Wade T. Gordon

Outcomes Associated with the Internal Fixation of Long-Bone Fractures Proximal to Traumatic Amputations

BACKGROUND Preservation of optimal residual limb length following a traumatic amputation can be challenging. The purpose of this study was to determine if acceptable results can be achieved by definitive fixation of a long-bone fracture proximal to a traumatic amputation. METHODS We identified thirty-seven active-duty military service members who underwent internal fixation of a long-bone fracture proximal to a traumatic amputation. Functional status was assessed with the Tegner activity level scale and prosthesis use. Secondary outcome measures were the development of nonunion, infection, and heterotopic ossification. RESULTS Twelve patients (32%) underwent amputation and fracture in the same osseous segment. Ten patients (27%) sustained bilateral traumatic amputations, and eight (22%) had a major fracture of the contralateral extremity. The median times to fracture fixation and amputation closure were twelve days and nineteen days, respectively, after the injury. The mean Tegner activity score was 3.32 (range, 1 to 6); patients with isolated extremity injuries had significantly higher Tegner scores than those with severe bilateral injuries (3.59 and 2.38, respectively; p = 0.04). Thirty-three patients (89%) developed an infection requiring surgical debridement. However, all fractures were treated until union occurred, and amputation level salvage was successful in all instances. Heterotopic ossification developed in twenty-eight patients (76%), with operative excision required in eleven patients (39%). CONCLUSIONS High complication rates, but acceptable final results, can be achieved with internal fixation of a fracture proximal to a traumatic amputation to preserve functional joint levels or salvage residual limb length.

The Use of Dilute Dakin's Solution for the Treatment of Angioinvasive Fungal Infection in the Combat Wounded: A Case Series

Disseminated fungal infections are normally opportunistic infections in the immunocompromised population. Current literature has documented a high mortality rate with these infections in civilian trauma or as complications of severe burns. There is only one published case of fungal infection in a combat-injured individual to date, which resulted in mortality despite aggressive debridement and appropriate antifungal agents. We present here three patients in whom aggressive debridement, antifungals, and the addition of dilute Dakins solution with negative pressure wound therapy was used to treat angioinvasive mold. Angioinvasive fungal infection continue to be one of the most aggressive and devastating infections that our combat-injured patients face. With the addition of dilute Dakins solution, we successfully managed three critically ill patients. Previous literature had shown close to 30% mortality associated with cutaneous mucormycosis and the mortality rate approaches 100% with disseminated angioinvasive fungal infections. These results provide hope not only for the combat-injured patients being treated for both local and disseminated angioinvasive fungal infections, but also for the civilian trauma and immunocompromised patients.

Posterior cruciate ligamentreconstruction: Tibial inlay technique—principles and procedure

Abstract This article provides an overview of posterior cruciate ligament (PCL) reconstruction using the tibial inlay technique. Preoperative evaluation should include a careful clinical examination, stress radiographs, and other studies, as necessary. Treatment options include both nonsurgical and surgical methods. The focus of this article is the surgical technique for PCL reconstruction using a tibial inlay graft.

Outcomes of manipulation under anesthesia versus surgical management of combat-related arthrofibrosis of the knee.

The purpose of this study was to compare the outcomes of manipulation under anesthesia (MUA) to arthrolysis for combat-related arthrofibrosis. Sixty-one knees in 56 patients who underwent treatment for arthrofibrosis secondary to lower extremity trauma were reviewed. Knee range of motion preoperatively, postoperatively, and at follow-up was analyzed. The primary outcome measure was the difference in knee arc of motion between the two cohorts. Forty-one knees (67.2%) underwent MUA and 20 knees (32.8%) were managed operatively. There was no difference in the preoperative arc of motion. Knees that underwent MUA had significant improvements in arc of motion compared to knees that underwent arthrolysis (106.3° vs. 82.3°) at a follow-up of 2 years (p = .008). The complication rate was greater in knees that underwent arthrolysis (40%) compared to knees that underwent MUA (12.2%; p = .04). In conclusion, knees that underwent MUA demonstrated significant improvements in arc of motion at 2-year follow-up with fewer complications.

Reprioritization of research for combat casualty care

&NA; Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Risk factors for decreased range of motion and poor outcomes in open periarticular elbow fractures

INTRODUCTION The purpose of this study was to identify risk factors present at the time of injury that predict poor functional outcomes and heterotopic ossification (HO) in open periarticular elbow fractures. MATERIALS AND METHODS We performed a retrospective review of 136 combat-related open elbow fractures from 2003 to 2010. Patient demographics, injury characteristics, treatment variables, and complications were recorded. Functional outcomes were analyzed to determine range of motion (ROM) and Mayo Elbow Performance Score (MEPS). Secondary outcome measures included the development of HO, return to duty, and revision operation. RESULTS At a median 2.7 years from injury the median MEPS was 67.8 (range 30-100) with an average ulnohumeral arc motion of 89°. Bipolar fractures, with periarticular fractures on both sides of the elbow and at least one side containing intra-articular extension, were independently associated with decreased ulnohumeral motion (p=0.02) and decreased MEPS (p<0.004). Additional independent risk factors for decreased ROM included more severe osseous comminution (p=0.001), and increased time to definitive fixation (p=0.03) and HO (p=0.02). More severe soft tissue injury (Gustilo and Anderson fracture type, p=0.02), peripheral nerve injury (p=0.04), and HO (p=0.03) were independently associated with decreased MEPS. HO developed in 65% (89/136) of extremities and was associated with more severe Orthopaedic Trauma Association (OTA) fracture type (p=0.01) and escalating Gustilo and Anderson fracture classification (p=0.049). CONCLUSIONS In the largest series of open elbow fractures, we identified risk factors that portend a poor clinical outcome and decreased ROM. Bipolar elbow fractures, which have not previously been associated with worse results, are particularly prone to decreased ROM and worse outcomes. LEVEL OF EVIDENCE Prognostic level IV.

A Model to Predict Limb Salvage in Severe Combat-related Open Calcaneus Fractures

BackgroundOpen calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern.Questions/purposesWe developed two decision support tools, an artificial neural network and a logistic regression model, based on presenting data from severe combat-related open calcaneus fractures. We then determined which model more accurately estimated the likelihood of amputation and which was better suited for clinical use.MethodsInjury-specific data were collected from wounded active-duty service members who sustained combat-related open calcaneus fractures between 2003 and 2012. One-hundred fifty-five open calcaneus fractures met inclusion criteria. Median followup was 3.5 years (interquartile range: 1.5, 5.1 years), and amputation rate was 44%. We developed an artificial neural network designed to estimate the likelihood of amputation, using information available on presentation. For comparison, a conventional logistic regression model was developed with variables identified on univariate analysis. We determined which model more accurately estimated the likelihood of amputation using receiver operating characteristic analysis. Decision curve analysis was then performed to determine each model’s clinical utility.ResultsAn artificial neural network that contained eight presenting features resulted in smaller error. The eight features that contributed to the most predictive model were American Society of Anesthesiologist grade, plantar sensation, fracture treatment before arrival, Gustilo-Anderson fracture type, Sanders fracture classification, vascular injury, male sex, and dismounted blast mechanism. The artificial neural network was 30% more accurate, with an area under the curve of 0.8 (compared to 0.65 for logistic regression). Decision curve analysis indicated the artificial neural network resulted in higher benefit across the broadest range of threshold probabilities compared to the logistic regression model and is perhaps better suited for clinical use.ConclusionsThis report demonstrates an artificial neural network was capable of accurately estimating the likelihood of amputation. Furthermore, decision curve analysis suggested the artificial neural network is better suited for clinical use than logistic regression. Once properly validated, this may provide a tool for surgeons and patients faced with combat-related open calcaneus fractures in which decisions between limb salvage and amputation remain difficult.Level of EvidenceLevel IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

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.

Evolution of orthopaedic rehabilitation care.

&NA; Rehabilitation following surgical reconstruction for combat‐related extremity injuries sustained in the current conflicts in Iraq and Afghanistan has been challenging. The goal of rehabilitation is to restore limb function to facilitate the reintegration of patients with these severe injuries into society. The US Department of Defense has developed a network of rehabilitation centers of excellence within the military healthcare system in collaboration with the US Department of Veterans Affairs to optimize outcomes using technologic and systemic advances in prostheses in patients who have undergone limb salvage procedures or amputation. Managing pain during rehabilitation and optimizing function following high bilateral lower extremity amputation remains a clinical challenge. However, continued research is likely to improve outcomes in this severely injured patient population. To that end, two research consortia, the Bridging Advanced Developments for Exceptional Rehabilitation and the Center for Rehabilitation Sciences Research, have recently been created to address identified knowledge gaps.

Open, combat-related loss, or disruption of the knee extensor mechanism: treatment strategies, classification, and outcomes.

Objective: To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. Design: Retrospective review. Setting: Tertiary (Level/Role V) Military Treatment Facility. Patients: Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. Intervention: Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. Main Outcome Measures: Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. Results: The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12–89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of <10 degrees, and 5 had no extensor lag. The presence of a major periarticular or patellar fracture was significantly associated with the knee requiring a subsequent extensor mechanism allograft reconstruction procedure. One extremity each underwent knee arthrodesis or transfemoral amputation due to severe infection. Conclusions: High-energy, open knee extensor mechanism injuries are severe and rarely occur in isolation, but limb salvage is generally successful after multiple procedures. Patients who required staged allograft reconstruction, despite high complication rates, generally had favorable results. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.