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Background: The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). Methods: A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. Results: The average duration of follow-up after amputation (and standard deviation) was 32 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p 0.005), and significantly more modified Ertl patients had delayed amputations (p 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. Conclusions: The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation., Published in the Journal of Bone and Joint Surgery of America, v95A n10 p888-893, 15 May 2013. Sponsored in part by the Military Amputee Intramural Research Program (MAIRP) via the Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD.

Concerning the past decade of war, three special topics were examined at the Extremity War Injuries VII Symposium. These topics included the implementation of tourniquets and their effect on decreasing mortality and the possibility of transitioning the lessons gained to the civilian sector. In addition, the training of surgeons for war as well as residents in a wartime environment was reviewed., Pub. in Journal of American Academy of Orthopaedic Surgeons, v20 n1, ps94-s08, 2012.

Background: Predictive models permitting individualized prognostication for patients with fracture nonunion are lacking. The objective of this study was to train, test, and cross-validate a native Bayesian classifier for predicting fracture-nonunion healing in a population treated with extracorporeal shock wave therapy. Methods: Prospectively collected data from 349 patients with delayed fracture union or a nonunion were utilized to develop a naive Bayesian belief network model to estimate site-specific fracture-nonunion healing in patients treated with extracorporeal shock wave therapy. Receiver operating characteristic curve analysis and tenfold cross-validation of the model were used to determine the clinical utility of the approach. Results: Predictors of fracture-healing at six months following shock wave treatment were the time between the fracture and the first shock wave treatment, the time between the fracture and the surgery, intramedullary stabilization, the number of bone-grafting procedures, the number of extracorporeal shock wave therapy treatments, work-related injury, and the bone involved (p < 0.05 for all comparisons). These variables were all included in the naive Bayesian belief network model. Conclusions: A clinically relevant Bayesian classifier was developed to predict the outcome after extracorporeal shock wave therapy for fracture nonunions. The time to treatment and the anatomic site of the fracture nonunion significantly impacted healing outcomes. Although this study population was restricted to patients treated with shock wave therapy, Bayesian-derived predictive models may be developed for application to other fracture populations at risk for nonunion., Investigation performed at the AUVA-Trauma Center, Meidling, Vienna, Austria; DecisionQ Corporation, Washington, DC; Walter Reed Army Medical Center, Washington, DC; and National Naval Medical Center, Bethesda, Maryland.. The original document contains color images. Published in Journal of Bone and Joint Surgery, v93 A p187-194, 19 Jan 2011.

Objectives: Delayed and nonunion of the tibia are not uncommon in orthopaedic practice. Multiple methods of treatment have been developed with variable results. The objective of this study was to define disease-specific and treatment-related factors of prognostic significance in patients undergoing shock wave therapy for tibia nonunion. Design: Retrospective analysis. Patients: One hundred ninety-two patients treated with extracorporeal shock wave therapy (ESWT) at a single referral trauma center, AUVA-Trauma Center Meidling, a large single-referral trauma center located in Vienna, Austria, in an attempt to determine the feasibility and factors associated with the use of ESWT in the treatment for tibia nonunion. Intervention: ESWT coupled with posttreatment immobilization, external fixation, or ESWT alone. Main Outcome Measures: Fracture healing, overall healing percent, and factors associated with ESWT success or failure. Results: At the time of last follow up, 138 of 172 ( 80.2%) patients have demonstrated complete fracture healing. Mean time from first shock wave therapy to complete healing of the tibia nonunion was 4.8 + or - 4.0 months. Number of orthopaedic operations (P = 0.003). shock wave treatments (P = 0.002), and pulses delivered (P = 0.04) were significantly associated with complete bone healing. Patients requiring multiple (more than one) shock wave treatments versus a single treatment had a significantly lower likelihood of fracture healing (P = 0.003). This may be attributable to the finding that a significantly greater proportion of patients with multiple rather than single ESWT treatments had three or more prior orthopaedic procedures (more than one ESWT, 63.9% versus one ESWT. 23.5%; p 0.001). Conclusions: ESWT is a feasible treatment modality for tibia nonunion., Published in Journal of Orthopaedic Trauma, v24 n3 p133-141, Mar 2010.