Reoperations following combat-related upper-extremity amputations.

BACKGROUND: Amputation revision rates following major upper-extremity amputations have not been previously reported in a large cohort of patients. We hypothesized that the revision rates following major upper-extremity amputation were higher than the existing literature would suggest, and that surgical treatment of complications and persistent symptoms would lead to improved outcomes. METHODS: We performed a retrospective analysis of a consecutive series of ninety-six combat-wounded personnel who had sustained a total of 100 major upper-extremity amputations in Operation Iraqi Freedom and Operation Enduring Freedom. Prerevision and postrevision outcome measures, including prosthesis use and type, the presence of phantom and residual limb pain, pain medication use, and return to active military duty, were identified for all patients. RESULTS: All amputations resulted from high-energy trauma, with 87% occurring secondary to a blast injury. Forty-two residual limbs (42%) underwent a total of 103 repeat surgical interventions. As compared with patients with all other levels of amputation, those with a transradial amputation were 4.7 (95% confidence interval [CI]: 1.75 to 12.46) times more likely to have phantom limb pain and 2.8 (95% CI: 1.04 to 7.39) times more likely to require neuropathic pain medications. In the group of patients who underwent revision surgery, regular prosthesis use increased from 19% before the revision to 87% after it (p < 0.0001). CONCLUSIONS: In our cohort, revision amputation to address surgical complications and persistently symptomatic residual limbs improved the patient's overall acceptance of the prosthesis and led to outcomes equivalent to those following amputations that did not require revision.

Traumatic and trauma-related amputations: Part II: Upper extremity and future directions.

Trauma is the most common reason for amputation of the upper extremity. The morphologic and functional distinctions between the upper and lower extremities render the surgical techniques and decision-making different in many key respects. Acceptance of the prosthesis and the outcomes are improved by performing a transradial rather than a more proximal amputation. Substantial efforts, including free tissue transfers when necessary, should be made to salvage the elbow. Careful management of the peripheral nerves is critical to minimize painful neuroma formation while preserving options for possible future utilization in targeted muscle reinnervation and use of a myoelectric prosthesis. Rapid developments with targeted muscle reinnervation, myoelectric prostheses, and composite tissue allotransplantation may dramatically alter surgical treatment algorithms in the near future for patients with severe upper-extremity trauma.

Radiographic evaluation of the modified Brunelli technique versus the Blatt capsulodesis for scapholunate dissociation in a cadaver model.

PURPOSE: A variety of soft tissue surgical procedures have been developed for treatment of scapholunate (SL) dissociation. The purpose of this study was to compare the degree of correction obtained (as measured on preoperative and postoperative radiographs) when performing the modified Brunelli technique (MBT) with that of the more commonly performed Blatt capsulodesis (BC) and to evaluate each technique after simulated wrist motion. METHODS: Five cadaver wrists were used for this study. The SL interval, SL angle, and radiolunate angle were recorded radiographically, with the SL ligament intact, for each wrist in several loaded positions: neutral, flexion, extension, radial deviation, ulnar deviation, and clenched fist. The SL interosseous ligament was then completely incised, and the radiographic measurements were repeated to demonstrate SL instability. The radiographic measurements were then repeated after MBT reconstruction and after BC reconstruction. Additional radiographic measurements were taken after simulated wrist motion. RESULTS: Sectioning of the SL ligament resulted in radiographic evidence of SL dissociation. Use of the MBT demonstrated improved correction of the SL interval and the SL angle in the clenched fist position, which was statistically significant when compared with BC. The correction for the SL angle was maintained on the MBT specimens with simulated wrist motion. CONCLUSIONS: The results demonstrate that in this cadaver model, the MBT better restores the normal carpal relationship of the SL interval and SL angle when compared to the BC, as measured on radiographs. This correction might correlate with improved carpal dynamics and improved clinical outcomes.

Damage control orthopaedics: an in-theater perspective.

Damage control orthopaedics is well described for civilian trauma. However, significant differences exist for combat-related extremity trauma. Military combat casualty care is defined by levels of care. Each level of care has a specific role in the care of the wounded patient. Because of lack of equipment, austere environments, and significant soft tissue wounds, most combat fractures are stabilized with external fixation even in a stable patient, unlike civilian trauma. External fixation allows for rapid stabilization of fractures and easy access to wounds and requires little shelf stock of implants. Unique situations exist in the care of the combat-injured casualty, which include working in an isolated facility, caring for enemy combatants, large soft tissue wounds, and the need to rapidly transport patients out of the theater of operations.

Soft tissue management of war wounds to the foot and ankle.

This article details the experiences of United States military reconstructive surgeons in the soft tissue management of war wounds of the foot and ankle resulting from the conflicts in Iraq and Afghanistan. War wounds from this conflict are commonly caused by blast and fragmentation, and are characteristically extensive, heterogeneous, and severe. Multiple serial débridement episodes are routinely necessary because of deterioration of the wounds over time, which is in contrast to civilian trauma wherein fewer débridement episodes are generally required. Wound therapy adjuncts, such as subatmospheric wound dressing and synthetic dermal replacement, have been used extensively with favorable results. Pedicled flaps, such as the distally based sural neurofasciocutaneous flap, are reliable, and avoid the risks and technical demands associated with microsurgery. Free tissue transfer, such as the anterolateral thigh flap, the latissimus dorsi muscle flap, and the rectus abdominis muscle flap, are powerful reconstructive tools, and have been extensively used in the reconstruction of war wounds of the foot and ankle.

Orthopaedic war injuries: recent developments in treatment and research.

Musculoskeletal injury is the most common type of injury among survivors of combat trauma, and combat-related trauma is challenging for an orthopaedic surgeon to treat. Methods of treatment are evolving, but significant gaps remain as knowledge of civilian trauma is extrapolated to combat trauma.

Carpal canal pressure of the distracted wrist.

PURPOSE: This study was conducted to study the effect of distraction across the wrist joint on carpal canal pressure. METHODS: Ten cadaver specimens were mounted vertically in neutral forearm rotation by 2 half pins that transfixed the radius and ulna. The wrist joint was distracted by suspending weights from the middle finger. A balloon-tipped catheter, percutaneously introduced into the carpal canal and connected to a transducer, was used to measure carpal canal pressure. The carpal canal pressure was measured at 0 to 4.54 kg of distraction in 0.45-kg increments and at 6.81 kg and 9.08 kg of distraction. Three wrist positions were tested: neutral, 30 degrees of flexion, and 30 degrees of extension. RESULTS: Highly linear direct relationships between wrist distraction force and carpal canal pressure over baseline were observed in all positions of the wrist. Statistically significant increases in carpal canal pressure over baseline were observed at a wrist distraction force of 2.27 kg or more with the wrist in neutral position, at 1.82 kg or more with the wrist in 30 degrees of extension, and at 4.09 kg or more with the wrist in 30 degrees of flexion. At each level of wrist distraction force of 3.63 kg or less the carpal canal pressure of the extended wrist was significantly higher than that of the wrist in neutral position. At each level of wrist distraction force 4.54 kg or less the carpal canal pressure of the extended wrist was significantly higher than that of the flexed wrist. No statistically significant differences were observed at any level of wrist distraction force between carpal canal pressures in the neutral and flexed positions of the wrist. CONCLUSIONS: Distraction across the wrist joint causes a statistically significant highly linear increase in carpal canal pressure. The position of the distracted wrist also has a considerable effect on carpal canal pressure, with the extended position associated with the largest increases in carpal canal pressure and the flexed position with the smallest increases in carpal canal pressure.

Patient positioning for shoulder arthroscopy based on variability in lateral acromion morphology.

The purpose of this article is to highlight the variability among shoulders in the relationship between the lateral acromion and the humeral head and to describe how this variability may influence a surgeon's choice of patient positioning for shoulder arthroscopy. In cases of increased lateral coverage of the humeral head by the acromion, arthroscopic access to the superior aspect of the glenoid through lateral portals becomes increasingly difficult because of a narrowed corridor of approach. Placing the ipsilateral arm in traction will lower the station of the humeral head and widen the arthroscopic corridor of approach to the superior labrum. Based on preoperative assessment of lateral acromion morphology, if the surgeon determines that inferior displacement of the humeral head of 25% or more of the humeral head diameter will be necessary to achieve adequate arthroscopic accessibility of the superior glenoid through lateral portals, we recommend the lateral decubitus position with continuous traction on the ipsilateral arm over the beach-chair position.

Coxa saltans externa treated with Z-plasty of the iliotibial tract in a military population.

Coxa saltans, or snapping hip, can be attributable to a number of causes. Coxa saltans externa typically occurs when the thickened portion of the iliotibial band snaps over the greater trochanter as the hip is flexed. This condition generally resolves with a course of nonoperative treatment. We have treated three patients with Z-plasty of the iliotibial band, which has the highest published success rate in the English language literature. Only one of three patients was able to return to full activities postoperatively. In our small series, this method of surgical treatment in an active duty military population yielded less than optimal results.