Consensus and Equipose in the Management of Military Trainee Femoral Neck Stress Fractures: A Survey of Military Surgeons.

BACKGROUND: Femoral neck stress fractures (FNSFs) are a unique injury pattern not commonly treated in the civilian trauma population; however, it is particularly high with military trainees engaged in basic combat training. To date, no study has surveyed a population of military orthopedic surgeons on treatment preferences for military service members (SMs) with FNSF. QUESTIONS: We aim to evaluate the extent of clinical equipoise that exists in the management of these injuries, hypothesizing that there would be consensus in the factors dictating surgical and non-surgical intervention for FNSF. PATIENTS AND METHODS: A 27-question survey was created and sent to U.S. military orthopedic surgeon members of the Society of Military Orthopaedic Surgeons. The survey was designed in order to gather the experience among surgeons in treating FNSF and identifying variables that play a role in the treatment algorithm for these patients. In addition, seven detailed, clinical vignettes were presented to further inquire on surgeon treatment preferences. Binomial distribution analysis was used to evaluate for common trends within the surgeon's treatment preferences. RESULTS: Seventy orthopedic surgeons completed the survey, the majority of whom were on active duty status in the U.S. Military (82.86%) and having under 5 years of experience (61.43%). Majority of surgeons elected for a multiple screw construct (92.86%), however the orientation of the multiple screws was dependent on whether the fracture was open or closed. Management for compression-sided FNSF involving ≥50% of the femoral neck width, tension-sided FNSF, and stress fractures demonstrating fracture line progression had consensus for operative management. Respondents agreed upon prophylactic fixation of the contralateral hip if the following factors were involved: Complete fracture (98.57%), compression-sided fracture line >75% (88.57%), compression-sided fracture line >50-75% with hip effusion (88.57%), contralateral tension-sided fracture (87.14%), and compression-sided fracture line >50-75% (84.29%). An FNSF < 50% on the contralateral femoral neck or a hip effusion was indeterminate in surgeons indicating need for prophylactic fixation. Majority of surgeons (77.1%) utilized restricted toe-touch weight-bearing for postoperative mobility restrictions. CONCLUSIONS: Consensus exists for surgical and non-surgical management of FNSF by U.S. military orthopedic surgeons, despite the preponderance of surgeons reporting a low annual volume of FNSF cases treated. However, there are certain aspects in the operative and non-operative management of FNSF that are unanimously adhered to. Specifically, our results demonstrate that there is no clear indication on the management of FNSF when an associated hip effusion is involved. Additionally, the indications for surgically treating contralateral FNSF are unclear. LEVEL OF EVIDENCE: IV.

Pectoralis Major Tendon Tears During Airborne Operations: Are These Injuries Isolated?

INTRODUCTION: Pectoralis major tendon tears are an injury pattern often treated in military populations. Although the majority of pectoralis major tendon tears occur during eccentric loading as in bench press weightlifting, military service members may also experience this injury from a blunt injury and traction force produced by static line entanglement during airborne operations. Although these injuries rarely occur in isolation, associated injury patterns have not been investigated previously. MATERIALS AND METHODS: After obtaining institutional review board approval, medical records were reviewed for all patients who underwent surgical repair of a pectoralis major tendon tear sustained during static line parachuting at a single institution. Radiology imaging, operative notes, and outpatient medical records were examined to determine concomitant injury patterns for each patient identified over a 4-year study period. RESULTS: Twenty-five service members met the study inclusion criteria. All patients underwent presurgical magnetic resonance imaging. Of these 25 service members, 10 (40%) presented with a total of 13 concomitant injuries identified on physical exams or imaging studies. The most common associated injuries were injuries to the biceps brachii and a partial tear of the anterior deltoid. Biceps brachii injuries consisted of muscle contusion proximal long head tendon rupture, proximal short head tendon rupture, partial muscle laceration, and complete muscle transection. Additional concomitant injuries included transection of coracobrachialis, a partial tear of the inferior subscapularis tendon, antecubital fossa laceration, an avulsion fracture of the sublime tubercle, and an avulsion fracture of the coracoid process. CONCLUSIONS: Military static line airborne operations pose a unique risk of pectoralis major tendon tear. Unlike the more common bench press weightlifting tear mechanism, pectoralis major tendon tears associated with static line mechanism present with a concomitant injury in 40% of cases, with the most common associated injury occurring about the biceps brachii. Treating providers should have a high index of suspicion for concomitant injuries when treating pectoralis major tendon tears from this specific mechanism of injury.

Femoral Neck Stress Fractures in Athletes and the Military.

➤: Femoral neck stress fractures (FNSFs) are an infrequent condition in athletic and military populations. ➤: A high index of suspicion with liberal use of magnetic resonance imaging (MRI) is vital for early recognition and treatment initiation. ➤: An associated hip effusion on MRI is a risk factor for an evolving stress injury and requires close assessment and consideration for repeat MRI. ➤: Stress reactions and stable, incomplete FNSFs (<50% of femoral neck width) can be treated nonsurgically. ➤: Surgical intervention is accepted for high-risk, incomplete (≥50% of femoral neck width), and complete FNSFs. ➤: Overall, there is a paucity of high-quality literature on the rates of return to activity following FNSF.

Parachute-Induced Pectoralis Major Tears in Military Servicemembers: What Is the Functional Recovery?

BACKGROUND: Although the most common injury mechanism for pectoralis major (PM) tears is an eccentric loading mechanism typically caused by bench pressing, within the military, there is a unique injury mechanism associated with airborne operations. The results of operative repair for these parachute-induced PM tears have not been previously reported. PURPOSE/HYPOTHESIS: To assess the functional outcomes in military servicemembers undergoing operative repair of parachute-induced PM tears. We hypothesized that functional recovery would be impaired with delayed surgical intervention. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were active duty military servicemembers who underwent operative repair for PM tears caused by a parachute-induced mechanism. Charts were reviewed to identify characteristic, injury, and surgical variables. Patients completed the functional outcome assessment with the Disabilities of the Arm, Shoulder and Hand (DASH) and the American Shoulder and Elbow Surgeons (ASES) questionnaires. Outcomes were compared between patients treated within 6 weeks of injury and those treated beyond 6 weeks. RESULTS: Of the 68 identified PM tears, 25 were the result of parachute-induced mechanisms. A total of 13 patients consented and completed the functional outcome assessment. The mean patient age was 30.6 ± 6.4 years, and the mean follow-up period was 5.46 ± 1.26 years. Ten patients underwent repair within 6 weeks of injury, and the remaining 3 patients underwent repair at a mean of 338 days after injury (95% CI, -42.8 to 718.8 days), a significant difference between groups (P = .006). All 13 patients were able to return to military duties at a mean of 6 months from injury. Patients treated within 6 weeks of injury had significantly higher functional outcomes (DASH score, 6.17 vs 26.67; P = .018; ASES score, 85.97 vs 49.5; P = .008), with greater strength performance compared with preinjury (bench press, 90.58% vs 38.95%; P = .0057; push-ups, 81.9% vs 23.8%; P = .023) compared with patients treated beyond 6 weeks of injury. CONCLUSION: Operative repair of parachute-induced PM tears within 6 weeks of injury provided a superior functional and strength recovery when compared with delayed surgical repair. Acute repair should be recommended for military servicemembers who experience this unique injury mechanism.

Primary Medial Patellofemoral Ligament Reconstruction in Military Servicemembers: Can We Reliably Restore Preinjury Function and Stability?

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction for patellar instability is a commonly performed procedure with a reported high rate of return to preinjury activity. However, no previous study has assessed the functional outcomes of military servicemembers undergoing MPFL reconstruction. HYPOTHESIS: Primary MPFL reconstruction confers patellar stability, but with limited return to preinjury function and ability to maintain unrestricted military active duty status. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Using the Management Analysis and Reporting Tool database, we conducted a retrospective review of active duty servicemembers throughout the US Department of Defense Health System who underwent primary MPFL reconstruction between 2012 and 2015. Demographic variables were recorded as well as ability to return to impact activities-defined as running, jumping, rucking with a load >40 pounds (18 kg), and returning to airborne operations-and to remain on active duty status. The rates of recurrent instability and the need for subsequent surgeries were identified and assessed for statistical significance using uni- and multivariate analyses. Patients were evaluated for a minimum of 2 years postoperatively. RESULTS: Of the 213 patients who underwent primary MPFL reconstruction, including 34 with concomitant tibial tubercle osteotomy, 19 (8.9%) patients developed recurrent instability. The presence of bilateral patellar instability was associated with higher recurrence rate. Patients with bilateral instability comprised 47.3% of those with recurrence but only 24.9% of patients without recurrence (P = .019). Impact activity restrictions were present in 57.6% of patients (n = 121), with 86 patients (52.1%) undergoing medical separation from the military. Patients who were prescribed activity restriction before surgery were significantly more likely to have postoperative activity restrictions (64.5%; P = .019), and junior enlisted servicemembers were more likely to be medically separated from service postoperatively than higher ranking senior enlisted members or officers. CONCLUSION: Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. Bilateral instability negatively affected return to impact activities. Military servicemembers, particularly junior enlisted members, should be counseled on this poor prognosis for a full return to unrestricted activity postoperatively.

Bilateral Recurrent, Atraumatic Anterior Knee Dislocations in a Pediatric Patient With Congenital Absence of the Anterior Cruciate Ligament.

An 8 yo 15 kg male child with an undiagnosed congenital syndrome presented with painful, recurrent atraumatic bilateral knee dislocations. Recurrent dislocations were reduced in the emergency department and were never associated with neurovascular compromise. Magnetic resonance imaging identified congenital agenesis of the anterior cruciate ligament (ACL) bilaterally. He underwent staged bilateral physeal-sparing ACL reconstructions with autograft iliotibial band and had no subsequent dislocations during 14 month follow-up. To our knowledge, this is the only reported case of atraumatic spontaneous bilateral knee dislocations in a patient with bilateral congenital absence of the ACL. This case describes a novel indication for physeal-sparing ACL reconstruction in a rare clinical entity.

Late acetabular dysplasia after successful treatment for developmental dysplasia of the hip using the Pavlik method: A systematic literature review.

The Pavlik method is the most common method used for treatment of developmental dysplasia of the hip (DDH). Late acetabular dysplasia despite successful treatment, however, has had varied reporting. A systematic review was performed, investigating the long-term outcomes of DDH treated with the Pavlik method. Seventeen studies met inclusionary criteria, including 6029 hips treated with an average of 5.29 years follow-up. Radiographic evidence of late dysplasia was present in 280 hips, with 109 hips requiring additional surgery. A specified treatment algorithm had significantly decreased rates of radiographic dysplasia (3.8% vs 17.6%, p = 0.004). LEVEL OF EVIDENCE: IV.

Expansion of visual receptive fields in experimental glaucoma.

Glaucoma is a major cause of blindness and is characterized by death of retinal ganglion cells. In a rat model of glaucoma in which intraocular pressure is raised by cautery of episcleral veins, the somata and dendritic arbors of surviving retinal ganglion cells expand. To assess physiological consequences of this change, we have measured visual receptive-field size in a primary retinal target, the superior colliculus. Using multiunit recording, receptive-field sizes were measured for glaucomatous eyes and compared to both those measured for contralateral control eyes and to homolateral eyes of unoperated animals. Episcleral vein occlusion increased intraocular pressure. This was accompanied by a significant increase in receptive-field size across the superior colliculus. The expansion of receptive fields was proportional to both degree and duration of the increase of intraocular pressure. We suggest that this increase in the size of receptive fields of glaucomatous eyes may be related to the increase in the size of dendritic arbors of the surviving ganglion cells in retina.