Occupational Outcomes and Revision Rates for Medial Unicondylar Knee Arthroplasty in U.S. Military Servicemembers.

This study evaluates return to work and revision rates for medial unicondylar knee arthroplasty (UKA) in a high-demand military cohort. Patient demographic and clinical variables were isolated from the medical records of active-duty military servicemembers with at least 2 years of postoperative follow-up and correlated with return to work, medial UKA survivorship, and perioperative complications. The medial UKA annual revision rate was calculated as the percentage of implants revised per observed component year. A total of 39 servicemembers underwent 46 primary medial UKAs (32 unilateral and 7 bilateral) with a mean follow-up of 3.9 (2.0-6.6) years. At a minimum of 2 years postoperatively, 33 (85%) servicemembers returned to military service or successfully completed their service obligation. Older servicemembers (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.45, 0.99) had a significantly decreased OR for knee-related medical separation. Nine servicemembers (20%) had conversion to TKA at an average of 2.4 (range, 0.6-5.6) years with a medial UKA annual revision rate of 5%. When compared with Navy/Air Force, Army/Marine servicemembers had an increased TKA conversion rate (OR = 5.40; 95% CI: 1.13, 25.81). Older age decreased the likelihood of medical separation and Army/Marines service was the sole risk factor associated with conversion to TKA. The level of evidence is IV, therapeutic case series.

The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review.

BACKGROUND: Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty. METHODS: We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation. RESULTS: Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again. CONCLUSION: For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.

Intraoperative fluoroscopy with a direct anterior approach reduces variation in acetabular cup abduction angle.

INTRODUCTION: The purpose of this study was to compare acetabular cup position for 2 cohorts of total hip arthroplasty (THA) patients who had a direct anterior approach. METHODS: 100 THA cases were performed with an anterior approach using intraoperative fluoroscopy (IF) to aid in cup positioning. Another group of 100 cases underwent THA with an anterior approach without the use of any fluoroscopy. Postoperative abduction and anteversion angles were measured using Martell's hip analysis software. RESULTS: Mean abduction angle was 43.2° (standard deviation (SD) = 4.5°) for the IF group versus 37.5°(SD = 7.4°) for cases without IF (p<0.001). 18% more cases with IF fell within the Lewinnek safe zone (p<0.001); however, a similar number of cases had over 50° of abduction. The mean anteversion angles of the two groups were also significantly different (IF 21.8° vs. 24.9°) (p<0.01). CONCLUSIONS: There was significantly less variation in cup position among the cases using IF with regards to abduction.

Predictors of hospital readmission following revision total knee arthroplasty.

PURPOSE: Hospital readmission is emerging as an important quality measure, yet modifiable predictors of readmission remain unknown. This study was designed to identify risk factors for readmission following revision total knee arthroplasty. METHODS: The National Surgical Quality Improvement Program dataset was queried to identify patients undergoing revision total knee arthroplasty from 2011 to 2012. Patient demographics, medical co-morbidities, laboratory values, surgical characteristics and surgical outcomes were examined using bivariate and multivariate logistic regression to identify significant predictors for readmission within 30 days of discharge. RESULTS: There were 108 readmissions (6.2 %) among 1754 patients. Risk factors for readmission included a history of transient ischaemic attack/cerebrovascular accident (OR 3.47; 13 95 % CI 1.30, 9.25), female sex (OR 1.75, 95 % CI 1.15, 2.68) and general anaesthesia (OR 14 1.74, 95 % CI 1.09, 2.79). Hypertension treated with medication (OR 0.61, 95 % CI 0.39, 0.96) was associated with a lower risk of readmission. Post-operative complications that were significant predictors of hospital readmission included periprosthetic joint infection (OR 15.09, 95 % CI 5.57, 40.91), superficial wound infection (OR 16.57, 95 % CI 5.82, 47.22) and deep venous thrombosis (OR 8.59, 95 % CI 2.36, 31.24). CONCLUSIONS: The preferred use of neuraxial anaesthesia and coordinated discharge planning in patients with a history of transient ischaemic attack/cerebrovascular accident may reduce the risk of readmission following discharge after revision total knee arthroplasty. Additionally, patients with post-operative infections and deep venous thrombosis following these procedures can benefit from close observation in the first weeks following discharge to minimize the likelihood of readmission. LEVEL OF EVIDENCE: III.

Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence.

BACKGROUND: Cardiac complications are a major cause of postoperative morbidity. The purpose of this study was to determine the rates, risk factors, and time of occurrence for cardiac complications within thirty days after primary unilateral total knee arthroplasty and total hip arthroplasty. METHODS: The American College of Surgeons National Surgical Quality Improvement Program data set from 2006 to 2011 was used to identify all total knee arthroplasties and total hip arthroplasties. Cardiac complications occurring within thirty days after surgery were the primary outcome measure. Patients were designated as having a history of cardiac disease if they had a new diagnosis or exacerbation of chronic congestive heart failure or a history of angina within thirty days before surgery, a history of myocardial infarction within six months, and/or any percutaneous cardiac intervention or other major cardiac surgery at any time. An analysis of the occurrence of all major cardiac complications and deaths within the thirty-day postoperative time frame was performed. RESULTS: For the 46,322 patients managed with total knee arthroplasty or total hip arthroplasty, the cardiac complication rate was 0.33% (n = 153) at thirty days postoperatively. In both the total knee arthroplasty and total hip arthroplasty groups, an age of eighty years or more (odds ratios [ORs] = 27.95 and 3.72), hypertension requiring medication (ORs = 4.74 and 2.59), and a history of cardiac disease (ORs = 4.46 and 2.80) were the three most significant predictors for the development of postoperative cardiac complications. Of the patients with a cardiac complication, the time of occurrence was within seven days after surgery for 79% (129 of the 164 patients for whom the time of occurrence could be determined). CONCLUSIONS: An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. Consideration should be given to a preoperative cardiology evaluation and co-management in the perioperative period for individuals with these risk factors.

The Influence of Musculoskeletal Conditions, Behavioral Health Diagnoses, and Demographic Factors on Injury-Related Outcome in a High-Demand Population.

BACKGROUND: The extent to which musculoskeletal injuries and sociodemographic factors impact long-term outcome remains unknown. The purpose of this study was to provide a prognostic analysis of the influence of musculoskeletal conditions, behavioral health diagnoses, and patient-based characteristics on outcomes among a longitudinal cohort. METHODS: This is a longitudinal observational study of the population of an Army brigade deployed to Iraq from 2006 to 2007. The 4087 soldiers who survived the deployment were followed for forty-eight months and were observed for the development of chronic musculoskeletal conditions, behavioral health disorders, and inability to remain in active service as indicated by the findings of the Physical Evaluation Board. The influence of demographic factors, behavioral health conditions, and deployment-related musculoskeletal injuries on the capacity to remain in the military was assessed using Poisson multivariate analysis and receiver operating characteristic curves. RESULTS: The mean age of the cohort was twenty-seven years (range, eighteen to fifty-two years). One hundred and sixty-three soldiers sustained combat-related musculoskeletal trauma, and 587 soldiers had musculoskeletal injuries not related to battle. Three hundred and seventy-four soldiers (9%) were found to be unfit by the Physical Evaluation Board, with 236 soldiers (63%) referred for at least one musculoskeletal condition. Of these 236 soldiers, 116 (49%) also had a behavioral health diagnosis. Multivariate regression analysis revealed that junior enlisted rank (incidence rate ratio, 9.7 [95% confidence interval, 3.1 to 30.3]), senior enlisted rank (incidence rate ratio, 5.6 [95% confidence interval, 1.8 to 17.7]), behavioral health diagnosis (incidence rate ratio, 7.4 [95% confidence interval, 5.6 to 9.6]), age of eighteen to twenty-three years (incidence rate ratio, 1.6 [95% confidence interval, 1.2 to 2.3]), and male sex (incidence rate ratio, 2.5 [95% confidence interval, 1.2 to 5.0]) were significant predictors of referral to the Physical Evaluation Board for a musculoskeletal condition. A prognostic model developed using receiver operating characteristic curves and the risk factors of musculoskeletal injury, presence of a psychiatric condition, and lower rank explained 78% (95% confidence interval, 77% to 80%) of the risk of being found unfit by the Physical Evaluation Board. CONCLUSIONS: Musculoskeletal conditions, psychological diagnoses, and lower rank (socioeconomic status) were identified as potent predictors of inferior outcome in this study. Targeting at-risk patients within populations may improve results. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence.

The study sought to ascertain the incidence rates and risk factors for 30-day post-operative complications after primary total hip arthroplasty (THA). Complications were categorized as systemic or local and subcategorized as major or minor. There were 17,640 individuals who received primary THA identified from the 2006-2011 ACS NSQIP. The mortality rate was 0.35% and complications occurred in 4.9%. Age groups ≥ 80 years (P <0.001) and 70-79 years old (P = 0.003), and renal insufficiency (P = 0.02) best predicted mortality. Age ≥80 years (P <0.001) and cardiac disease (P = 0.01) were the strongest predictors of developing any postoperative complication. Morbid obesity (P <0.001) and operative time > 141 minutes (P <0.001) were strongly associated with the development of major local complications.

Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients.

BACKGROUND: The purpose of this investigation was to determine the incidence rates of, and identify risk factors for, thirty-day postoperative mortality and complications among more than 15,000 patients who underwent a primary unilateral total knee arthroplasty as documented in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). METHODS: The NSQIP database was queried to identify patients who had undergone primary unilateral total knee arthroplasty between 2006 and 2010. Patient demographics, medical history, and surgical characteristics were recorded, as were thirty-day postoperative complications, mortality, and length of hospital stay. Complications were divided into categories, which included major systemic complications (complications requiring complex medical intervention) and major local complications (including deep wound infection and peripheral nerve injury). Univariate testing and multivariate logistic regression analysis were used to identify significant independent predictors of the outcome measures. RESULTS: A total of 15,321 individuals underwent primary unilateral total knee arthroplasty. The mean age (and standard deviation) of the patients was 67.3 ± 10.2 years. Obesity (a body mass index [BMI] of ≥30 kg/m²) was documented in 61.2% of cases, 18.2% of patients had diabetes, and 50% were graded as Class 3 or higher on the basis of the American Society of Anesthesiologists (ASA) classification system. The thirty-day mortality rate was 0.18%, and 5.6% of the patients experienced complications. Patient age (odds ratio [OR] = 1.12; 95% confidence interval [CI] = 1.06 to 1.17) and diabetes (OR = 2.99; 95% CI = 1.35 to 6.62) were independent predictors of mortality. A BMI of ≥40 kg/m² was an independent predictor of postoperative complications (OR = 1.47; 95% CI = 1.09 to 1.98). Patient age of eighty years or older, an ASA classification of ≥3, and an operative time of >135 minutes influenced the development of any postoperative complication as well as major and minor systemic complications. Cardiac disease (OR = 4.32; 95% CI = 1.01 to 18.45) and a BMI of ≥40 kg/m² (OR = 2.01; 95% CI = 1.02 to 3.97) were associated with minor local complications. CONCLUSIONS: Patient age and diabetes increased the risk of mortality after primary total unilateral knee arthroplasty. Predictive factors impacting the development of postoperative complications included an ASA classification of ≥3, increased operative time, increased age, and greater body mass.

Non-emergent orthopaedic injuries sustained by soldiers in Operation Iraqi Freedom.

BACKGROUND: The majority of soldiers deployed to the theater of combat operations return safely after completion of the deployment. Many of these soldiers sustain non-emergent musculoskeletal injuries that initially are treated nonoperatively and ultimately require surgery following their combat tour. METHODS: A prospective evaluation of the orthopaedic surgery consultations and surgical procedures required by soldiers returning from a full combat deployment was performed. Demographic information (including age and sex) as well as information on the mechanism of injury, the reason for orthopaedic consultation, and the procedures performed was collected for each soldier. The overall incidence of non-emergent orthopaedic injuries was calculated, and multivariate Poisson regression analysis was utilized to determine the effect of age and sex on the type of orthopaedic injury sustained. RESULTS: There were 3787 soldiers who returned from combat operations at the end of a fifteen-month deployment without having been medically evacuated. There were 731 orthopaedic surgical consultations for the evaluation of a non-emergent musculoskeletal complaint, and 140 orthopaedic operations were performed as a result. An age of thirty years or more was an important risk factor for requiring an orthopaedic consultation (p < 0.0001). The most common surgical procedures were performed for shoulder stabilization, for superior labrum anterior to posterior lesion repair, for the treatment of internal derangement of the knee, and for the treatment of foot deformity. CONCLUSIONS: Nineteen percent of all soldiers who completed a combat deployment required an orthopaedic surgical consultation on return, and 4% of soldiers required orthopaedic surgery. More than half of the surgical procedures involved the knee or shoulder. This represents a large burden of care for returning soldiers on orthopaedic surgical services and has important implications for future resource utilization.

Characterization of combat-related spinal injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom.

BACKGROUND CONTEXT: The United States is presently engaged in the largest scale armed conflict since Vietnam. Despite recent investigations into the scope of injuries sustained by soldiers in Iraq and Afghanistan, little information is available regarding the incidence and epidemiology of spine trauma in this population. PURPOSE: Characterize the incidence and epidemiology of spinal injuries sustained during combat by soldiers of a US Army Brigade Combat Team (BCT) that participated in Operation Iraqi Freedom. STUDY DESIGN: Descriptive epidemiologic study. PATIENT SAMPLE: A total of 4,122 soldiers who served in Iraq with an Army BCT during "The Surge" operation. OUTCOME MEASURES: Spine injury epidemiology was calculated for the BCT, including the spine combat casualty rate, and percent medically evacuated (MEDEVAC). METHODS: Unit rosters were obtained, and a comprehensive database identifying all combat-related spine injuries was created by querying each soldiers' electronic medical record and the unit's casualty rosters. Demographic information was recorded including age, sex, rank, injury mechanism, presence of polytrauma, and injury outcome. Injury outcomes were classified as killed in action, died of wounds, MEDEVAC, or returned to duty. The incidence of spine injuries was determined, and epidemiology was characterized using calculations of the spine combat casualty rate and percent MEDEVAC. Comparisons were made to published reports from previous conflicts. RESULTS: A total of 29 soldiers sustained 31 combat-related spine injuries. These accounted for 7.4% (29 out of 390) of all casualties sustained during combat. Blunt trauma to the spine, often resulting from an explosive mechanism, was encountered in 65% of cases. Closed fractures of the spine occurred in 21% of casualties and open injuries occurred in 7%. The spine combat casualty rate was 5.6 out of 1,000 soldier combat-years, and the percent MEDEVAC was 19%. CONCLUSIONS: This investigation is the first of its kind, documenting the nature of spine trauma in a major American conflict. The incidence of spine injuries in this study is the highest ever documented and is indicative of the tactics used by the enemy in the current war. Given this fact, it is likely that the prevalence of combat-related spine trauma will increase in the future. Larger, more extensive, studies of this kind must be conducted in the future.

Burden of musculoskeletal disease and nonbattle nontraumatic injury in both war and disaster zones.

Disasters, both man-made and natural, are a known cause of morbidity and mortality among vulnerable populations. The initial phase of public health response typically addresses immediate traumatic injury or death in the wake of a disaster. However, little is known about the magnitude and cost of subsequent nontraumatic injury and illness in disaster zones. Known as ``the hidden epidemic,'' the incidence and epidemiology of disease and nonbattle injuries among military service members in deployed settings has been more extensively investigated and may serve as a proxy for the evaluation of civilian populations following natural disaster. Further, prior reports from the military setting may serve to inform the broader population on the ultimate burden of nontraumatic injury and illness in recent disasters, particularly as they relate to musculoskeletal health.

HNO and NO release from a primary amine-based diazeniumdiolate as a function of pH.

The growing evidence that nitroxyl (HNO) has a rich pharmacological potential that differs from that of nitric oxide (NO) has intensified interest in HNO donors. Recently, the diazeniumdiolate (NONOate) based on isopropylamine (IPA/NO; Na[(CH(3))(2)CHNH(N(O)NO)]) was demonstrated to function under physiological conditions as an organic analogue to the commonly used HNO donor Angeli's salt (Na(2)N(2)O(3)). The decomposition mechanism of Angeli's salt is dependent on pH, with transition from an HNO to an NO donor occurring abruptly near pH 3. Here, pH is shown to also affect product formation from IPA/NO. Chemical analysis of HNO and NO production led to refinement of an earlier, quantum mechanically based prediction of the pH-dependent decomposition mechanisms of primary amine NONOates such as IPA/NO. Under basic conditions, the amine proton of IPA/NO is able to initiate decomposition to HNO by tautomerization to the nitroso nitrogen (N(2)). At lower pH, protonation activates a competing pathway to NO production. At pH 8, the donor properties of IPA/NO and Angeli's salt are demonstrated to be comparable, suggesting that at or above this pH, IPA/NO is primarily an HNO donor. Below pH 5, NO is the major product, while IPA/NO functions as a dual donor of HNO and NO at intermediate pH. This pH-dependent variability in product formation may prove useful in examination of the chemistry of NO and HNO. Furthermore, primary amine NONOates may serve as a tunable class of nitrogen oxide donor.

Epidemiology of psychiatric disorders sustained by a U.S. Army brigade combat team during the Iraq War.

OBJECTIVE: This study was designed to describe the epidemiology of psychiatric illnesses experienced by soldiers in a combat environment, which has been previously underreported. METHODS: A U.S. Army brigade combat team deployed to Iraq during the Iraq War "Troop Surge" was followed by reviewing unit casualty rosters and electronic medical records for psychiatric diagnoses made by treating providers. The main outcome was the incidence rates of psychiatric disease and nonbattle injury (DNBI). RESULTS: Of the 4122 soldiers deployed, there were 308 psychiatric DNBI casualties (59.8 per 1000 soldier combat-years), which represented 23% of all DNBIs and was second only to musculoskeletal injuries (50% of all DNBI). Most psychiatric DNBI (88%) were treated in theater and returned to duty, 11% were medically evacuated and 1% died. Junior enlisted soldiers, compared with junior officers, and women, compared with men, were at a significantly increased risk for becoming a psychiatric DNBI casualty (77.3 vs. 32.2 per 1000 combat-years, P<.002 and 110.8 vs. 55.4 per 1000 combat-years P<.05, respectively). CONCLUSIONS: Psychiatric diagnoses are second only to musculoskeletal injuries as a cause for DNBIs sustained in the current combat environment. Most can be treated in theater and permit soldiers to return to duty.

Combat musculoskeletal wounds in a US Army Brigade Combat Team during operation Iraqi Freedom.

BACKGROUND: A prospective, longitudinal analysis of musculoskeletal combat injuries sustained by a large combat-deployed maneuver unit has not previously been performed. METHODS: A detailed description of the musculoskeletal combat casualty care statistics, distribution of wounds, and mechanisms of injury incurred by a US Army Brigade Combat Team during "The Surge" phase of Operation Iraqi Freedom was performed using a centralized casualty database and an electronic medical record system. RESULTS: Among the 4,122 soldiers deployed, there were 242 musculoskeletal combat wounds in 176 combat casualties. The musculoskeletal combat casualty rate for the Brigade Combat Team was 34.2 per 1,000 soldier combat-years. Spine, pelvis, and long bone fractures comprised 55.9% (33 of 59) of the total fractures sustained in combat. Explosions accounted for 80.7% (142 of 176) of all musculoskeletal combat casualties. Musculoskeletal combat casualty wound incidence rates per 1,000 combat-years were as follows: major amputation, 2.1; minor amputation, 0.6; open fracture, 5.0; closed fracture, 6.4; and soft-tissue/neurovascular injury, 32.8. Among musculoskeletal combat casualties, the likelihood of a gunshot wound causing an open fracture was significantly greater (45.8% [11 of 24]) when compared with explosions (10.6% [15 of 142]) (p = 0.0006). Long bone amputations were more often caused by explosive mechanisms than gunshot wounds. CONCLUSIONS: A large burden of complex orthopedic injuries has resulted from the combat experience in Operation Iraqi Freedom. This is because of increased enemy reliance on explosive devices, the use of individual and vehicular body armor, and improved survivability of combat-injured soldiers.

Disease and nonbattle injuries sustained by a U.S. Army Brigade Combat Team during Operation Iraqi Freedom.

BACKGROUND: A longitudinal cohort analysis of disease nonbattle injuries (DNBI) sustained by a large combat-deployed maneuver unit has not been performed. METHODS: A descriptive analysis was undertaken to evaluate for DNBI casualty care statistics incurred by a U.S. Army Brigade Combat Team (BCT) during a counterinsurgency campaign of Operation Iraqi Freedom. RESULTS: Of the 4,122 soldiers deployed, there were 1,324 DNBI with 5 (0.38%) deaths, 208 (15.7%) medical evacuations (MEDEVAC), and 1,111 (83.9%) returned to duty. The DNBI casualty rate for the BCT was 257.0/1,000 soldier combat-years. Females, compared with males, had a significantly increased incidence rate ratio for becoming a DNBI casualty 1.67 (95% CI 1.37, 2.04). Of 47 female soldiers receiving MEDEVAC 35 (74%) were for pregnancy-related issues. Musculoskeletal injuries (50.4%) and psychiatric disorders (23.3%) were the most common body systems involved with DNBI casualties. Among the BCT cohort the psychiatric DNBI casualty rate and suicide rate were 59.8 and 0.58 per 1,000 soldier combat-years. The BCT cohort incidence rates for common musculoskeletal injuries per 1,000 combat-years were as follows: ankle sprain 15.3, anterior cruciate ligament rupture 3.3 and shoulder dislocation 1.2. CONCLUSIONS: Musculoskeletal injuries and psychiatric disorders accounted for 74% of the total DNBI casualties, and 43% of the DNBI casualties requiring subsequent MEDEVAC. The BCT cohort had a suicide rate nearly four times greater than previously reported, and selected musculoskeletal injury incidence rates were fivefold greater than the general population.

Incidence and epidemiology of combat injuries sustained during "the surge" portion of operation Iraqi Freedom by a U.S. Army brigade combat team.

BACKGROUND: A prospective, longitudinal analysis of injuries sustained by a large combat-deployed maneuver unit has not been previously performed. METHODS: A detailed description of the combat casualty care statistics, distribution of wounds, and mechanisms of injury incurred by a U.S. Army Brigade Combat Team during "The Surge" phase of Operation Iraqi Freedom was performed using a centralized casualty database and an electronic medical record system. RESULTS: Among the 4,122 soldiers deployed, there were 500 combat wounds in 390 combat casualties. The combat casualty rate for the Brigade Combat Team was 75.7 per 1,000 soldier combat-years. The % killed in action (KIA) was 22.1%, and the %died of wounds was 3.2%. The distribution of these wounds was as follows: head/neck 36.2%, thorax 7.5%, abdomen 6.9%, and extremities 49.4%. The percentage of combat wounds showed a significant increase in the head/neck region (p < 0.0001) and a decrease in the extremities (p < 0.03) compared with data from World War II, Korea, and Vietnam. The percentage of thoracic wounds (p < 0.03) was significantly less than historical data from World War II and Vietnam. The %KIA was significantly greater in those soldiers injured by an explosion (26.3%) compared with those soldiers injured by a gunshot wound (4.6%; p = 0.003). Improvised explosive devices accounted for 77.7% of all combat wounds. CONCLUSIONS: There was a significantly higher proportion of head/neck wounds compared with previous U.S. conflicts. The 22.1% KIA was comparable with previous U.S. conflicts despite improvements in individual/vehicular body armor and is largely attributable to the lethality of improvised explosive devices. The lethality of a gunshot wound in Operation Iraqi Freedom has decreased to 4.6% with the use of individual body armor.

Long-term vaginal sequelae secondary to pediatric pelvic fracture.

BACKGROUND: Pediatric pelvic fractures often appear radiographically benign despite significant injury to viscera. Vaginal injuries are rare, and therefore require a high index of suspicion. CASE: A 26-year-old female patient who sustained a pelvic fracture in a motorcycle accident at the age of 10 presented with vaginal stenosis precluding sexual intercourse. Patient menstruated through a fistula in the distal vaginal vault. Radiographic and dye studies showed almost complete vaginal obstruction with heterotopic ossification. An extensive 30-year review of the literature was conducted looking for documented cases of vaginal injuries secondary to pelvic injury. SUMMARY AND CONCLUSION: This is the only recorded case of a long-term vaginal complication with subsequent heterotopic ossification secondary to pelvic fracture. Preventing debilitating long-term sequelae from vaginal injuries requires close patient follow-up and age-appropriate assessments.