Search

In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS).Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal.Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones.Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication.The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS.Elhessy AH, Rivera JC, Shu HT

Background Musculoskeletal conditions often affect patients' mobility and ability to participate in health behaviors such as exercise, potentially affecting their systemic health. The purpose of this research is to determine how frequently cardiac-related comorbidities present in a veteran population with musculoskeletal service-connected disability and how this affects musculoskeletal health care utilization. Methodology A retrospective cohort of Iraq and Afghanistan Veterans who received a Veterans Affairs (VA) disability determination for service-connected musculoskeletal disability were categorized according to the diagnosis of cardiac comorbidity including diabetes mellitus, hyperlipidemia, hypertension, and obesity, and atherosclerosis disease documented by ICD-9 codes in the VA administrative data. Among veterans with musculoskeletal service-connected disability, logistic regression was modeled to determine if musculoskeletal clinic utilization was associated with also having a cardiac comorbid condition. Results Veterans with musculoskeletal disability had a comorbid cardiac disorder 43% of the time. Post-traumatic arthritis was the only musculoskeletal condition positively associated with comorbid cardiac conditions. Veterans with comorbid cardiac diagnoses had 26-37% higher odds of receiving care by physical and occupational therapy, physical medicine, and orthopaedic surgery clinics compared to veterans without comorbid cardiac disease. Conclusions Veterans in this cohort with musculoskeletal service-connected disability, plus cardiac conditions had greater clinic use for musculoskeletal and rehabilitation services compared to those without cardiac conditions. These results have implications for the rehabilitation and other health service needs of a new generation of veterans.

Supplemental Digital Content is Available in the Text., Summary: The challenging problem of long bone infection and limb length difference cannot be addressed using only an antibiotic-coated nonmagnetic static nail. The combined use of resorbable calcium sulfate and magnetic lengthening nails offers a possible solution to this dilemma, as well as for infected nonunions that require compression. We present a combined technique to treat or prevent infection using femoral or tibial intramedullary antibiotic delivery with an absorbable calcium sulfate depot and concomitant internal lengthening or compression using a nail. Adequate débridement is required in cases of established infection and is a prerequisite for this technique.

In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.

The recent COVID-19 pandemic has brought attention to cytokines and the phenomenon of cytokine storm into mainstream discussions. In this disease specifically, a cytokine storm overwhelming immune response contributes to the pathophysiology and mortality of the COVID-19 infection. Analogous perturbed immune reactions are experienced in polytrauma patients, compromising local tissue healing while threatening multiple organ systems. The expanding field of osteoimmunology should contribute to the orthopaedic community's understanding of how the immune system response, whether normal or pathologic, affects the whole body outcome of our patients.

Limb lengthening has not been widely employed in the elderly population due to concerns that outcomes will be inferior. The purpose of this multicenter, retrospective case-control series was to report the bone healing outcomes and complications of lower limb lengthening in older patients (≥60 years) using magnetic intramedullary lengthening nail (MILN). Our hypothesis was that healing parameters including consolidation days, the consolidation index, maturation days, and the maturation index, as well as the number of adverse events reported in the older population, would be no different to those of the general adult population. We retrospectively reviewed charts and radiographs from patients ≥60 years of age with limb-length discrepancies who underwent femoral or tibial lengthening using a MILN. Parameters were compared among the age categories “≤19 years,” “20–39 years,” “40–59 years,” or “≥60 years” and propensity-matched cohorts for the age groups 20–59 years and ≥60 years. Complications were reported as percentages for each age category. In the study period, 354 MILN were placed in 257 patients. Sixteen nails were placed in patients 60 years of age or older (mean 65 ± 5 years; range 60–72 years). Comparisons of healing parameters showed no difference between those aged 60+ and the younger cohort. Complication percentages were not statistically significant (p = 0.816). Limb lengthening with MILN may therefore be considered a safe and feasible option for a generally healthy elderly population.

Introduction Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. Methods and analysis PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. Ethics and dissemination The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. Trial registration number NCT02984384.

Background: Previous simulation studies evaluated either dry lab (DL) or virtual reality (VR) simulation, correlating simulator training with the performance of arthroscopic tasks. However, these studies did not compare simulation training with specific surgical procedures. Purpose/Hypothesis: To determine the effectiveness of a shoulder arthroscopy simulator program in improving performance during arthroscopic anterior labral repair. It was hypothesized that both DL and VR simulation methods would improve procedure performance; however, VR simulation would be more effective based on the validated Arthroscopic Surgery Skill Evaluation Tool (ASSET) Global Rating Scale. Study Design: Controlled laboratory study. Methods: Enrolled in the study were 38 orthopaedic residents at a single institution, postgraduate years (PGYs) 1 to 5. Each resident completed a pretest shoulder stabilization procedure on a cadaveric model and was then randomized into 1 of 2 groups: VR or DL simulation. Participants then underwent a 4-week arthroscopy simulation program and completed a posttest. Sports medicine–trained orthopaedic surgeons graded the participants on completeness of the surgical repair at the time of the procedure, and a single, blinded orthopaedic surgeon, using the ASSET Global Rating Scale, graded participants’ arthroscopy skills. The procedure step and ASSET grades were compared between simulator groups and between PGYs using paired t tests. Results: There was no significant difference between the groups in pretest performance in either the procedural steps or ASSET scores. Overall procedural step scores improved after combining both types of simulator training ( P = .0424) but not in the individual simulation groups. The ASSET scores improved across both DL ( P = .0045) and VR ( P = .0003), with no significant difference between the groups. Conclusion: A 4-week simulation program can improve arthroscopic skills and performance during a specific surgical procedure. This study provides additional evidence regarding the benefits of simulator training in orthopaedic surgery for both novice and experienced arthroscopic surgeons. There was no statistically significant difference between the VR and DL models, which disproved the authors’ hypothesis that the VR simulator would be the more effective simulation tool. Clinical Relevance: There may be a role for simulator training in the teaching of arthroscopic skills and learning of specific surgical procedures.

Introduction Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense’s Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. Materials and Methods MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. Results This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. Conclusions MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency’s Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Heterotopic ossification (HO) is derived from the Greek terms “heteros” (“other”), topos (“place”), and “ossification,” a Latin‐derived term for “to turn to bone.” HO references lamellar bone ossifying in aberrant locations, such as in joints and muscle. It has been cited through medical history, dating to 1,000 C.E. when Al‐Zahrawi described a complication of fracture as a “callus often occurs after the healing of a fracture…and sometimes there is limitation of the natural function of the limb…”.1 Outside of rare genetic forms of HO, any state that causes local soft tissue damage, such as high‐energy trauma injuries and surgical approaches, can cause HO.2 Because of its correlation with trauma, HO is among the postinjury and iatrogenic complications that can cause pain and impact a patient's recovery and rehabilitation efforts.3

Post-traumatic arthritis (PTA) is characterized by the deterioration of articular cartilage temporally associated with an articular injury. With a paucity of literature comparing joint preservation techniques, we performed a systematic review of the literature intending to describe and summarize the results of ankle distraction arthroplasty as it compares with studies on tibio-talar microfracture, allograft, and autograft for ankle joint preservation in the post-traumatic population under 50 years of age. Research databases were searched and abstracts screened for relevance on our topic of interest. Abstracts meeting screening criteria with high interobserver reliability underwent full-manuscript review and coding for pertinent citation, study level, treatment, and outcome variables. Outcome variables for patient-reported pain scales, validated outcome measurement tools, radiographic progression, reoperation/re-treatment rates, and complication rates were recorded. Out of 105 unique citations, 10 publications were included. The distraction arthroplasty studies had 36 out of 181 patients requiring reoperation for complications (19.9%), while other joint-preserving procedures studies had 40 out of 177 patients requiring reoperations for complications (22.6%). Clinical outcome scores at mean follow-up time ranging from 2 to 10 years between studies were similar. Reported results for a variety of cartilage preservation procedures, including distraction arthroplasty, are satisfactory and reoperation rates for complication are similar. Limitations in available data and underlying study quality affect synthesis of the results therein. While distraction arthroplasty is an option for cartilage preservation in patients with PTA of the ankle, the technique is highly specialized which may affect the external validity. Level of evidence: III.

Volumetric muscle loss (VML) injuries present chronic loss of muscle fibers followed by expansive fibrotic tissue deposition. Regenerative medicine therapies are under development to promote regeneration. However, mitigation of the expansive fibrous tissue is required for integration with the remaining muscle. Using a porcine VML model, delayed debridement of injury fibrosis was performed 3 months post‐VML and observed for an additional 4 weeks. A second group underwent the initial VML and was observed for 4 weeks, allowing comparison of initial fibrosis formation and debrided groups. The following salient observations were made: (i) debridement neither exacerbated nor ameliorated strength deficits; (ii) debridement results in recurrent fibrotic tissue deposition of a similar magnitude and composition as acute VML injury; and (iii) similarly upregulated transcriptional fibrotic and transcriptional pathways persist 4 weeks after initial VML or delayed debridement. This highlights the need for future studies to investigate adjunctive antifibrotic treatments for the fibrosed musculature.

Volumetric muscle loss (VML) resulting from extremity trauma presents chronic and persistent functional deficits which ultimately manifest disability. Acellular biological scaffolds, or decellularized extracellular matrices (ECMs), embody an ideal treatment platform due to their current clinical use for soft tissue repair, off-the-shelf availability, and zero autogenous donor tissue burden. ECMs have been reported to promote functional skeletal muscle tissue remodeling in small and large animal models of VML injury, and this conclusion was reached in a recent clinical trial that enrolled 13 patients. However, numerous other pre-clinical reports have not observed ECM-mediated skeletal muscle regeneration. The current study was designed to reconcile these discrepancies. The capacity of ECMs to orchestrate functional muscle tissue remodeling was interrogated in a porcine VML injury model using unbiased assessments of muscle tissue regeneration and functional recovery. Here, we show that VML injury incites an overwhelming inflammatory and fibrotic response that leads to expansive fibrous tissue deposition and chronic functional deficits, which ECM repair does not augment.

Veteran populations are known to have frequencies of arthritis higher than civilian populations. The aim of this study is to define the prevalence of arthritis among a cohort of veterans from ongoing U.S. military operations. A retrospective cohort study using Veterans Administration data sources for service connected disability, comorbidities, clinic utilization, and pharmacy utilization was conducted including veterans who deployed in service to operations in Afghanistan or Iraq, comparing veterans with a diagnosis of arthritis, arthritis plus back pain, and veterans with no pain diagnoses. The frequency of arthritis was 11.8%. Veterans with arthritis and arthritis plus back pain had greater frequencies of diabetes, hyperlipidemia, hypertension, and obesity compare to veterans with no pain diagnosis. Veterans with arthritis plus back pain had the highest pain clinic utilization and prescription use of opioids and anti-inflammatories. Veterans with no pain diagnosis had higher frequencies of diagnosis and clinic utilization for mental health disorders. Arthritis is prevalent among the latest generation of combat veterans and is associated with diabetes, obesity, and cardiovascular comorbidities. The need for arthritis care and associated comorbidities is expected to increase as the Veterans Administration and the civilian health care sector assumes care of these veterans. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:682-687, 2017.

Military literature has demonstrated the utility and safety of tourniquets in preventing mortality for some time, paving the way for increased use of tourniquets in civilian settings, including perioperatively to provide a bloodless surgical field. However, tourniquet use is not without risk and the subsequent effects of tissue ischemia can impede downstream rehabilitative efforts to regenerate and salvage nerve, muscle, tissue and bone in the limb. Limb ischemia studies in both the mouse and pig models have indicated not only that there is residual flow past the tourniquet by means of microcirculation, but also that recovery from tissue ischemia is dependent upon this microcirculation. Here we expand upon these previous studies using portable Near-Infrared Imaging to quantify residual plasma flow distal to the tourniquet in mice, pigs, and humans and leverage this flow to show that plasma can be supersaturated with oxygen to reduce intracellular hypoxia and promote tissue salvage following tourniquet placement. Our findings provide a mechanism of delivery for the application of oxygen, tissue preservation solutions, and anti-microbial agents prior to tourniquet release to improve postoperative recovery. In the current environment of increased tourniquet use, techniques which promote distal tissue preservation and limb salvage rates are crucial.

Importance The risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair. Objective To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. Design, Setting, and Participants The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidone-iodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. Discussion The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. Trial Registration ClinicalTrials.gov Identifiers:NCT03385304andNCT03523962

Background Volumetric muscle loss (VML) following extremity orthopaedic trauma or surgery results in chronic functional deficits and disability. A current translational approach to address the devastating functional limitations due to VML injury is the use of an autologous minced muscle graft (~1 mm3 pieces of muscle tissue) replacement into the injured defect area, although limitations related to donor site morbidity are still unaddressed. This study was designed to explore adjunct pharmacological immunomodulation to enhance graft efficacy and promote muscle function following VML injury, and thereby reduce the amount of donor tissue required. Findings Using a validated VML porcine injury model in which 20% of the muscle volume was surgically removed, this study examined muscle function over 3 months post-VML injury. In vivo isometric torque of the peroneus teritus (PT) muscle was not different before surgery among sham, non-repaired, non-repaired with tacrolimus, graft-repaired, and graft-repaired with tacrolimus VML groups. Bi-weekly torque analysis of the VML injured musculature presented a significant strength deficit of ~26% compared to pre-injury in the non-repaired, non-repaired with tacrolimus, and graft-repaired groups. Comparatively, the strength deficit in the graft-repair with systemic tacrolimus was marginally improved (~19%; p = 0.056). Both of the minced graft repaired groups presented a greater proportion of muscle tissue in full-thickness histology specimen. Conclusions We demonstrate that adjunctive use of tacrolimus with an ~50% minced muscle graft replacement resulted in modest improvements in muscle function 3 months after injury and repair, but the magnitude of improvement is not expected to elicit clinically meaningful functional improvements.

Diagnosis of lower limb pain in an athlete can be a challenging task due to the variety of potential etiologies and ambiguity of presenting symptoms. Five of the most commonly encountered causes of limb pain in athletes are chronic exertional compartment syndrome (CECS), medial tibial stress syndrome (MTSS), tibial stress fractures, soleal sling syndrome, and popliteal artery entrapment syndrome (PAES). Of these, the least frequent but potentially most serious of the pathologies is PAES. With an incidence of less than 1% seen in living subject studies, the condition is rare. However, a missed diagnosis will likely lead to progression of the disease and potential for unnecessary invasive procedures (McAree et al. 2008). In this paper, we present a young athlete misdiagnosed and treated for chronic exertional compartment syndrome. In both descriptive and a quick-reference table format, we review current literature and discuss how best to distinguish functional PAES from other causes of activity-related leg pain.

The number of female veterans has increased four-fold over the past 20 years, yet the study of specific care for female veterans is lacking. Given our military's growing number of female veterans, this article aims to review historical and recent knowledge as well as define research priorities for treatment of the unique physical and mental health issues experienced by women who have served in Operations Enduring Freedom and Iraqi Freedom.A literature review was performed of publications spanning the Vietnam War, Persian Gulf War, and Operation Iraqi Freedom and Operation Enduring Freedom periods to determine what health issues persist among female veterans.Female veterans historically report more reproductive and gynecological problems than the general population. They also potentially experience higher incidences of post-traumatic stress disorder and depression compared to male veterans, and overall exhibit a higher prevalence of several mental health disorders compared to the general population.The study of military trauma outcomes and treatments for female veterans as a distinct population continues to be lacking despite evidence that female veterans experience substantial disability from gynecological and mental health issues. Policy guiding attention to female veterans' health issues is needed.

Oral nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed for heterotopic ossification prophylaxis following at-risk injuries and procedures. We hypothesized that NSAIDs may be delivered locally in a wound for heterotopic ossification prophylaxis. In in vitro work, we cultured osteoblasts with three commercially available NSAIDs and then measured cell viability and DNA content. Indomethacin caused a 50% decrease in DNA at the lowest dose (0.0001 mM) and the most potent decrease in cell viability (

Fractures continue to account for a large proportion of combat-related injuries. The basic tenets of irrigation, debridement, soft tissue care, and vigilant monitoring/fasciotomy for acute compartment syndrome persist. Closed management of fractures with splinting or casting is acceptable. If time and facility allow, external fixation of fractures offer many advantages over closed treatment but require knowledge, experience and skill in the safe placement of pins. The care of host nationals presents unique challenges and deployed surgeons must be flexible and resourceful in these situations.

Aberrations in sexual health within the military culture is documented even in uninjured service members. The military culture emphasizes fitness, endurance, performance, and resilience. These masculine “values” likely reflect the male predominance in the military but also overlap with an emphasis on an ideal, vigorous, capable body [3], placing a service member with any perceived body image deficiency at risk of sexual dysfunction. A recent survey of male military personnel without bodily injury found erectile dysfunction rates as high as 33% [4].

Oral nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed for heterotopic ossification prophylaxis following at‐risk injuries and procedures. We hypothesized that NSAIDs may be delivered locally in a wound for heterotopic ossification prophylaxis. In in vitro work, we cultured osteoblasts with three commercially available NSAIDs and then measured cell viability and DNA content. Indomethacin caused a 50% decrease in DNA at the lowest dose (0.0001 mM) and the most potent decrease in cell viability (

The aim of our study was to determine military-specific outcomes for transtibial amputations of US Service members using either the traditional technique (Burgess) or the Ertl technique. All US Service members sustaining transtibial, combat-related amputation from September 2001 through July 2011 were reviewed. Amputation type, mechanism of injury, time interval to amputation, age, sex, branch of service, rank, force, nature, and injury severity score were recorded. Outcomes were determined by analyzing military-specific medical review results, to include the following: Physical Evaluation Board Liaison Office (PEBLO) rating (0–100), PEBLO outcome (permanent retirement, temporary disability retirement, separation without benefits, continuation of active duty, or fit for redeployment), and the rate of redeployment. Amputation type (Ertl vs. Burgess) was determined by reviewing postoperative radiographs and radiology reports. Data from all of the above categories were compared for both Ertl and Burgess amputees. Of 512 subjects identified, 478 had radiographs or radiology reports distinguishing between Ertl or Burgess transtibial amputation. A total of 406 subjects underwent the Burgess procedure, and 72 subjects underwent the Ertl procedure. There was not a significant difference between the two groups in review board rating (p = 0.858), review board outcome (p = 0.102), or ability to deploy (p = 0.106); however, subjects that underwent the Ertl procedure remained on active duty at a significantly higher rate (p = 0.021). There is a higher rate of remaining on active duty using the Ertl technique. This study suggests that there is an improvement in functional outcome with the Ertl technique. Electronic supplementary material The online version of this article (doi:10.1007/s11751-015-0240-4) contains supplementary material, which is available to authorized users.

Background Civilian trauma literature suggests sexual dimorphism in outcomes after trauma. Because women represent an increasing demographic among veterans, the question remains if war trauma outcomes, like civilian trauma outcomes, differ between genders.

Extremity injuries comprise the majority of battlefield injuries and contribute the most to long-term disability of servicemembers. The purpose of this study was to better define the contribution of muscle deficits and volumetric muscle loss (VML) to the designation of long-term disability in order to better understand their effect on outcomes for limb-salvage patients. Medically retired servicemembers who sustained a combat-related type III open tibia fracture (Orthopedic cohort) were reviewed for results of their medical evaluation leading to discharge from military service. A cohort of battlefield-injured servicemembers (including those with nonorthopedic injuries) who were medically retired because of various injuries (General cohort) was also examined. Muscle conditions accounted for 65% of the disability of patients in the Orthopedic cohort. Among the General cohort, 92% of the muscle conditions were identified as VML. VML is a condition that contributes significantly to long-term disability, and the development of therapies addressing VML has the potential to fill a significant void in orthopedic care.

The capacity of servicemembers with amputation to return to duty after combat-related amputation and the associated disabilities remains largely unknown. The purpose of this study was to examine the disabling conditions and return to duty rates of servicemembers with amputation across all service branches following major limb amputations from September 2001 through July 2011. Pertinent medical information, military occupation status, return to duty designation, disabling conditions, and disability ratings for each servicemember were obtained from the Physical Evaluation Board Liaison Office (PEBLO). Across all service branches, 16 (2%) servicemembers were found fit for duty (Fit) and allowed to continue with their preinjury occupation. Another 103 (11%) were allowed to continue on Active Duty (COAD) in a less physically demanding role. More than half (554, 56%) were determined fully disabled (PEBLO rating75); the average disability rating was 73. COAD and Fit Army servicemembers had lower Injury Severity Scores than other servicemembers (17.4, p = 0.009 and 11.2, p0.001, respectively). Despite improvements in their care and rehabilitation, only 13% of all servicemembers with amputation are able to return to Active Duty and many have multiple disabling conditions that contribute to a very high level of disability.

Bone morphogenetic proteins (BMPs) other than the clinically available BMP-2 and BMP-7 may be useful for improving fracture healing through both increasing osteogenesis and creating a favorable healing environment by altering cytokine release by endogenous cells. Given the spectrum of potential applications for BMPs, the objective of this study was to evaluate various BMPs under a variety of conditions to provide further insight into their therapeutic capabilities. The alkaline phosphatase activity (ALP) of both C2C12 and human adipose-derived stem cells (hASCs) was measured after exposure of increasing doses of recombinant human BMP-2, -4, -5, -6, -7, or -9 for 3 and 7 days. BMPs -2, -4, -5, -6, -7, and -9 were compared in terms of their ability to affect the release of stromal derived factor-1 (SDF-1), vascular endothelial growth factor (VEGF), and basic fibroblast growth factor (b-FGF) from human bone marrow stromal cells (hBMSCs). Gene expression of ALP, osteocalcin, SDF-1, VEGF, and b-FGF following shRNA-mediated knockdown of BMP-2 and BMP-6 in hBMSCs or human osteoblasts under osteogenic differentiation conditions was also evaluated. Collectively, BMPs-6 and -9 produced the greatest osteogenic differentiation of C2C12 and hASCs as determined by ALP. The hBMSC secretion of SDF-1 was most affected by BMP-5, VEGF by BMP-4, and b-FGF by BMP-2. The knockdown of BMP-2 in BMSCs had no effect on any of the genes measured whereas BMP-6 knockdown in hBMSCs caused a significant increase in VEGF gene expression. BMP-2 and BMP-6 knockdown in human osteoblasts caused significant increases in VEGF gene expression and trends towards decreases in osteocalcin expression. These findings support efforts to study other BMPs as potential bone graft supplements, and to consider combined BMP delivery for promotion of multiple aspects of fracture healing.

The Army Physical Evaluation Board results for wounded warriors from a previously described cohort were reviewed to identify permanently disabling conditions and whether the conditions were preexisting or caused by battlefield injury. Arthritis was the most common unfitting condition in this cohort, with 94.4% of cases attributed to combat injury and only 5.6% attributed to preexisting conditions or documented in the health records prior to battle injury. The most common causes of injury that resulted in arthritis were intra-articular fractures secondary to explosions, traumatic arthrotomies resulting from fragment projectiles, and gunshot wounds. Arthritis was recognized as a disabling condition an average of 19 ± 10 months after injury. Research is needed to enhance prevention and management of joint injuries in order to minimize the disabling effects of joint degeneration in this young patient population.