Overuse Injury in Military Working Dog Handlers: A Pattern of Behavior and a Path to Prevention.

Military working dog handlers and their canine partners continue to be invaluable team members on missions of national importance, but little information exists in the medical literature regarding specific musculoskeletal injuries to military working dog handlers. We report a case of a dog handler with overuse shoulder traction injuries due to leash lunges from their dog in an effort to provide diagnostic insight and treatment options and look at prevention of common musculoskeletal manifestations of overuse in working dog handlers.

A simple surgical technique for subpectoral biceps tenodesis using a double-loaded suture anchor.

Multiple different surgical techniques have previously been described to address long head of the biceps tendinopathy. Subpectoral biceps tenodesis has proven to be an effective procedure to relieve pain and maintain function. We describe a surgical technique for subpectoral biceps tenodesis using a single double-loaded suture anchor implant. Advantages of this procedure include the ease of implant placement and the freedom this technique affords to perform the anchor placement without direct visualization of the docking site.

Comparison of complication rates of intramedullary pin fixation versus plating of midshaft clavicle fractures in an active duty military population.

Military service members have increased requirements of shoulder weight bearing to perform duties. Operative intervention has increased for treatment of displaced middle one-third clavicle fractures. Complications of operatively treated clavicle fixation have not been extensively studied. A retrospective, longitudinal cohort chart evaluation was conducted of all active duty members undergoing fixation of middle one-third clavicle fractures, for complications between intramedullary pin fixation and plate constructs. This review found 62 patients meeting inclusion criteria. Thirty-three patients underwent intramedullary pin fixation with Hagie pins and 31 patients underwent precontoured superior clavicle plate fixation of their middle one-third clavicle fractures. Complications included wound infection, skin and/or soft tissue irritation, and need for unplanned hardware removal. The overall complication rate was 31% in the plate fixation group versus 9% in the intramedullary pin group (p = .024). All patients achieved fracture union with return to duty; however, increased overall complications were seen in the plate fixation group.

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.

Preliminary in vitro evaluation of an adjunctive therapy for extremity wound infection reduction: rapidly resorbing local antibiotic delivery.

Despite the continuing advances in treatment of open fractures and musculoskeletal wounds, infection remains a serious complication. Current treatments to prevent infection utilize surgical debridement and irrigation, and high doses of systemic antimicrobial therapy. The aim of this work was to evaluate, in vitro, the potential of a fast-resorbing calcium sulfate pellet loaded with an antibiotic. The pellet could be used as an adjunctive therapy at the time of debridement and irrigation to reduce bacterial wound contamination. Small pellets containing a binder and calcium sulfate were engineered to resorb rapidly (within 24 h) and deliver high local doses of antibiotic (amikacin, gentamicin, or vancomycin) to the wound site while minimizing systemic effects. Results from dissolution, elution, and biological activity tests against P. aeruginosa and S. aureus were used to compare the performance of antibiotic-loaded, rapidly resorbing calcium sulfate pellets to antibiotic-loaded crushed conventional calcium sulfate pellets. Antibiotic-loaded rapidly resorbing pellets dissolved in vitro in deionized water in 12-16 h and released therapeutic antibiotic levels in phosphate buffered saline that were above the minimal inhibitory concentration for P. aeruginosa and S. aureus, completely inhibiting the growth of these bacteria for the life of the pellet. Crushed conventional calcium sulfate pellets dissolved over 4-6 days, but the eluates only contained sufficient antibiotic to inhibit growth for the first 4 h. These data indicate that fast-resorbing pellets can release antibiotics rapidly and at therapeutic levels. Adjunctive therapy with fast-acting pellets is promising and warrants further in vivo studies.

Osteomyelitis in military personnel wounded in Iraq and Afghanistan.

BACKGROUND: Orthopedic injuries occurring in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) are complicated by infections with multidrug resistant bacteria. We describe demographics and microbiology of OIF/OEF casualties with primary and recurrent osteomyelitis. METHODS: A retrospective cohort study was performed of OIF/OEF casualties admitted to our facility from February 1, 2003 to August 31, 2006. Electronic records were queried for demographic information, bacteria recovered, antibiotic therapies and duration, site of osteomyelitis, orthopedic devices, and outcomes. RESULTS: There were 110 patients with 139 hospitalizations for osteomyelitis; 94 involved lower extremities, 43 involved upper extremities, and 2 involved the axial skeleton. One hundred three admissions were initial episodes whereas 36 admissions were recurrences. The median age was 27 years; 95% were men. Duration of follow-up ranged from 2 weeks to 36 months. Those patients with orthopedic devices had recurrent infections more frequently (26 vs. 5%, p < 0.01). Bacteria, antibiotics, or infection site were not predictive of recurrence. Acinetobacter spp. (70 vs. 5%, p < 0.01), Klebsiella pneumoniae (18 vs. 5%, p = 0.04), and Pseudomonas aeruginosa (24 vs. 5%, p < 0.01) were more likely to be recovered during original episodes than during recurrences. Gram-positive organisms were more likely during recurrences; Staphylococcus aureus (13 vs. 53%, p < 0.01); methicillin susceptible S. aureus (5 vs. 22%, p < 0.01), methicillin resistant S. aureus (8 vs. 31%, p < 0.01). CONCLUSIONS: The microbiology of osteomyelitis in veterans of OIF/OEF differs substantially depending upon whether the infection is new or recurrent. Gram-negative pathogens predominate early, being replaced with staphylococci after treatment, despite nearly universal use of gram- positive therapy.

Amputations in U.S. military personnel in the current conflicts in Afghanistan and Iraq.

OBJECTIVES: To determine rates of major limb amputation in U.S. military casualties in the current conflicts in Afghanistan and Iraq, to correlate these with mechanism of injury, and compare the rate with that seen in U.S. casualties from the Vietnam War. DESIGN: Retrospective study of all U.S. casualties recorded for the current conflicts from the start in October 1, 2001 to June 1, 2006. SETTING: Records from U.S. military forward surgical teams (Level IIb) and combat support hospitals (Level III) in theater, evacuation (Level IV, Germany), and major military medical centers (Level V, United States). PATIENTS/PARTICIPANTS: All recorded U.S. military casualties from the Afghanistan and Iraq theaters with injuries requiring evacuation out of theater or prohibiting the individual from returning to duty for more than 72 hours. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Major limb injury, level of amputation, principal mechanism of injury. RESULTS: Over the past 56 months, of the 8058 military casualties meeting the listed criteria, 5684 (70.5%) were recorded as having major limb injuries. Of these, 423 (5.2% of all serious injuries; 7.4% of major limb injuries) underwent major limb amputation or amputation at or proximal to the wrist or ankle joint. The mechanism of injury for 87.9% was some form of explosive device. The major amputation rate during Vietnam was 8.3% of major limb injuries. CONCLUSIONS: Overall, major limb amputation rates for the current U.S. engagement in Afghanistan and Iraq are similar to those of previous conflicts.

Amputation in military trauma surgery.

BACKGROUND: Major limb amputations are among the most debilitating wounds sustained by those who survive a combat injury and these injuries leave a lasting impression with the public. This article will review the history of major limb amputation in military trauma surgery. METHODS: Review of published historic and modern battle casualty information was undertaken in the collections of the medical library of the National Naval Medical Center and the National Library of Medicine, both in Bethesda, Maryland, and the University of Maryland Health Sciences Center in Baltimore, Maryland. RESULTS: The potential utility of major limb amputation as a life-saving surgical intervention for compound fractures and other devastating limb injuries has been recognized through much of written human history. However, the advent of gunpowder onto the battlefields of Europe in the 14th century forced surgeons to solve the problems of, first, hemorrhage and then, as casualties survived the initial surgery, sepsis for amputation to actually improve outcomes. In the latter half of the 20th century, rapid evacuation from the battlefield and successful neurovascular repair has reduced the need for major limb amputations essentially for those required by insurmountable tissue loss. CONCLUSIONS: Major limb amputation remains a fearsome outcome of limb injury. However, during the last 500 years, military trauma surgeons have solved the problems of bleeding, infection, and neurovascular repair after major limb injury such that amputation rates even during times of active military conflict are at historic lows.

Arthroscopic treatment of unresolved Osgood-Schlatter lesions.

Osgood-Schlatter disease is a self-limiting condition in most cases. Those with unresolved pain after conservative treatment can obtain relief with surgical debridement of the mobile ossicles and tibial tuberosity. We present an arthroscopic technique for debridement. The location of the inferomedial and lateral parapatella tendon portals can be raised slightly to allow improved instrumentation and visualization in the anterior interval. An anterior interval release is performed with the mechanical shaver and radiofrequency ablation device. Care is taken to visualize the meniscal anterior horns and intermeniscal ligament. By staying anterior to these structures, debridement can be performed aggressively onto the anterior tibial slope. The bony lesions are shelled out from their soft-tissue attachments. Small and loose fragments are removed with a pituitary ronguer, whereas larger lesions are removed with an arthroscopic burr. Working deep along the anterior tibial slope is facilitated by extending the knee and taking tension off the patellar tendon. Postoperatively, patients are allowed full weight bearing and unrestricted range of motion. The advantages of this technique include the avoidance of the patellar tendon longitudinal split required for open procedures and the ability to address concomitant intra-articular pathology.

Suture holes in anterior cruciate ligament bone-patellar tendon-bone grafts.

Anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft is a common and technically demanding surgery. Traditional preparation of the femoral bone plug includes 2 transcortical holes with leading sutures to pull the graft into the knee. The pull of the sutures and patellar tendon are not colinear with the bone plug and femoral socket. The bone plug tilts, thus impairing passage into the femoral socket. A new preparation technique was devised that, by changing the location of the suture holes, decreases graft tilting and improves passage. In our study, traditional and new techniques of femoral bone plug preparation were investigated by force diagramming and then graft modeling. Bone plug tilting was caused by the trailing pull of the patellar tendon eccentric to the plug and socket. By preparing the femoral bone plug with a diametric, transverse trailing suture hole, the plug became colinear with the femoral socket for easier passage. The new technique was then surgically implemented with straighter and faster graft passage.