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Background: Many wounded warriors experienced high-energy lower-extremity trauma (HELET) that may be limb threatening. Volumetric muscle loss, post-traumatic osteoarthritis, nerve injuries, and pain may severely limit physical function. Several wounded warriors express a strong desire to return to their units and be deployed in their original military occupational specialty. We began the return-to-run (RTR) clinical pathway at our institution 2 years ago to facilitate high-performance goals such as these. It involves an energy storing ankle foot orthosis, the intrepid dynamic exoskeletal orthosis in combination with high-intensity, progression oriented rehabilitation. We sought to determine the rate of deployment or predeployment training after participation in this noninvasive intervention. METHODS: A retrospective analysis of the RTR databasewas performed to determine the rate of deployment or predeployment training among those servicemembers who began participation in the RTR between November of 2009 and March of 2011. Medical records were reviewed for demographics, injury, surgical data, and major complications. Requests for delayed amputation were recorded, and charts were reviewed to determine if patients eventually elected to proceed with amputation or if they chose to continue with limb salvage. RESULTS: Between November 2009 and March 2011, 87 service members completed the RTR. Of these, 17 (19.5%) have been deployed to combat or are in predeployment training. Sixteen serve in combat arms (nine Special Forces, four infantry/ranger, two combat engineers, and one gunner), and one is amember of the military intelligence community. Fifteen patients sustained their injuries as a result of HELET (four gunshot, five motor vehicle collisions, four explosions, one parachute injury, and one fall from height), one had idiopathic avascular necrosis of the talus, and one had an iatrogenic nerve injury after pelvic surgery., Published in the Journal of Trauma and Acute Care Surgery v73 n2 Supplement 1, pS112-S115, 2012. This study was presented at the Advanced Technology Applications for Combat Casualty Care Conference Held in Fort Lauderdale, Florida on August 15-18, 2011. This study was conducted under a protocol reviewed and approved by the US Army

The optimal surgical exposure to the posterior ankle for trauma and reconstruction is a source of debate. We hypothesized that the Achilles tendon-splitting approach would provide greater exposure to the posterior ankle than the posterolateral approach. Forty surgical approaches were performed from twenty fresh-frozen cadavers. Achilles tendon splitting and posterolateral approaches were performed using a randomized crossover design for surgical sequence. Six landmarks (medial malleolus, ankle joint, subtalar joint, incisura fibularis, lateral malleolus and medial gutter) were identified by direct visualization or palpation. A calibrated digital photograph was taken and Image J (http://rsb.info nih.gov/ij/) was used to calculate the surface area of the distal tibia and talus exposed in neutral and dorsiflexion. Results: Using a posterolateral approach, the average distal tibia exposed was 11.3cm2 in neutral and 10.2 cm2 in dorsiflexion. The average talus exposed was 2.0 cm2 in neutral and 2.4 cm2 in dorsiflexion. Using an Achilles tendon-splitting approach, the average exposed distal tibia was 33% more (15.0 cm2) in neutral and 43% more (14.6 cm2) in dorsiflexion. The average talus exposed was 47% more (3.0 cm2) in neutral and 76% more (4.2 cm2) in dorsiflexion. All increases in exposure were statistically significant., Published in Foot & Ankle International v33 n10 p900-904, Oct 2012.

Objective: To define the anatomic safe zone for placement of external fixator half pins into the anterior and lateral femur. Methods: In 20 fresh frozen hemipelvis specimens, the femoral nerve and all branches crossing the femur were dissected out to their final muscular locations. The location where the nerves crossed the anterior femur was measured from the anterior superior iliac spine and inferior margin of the lesser trochanter. The knee joint was then opened, and the distance from the superior reflection of the suprapatellar pouch to the last branch of the femoral nerve crossing the anterior femur was measured, defining the safe zone for anterior pin placement. Results: The last branch of the femoral nerve crossed at an average distance from the anterior superior iliac spine of 174 43 mm (range, 95 248 mm) and from the lesser trochanter at a distance of 58 36 mm (range, 0 136 mm). The average distance from the proximal pole of the patella to the superior reflection of the supra patellar pouch was 46.3 13.1 mm (range, 20 74 mm). Using the linear distance between the last crossing femoral nerve branch and the superior reflection of the pouch, the average safe zone measured 199 39.8 mm (range, 124 268 mm). The safe zone correlated with thigh length (r 0.48, P 0.03). All nerve branches terminated at their muscular origins without crossing lateral to a line from the anterior greater trochanter to the anterior aspect of the lateral femoral condyle. Conclusions: The safe zone for anterior external fixator half pin placement into the femur is on average 20 cm in length and can be as narrow as 12 cm. Anterior pins should begin 7.5 cm above the superior pole of the patella to avoid inadvertent knee joint penetration., Published in the Journal of Orthopaedic Trauma, v26 n11 p643-647, Nov 2012. Prepared in collaboration with the Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX, and the United States Army Trauma Training Center/Ryder Trauma Center, Miami, FL.

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., Journal of the American Academy of Orthopaedic Surgeons, August 2012 vol. 20 no. suppl S48-S53. The original document contains color images.

Orthopaedic disorders account for significant disability among adults in the United States. Previous studies have demonstrated long-term disability in military personnel with musculoskeletal conditions. However, these studies focused primarily on battle field injured service members and did not evaluate the entire population. The goal of this study was to determine and compare the disabling conditions of the entire United States Army during peacetime and war. We identified the conditions leading to separation from military service before and during Operation Iraqi Freedom and Operation Enduring Freedom. During war, more soldiers are found to be unfit for duty, and they have more conditions per individual that make them unfit. Orthopaedic conditions account for the greatest number of soldiers separated from military service at both time points studied (ie, January through March 2001, January through March 2009). Back pain and osteoarthritis are the two most common causes of separation from military service; these conditions are responsible for the most disability during peacetime and war., Pub. in Journal of the American Academy of Orthopaedic Surgeons, v20 n1, pS23-S30, 2012.

The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population., Published in the Journal of Surgical Orthopaedic Advances, v20 n1 p8-18, Spring 2011.

The ability to return to running and sports participation after lower extremity limb salvage has not been well documented previously. Although the ability to ambulate without pain or assistive devices is generally a criteria for a good limb salvage outcome, many patients at our institution have expressed a desire to return to a more athletic lifestyle to include running and sports participation. The purpose of this study was to investigate the types of athletic endeavors our high-energy lower extremity trauma patients were able to pursue after limb salvage. We retrospectively analyzed lower extremity limb salvage patients who were at least 12 weeks status after external fixation removal and participated in our limb salvage return-to-running clinical pathway. Patients were rehabilitated to their highest functional level through a sports medicine-based approach. A custom energy-storing ankle-foot orthosis was implemented to help augment plantarflexion strength in conjunction with running gait retraining. The first 10 patients to complete the clinical pathway were identified. All patients were treated at the same institution by the same orthopedic surgeon and physical therapist. Eight patients have returned to running, and 10 patients have returned to weight-lifting. Seven patients have returned to cycling, three have returned to golf, three to basketball, and two to softball. Two patients have completed a mini-triathlon. Aggressive rehabilitation, an energy-storing ankle-foot orthosis, and running gait retraining can restore an active recreational lifestyle to patients who have undergone lower extremity limb salvage., The Journal of TRAUMA, Injury, Infection, and Critical Care, v71, number 1, July Supplement 2011, Government or Federal Purpose Rights License. The original document contains color images.

Jeanne C Patzkowski1, Frank P Hurst1,2, Robert T Neff1,2, Kevin C Abbott1,21Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, Bethesda, MD, USA; 2Nephrology Service, Walter Reed Army Medical Center, Washington, DC, USAAbstract: Proper management of infected tunneled-cuffed catheters (TCC) is essential in order to avoid catastrophic consequences for the patient. Hematogenous dissemination of infection can result in serious secondary infections, including infective endocarditis, osteomyelitis, and epidural abscess. Pelvic osteomyelitis is an extremely rare condition in adults with no reported cases of infection localized to more than one pelvic bone at a time. We present a case of a hemodialysis patient who developed osteomyelitis of the entire right hemipelvis due to MRSA bacteremia after repeated attempts at TCC salvage.Keywords: pelvic osteomyelitis, indwelling catheter, staphylococcus aureus, catheter-related bacteremia

Jeanne C Patzkowski1, Frank P Hurst1,2, Robert T Neff1,2, Kevin C Abbott1,21Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, Bethesda, MD, USA; 2Nephrology Service, Walter Reed Army Medical Center, Washington, DC, USAAbstract: Proper management of infected tunneled-cuffed catheters (TCC) is essential in order to avoid catastrophic consequences for the patient. Hematogenous dissemination of infection can result in serious secondary infections, including infective endocarditis, osteomyelitis, and epidural abscess. Pelvic osteomyelitis is an extremely rare condition in adults with no reported cases of infection localized to more than one pelvic bone at a time. We present a case of a hemodialysis patient who developed osteomyelitis of the entire right hemipelvis due to MRSA bacteremia after repeated attempts at TCC salvage.Keywords: pelvic osteomyelitis, indwelling catheter, staphylococcus aureus, catheter-related bacteremia