Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review.

Background Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence This is a Level IC, therapeutic interventional study.

Predictors of Persistent Pain After Fixation of Distal Clavicle Fractures in an Active Military Population.

Patients who undergo open reduction and internal fixation of distal clavicle fractures have a high rate of hardware removal and persistence of symptoms, particularly when attempting to return to high-demand activities. This study evaluated the outcomes of military servicemembers after surgical treatment of distal clavicle fractures. The authors performed a retrospective analysis of active duty servicemembers who underwent open reduction and internal fixation of Neer type II distal clavicle fractures between October 17, 2007, and July 20, 2012, with a minimum of 2-year clinical follow-up. The electronic health record was queried to extract demographic features and clinical outcomes, primarily persistence of pain, removal of hardware, and postoperative return to high-level activity. A total of 48 patients were identified, with mean follow-up of 3.8 years. A total of 44% of patients underwent subsequent hardware removal. All fractures achieved radiographic union, and 35% of patients had persistence of symptoms. Patients who were treated with hook plating had a 3.64-fold higher risk of persistence of pain compared with those treated with conventional plating techniques. A total of 35% of patients successfully returned to full military function and completed a postoperative military deployment. Coracoclavicular reconstruction did not improve outcomes. Persistence of symptoms and requirement for hardware removal were not associated with the rate of postoperative deployment. Achieving excellent functional outcomes with open reduction and internal fixation of distal clavicle fractures remains a challenge. Where possible, conventional plate fixation should be considered over hook plate fixation. However, subsequent hardware removal and continuing shoulder pain do not preclude a return to high-level activity. [Orthopedics. 2018; 41(1):e117-e126.].

Occupational outcomes following combat-related gunshot injury: Cohort study.

BACKGROUND: The long-term impact of gun violence on physical function and occupational disability remains poorly explored. We sought to examine the effect of combat-related gunshot injury on work capacity within a cohort of military servicemembers and identify clinical characteristics that influence the capacity to return to work. METHODS: A query was performed to identify all servicemembers injured by gunshot in the years 2005-2009. These soldiers were then followed for a period up to the end of 2014 in order to identify those separated from service due to an inability to perform military duties as a result of their injury. Socio-demographic and clinical characteristics were considered co-variates. The dependent variable in this study was inability to effectively return to work, as delineated by the proxy of medical separation from military service. A multivariable logistic regression model was used to evaluate factors associated with an increased likelihood of medical separation following gunshot injury. RESULTS: Of the 1417 individuals meeting inclusion criteria, 40% (n = 572) of the cohort were medically separated in the time-period under study. Significant predictors of separation included non-thoracic injuries, increased injury severity score (ISS; OR 1.05; 95% CI 1.04, 1.06), Senior Enlisted (OR 3.90; 95% CI 2.16, 7.01), and Junior Enlisted military rank (OR 6.99; 95% CI 3.93, 12.44). CONCLUSIONS: This is the largest study in the literature to assess the long-term capacity to return to work following gunshot injury in any population. Individuals in high-demand occupations and those with non-thoracic wounds, or elevated ISS, should be counseled in the post-gunshot injury period regarding the negative associations of these characteristics with the capacity to return to work. Enhanced access to social services in the period following injury could similarly benefit individuals of low socioeconomic background.