Tad L. Gerlinger

Combat Casualties in Afghanistan Cared for by a Single Forward Surgical Team during the Initial Phases of Operation Enduring Freedom

BACKGROUNDnThe 274th Forward Surgical Team (FST) was the first FST deployed to Bagram, Afghanistan, to provide surgical care for combat casualties during the initial phases of Operation Enduring Freedom. This is an analysis of the distribution, cause, and severity of wounds for combat casualties and the surgical procedures they required.nnnMETHODSnA prospective database was maintained for combat casualties cared for by the 274th FST. The database included demographic data, vital status, mechanism of injury, distribution and severity of wounds, and surgical care provided.nnnRESULTSnThe FST cared for 224 combat casualties, including 153 U.S. soldiers, 19 coalition soldiers, 32 Afghan militia forces soldiers, and 20 detainees. Fragments were the most common mechanism of injury (49%), and the extremity was the most common location of injury (58%), whereas gunshot wounds were the most common cause of death (57%). There were few significant head, chest, or abdominal wounds (13%). The FST treated 103 surgical cases (73 with combat wounds), including neurosurgical, thoracic, general, orthopedic, and vascular cases, with a total of 180 procedures.nnnCONCLUSIONSnThe distribution, cause, and severity of wounds were similar to those in the Persian Gulf War, despite the obvious differences between these conflicts. The use of modern technologies, such as compact, portable, ultrasound and digital X-ray systems, expanded the capabilities of the FST. Even low-intensity conflicts can produce significant numbers of combat casualties, and the FST must be manned, trained, equipped, and supplied to treat a wide variety of combat wounds.

The 274th Forward Surgical Team experience during Operation Enduring Freedom.

The 274th Forward Surgical Team (FST) was deployed in support of Operation Enduring Freedom from October 14, 2001 to May 8, 2002. During this period, the FST was asked to perform many nondoctrinal missions. The FST was tasked with functioning as a mini-combat support hospital during the earlier phases of Operation Enduring Freedom, performing in-flight surgical procedures and resuscitation of combat wounded, conducting split operations with surgical coverage of both Karshi and Khanabad, Uzbekistan, and Bagram, Afghanistan, and leading the multinational medical coalition assembled for Operation Anaconda and other combat operations staged from Bagram. Overall, the 274th FST took care of approximately 90% of U.S. combat casualties during this period and treated a total of 221 combat casualties. The FST treated 103 total surgical cases, including 73 with combat wounds. At the time, this experience with combat casualties and the surgical care of combat wounds was the largest since the Persian Gulf War. More importantly, this account describes the flow, frequency, and type of combat casualties seen in a low-intensity conflict like that being waged currently in Afghanistan. It is hoped that this depiction will aid in the preparation, equipping, and overall utilization of surgical assets in similar future conflicts.

The James A. Rand Young Investigator's Award: A Randomized Controlled Trial of Oral and Intravenous Tranexamic Acid in Total Knee Arthroplasty: The Same Efficacy at Lower Cost?

BACKGROUNDnTranexamic acid (TXA) is a synthetic antifibrinolytic agent successfully used intravenously (IV) to reduce blood loss after total knee arthroplasty (TKA). An oral formulation of the medication is available, at a fraction of the cost of the IV preparation. The purpose of this randomized controlled trial is to determine if oral TXA is equivalent to IV TXA in reducing blood loss in TKA.nnnMETHODSnIn this double-blinded, placebo-controlled trial, patients undergoing primary TKA were randomized to receive 1.95g of TXA orally 2 hours preoperatively or 1g IV bolus before wound closure. The primary outcome was reduction of hemoglobin. Power analysis determined that 30 patients were required in each group. Equivalence analysis was performed with pooled and Satterthwaite t tests with a P-value of <.05 suggesting equivalence between treatments.nnnRESULTSnThirty-four patients received oral TXA and 37 patients received IV TXA. There was no difference in the mean reduction of hemoglobin between oral and IV groups (3.45g/dL vs 3.31g/dL, respectively; Pxa0=xa0.001, equivalence), and total blood loss was equivalent at 1281 mL vs 1231 mL, respectively (Pxa0= .02, equivalence). One patient in each group was transfused.nnnCONCLUSIONnOral TXA provides equivalent reductions in blood loss, at a cost of

Quantification of Femoral Neck Exposure Through a Minimally Invasive Smith-Petersen Approach

14 compared with

Catastrophic Failure of Ceramic-Polyethylene Bearing Total Hip Arthroplasty

47-

The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on Surgical Management of Osteoarthritis of the Knee

108 depending on the IV formulation selected. As approximately 700,000 primary TKA are performed in the United States annually, a switch to oral TXA could yield total cost savings of between

Acute Compartment Syndrome of the Thigh in Combat Casualties

23 million and

The most frequently requested precombat refresher training by the Special Forces medics during operation Enduring Freedom

67 million dollars per year for our health care system.

Return to Duty and Deployment after Major Joint Arthroplasty

Objectives: To quantify the area of osseous exposure and identify six anatomic landmarks using a direct anterior approach to the hip. Methods: Ten fresh-frozen hemipelves were dissected using a minimally invasive Smith-Petersen approach. Upon completion of the exposure, a calibrated digital image was taken from the surgeons perspective. Identification of six osseous landmarks (anterior-superior acetabulum, anterior-inferior acetabulum, greater trochanter, lesser trochanter, anterior inferior iliac spine, and vastus ridge) was attempted either by direct visualization or palpation with a tonsil clamp. These landmarks exceed the border for any intracapsular hip fracture. The digital images were then analyzed using a computer software program, ImageJ (National Institutes of Health, Bethesda, MD), to calculate the square area of proximal femur exposed. Results: The average square area of proximal femur exposed was 20.31 cm2 (standard deviation: 3.09, range: 15.16-24.18). The area exposed correlated with the original height of the cadaver (r = 0.69, P < 0.05). With the numbers available, there was no correlation between exposure and weight (P = 0.71) or body mass index (P = 0.87). In all 10 cadaver specimens, the 6 osseous landmarks were easily identified, 5 by direct visualization and 1 by palpation (lesser trochanter, deep portion) because of incomplete visualization. Conclusions: The minimally invasive Smith-Petersen approach to the hip allows for a wide exposure of the femoral neck averaging 20.31 cm2 and identification of six bony critical landmarks of the hip. It may be used for open reduction of subcapital, mid-cervical, and basicervical femoral neck fractures.

The Painful Total Knee Arthroplasty

Complications of ceramic-polyethylene bearing total hip arthroplasty (THA) include osteolysis, loosening, dislocation, and component failure. Catastrophic acetabular component failure involves severe damage to both the polyethylene liner and metal shell. This case study presents the first reported complete wear-through of the acetabular portion of a ceramic-polyethylene arthroplasty presenting as a dislocation and a review of the literature. In this study, a patients alumina ceramic femoral head penetrated the polyethylene liner and titanium shell and presented as a dislocated THA. The contributing factors for this catastrophic failure include young patient age, high activity level, thin polyethylene liner, backside wear, component positioning, polyethylene sterilization with gamma irradiation in air, and lack of appropriate follow-up. Revision THA was performed without complications.