Particulated Juvenile Articular Cartilage Allograft for Treatment of Chondral Defects of the Knee: Short-Term Survivorship with Functional Outcomes.

While basic science research confirms the robust biological profile of juvenile chondrocytes, the clinical outcomes after particulated juvenile cartilage allograft transplantation are not well established. A retrospective analysis of active duty servicemembers undergoing surgical treatment with particulated juvenile articular cartilage allograft transplantation for chondral defects of the knee from two military treatment facilities was completed. Demographic variables, operative details, activity limitations, and medical discharges were obtained. A total of 29 patients with 36 treated chondral defects were isolated at an average follow-up of 16.2 months. The cohort was comprised of male service members in the Army with mean age of 33.1 years. Location of chondral lesion included the patellofemoral articulation (patella 39%, trochlea 31%, bipolar lesions 8%) and condyles (31%). Offloading or realignment osteotomy procedures were performed in 7 patients (23%). Of all patients, 14 servicemembers (48%) underwent knee-related medical discharge, and one patient underwent conversion to total knee arthroplasty. In this small patient cohort, particulated juvenile cartilage allograft transplantation for chondral defects of the knee did not reliably restore military servicemembers to full military function. At least one in two patients had persisting knee pain after chondral restoration procedure. (Journal of Surgical Orthopaedic Advances 30(1):010-013, 2021).

Return to Military Duty After Anterior Cruciate Ligament Reconstruction.

Background: Return to play and risk factors for functional limitations have been widely reported among athletes following anterior cruciate ligament reconstruction (ACLR) but has not been well studied in the military population. Methods: We conducted a retrospective review of all active duty service members who underwent primary ACLR at our institution between 2005 and 2010. The primary endpoints evaluated included Medical Evaluation Board (MEB) and activity limitations as noted by permanent profile (PP) following surgery. Demographic and surgical information was collected including age, gender, Military Occupational Specialty, tobacco use, rank, associated meniscal/chondral injuries, graft type, graft size, graft failure, and subsequent surgeries. All patients were greater than 2 yr postoperatively from index ACLR. Findings: A total of 470 patients met inclusion criteria for the study. There were 428 men and 42 women with a mean age of 28.5 yr. Of the 470 patients, 247 (52.6%) required either MEB, PP, or both following surgery; 129 (27.4%) required a PP only; 53 (11.3%) required a MEB only; and 65 (13.8%) required both PP and MEB following surgery. Only 223 patients (47.4%) returned to full duty without restrictions following ACLR. Both anterior cruciate ligament graft failure and subsequent surgeries were found to be statistically significant predictors for PP and/or MEB (p < 0.0001). Age, tobacco use, rank, associated meniscal/chondral injury, graft type, and graft size were not found to be significant predictors for subsequent PP and/or MEB. Female gender trended toward significance as a risk factor with 27 of 41 females (65.9%) requiring PP and/or MEB (p = 0.07). Service members in a noncombat arms role were more likely to require PP and/or MEB than those in a combat arms role (p = 0.03). Discussion: Return to full duty following ACLR in active duty soldiers is lower than may be expected. More than 50% of service members have activity limitations or are unable to return to duty following surgery. These findings allow for preoperative discussion of expected outcome and the possibility that an anterior cruciate ligament tear even when reconstructed can lead to permanent military activity limitations and MEB.

2014 Fort Hood, Texas, mass casualty incident: reviews and perspectives.

On April 2, 2014, in Fort Hood, Texas, an active shooter incident occurred where four active duty soldiers were tragically killed. Active shooter incidents are becoming alarmingly more frequent over the last decade in the USA. The authors provide a detailed account of the events that occurred within the hospital and an evaluation of the triage decisions made on that day. A detailed review of mass casualty preparedness and the general approach to triage processes are also described.

Bacterial adherence to titanium, poly-L-lactic acid, and composite hydroxyapatite and poly-L-lactic acid interference screws.

This study investigates a potential site of bacterial adherence, the implant surface, comparing titanium, poly-L-lactic acid (PLLA), and composite hydroxyapatite and poly-L-lactic acid (PLLA-HA) interference screws using a bioluminescent in vitro model. Interference screws of three materials, titanium (Arthrex, Naples, FL), bioabsorbable poly-L-lactic acid (BIORCI, Smith & Nephew, Andover, MA), and bioabsorbable composite hydroxyapatite and poly-L-lactic acid (BIORCI-HA, Smith & Nephew, Andover, MA) were immersed in a broth of bioluminescent Staphylococcus aureus. The screws were irrigated and then imaged with a photon-capturing camera system yielding a total photon count correlating with residual adherent bacteria. The titanium screws had the lowest mean total bacterial counts followed by the PLLA-HA screws and with the PLLA screws having the highest mean total counts. The difference in means between the titanium group and the PLLA group was statistically significant (p < .001). Titanium interference screws have less bacterial adherence than comparable bioabsorbable PLLA screws.

Silver dressings augment the ability of negative pressure wound therapy to reduce bacteria in a contaminated open fracture model.

BACKGROUND: Despite a lack of evidence supporting their use, silver dressings are often used with negative pressure wound therapy (NPWT). This study investigates the effectiveness of silver dressings to reduce bacteria in contaminated wounds when used with NPWT. METHODS: Complex orthopedic wounds were created on the proximal left legs of anesthetized goats. The wounds were inoculated with either a strain of bioluminescent Pseudomonas aeruginosa or Staphylococcus aureus. These bacteria are genetically modified to emit photons, thereby allowing quantification of bacterial concentration with a photon-counting camera system. The wounds were debrided 6 hours after inoculation and were treated with silver impregnated gauze combined with NPWT. Repeat debridements were performed every 48 hours for 6 days. Imaging was performed pre- and postdebridement. These results were compared with standard NPWT controls that used dressings without silver. RESULTS: There were fewer bacteria in the silver groups than the standard NPWT groups at 6 days. In the groups that were inoculated with P. aeruginosa, wounds in the silver group contained 21% ± 5% of baseline bacterial load compared with 43% ± 14% in the standard NPWT group. The addition of the silver dressings has a more pronounced effect on Staphylococcus. Wounds in the silver group contained 25% ± 8% of baseline bacterial load compared with 115% ± 19% in the standard NPWT group. CONCLUSIONS: The use of silver dressings with NPWT is a fairly common practice with limited literature to support its use in contaminated wounds. This study demonstrates that the addition of a silver dressing to NPWT effectively reduces bacteria in contaminated wounds and is more beneficial on the gram-positive bacteria. These data support the use of silver dressings in contaminated wounds, particularly ones contaminated by S. aureus.

Bacterial adherence to high--tensile strength sutures.

PURPOSE: The purpose of this study was to evaluate the bacterial adherence to high--tensile strength suture materials using a bioluminescent in vitro model. METHODS: Eleven strands each of No. 2 MaxBraid (Arthrotek [Biomet], Warsaw, IN), FiberWire (Arthrex, Naples, FL), Ethibond (Ethicon, Somerville, NJ), Orthocord (DePuy Mitek, Raynham, MA), and silk (Ethicon) sutures were immersed in a broth of bioluminescent Staphylococcus aureus, which is genetically engineered to emit photons. After 12 hours in the broth, the suture strands were individually irrigated with 10 mL of low-pressure normal saline solution and imaged with a photon-capturing camera system that yields a total photon count that correlates directly with residual bacterial counts. RESULTS: MaxBraid had the greatest adherence, followed by FiberWire, Ethibond, Orthocord, and silk. Orthocord had only 25% of the bacterial adherence of MaxBraid (P < .001). Ethibond and FiberWire had 53% (P < .001) and 75% (P = .003) of the adherence of MaxBraid, respectively. Differences between each suture were also statistically significant, with Ethibond and Orthocord having 71% (P = .007) and 33% (P < .001) of the adherence of FiberWire, respectively, and Orthocord having 47% (P < .001) of the adherence of Ethibond. The adherence to silk was statistically lower than all of the high-tensile strength sutures. CONCLUSIONS: Among high--tensile strength sutures, Orthocord has significantly less bacterial adherence than MaxBraid and FiberWire. Although infections in arthroscopic shoulder surgery are rare, the physical properties of surgical implants should be known by surgeons. In addition, bacterial adherence may contribute to suture selection in a patient prone to infection or to the use of suture in other body areas at greater risk for contamination. CLINICAL RELEVANCE: Bacterial adherence to high--tensile strength sutures may be a useful factor in implant selection in a patient with predisposition for contamination or infection.

Bacterial adherence to suture materials.

BACKGROUND: Wound infections may be problematic for physicians. Whether a practitioner is managing complex penetrating trauma or a skin biopsy, there may be a need for suture closure. Suture material is an operator dependent variable and while little objective data exist to guide the choice of suture, it may play a role in wound infection. This study evaluates bacterial adherence to commonly used suture materials with a bioluminescent in vitro model. METHODS: In all, 11 strands of size 2-0 poliglecaprone suture (Monocryl; Ethicon, Inc, Somerville, New Jersey), polypropylene suture (Prolene; Ethicon, Inc), silk suture (Ethicon, Inc), polyglycolic acid suture (Vicryl; Ethicon, Inc), and antimicrobial polyglycolic acid suture treated with triclosan (VicrylPlus; Ethicon, Inc) were immersed in a broth of Staphylococcus aureus engineered to emit photons. After biofilm formation, the suture strands were irrigated and imaged with a photon-capturing camera system yielding a total photon count that correlates with residual bacteria. RESULTS: The Vicryl suture had the highest counts and was statistically significant in bacterial adherence versus all other sutures. No other suture material was significantly different from any other. CONCLUSIONS: This study gives data to guide the selection of suture materials. Absorbable braided suture should not be used in closure of contaminated wounds or wounds at risk for developing infection. The antibiotic impregnated absorbable braided suture was similar to the other suture types; however, it is at risk for reverting to the properties of its untreated counterpart over time. The bacterial adherence of suture materials should be taken into account by all practitioners when closing wounds or debriding infected wounds.

Safety analysis of all-inside arthroscopic repair of peripheral triangular fibrocartilage complex.

PURPOSE: The purpose of this study was to determine whether an all-inside peripheral triangular fibrocartilage complex (TFCC) repair using the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) is safe by measuring the proximity of the anchors to ulnar-sided anatomic structures. METHODS: Eleven fresh-frozen cadaveric wrists were thawed and placed in traction. Under direct arthroscopic visualization, an all-inside arthroscopic peripheral TFCC repair was completed by placing a single FasT-Fix device in a vertical mattress fashion. The wrists were then dissected to visualize the 2 anchors. The distance between these anchors and the flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and dorsal branch of the ulnar sensory nerve (DBUN) were measured with digital calipers and recorded. RESULTS: The peripheral anchor averaged 4.2 mm (range, 0 to 14 mm) from the ECU tendon, 3.8 mm (range, 0 to 9 mm) from the DBUN, and 8.3 mm (range, 1 to 15 mm) from the FCU tendon. The central anchor averaged 9.6 mm (range, 2 to 15 mm) from the ECU tendon, 6.8 mm (range, 1 to 13 mm) from the DBUN, and 7.6 mm (range, 1 to 13 mm) from the FCU tendon. CONCLUSIONS: This study exposes some safety concerns with the all-inside peripheral TFCC repair using the FasT-Fix device, which was found to reside in close proximity to the ECU, FCU, and DBUN. In multiple wrists the anchors were noted to underlie the anatomic structure that we measured, making it possible to pierce these structures with the needle before deployment of the anchor. CLINICAL RELEVANCE: Though technically feasible, all-inside arthroscopic repair of the peripheral TFCC risks injury to the ulnar-sided anatomy.

Negative pressure wound therapy reduces pseudomonas wound contamination more than Staphylococcus aureus.

PURPOSE: The purpose of this study is to determine if negative pressure wound therapy (NPWT) treatment results in fewer bacteria than wet-to-dry (WTD) dressings in a contaminated open fracture wound model. METHODS: For Study 1, complex wounds were created on the proximal left leg of goats. The wounds were inoculated with Pseudomonas aeruginosa. The wounds were débrided and irrigated 6 hours after inoculation. The first group received WTD dressing changes twice daily; the second and third groups received NPWT using systems from two different companies. All three groups received repeat débridements every 48 hours for 6 days. Bacteria quantification was performed both immediately before and after each débridement. For Study 2, the only changes were that Staphylococcus aureus was used and only one NPWT group was included. RESULTS: In Study 1, there were significantly fewer Pseudomonas in both NPWT groups at all imaging sessions after the initial débridement and irrigation. At the 6-day time point, the wounds in the NPWT groups were 43 +/- 14% and 68 +/- 6% of the baseline amount, respectively. The WTD groups were 464 +/- 102% of the baseline amount. In Study 2, NPWT did not reduce the S. aureus contamination within the wound. At the 6-day time point, the wounds in the NPWT and WTD groups contained 115 +/- 19% and 192 +/- 52% of the baseline values, respectively. CONCLUSION: NPWT showed a significant and sustained decrease in the Pseudomonas levels compared with WTD dressings at all time points. This beneficial effect was seen not seen in S. aureus.

Coccidioidal osteomyelitis of the patella.

Known as "Valley Fever," coccidiomycosis is a soil-borne, fungal infection predominately found in endemic regions of the southwestern United States and Latin America. While most infected individuals are asymptomatic, <1% of patients have hematogenous seeding of bone, skin, and soft tissue. When the musculoskeletal system is involved, the knee is most commonly affected, although infection has been described in the spine, hand, wrist, ankle, foot, and pelvis. Treatment typically includes a combination of surgical debridement and antifungal treatment.An 11-year-old boy presented with a 7-month history of left anterior knee pain. Physical examination revealed mild knee effusion and quadriceps atrophy with focal tenderness to palpation to the distal pole of the patella. Laboratory studies were unremarkable and plain radiographs revealed a radiolucency in the inferomedial aspect of the patella. Magnetic resonance imaging revealed a corresponding focus of increased T2 signal with sclerotic margins and peripheral edema within the patella. Open biopsy with curettage confirmed coccidiomycosis, and the patient was successfully managed with long-term antifungal antibiotics.To our knowledge, this article presents the first known case of coccidioidal osteomyelitis of the patella.

Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom.

OBJECTIVES: Injuries are common during combat operations. The high costs of extremity injuries both in resource utilization and disability are well known in the civilian sector. We hypothesized that, similarly, combat-related extremity injuries, when compared with other injures from the current conflicts in Iraq and Afghanistan, require the largest percentage of medical resources, account for the greatest number of disabled soldiers, and have greater costs of disability benefits. DESIGN: Descriptive epidemiologic study and cost analysis. METHODS: The Department of Defense Medical Metrics (M2) database was queried for the hospital admissions and billing data of a previously published cohort of soldiers injured in Iraq and Afghanistan between October 2001 and January 2005 and identified from the Joint Theater Trauma Registry. The US Army Physical Disability Administration database was also queried for Physical Evaluation Board outcomes for these soldiers, allowing calculation of disability benefit cost. Primary body region injured was assigned using billing records that gave a primary diagnosis International Classification of Diseases Ninth Edition code, which was corroborated with Joint Theater Trauma Registry injury mechanisms and descriptions for accuracy. RESULTS: A total of 1333 soldiers had complete admission data and were included from 1566 battle injuries not returned to duty of 3102 total casualties. Extremity-injured patients had the longest average inpatient stay at 10.7 days, accounting for 65% of the $65.3-million total inpatient resource utilization, 64% of the 464 patients found "unfit for duty," and 64% of the $170-million total projected disability benefit costs. Extrapolation of data yields total disability costs for this conflict, approaching $2 billion. CONCLUSIONS: Combat-related extremity injuries require the greatest utilization of resources for inpatient treatment in the initial postinjury period, cause the greatest number of disabled soldiers, and have the greatest projected disability benefit costs. This study highlights the need for continued or increased funding and support for military orthopaedic surgeons and extremity trauma research efforts.