Early analysis of the United States Army's telemedicine orthopaedic consultation program.

Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army's telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting were the most common recommended treatments for all orthopaedic consults. Of the 170 consults requesting specific treatment recommendations for patients who likely otherwise would have been evacuated for further evaluation, surgical intervention or medical evacuation was only recommended in 25% and 16% of the consultations, respectively. The novel Army telemedicine orthopaedic consultation program developed for combat-deployed service members provides expert treatment recommendations for a variety of musculoskeletal injuries. Deployed health care providers located in austere combat environments can better determine both the necessity of medical evacuation and appropriate treatments for service members with musculoskeletal injuries when aided by orthopaedic surgery consultants, thereby limiting the number of unnecessary medical evacuations.

Comparison of operative times between pressure and flow-control pump versus pressure-control pump for ACL reconstruction.

Evidence suggests that a pressure and flow-control pump provides better visualization than a pressure-control pump alone. Increased visualization may lead to decreased operative time. We sought to perform a direct comparison in terms of operative times in anterior cruciate ligament (ACL) reconstructive surgery using these 2 automated pump systems. We retrospectively studied all ACL reconstruction procedures performed at our institution over an 8-month period. During the first 4-month period, a pressure-driven pump was used (HydroFlex Multipurpose Irrigation Pump; Davol, Warwick, Rhode Island). During the second 4-month period, a pressure and flow-control pump was used (FMS Duo+; DePuy Mitek, Raynham, Massachusetts). Procedures that involved multiligament reconstruction or meniscal repair were excluded. Surgical time was defined as the time from incision to skin closure. The data were analyzed with the Student t test with significance set at P<.05. Forty-four procedures met our inclusion criteria, with 21 surgeries performed using the pressure-control pump and 23 surgeries performed using the pressure and flow system. Mean operative time using the pressure-control pump was 126 minutes (95% CI 118.9, 133.3), while mean operative time using the pressure and flow-control system was 111 minutes (95% CI 104.1, 117.9). This difference was significant (P=.004). These results indicate that the use of pressure and flow-control pump system results in time savings compared with the pressure-control pump.

Anterior cruciate ligament revision of a relatively new implant system.

Cayenne AperFix (Cayenne Medical, Inc, Scottsdale, Arizona) is a relatively new implant used in anterior cruciate ligament (ACL) reconstruction. To date, there have been more than 4500 primary reconstructions performed using the device, and removal of the implant during revision surgery has not been discussed in any published literature. The focal point of the procedure involves removing the center screw within the femoral component, followed by using a core reamer to extract the entire device, leaving behind a femoral tunnel with no defects that can accept a new graft. We present the case of failed primary ACL reconstruction in a 23-year-old man due to a single traumatic event. We discuss the technical challenges associated with this implant as well as the technique used for removal.

Management of large soft-tissue wounds with negative pressure therapy-lessons learned from the war zone.

The recent conflicts in Afghanistan and Iraq have demonstrated that body armor has led to increase survival of combatants but the extremity injuries have been alarming. The increased numbers of extremity injuries have led to the acceptance and use of negative pressure therapy (NPT) in managing large wounds. This article reviews some of the lessons learned in treating wounds of the upper extremity using NPT.

Rhabdomyolysis attributable to severe overuse of the supraspinatus muscle: a report of two cases.

Rhabdomyolysis can occur after overuse of or injury to any muscle. This results in cell membrane compromise and the escape of cellular contents into the extracellular fluid. After strenuous exercise, a small amount of rhabdomyolysis normally occurs but is usually self-limited and does not progress to compartment syndrome. Two cases diagnosed as supraspinatus compartment syndrome have been reported in the literature; however, the clinical presentation was similar to the two cases with rhabdomyolysis presented here.

Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy?

The orthoroentgenogram, commonly known as the 'scanogram', continues to be the most widely used imaging technique for measuring limb length discrepancy (LLD). This study reviews other methods of measuring LLD including full-length standing anteroposterior radiographs, computed tomography/digital localization image, and microdose digital scanography. We present seven cases that demonstrate the pitfalls of scanograms as compared with full-length standing anteroposterior radiographs. Illustrative cases provide the rationale for the clinician managing LLD on a regular basis to utilize full-length standing anteroposterior radiographs as the instrument that will provide the most clinically relevant information.

Modified arthroscopic suture fixation of a displaced tibial eminence fracture.

This study describes a new arthroscopic method using a whip-stitch technique for treating a displaced type III tibial eminence fracture. A 12-year-old girl who sustained a displaced type III tibial eminence fracture was treated with arthroscopic fixation using the Arthrosew disposable suture device (Surgical Dynamics, Norwalk, CT) to place a whip stitch into the anterior cruciate ligament (ACL). The Arthrex ACL guide (Arthrex, Naples, FL) was used to reduce the avulsed tibial spine fragment. Sutures were then passed through the tibial tunnel and secured over a bony bridge with the knee in 20 degrees of flexion. At 9 months, the patient has a full range of motion with normal Lachman and anterior drawer testing, and she has returned to competitive basketball. Radiographs show complete fracture healing. KT-1000 and isokinetic testing at 9-month follow-up show only minimal side-to-side differences. The Arthrosew device provides a significant advantage in the treatment of type III and IV fractures of the tibial eminence by obtaining arthroscopic fixation within the substance of the ACL, thus obviating arthrotomy and hardware placement. This technique also restores the proper length and tension to the ACL, and provides a simplified, reproducible method of treatment for this injury.

The effect of low intensity pulsed ultrasound on regenerate bone in a less-than-rigid biomechanical environment.

The purpose of this study was to investigate effects of low intensity pulsed ultrasound (LIPU) on distraction osteogenesis in a less-than-rigid biomechanical environment in a rabbit model. A less-rigid mini-lengthener was applied and a mid-tibial osteotomy performed in 20 New Zealand White rabbits. After a 7 day latency period, the tibiae were distracted 0.5 mm every 12 hours for 10 days. Ten of the rabbits received LIPU for 20 min/day (ultrasound group) and 10 received sham LIPU (control group) from day 17 until sacrifice on day 37. Radiographs were taken weekly after distraction and the callus area was measured. After sacrifice, dual-energy X-ray absorptiometry (DEXA), torsional testing to failure, and histomorphometry were performed. On radiographs, all the treatment tibiae displayed persistent radiolucencies; however, only one of the control tibiae displayed a radiolucent interzone. Torsional strength of the treatment group was 54% of the contralateral tibia compared to 139% in the control group (p<0.008). Bone density and callus size were not significantly different between the 2 groups; however, the ultrasound group displayed a tendency towards more cartilage and fibrous tissue formation (p<0.16) and less bone (p<0.16) than controls. In a biomechanically unstable environment, LIPU appears to stimulate more cartilage formation in regenerated callus than in controls. This callus is biomechanically inferior to unstimulated callus at the early stage of healing tested. During distraction osteogenesis a sound biomechanical environment is important to achieving anticipated results.

The effect of low intensity pulsed ultrasound applied to rabbit tibiae during the consolidation phase of distraction osteogenesis.

The purpose of this study was to determine if low intensity pulsed ultrasound (LIPU) accelerated the maturation of regenerate bone when applied after distraction in a rabbit model. A mid-tibial osteotomy was performed in 26 New Zealand white rabbits and an external fixator applied anteromedially. After a seven day latency period, the tibiae were distracted 0.5 mm every 12 h for 10 days. Thirteen of the rabbits received LIPU for 20 min/day (treatment group) and 13 received sham LIPU (control group) from day 17 until sacrifice on day 37. Radiographs were taken weekly after distraction and the total and mineralized areas of the callus were measured. After sacrifice, dual-energy X-ray absorptiometry, torsional testing to failure, and histomorphometry were performed. Ultrasound-treated tibiae were a mean of 68.8 +/- 3.8% as stiff as and 68.2 +/- 6.0% as strong as the contralateral tibiae. Control tibiae were 78.7 +/- 7.0%, as stiff as and 70.2 +/- 7.9% as strong as the contralateral tibiae. The differences in stiffness and strength were not significant (p = 0.39 and 0.81, respectively) with the number of the animals tested in the study. The treatment group was 91.6% as dense as the contralateral side and the control group was 88.5% as dense as the contralateral side (p = 0.84). Radiographs revealed a significantly larger callus in the LIPU-treated tibiae at 1, 2 and 3 weeks after distraction compared to control tibiae (p < 0.01, 0.008 and 0.05, respectively). Histomorphometry revealed significantly less fibrous tissue in the LIPU-treated tibiae (p < 0.05) and a strong trend towards more bone in the LIPU-treated tibiae compared to controls (p = 0.06). LIPU was found to increase the size of the distraction callus and it might alter the composition of regenerate bone but it did not have a positive effect on the mechanical properties or density of regenerate bone when applied during the consolidation phase of distraction osteogenesis.