Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review.

INTRODUCTION: Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities. METHODS: A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified. RESULTS: From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions. CONCLUSION: Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Newer generation of proximal tibia locking plates demonstrate large variability in their ability to capture the posteromedial fragment in bicondylar tibial plateau fractures.

INTRODUCTION: The early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology -which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures. MATERIALS & METHODS: Axial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates-in seven total configurations-were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment. RESULTS: On average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p<0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p<0.0001) when compared to fixed angle constructs. CONCLUSION: Newer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.