = .002), as was the change between groups in the ratio of C2C:CPII over time (P = .013). No preinjury differences in the ratio of C1,2C:CPII or C2C:CPII were observed between groups; however, postinjury differences were observed for both ratios. Conclusion: Changes in biomarker concentrations after an ACL injury suggest an alteration in cartilage turnover and joint metabolism in those sustaining ACL injuries compared with uninjured matched controls.

Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation

BACKGROUND Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. METHODS As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45° of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. RESULTS Overall, 45° posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass correlation coefficient = 0.55; 95% confidence interval, 0.53 to 0.56). Similarly, the 45° posteroanterior flexion weight-bearing radiographs had higher correlation with arthroscopic findings of chondral disease (Spearman rho = 0.36; 95% confidence interval, 0.32 to 0.39) compared with anteroposterior radiographs (Spearman rho = 0.29; 95% confidence interval, 0.26 to 0.32). With respect to standards for the magnitude of the reliability coefficient and correlation coefficient (Spearman rho), the International Knee Documentation Committee classification demonstrated the best combination of good interobserver reliability and medium correlation with arthroscopic findings. CONCLUSIONS The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. The International Knee Documentation Committee classification assessed with use of 45° posteroanterior flexion weight-bearing radiographs had the most favorable combination of reliability and correlation. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Normative Values for the KOOS and WOMAC in a Young Athletic Population History of Knee Ligament Injury Is Associated With Lower Scores

Background: The use of patient-reported outcome measures to assess clinical outcomes after injury and surgery has become common in treating young athletes with orthopaedic injuries; however, normative data for these measures are limited and often include a wide range of ages and activity levels. Purpose: To provide normative data for the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in a young and athletic population, and to compare scores between participants with a history of knee ligament injury and those with no history. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We administered the KOOS and WOMAC to 1177 college freshmen entering the United States Military Academy in June 2011. All participants were healthy and had been medically screened to meet the physical induction standards for military service. We calculated means, standard deviations, percentiles, ranges, and interquartile ranges for the KOOS and WOMAC by sex and injury history. We also compared median scale scores for those with a history of knee ligament injury with those with no history using the Kruskal-Wallis test. Results: Among the 1177 participants, 971 were male (age, 18.8 ± 0.9 years), and the remaining 206 were female (age, 18.7 ± 0.8 years). Normative median values and interquartile ranges (IQRs) for the KOOS scale scores among men with no history of knee ligament injury were the following: Symptoms (96.4; IQR, 10.7), Pain (100; IQR, 2.8), Functional Activities of Daily Living (ADL) (100; IQR, 0.0), Sports and Recreation Function (100; IQR, 5.0), and Knee-Related Quality of Life (QOL) (100; IQR, 12.5). For women with no history of knee ligament injury, the KOOS scale scores were the following: Symptoms (92.9; IQR, 14.3), Pain (100; IQR, 5.6), Functional ADL (100; IQR, 2.9), Sports and Recreation Function (100; IQR, 10.0), and Knee-Related QOL (93.8; IQR, 18.8). Among the men, 139 (14%) reported a history of knee ligament injury, while 33 (16%) women also reported a history of injury. All KOOS scale scores and the WOMAC Stiffness and Function scale scores were significantly lower (P < .05) for men who reported a history of knee ligament injury. Similarly, Symptoms, Pain, and Knee-Related QOL on the KOOS and Pain on the WOMAC were significantly lower among women with a history of knee ligament injury. Conclusion: Normative values for all KOOS scales suggest a high level of functioning among participants with no history of knee ligament injury. Despite meeting the medical standards for military service, participants with a history of knee ligament injury had significantly lower KOOS and WOMAC scores upon entry to military service.