Return to duty after type III open tibia fracture.

INTRODUCTION: Despite the high incidence of battlefield orthopaedic injuries, long-term outcomes and return to duty (RTD) status have rarely been studied. Our purpose was to determine the RTD rate for soldiers who sustained Type III open tibia fractures in active combat. METHODS: One hundred fifteen soldiers who sustained battle-related Type III open tibia fractures were retrospectively reviewed. The Army Physical Evaluation Board database was reviewed to determine which soldiers were able to RTD and the disability ratings of those not able to RTD. RESULTS: The overall RTD rate was 18%, isolated open fractures had a RTD rate of 22%, salvaged extremities had a RTD rate of 20.5%, and amputees had a RTD rate of 12.5%. Older age and higher rank were both significant factors in increasing the likelihood of RTD and amputees had significantly higher disability ratings than those with salvaged extremities. CONCLUSION: Despite the severe nature of combat extremity wounds, 20% of patients with salvaged Type III open tibia fractures and 22% with isolated injuries were able to return to active duty. These rates are similar to those reported for civilian amputees. Amputees in our cohort were less likely to RTD.

Effect of various concentrations of antibiotics on osteogenic cell viability and activity.

Infection is a common complication of open fractures. Systemic antibiotics often cause adverse events before eradication of infected bone occurs. The local delivery of antibiotics and the use of implants that deliver both growth factors and antimicrobials are ways to circumvent systemic toxicity while decreasing infection and to reach extremely high levels required to treat bacterial biofilms. When choosing an antibiotic for a local delivery system, one should consider the effect that the antibiotic has on cell viability and osteogenic activity. To address this concern, osteoblasts were treated with 21 different antibiotics over 8 concentrations from 0 to 5000 µg/ml. Osteoblast deoxyribonucleic acid content and alkaline phosphatase activity (ALP) were measured to determine cell number and osteogenic activity, respectively. Antibiotics that caused the greatest decrement include rifampin, minocycline, doxycycline, nafcillin, penicillin, ciprofloxacin, colistin methanesulfonate, and gentamicin; their cell number and ALP were significantly less than control at drug concentrations ≤ 200 µg/ml. Conversely, amikacin, tobramycin, and vancomycin were the least cytotoxic and did not appreciably affect cell number and ALP until very high concentrations were used. This comprehensive evaluation of numerous antibiotics' effects on osteoblast viability and activity will enable clinicians and researchers to choose the optimal antibiotic for treatment of infection and maintenance of healthy host bone.

Data-driven disaster management requires data: implementation of a military orthopaedic trauma registry.

The Military Orthopaedic Trauma Registry (MOTR) is a comprehensive joint service registry of military orthopaedic injuries. Conceived in 2006, MOTR is now operational for retrospective data entry and prospective data collection of extremity injuries sustained by U.S. service members serving in current Overseas Contingency Operations. Running in tandem with data from the United States Army Institute of Surgical Research's Joint Theater Trauma Registry (JTTR), MOTR augments the casualty data included in JTTR with additional orthopaedic specific data (i.e., the injury patterns, characteristics, treatment, and complications associated with extremity war injuries). Extremity war injuries are the major clinical burden of the current conflicts. However, the scope of the injuries in detail useful to the orthopaedic researcher has never been prospectively collected. MOTR is designed to fill that gap in extremity trauma research. As such, MOTR represents an evolutionary step in the refinement of data-driven disaster management.

Mortality in female war veterans of operations enduring freedom and Iraqi freedom.

BACKGROUND: Combat-wounded service members are surviving battle injuries more than ever. Given different combat roles held by men and women, female service members should survive wounds at an unprecedented rate. QUESTIONS/PURPOSES: We determined whether the casualty rates for females differ from their male counterparts and characterized wounds sustained by female casualties. METHODS: We calculated the percentage of the 5141 deaths among the 40,531 casualties by gender for those serving in Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) from Defense Manpower Statistics between 2001 and 2009. We searched the Joint Theatre Trauma Registry for female casualties and described their injury characteristics. No matched cohort of male casualties was searched. RESULTS: Female veterans comprised 1.9% of all casualties and 2.4% of all deaths. In OIF, the percent death for women was 14.5% (103 deaths) versus 12.0% (4226 deaths) for men. In OEF, the percent death for women was 35.9% (19 deaths) versus 17.0% (793 deaths) for men. Battle-injured females had a greater proportion of facial and external injuries and more severe extremity injuries compared with those nonbattle-injured. CONCLUSIONS: The casualty death rate appears higher for women than men although the mechanisms of fatal injuries are not known and may not be comparable. Although facial, external, and extremity injuries were common among battle-injured females, no conclusion can be made as to whether male casualties sustain similar wounding patterns. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Comparison of dorsal and volar approaches to the proximal radius.

Proximal radius exposure may be acquired by either the dorsal or volar approach depending on surgical requirements. The dorsal approach is traditionally recommended for fracture fixation of the proximal radius because of theoretically improved exposure and because the dorsal aspect of the bone is the tensile surface. The posterior interosseous nerve can be visualized and protected using this approach. The volar approach is preferred for biceps repair and boasts a distal extensile approach with adequate soft tissue coverage. Impingement on the bicipital tuberosity and biceps tendon, in addition to positioning on the compression side of the bone, makes the anterior or anterolateral position for plate placement less desirable. The goal of this study was to quantify and compare in a cadaver model the area of bone exposed using both approaches. We hypothesized that equivalent exposures can be obtained and the posterior interosseous nerve can be identified with either the Thompson or Henry approach. Standard dorsal and volar approaches were performed on 10 fresh-frozen adult cadaveric upper-limb specimens. Cross-sectional area of exposure was quantified from digital photographs using software. The 2 approaches did not result in a significant difference in area exposed. Depending on case requirements, either the dorsal or volar approach will provide adequate exposure to the proximal radius.

Battlefield orthopaedic injuries cause the majority of long-term disabilities.

Extremity injuries make up 54% of combat wounds sustained in Operation Iraqi Freedom and Operation Enduring Freedom. In a cohort of war-wounded service members, we identified the conditions secondary to battle injury that result in disqualification from continued service. The Army Physical Evaluation Board records of 464 wounded service members who were injured between October 2001 and January 2005 were reviewed to determine the codes indicating unfitting conditions. Sixty-nine percent of these conditions were orthopaedic. Fifty-seven percent of the injured had unfitting conditions that were orthopaedic only. Of those evacuated from theater with a primary diagnosis of injury to the head, thorax, or abdomen and who suffered an orthopaedic injury as well, 76% had an orthopaedic diagnosis as the primary unfitting condition. Orthopaedic-related disability has a significant impact on the affected patient, the health care system, and, in the case of wounded service members, on military strength and readiness.

Fracture risk in men with congestive heart failure risk reduction with spironolactone.

OBJECTIVES: The purpose of this study was to determine whether spironolactone use is associated with fractures in men with congestive heart failure (CHF). BACKGROUND: In rats with aldosteronism, spironolactone preserves skeletal strength. However, in humans, the relationship of spironolactone to fractures is not known. METHODS: The medical records of all male patients with CHF from 1999 to 2005 treated at the Veterans Affairs Medical Center, Memphis, Tennessee, were reviewed (n = 4,735). Odds ratios with 95% confidence intervals of having a fracture associated with spironolactone use were estimated using conditional logistic regression. RESULTS: We identified 167 cases with a single-incident fracture and matched these by age and race to 668 control subjects without fractures. After adjustment for covariates, spironolactone use was inversely associated with total fracture (odds ratio: 0.575; 95% confidence interval: 0.346 to 0.955, p = 0.0324). CONCLUSIONS: The use of spironolactone is inversely associated with fractures in men with CHF.