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Purpose Combat-sustained peripheral nerve injuries (CSPNIs) are often the result of high-energy blast mechanisms and are increasing in frequency and severity among US forces engaged in contemporary warfare. The purpose of this study was to describe CSPNIs and report outcomes after evaluation in a military multidisciplinary peripheral nerve clinic. We hypothesized that a shorter time to evaluation by a multidisciplinary peripheral nerve team would improve outcomes. Methods The Peripheral Nerve Consortium (PNC) maintains an electronic database of all active duty service members who sustained a peripheral nerve injury (PNI) and were treated by the PNC between 2004 and 2009. This database was queried for service member demographic information, injury characteristics, wounding patterns, CSPNI description, surgical procedures, and Medical Research Council final motor and sensory outcome. Results Among the 104 service members treated by the PNC in the 6-year period reviewed, there were 138 PNIs. Average age was 27 years, time to initial evaluation by the PNC was 4 (±7) months, and average follow-up was 18 (±18) months. Associated injuries included fractures (31.1%), multiple PNIs (76.8%), vascular injury (30.4%), and traumatic brain injury (34.1%). There was no association between Sunderland classification and time to evaluation, mechanism of injury, or nerve injured. However, Sunderland classification was correlated with final motor and final sensory scores. Service members with better final sensory score (S1 or S2) had shorter time to initial evaluation than did patients with a final sensory score of S0 ( Conclusions Service members with more severe initial injuries had worse final outcomes. Although timely referral does not occur for most CSPNIs, a shorter time to presentation also led to improved sensory recovery. Complex combat-sustained PNIs may be best understood and treated within a multidisciplinary team. Type of study/level of evidence Prognostic IV.

Pediatric tibial nonunion following corrective osteotomy is a rare complication that is not well understood. While adult nonunions have been linked to endocrine and metabolic aberrations, this has not been established in a pediatric population. Pediatric tibial nonunion has been shown to respond to debridement with revision fixation using dynamic compression plating, supplementary bone graft, and fibular osteotomy to allow compression. Necessity of referral for metabolic and endocrinology workup remains unclear in the pediatric population, though inflammatory markers should be obtained in each case to rule out infection. We present three consecutive cases of pediatric tibial nonunion following osteotomy over a five-year period and discuss the management.

Background The purpose of this study was to determine if scapular anatomy differs between younger and older patients with atraumatic full-thickness supraspinatus tears. Methods The critical shoulder angle, acromial index and lateral acromial angle were measured on standardized radiographs of two groups of patients who underwent arthroscopic repair of full-thickness degenerative supraspinatus tears. Group 1 included 61 patients under the age of 50 years while Group 2 included 45 patients over the age of 70 years. The mean critical shoulder angle, acromial index, and lateral acromial angle were then compared. Results There was no significant difference between groups for the critical shoulder angle (p = .433), acromial index (p = .881) or lateral acromial angle (p = .263). Interobserver reliability for critical shoulder angle, acromial index, and lateral acromial angle was nearly perfect (interclass correlation coefficient 0.996, 0.996, 0.998, respectively). No significant correlation existed between age and critical shoulder angle (p = .309), acromial index (p = .484) or lateral acromial angle (p = .685). Discussion While the critical shoulder angle and acromial index were found to be high and in the typical range for patients with rotator cuff tears in both groups, there were no significant differences in acromial morphology between Groups 1 and 2.

What is the effect of placing the suspect in different positions in a sequential lineup? To explore this question, we developed and applied a model called the Independent Sequential Lineup model which analyzes a sequential lineup in terms of both identification position, the position at which the witness identifies a lineup item as the target, and target position, the position at which the target or suspect appears. We conducted a large-scale online eyewitness memory experiment with 7,204 participants each of whom was tested on a 6-item sequential lineup with an explicit stopping rule. The model fit these data well and revealed systematic effects of lineup position on underlying discriminability and response criteria. We also fit the model to data from a similar pair of experiments conducted recently by Wilson, Donnelly, Christenfeld and Wixted (2019; Journal of Memory and Language, 104, 108–125) both with and without application of a stopping rule. In all data sets, if a stopping rule is applied, underlying discriminability was found to be constant, or to increase slightly, across target position. In the absence of a stopping rule, discriminability was found to decrease substantially. We also observed a substantial increase in response criteria following presentation of the target. We discuss the implications of these findings for current theories of recognition memory and current applications of the sequential lineup in different jurisdictions.

Signed difference analysis (SDA), introduced by Dunn and James (2003), is used to derive testable consequences from a psychological model in which each dependent variable is presumed to be a monotonically increasing function of a linear or nonlinear combination of latent variables. SDA is based on geometric properties of the combination of latent variables that are preserved under arbitrary monotonic transformation and requires estimation neither of these variables nor of the monotonic functions. The aim of the present paper is to connect SDA to the mathematical theory of oriented matroids. This serves to situate SDA within an existing formalism, to clarify its conceptual foundation, and to solve outstanding conjectures. We describe the theory of oriented matroids as it applies to SDA and derive tests for both linear and nonlinear models. In addition, we show that state-trace analysis is a special case of SDA which we extend to models such as additive conjoint measurement where each dependent variable is the same unspecified monotonic function of a linear combination of latent variables. Lastly, we show how measurement error can be accommodated based on the model-fitting approach developed by Kalish et al. (2016).

Purpose To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. Methods A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. Results Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. Conclusions This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. Level of Evidence Level IV, systematic review and decision analysis.

PURPOSE This study evaluated the accuracy and interrater reliability of US Army physician assistants (PAs) in identifying ankle fracture patterns using existing classification schemes. METHODS Twenty-eight PAs reviewed criteria for stability, Danis-Weber, and Lauge-Hansen ankle fracture classification systems. Participants reviewed 45 ankle radiographs and independently rated each radiograph using these classification schemes. RESULTS Participants were able to successfully identify ankle fracture stability in 82.1% of cases (95% CI, 77.6, 86.6) with established criteria. Using the Danis-Weber classification, accurate classification was achieved in 77.8% of cases (95% CI, 72.8, 82.7). The Lauge-Hansen classification system was least reliable, with accuracy of 54.5% (95% CI, 46, 63). CONCLUSION Referring PAs can reliably discern unstable ankle fractures in more than 80% of cases. Lauge-Hansen classification was significantly less accurate than the Danis-Weber system or criteria for stability. Good communication between orthopedic surgeons and PAs and an emphasis on PA orthopedic education can improve patient care.

Hypothesis The purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability in an athletic population. Methods All US military service members who underwent LUCL reconstruction between 2008 and 2013 were identified. A retrospective chart review was performed, and the prospective Mayo Elbow Performance Score and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were obtained. The primary outcomes were return to preinjury activity and resolution of symptoms. Results We identified 23 patients with a mean age of 31.6 ± 7.2 years (range, 19-46 years), and 87% were men. A history of instability and/or dislocation was reported by 11 patients (48%), and 8 patients (35%) had undergone prior elbow surgery. At final follow-up of 4.6 ± 1.8 years (range, 2.2-7.6 years), all patients demonstrated significant decreases in pain (average pain score, 4 vs 1.34) with resolution of instability and achieved a functional arc of motion. After surgical reconstruction, 83% were able to return to prior activity, whereas 4 patients (17%) underwent medical separation, including 3 with elbow disability precluding continued service (13%). Overall 83% of patients reported good to excellent outcomes by the Mayo Elbow Performance Score, and 96% of patients reported no significant disability by the QuickDASH disability evaluation. Postoperatively, 4 patients (17%) experienced complications, with 3 (13%) requiring reoperation. Conclusion Although the diagnosis and surgical management of isolated LUCL injury are relatively infrequent, LUCL reconstruction for posterolateral rotatory instability offers a reliable return to preinjury level of function among active individuals with intense upper extremity demands. However, although function reliably improves, the rate of perioperative complications is greater than 15%.

The research described in this paper began with the goal to develop critical tests of the two-high-threshold model of memory. Based on initial findings by Kellen and Klauer (2014) , we focus on a ranking task in which one target and n − 1 foils are ranked in decreasing order of perceived likelihood of being the target. The resulting distribution of interest is the probability that the target is ranked in position k . We show that the two-high-threshold model predicts that the hazard function of this distribution increases monotonically for k > 1 . We generalize this result to the case in which each foil has a different probability of being detected under the model. These results are compared with two alternative models for recognition memory. The research exploring these issues has led us to an investigation of the Poisson-binomial distribution, showing that it too has a monotonically increasing hazard. In our opinion this finding is novel and significant because the Poisson binomial distribution can have many other applications outside of memory research and outside of psychology. In addition it is proved that any memory theory for the ranking task, which produces rank probabilities that form a strictly log-concave sequence, predicts a monotonically increasing hazard function. The hazard function for the ranking task for a single experimental condition thus enables a critical test for a potentially large class of memory theories other than just the two-high-threshold model.

Background: Radial head and neck fractures are the most common elbow fracture in the general adult population; however, the optimal treatment for radial head fractures remains a topic of ongoing clinical controversy. The purpose of this study was to determine the rate of return to function, complications, and reoperation following operative management of unstable radial head fractures in a young, active patient population with intense upper extremity demands. Methods: A military health care database was queried for all US military servicemembers undergoing open reduction with internal fixation (ORIF; Current Procedural Terminology [CPT] code: 24665) and radial head arthroplasty (RHA; CPT code: 24666) between 2010 and 2015. All patients with minimum 2-year follow-up were included. Univariate and chi-square analyses were performed to evaluate the association between potential risk factors and the primary outcome measures. Results: A total of 67 ORIF (n = 69 elbows) and 10 RHA patients were included. The average age was 31 ± 8.0 years. At mean follow-up of 3.5 ± 1.1 years, 90% of patients overall were able to return to active military service, 96% of which with unrestricted upper extremity function. Nearly one-third (31.2%) of patients developed at least 1 postoperative complication. RHA has higher overall complication rates (70% vs 48%) when compared with ORIF, but this finding did not reach statistical significance ( P = .073). However, RHA had significantly higher rates of implant failure (20% vs 2.9%, P = .0498). Seventeen (21%) individuals required reoperation, 5 of which (6.3%) were revision procedures. Dislocation, coronoid fracture, and concomitant ligamentous repair portended a significantly increased risk of sustaining 1 or more complications ( P < .05), while dislocation and requirement for ligamentous repair independently predicted revision surgery ( P < .05). Conclusions: Arthroplasty and ORIF are both viable options for treating unstable radial head fractures in a young, athletic population, offering comparable return to function despite increased complications with RHA.

Background: Carpal tunnel syndrome (CTS) is a common occupational pathology, representing a high percentage of workers’ compensation (WC) claims. Methods: The literature was reviewed for all studies evaluating CTS outcomes including WC patients between 1993 and 2016. A total of 348 articles were identified; 25 of which met inclusion and exclusion criteria. A systematic review was generated; patient demographics, outcomes, and complications were recorded. Weighted averages were calculated for the demographic and outcome data. Categorical data such as complications were pooled from the studies and used to determine the overall complication rate. Statistical significance was determined between WC and non-WC cohorts when applicable with the chi-square statistic. Results: The WC cohort included 1586 wrists, and the non-WC cohort included 2781 wrists. The WC cohort was younger and more often involved the dominant extremity. The WC cohort was less likely to have appropriate physical exam findings confirming diagnosis and electrodiagnostic studies. WC patients took almost 5 weeks longer to return to work, were 16% less likely to return to preinjury vocation, and had lower Standard Form (SF)-36 scores. Finally, WC patients had nearly 3 times the number of complications and nearly twice the rate of persistent pain. Conclusions: WC patients undergoing carpal tunnel release (CTR) fare poorly as compared with non-WC patients in nearly every metric. Higher rates of postoperative pain with delayed return to work can be anticipated in a WC cohort. In addition, WC patients receive suboptimal preoperative workup, and it is possible that unnecessary surgery is being completed in these cases. These findings are important to consider when treating the WC patient with CTS.

It is sometimes supposed that category learning involves competing explicit and procedural systems, with only the former reliant on working memory capacity (WMC). In 2 experiments participants were trained for 3 blocks on both filtering (often said to be learned explicitly) and condensation (often said to be learned procedurally) category structures. Both experiments (total N = 160) demonstrated that participants with higher WMC tended to be more accurate in condensation tasks, but not less accurate in filtering tasks. Furthermore, state-trace analysis did not find a differential influence of WMC on performance in these tasks. Finally, inspection of the mixture of response strategies at play across the 2 conditions and 3 blocks showed only a minor influence of WMC, and then only on later training blocks. The results provide no support for the existence of a "system" of category learning that is independent of working memory and are instead consistent with most single-system interpretations of category learning. (PsycINFO Database Record

Introduction. We performed a systematic review of the published literature to characterize patient demographic, surgical techniques, and functional outcomes to elucidate the complication and revision rates following isolated tibiotalar arthrodesis with anatomically contoured anterior plating. Methods. A comprehensive literature search was performed. Inclusion criteria were peer-reviewed studies in English, after 1990, at least 10 patients, and reporting clinical outcomes following contoured anterior plating and with follow-up of at least 80% and 1 year. Primary outcomes were fusion rate, time to fusion, return to activities, satisfaction, and functional outcome scores. Complication rates, reoperation, and revision were also extracted. Results. Eight primary studies with 164 patients met the inclusion criteria. The average sample size was 21 ± 10.0 patients and average age was 49.2 years with 61.6% male. Posttraumatic arthritis (49.4%) was the most common operative indication, followed by primary osteoarthrosis (18.9%). The average follow-up was 21.1 months. At this time, 97.6% of patients went on to uneventful union at a weighted average time of 18.7 weeks postoperatively. AOFAS scores improved significantly ( P < .05). 25% complication rate was reported with wound complication (7.9%) and hardware irritation (6.7%) most common. Overall, 21.3% of patients underwent reoperation; 4 for revision arthrodesis following nonunion. Conclusion. Isolated tibiotalar arthrodesis utilizing anatomically contoured anterior plating demonstrates excellent clinical and functional outcomes at short-term follow-up. Overall, 97.6% of patients went on to fusion and functional outcomes consistently improved following surgery. Furthermore, while one-quarter of patients experienced complications, wound complications were relatively uncommon and less than one-quarter of these required surgical intervention. Levels of Evidence: Level IV: Systematic Review

Scaphoid fractures are common injuries which traditionally have been treated with long periods of immobilization even after open reduction and internal fixation (ORIF). The purpose of this pilot investigation was two-fold: 1) describe a precise postoperative Early Active Motion (EAM) rehabilitation protocol following ORIF of scaphoid fractures and 2) record the outcomes of the EAM protocol. Eight consecutive patients having undergone ORIF of the scaphoid were enrolled in the EAM and followed for a minimum of 1 year. At 12 weeks, Disabilities of the Arm Shoulder and Hand (DASH) score, Mayo Wrist score, and range of motion values were obtained. At 1 year, a telephone survey was conducted and several data points were obtained including DASH and Mayo Wrist score, number of push-ups, satisfaction with surgery and ability to remain on active duty. All 8 patients were male, on active duty, with an average age of 26 years. Two patients used tobacco products and none had major health problems. All patients completed the EAM protocol and obtained CT; all CT exams demonstrated healing at 8 weeks. At 12 weeks postoperatively, the average DASH score was 8.8±16 (range: 0-47.5), Mayo wrist score was 88±10 (range: 75-100) and range of motion nearly symmetrical. At a mean final follow-up of 15.4 months postoperatively, the average DASH score was 1.1±1.7 (Range: 0-4.5), Mayo wrist score was 97.5±4 (range 90-100), average number of push-ups was 57 (40-70) at the prior Army Physical Fitness Test. All patients were satisfied with surgery and all remained on active duty at 1 year. There were no reported complications. The EAM protocol following scaphoid fracture ORIF is safe and effective. The EAM can reliably return patients back to high demand activity earlier than a traditional protocol.

Background: Posterior interosseous nerve neurectomies (PINN) are an option in the treatment of chronic dorsal wrist pain. However, the literature describing PINN consists primarily of small case series, and the procedure is typically done as an adjunct treatment; therefore, the outcomes of the PINN itself are not well known. We performed a systematic review of the literature to provide characteristics of patients following a PINN. Methods: A systematic review of the literature was performed. Papers published in the PubMed database in English on isolated PINN were included. Articles in which a PINN was performed as an adjunct were excluded. Primary outcomes were return to work, patient satisfaction, pain/function scores, wrist range of motion, complications, and pain recurrence. Weighted averages were used to calculate continuous data, whereas categorical data were noted in percentages. Results: The search yielded 427 articles including 6 studies and 135 patients (136 cases). The average age was 43.6 years (range, 17-75), and most patients were female (54.1%). At an average final follow-up of 51 months, 88.9% of patients were able to return to work. After initial improvement, a recurrence of pain occurred in 25.5% of patients at an average of 12.3 months. Excluding recurrence of pain, the complication rate was 0.9%, including 1 reflex sympathetic dystrophy. Overall, 88.4% of patients experienced a subjective improvement and were satisfied with the procedure. Conclusions: Isolated PINN have shown excellent clinical outcomes, with few patients experiencing recurrent pain at long-term follow-up. PINN can provide relief in patient’s chronic wrist pain.

We present a state-trace analysis of sentence ratings elicited by asking participants to evaluate the overall acceptability of a sentence and those elicited by asking participants to focus on structural well-formedness only. Appealing to literature on “grammatical illusion” sentences, we anticipated that a simple instruction manipulation might prompt people to apply qualitatively different kinds of judgment in the two conditions. Although differences consistent with the subjective experience of grammatical illusion dissociations were observed, the state trace analysis of the rating data indicates that responses were still consistent with both judgment types accessing a single underlying factor. These results add to the existing comparisons between analytic and probabilistic modeling approaches to predicting rating judgments.

Background The study sought to assess the patient-based variables, surgical risk factors, and postoperative conditions associated with readmission after total wrist arthroplasty (TWA). Materials and Methods All patients undergoing TWA were identified from the National Surgical Quality Improvement Program dataset from 2005 to 2016. Patient demographics, medical comorbidities, surgical characteristics, and outcomes were examined to isolate predictors for readmission within 30 days postoperatively. Results A total of 57 patients were identified to have undergone TWA. The average patients were 62.3 (13.8) years old, female (57.7%), and most were treated in the outpatient setting (67.3%). Comorbid conditions included smoking (17.3%), diabetes (15.4%), and chronic steroid therapy (15.4%). No complications were identified in the 30-day postoperative period. There was a trend for increasing utilization of TWA over the years included. Conclusion TWA is a safe procedure with low complication rates in the acute postoperative period. Increasing utilization is likely a result of improved outcomes and cost-effectiveness of TWA. Level of Evidence This is a Level II, prognostic study.

The objective of this analysis was to compare the efficiency of scholarly activity withinmilitary orthopaedic training programs. The authors obtained the lists of abstracts accepted for presentation at the 2009 through 2014 Society of Military Orthopaedic Surgeons (SOMOS) annual meetings. Data were extracted for each individual presentation. Three primary groups were compared: a traditional program, a research program, and a hybrid program. The hybrid program produced the highest percentage of the presentations (28.6%). The traditional program contributed the most presentations (3.32) and publications (2.16) per resident and had the highest publication rate (87.7%) and the shortest time to publication (14.4 months). The research program published in the highest average impact journals (3.2). The addition of a research year does not improve the number of academic presentations or published papers but may improve the impact factor of the journals in which the projects are published. (Journal of Surgical Orthopaedic Advances 28(3):175-179, 2019).

Purpose This study presents patient demographics, injury characteristics, outcomes, and complications associated with dorsal bridge plating (DBP) in the treatment of distal radius fractures . Methods A literature search performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines identified 206 articles, 12 of which met inclusion criteria, accounting for 310 patients. Included articles contained the results of DBP for treatment of distal radius fractures with reported outcomes between 1988 and 2018. Data were pooled and analyzed focusing on patient demographics, as well as 3 primary outcomes of complications, range of motion (ROM), and Disabilities of the Arm, Shoulder, and Hand (DASH) and QuickDASH scores. Results Average age was 55 years, median follow-up was 24 months, and the most common use was in comminuted (92%) intra-articular (92%) distal radius fracture caused by fall (58%), or motor vehicle collision or motorcycle collision (27%). A minority of patients had open fractures (16%) and most were cases of polytrauma (65%). Median time from placement to DBP removal was 17 weeks (mean, 119 days). At final follow-up, mean wrist ROM was 45° flexion, 50° extension, 75° pronation , and 73° supination . Mean DASH score was 26.1, and mean Quick DASH score was 19.8. The overall rate for any complication was 13%; the most common was hardware failure (3%) followed by symptomatic malunion or nonunion (3%), and persistent pain after hardware removal (2%). Conclusions Dorsal bridge plating was found to be used most commonly in intra-articular, comminuted distal radius fractures with overall functional wrist ROM, moderate patient-reported disability, and a 13% complication rate at follow-up. Type of study/level of evidence Therapeutic IV.

Four experiments examined the claims that people can intuitively assess the logical validity of arguments, and that qualitatively different reasoning processes drive intuitive and explicit validity assessments. In each study participants evaluated arguments varying in validity and believability using either deductive criteria (logic task) or via an intuitive, affective response (liking task). Experiment 1 found that people are sensitive to argument validity on both tasks, with valid arguments receiving higher liking as well as higher deductive ratings than invalid arguments. However, the claim that this effect is driven by logical intuitions was challenged by the finding that sensitivity to validity in both liking and logic tasks was affected in similar ways by manipulations of concurrent memory load (Experiments 1 and 2) and variations in individual working memory capacity (Experiments 3 and 4). In both tasks better discrimination between valid and invalid arguments was found when more working memory resources were available. Formal signal detection models of reasoning were tested against the experimental data using signed difference analysis (Stephens, Dunn, & Hayes, 2018b). A single-process reasoning model which assumes that argument evaluation in both logic and liking tasks involves a single latent dimension for assessing argument strength but different response criteria for each task, was found to be consistent with the data from each experiment (as were some dual-process models). The experimental and modeling results confirm that people are sensitive to argument validity in both explicit logic and affect rating tasks, but that these results can be explained by a single underlying reasoning process. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

All patients undergoing open reduction and internal fixation of a distal radius fracture (DRF) between the years 2010 and 2015 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, respective surgical volume, outcome variables, and complications were extracted. The primary outcomes were surgical time, hospital length of stay, and unplanned reoperation. A total of 6691 patients were included in the study, the majority of whom were treated by orthopaedic surgeons. While there were no significant differences in baseline demographics between the patients treated by orthopaedic and plastic surgeons, the overall operative time was significantly less for DRFs fixed by orthopaedic surgeons. While there was a significant difference for extra-articular fractures, this difference increased significantly for complex intra-articular fractures. Additionally, hospital length of stay was significantly shorter for patients treated by orthopaedic surgeons. To produce well-rounded, technically skilled surgeons, plastic surgery programs should incorporate fixation principles into their training programs. (Journal of Surgical Orthopaedic Advances 28(1):53-57, 2019).

Bastin et al. propose a dual-process model to understand memory deficits. However, results from state-trace analysis have suggested a single underlying variable in behavioral and neural data. We advocate the usage of unidimensional models that are supported by data and have been successful in understanding memory deficits and in linking to neural data.

Background:. Since the civil war, combat sustained peripheral nerve injuries (CSPNI) have been documented during wartime. Warfare has evolved and current combat involves a greater severity of blast injuries secondary to increased use of improvised explosive devices. The purpose of this study was to describe CSPNI and report outcomes after evaluation and treatment. We hypothesize that a shorter time to evaluation will improve outcomes. Methods:. A database including all active duty service members who sustained a CSPNI and were treated by the PNC between 2004 and 2009 was used. Service member demographic information, injury mechanism, CSPNI description, and Medical Research Council (MRC) final motor and sensory outcomes were queried from this database. Results:. One hundred and four military service members sustained 144 PNIs. The average age was 26.7 years, and nearly all were men (98.1%). There was no correlation between Sunderland classification and age, specific PNI, injury type, or time to evaluation. Higher Sunderland classifications were found to be correlated with worse final motor (r = 0.51, P < 0.001) and final sensory (r = 0.41, P < 0.001) scores. Final motor and sensory scores were not associated with specific nerve injury, mechanism of injury, initial EMG, or surgical procedure. Shorter time to initial assessment was associated with improved final motor and sensory scores, but was not found to be statistically significant. Conclusions:. As the complexity of CSPNIs progress as combat weaponry evolves, a firm understanding of treatment factors is important. Our study demonstrates in recent conflict that military service members’ initial injury severity is a key factor in expected outcome.

Background: Triceps tendon ruptures (TTR) are an uncommon injury. The aim of this systematic review was to classify diagnostic signs, report outcomes and rerupture rates, and identify potential predisposing risk factors in all reported cases of surgical treated TTR. Methods: A literature search collecting surgical treated cases of TTR was performed, identifying 175 articles, 40 of which met inclusion criteria, accounting for 262 patients. Data were pooled and analyzed focusing on medical comorbidities, presence of a fleck fracture on the preoperative lateral elbow x-ray film (Dunn-Kusnezov Sign [DKS]), outcomes, and rerupture rates. Results: The average age of injury was 45.6 years. The average time from injury to day of surgery was 24 days while 10 patients had a delay in diagnosis of more than 1 month. Renal disease (10%) and anabolic steroid use (7%) were the 2 most common medical comorbidities. The DKS was present in 61% to 88% of cases on the lateral x-ray film. Postoperatively, 89% of patients returned to preinjury level of activity, and there was a 6% rerupture rate at an average follow-up of 34.6 months. The vast majority (81%) of the patients in this review underwent repair via suture fixation. Conclusions: TTR is an uncommon injury. Risks factors for rupture include renal disease and anabolic steroid use. Lateral elbow radiographs should be scrutinized for the DKS in patients with extension weakness. Outcomes are excellent following repair, and rates of rerupture are low.

Background: Distal radius fractures represent a common fracture pattern frequently treated with volar locked plating for fixation. However, other methods may provide equivalent outcomes and minimize risks associated with the volar approach and hardware placement. One such method is the radial plate. Methods: After confirmation of institutional board review, we retrospectively reviewed data from 7 patients with our primary functional outcomes measured by Mayo wrist and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. The most recent radiographic and motion parameters were recorded. Results: Mean age at time of injury was 49 years (range, 19-68 years) with clinical follow-up of 81.6 months (range, 43.5-95.5 months). Five patients had good to excellent outcomes with a mean QuickDASH score of 0.92 for those patients. The mean QuickDASH score for all patients was 18.5. Mean radial height, inclination, and volar tilt were within 5% of the contralateral side. Standard deviation values for radiographic measures and clinical range of motion indicate significant variability in our data set. Conclusions: Although the results are mixed, our small cohort indicates radial plate fixation could provide a viable alternative to volar plate fixation of distal radius fractures. Further prospective investigation is warranted to better describe long-term outcomes using this technique.

This investigation sought to quantify incidence rates (IRs) and risk factors for primary and secondary (ie, posttraumatic) osteoarthritis (OA) of the knee in an active military population.We performed a retrospective review of United States military active duty servicemembers with first-time diagnosis of primary (International Classification of Disease, 9th Edition code: 715.16) and secondary (International Classification of Disease, 9th Edition code: 715.26) OA of the knee between 2005 and 2014 using the Defense Medical Epidemiology Database. IRs and 95% CIs were expressed per 1000 person-years, with stratified subgroup analysis adjusted for sex, age, race, military rank, and branch of military service. Relative risk factors were evaluated using IR ratios and multiple regression analysis.A total of 21,318 cases of OA of the knee were identified among an at-risk population of 13,820,906 person-years for an overall IR of 1.54 per 1000 person-years, including 19,504 cases of primary (IR: 1.41) and 1814 cases of secondary OA (IR: 0.13). The IRs of both primary and secondary OA increased significantly from 2005 to 2014. Increasing age (P.0001); black race (P.001); senior military rank (P.0001); and Army, Marines, and Air Force services (P.0001) were significantly associated with an increased risk for knee OA.This study is the first large-scale report of knee OA in a young athletic population. An increasing incidence and several risk factors for knee OA were identified, indicating a need for better preventative strategies and forecasting the increased anticipated demands for knee arthroplasty among US military servicemembers.

Introduction. Structural fresh osteochondral allograft transfer is an appropriate treatment option for large osteochondral lesions of the talus (OLTs), specifically lesions involving the shoulder of the talus. Sparse literature exists regarding functional outcome following this surgery in high-demand populations. Materials and Methods. Over a 2-year period, a single surgeon performed 8 structural allograft transfers for treatment of large OLTs in an active duty US military population. Lesion morphology and magnetic resonance imaging (MRI) stage were recorded. Preoperative and latest postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and pain visual analog scores were compared. Results. Eight male service members with mean age 34.4 years underwent structural allograft transfer for OLTs with mean MRI stage of 4.9 and a mean lesion volume of 2247.1 mm3. Preoperative mean AOFAS hindfoot-ankle score was 49.6, and mean pain visual analog score was 6.9. At mean follow-up of 28.5 months, postoperative mean AOFAS score was 73, and mean pain visual analog score was 4.5, representing overall improvements of 47% and 35%, respectively. Three patients were considered treatment failures secondary to continued ankle disability (2) or graft resorption requiring ankle arthrodesis. Conclusions. Despite modest improvements in short-term functional outcome scores, large osteochondral lesions requiring structural allograft transfer remain difficult to treat, particularly in high-demand patient populations. Surgeons should counsel patients preoperatively on realistic expectations for return to function following structural allograft transfer procedures. Levels of Evidence: Level IV: Retrospective study

The purpose of this study was to investigate the incidence and type of metacarpal (MC) fractures in a military population, and whether these fractures are related to age, military occupational specialty, aggression, or accidental injury. A retrospective record-based review was conducted at a single military center over a 5-year period. Service members with index finger through small finger MC fracture were identified. Data were collected utilizing Armed Forces Health Longitudinal Technology Application and electronic profile (e-profile) databases. Data collected included demographic information, mechanism of injury, nature of injury, total number of visits, and estimated time on physical restriction. 400 patients met inclusion criteria. Males accounted for 94% of the study population, 75% of fractures were of the small finger MC, 54% of patients were between 20 and 24 years, 90% were sustained by junior enlisted personnel, and most occurred by punching. Men aged25 years were more likely to have intentional injuries. Total time on limited duty profile averaged 38 days and the average medically nondeployable profile was 26 days. MC fractures most commonly affect young, male, junior enlisted service members and are often self-inflicted. As a result, these injuries account for time lost at work, reduced job performance, and decreased medical readiness.

Background: The purpose of this systematic review is to analyze the indications, outcomes, and complications of scaphoid fixation with a staple. Methods: The literature was reviewed for all cases of the scaphoid staple. Five articles including 188 patients, of 77 primary scaphoid fractures and 111 other indications that included delayed union, nonunion, and avascular necrosis, were reviewed. Demographic data, outcomes, and complications were recorded. Results: The union rate of the scaphoid staple is 94.7%, and 95.7% of patients return to work after an average of 9.8 weeks after a 4.7-week period of immobilization. The complication rate was 9.0%, and 7.5% required hardware removal. Clinical and radiographic healing was higher in primary fractures as compared with other indications. Other indications, as compared with primary fracture, had a higher rate of hardware removal. Conclusions: For all indications, the scaphoid staple has a high union rate and a low complication rate. In the authors’ experience, the procedure is fast, not technically challenging, and may be considered for primary fracture, delayed union, nonunion, and avascular necrosis of the scaphoid.

Fractures of the fifth metacarpal neck, or boxer's fractures, are common, particularly among young men. Because of the high frequency of this injury, there is a considerable range of treatment options. The purpose of this systematic review was to determine whether reduction and splint or cast immobilization is necessary for fractures of the fifth metacarpal neck. The authors conducted a systematic review of all published studies that randomized these fractures to cast immobilization vs treatment with soft wrap without reduction. Cast immobilization is not superior to soft wrap without reduction in most cases. The study found that reduction and cast immobilization is not necessary for boxer's fractures. [ Orthopedics. 2016; 39(3):188–192.]

Introduction Tourniquet use has not been studied regarding specifically combat-intense military occupational specificities. This analysis examined the survivability, frequency of use, and nature of injuries in which tourniquets were employed among personnel in a single combat-specific military occupational specialty during combat operations. Methods Injuries sustained by the combat-specific soldier, the cavalry scout, from 2003 to 2011 were identified using the Joint Theater Trauma Registry. Basic demographic information, mechanism of injury, injury characteristics, and mortality were recorded. Results Of the 453 cavalry scouts wounded in action, 313 had adequate documentation upon arrival to a field hospital. Tourniquets were applied to 24 (7.7%) extremity wounds, 23 (96%) of these soldiers survived and one died of wounds (4.2%). Among those is in which tourniquets were used, there were seven (30%) senior enlisted and 16 (70%) junior enlisted soldiers with an average age of 24.8 years. Injuries were caused by gunshot wounds in 4 (17%), explosions in 18 (74%) and other mechanisms in two (8.3%). The primary reason for tourniquet application was open fracture ( n = 14, 61%), followed by vascular injury ( n = 5, 22%), and amputation ( n = 3, 13%). Other penetrating injuries were present in 19 (83%) of scouts. Conclusion The high survivability of patients transported with tourniquet in place underscores the importance of battlefield tourniquet application. Continued focus on education and equipping combat personnel with tourniquets is critical to survivability of the injured solider.

Introduction Musculoskeletal oncology is a subspecialty of orthopaedics with few fellowship-training locations. Although orthopaedic oncologists comprise a minority within the field of orthopaedic surgery, most work at academic centers and serve in leadership roles with notable impact on patients and the training of residents. This article investigates the objective impact orthopaedic oncologists have regarding resident operative case volume and performance on in-training examinations. Methods The William Beaumont Army Medical Center and Texas Tech University Health Sciences Center of El Paso combined orthopaedic residency program's case logs and Orthopaedic In-Training Examination (OITE) scores between 2013 and 2018 were reviewed. This provided 3 academic years of data before and after an orthopaedic oncology faculty member arrived in 2016. The case volume and OITE examination performance before and after the addition of the orthopaedic oncology faculty member were compared. Results After the addition of an orthopaedic oncology faculty member, a significant increase was observed in the program's OITE overall correctly answered questions (171.30 versus 181.03, P = 0.004) and oncology subsection percentile (56th to the 66th percentile, P = 0.038). An increase was also observed in resident oncology case volume from 29 oncology cases per year to 138 cases on average (P = 0.022). Discussion The addition of a fellowship-trained orthopaedic oncologist results in increased exposure to orthopaedic oncology cases and improved resident performance on the OITE. This may correlate to improved American Board of Orthopaedic Surgeons Part I pass rates and improved overall resident satisfaction.

Purpose To compile and review the indications, outcomes, and complications of capitolunate arthrodesis (CLA). Methods We performed a literature search identifying 33 articles, 6 of which met inclusion criteria, including 80 patients. Included publications contained the results of CLA with minimum 12-month follow-up between 2000 and 2018. Data were pooled and analyzed focusing on the primary outcomes of union and complications. Results Average age of patients was 48 years (range, 22–86 years), median follow-up was 34 months (range, 12–198 months), and most common indication was scaphoid nonunion advanced collapse (59%). Nearly half underwent a concomitant triquetrum excision (49%). Most patients were pain-free (78%) and returned to work (92%). Grip strength and visual analog pain scale both improved after CLA. Whereas 96% fused within a reported 42 to 210 days (median, 70 days), 11% of patients had complications including nonunion (3.8%) and loose hardware (6.3%). The reoperation rate was 14%, including wrist arthrodeses and wrist arthroplasty. Conclusions Capitolunate arthrodesis is a feasible option for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists with complications similar to those encountered in 4-corner arthrodesis. Type of study/level of evidence Therapeutic IV.

Background: There are no clearly defined guidelines from hand surgical societies regarding preoperative antibiotic prophylaxis. Many hand surgeons continue to routinely use preoperative prophylaxis with limited supporting evidence. This study aimed to determine for which scenarios surgeons give antibiotics, the reasons for administration, and whether these decisions are evidence-based. Methods: An anonymous 25-question survey was e-mailed to the 921-member American Society for Surgery of the Hand listserv. We collected demographic information; participants were asked whether they would administer antibiotics in a number of surgical scenarios and for what reasons. Respondents were broken into 3 groups based on when they said they would administer antibiotics: Group 1 (40 respondents) would give antibiotics in the case of short cases, healthy patients, without hardware; group 2 (9 respondents) would not give antibiotics in any scenario; and group 3 (129 respondents) would give antibiotics situationally. The Fisher exact test compared demographic variables, frequency of use, and indications of antibiotic prophylaxis. Results: Of the 921 recipients, 178 (19%) responded. Demographic variables did not correlate with the antibiotic use group. Operative case time >60 minutes, medical comorbidity, and pinning each increased antibiotic use. Group 1 respondents were more likely to admit that their practice was not evidence-based (74.4%) and that they gave antibiotics for medical-legal concern (75%). Twenty-two percent of respondents reported seeing a complication from routine prophylaxis, including Clostridium difficile infection. Conclusions: Antibiotics are still given unnecessarily before hand surgery, most often for medical-legal concern. Clear guidelines for preoperative antibiotic use may help reduce excessive and potentially inappropriate treatment and provide medical-legal support.

As the United States plunged into World War II, the surgeon general, Norman T. Kirk, scrambled to care for the complex hand injuries sustained in combat. To remedy this problem, Major General Kirk appointed Sterling Bunnell, a general surgeon and a World War I veteran with a keen interest in hand injuries, to serve as the consultant to the Secretary of War. Kirk and Bunnell formed 9 US military hand centers that treated 22,000 hand injuries in World War II. Bunnell and his pupils would later form the nucleus of the American Society for Surgery of the Hand. Through Dr. Bunnell’s expertise, skillful care, dedication to teaching, and love of country, US hand surgery was born.

De Quervain’s Tenosynovitis (DQT) is a common condition characterized by pain about the dorsal-radial aspect of the wrist, just proximal to the radial styloid. The condition is precipitated by a thickened first dorsal compartment and its tendons. The impression that DQT is caused from work-related injury is misdirected, as no study has established an association between hand usage at work or trauma with DQT. Physicians should exercise caution when discussing the causes and natural history of DQT with symptomatic patients.

Hypothesis The objective of this study was to compare the subjective and objective midterm functional clinical outcomes of subcutaneous anterior transposition (SAT) vs. in situ decompression (SD) of the ulnar nerve for the treatment of cubital tunnel syndrome. Methods The US Military Health System was queried to identify all cases of ulnar neuroplasty (Current Procedural Terminology code 64718) between 2006 and 2010. Patient charts were reviewed to identify cases of isolated SAT and SD, and demographic and surgical variables were collected. The primary outcome variable was the Disabilities of the Arm, Shoulder and Hand score. The inclusion criteria were isolated primary SAT or SD and adult active-duty service members with a minimum 6-year telephone follow-up. Terminal follow-up was determined by a telephone interview. The exclusion criteria were revision procedures, trauma, cases that included other procedures (eg, medial epicondylectomy, submuscular transposition, arthroscopy, or fracture fixation), non–active-duty service members, patients without a minimum 6-year telephone follow-up, and patients who had incomplete medical records or could not be reached to complete the survey. Results A total of 65 SD and 67 SAT patients met the inclusion and exclusion criteria, with a 72% telephone interview response rate. The average age was 32.3 years for all patients, with an average follow-up period of 6.5 years for SD patients and 6.3 years for SAT patients. SD patients had a lower mean Disabilities of the Arm, Shoulder and Hand score than SAT patients. No difference in reoperation rate was found. Conclusion The active-duty cohort reported positive outcomes and a low reoperation rate at 6-year follow-up both after SAT and after SD. SD patients had mildly superior clinical outcomes compared with SAT patients.

Due to increased gun availability/prevalence in current times, low-velocity firearm injuries have risen dramatically. This study describes the epidemiology of gunshot wounds (GSW) to the hand. We identified all patients (January 2005 - August 2015) who presented to our Level 1 trauma center with GSW's to the hand. Analysis of each record was performed to collect epidemiological variables. Cross-sectional analyses were performed to quantify the results. Following inclusion/exclusion criteria, 97 patients were selected. Individuals who sustained GSW's to the hand were typically male (93.8%) between the ages of 18 and 30 (48.5%). Injuries were mostly self-inflicted (81.4%), and isolated (89.7%) to the digits (55.7%) or metacarpals (35.1%) of the left hand (74.2%). Most were fired from BB/pellet guns (45.4%) or handguns (33.0%), while cleaning/loading them (65.1%). Over one-half of patients (58.8%) were uninsured. Surgery was required in 35.1% of patients. Patients shot with something other than a BB/Pellet gun (e.g., handgun, shotgun) required surgery significantly more than those shot with a BB/Pellet gun (P 0.0001). An odds ratio further describing this relationship was 0.13 (P = 0.0002), reflecting an 87% reduction in the odds of surgery for individuals shot by a BB/pellet vs. a different type of gun. The typical GSW to the hand involves a middle-aged male receiving an isolated injury to the digits or metacarpals of the left hand, from a BB/Pellet gun or handgun while they are cleaning/loading the firearm. Patients sustaining injury by a BB/pellet gun are least likely to require surgery.

Lower extremity nervous anatomy is highly variable. This study sought to determine relationships of lower extremity peripheral nerves to anatomic landmarks. Sixteen well-preserved lower extremities were dissected. The distance from each nerve point of interest to relevant landmarks was measured in standardized fashion. The sciatic nerve divided on average 26.0% ± 5% of the distance from the superior aspect of the fibula to the greater trochanter proximal to the knee joint line [Pearson correlation coefficient (PCC) D 0.764]. The superficial peroneal nerve pierced the crural fascia at an average of 28.0% ± 6% of the fibular length proximal to the lateral malleolus (PCC D 0.718). The deep peroneal nerve emerged between the tibialis anterior and extensor hallucis longus on average 2.7% ± 0.4% of the fibular length proximal to the tibiotalar joint line (PCC D 0.530). While there was substantial variability in the course of lower extremity peripheral nerves, the study found strong correlation with femur and fibula length within each specimen. (Journal of Surgical Orthopaedic Advances 26(4):206-210, 2017).

Medial ulnar collateral ligament (MUCL) reconstruction outcomes are well described in competitive throwers but not in nonthrowers. This investigation elucidated epidemiologic variables, functional outcomes, and prognostic factors after MUCL reconstruction in young active patients.United States military service members undergoing MUCL reconstruction were isolated using the Management Analysis and Reporting Tool (M2) database from 2009 to 2016. Demographics, injury characteristics, and surgical variables were extracted. Multivariate analysis was performed, discerning variables predictive of postoperative functional outcomes, complications, and reoperation.Sixty-six patients met inclusion criteria, and 47% participated in throwing sports. Of these, 36.4% reported a throwing mechanism of injury (MOI), 60.6% reported an acute trauma MOI, 59% reported preoperative ulnar nerve symptoms, and 39.4% experienced symptoms postoperatively. At final follow-up, average Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS) scores were 10.8 ± 16.2 and 87.6 ± 17.1, respectively. A total of 86.4% reported no disability (DASH 30), and 83.3% experienced good or excellent outcomes (MEPS74). Age 30 years, dominant arm injury, competitive throwing history, and throwing MOI correlated with improved DASH and MEPS scores, push-up count, postoperative pain and instability, and rates of ulnar nerve symptoms (P .05). Psychiatric diagnosis and preoperative stiffness and instability were associated with lower outcome scores (P .05). Ulnar nerve interventions did not correlate with presence or absence of postoperative ulnar nerve symptoms.MUCL reconstruction demonstrates a high good-to-excellent outcome rate and low complication and revision rates in young active individuals with intense upper extremity demands. Nonthrowing MOIs and psychiatric pathology are associated with postoperative complications and poorer outcomes.

Three-experiments examined the number of qualitatively different processing dimensions needed to account for inductive and deductive reasoning. In each study, participants were presented with arguments that varied in logical validity and consistency with background knowledge (believability), and evaluated them according to deductive criteria (whether the conclusion was necessarily true given the premises) or inductive criteria (whether the conclusion was plausible given the premises). We examined factors including working memory load (Experiments 1 and 2), individual working memory capacity (Experiments 1 and 2), and decision time (Experiment 3), which according to dual-processing theories, modulate the contribution of heuristic and analytic processes to reasoning. A number of empirical dissociations were found. Argument validity affected deduction more than induction. Argument believability affected induction more than deduction. Lower working memory capacity reduced sensitivity to argument validity and increased sensitivity to argument believability, especially under induction instructions. Reduced decision time led to decreased sensitivity to argument validity. State-trace analyses of each experiment, however, found that only a single underlying dimension was required to explain patterns of inductive and deductive judgments. These results show that the dissociations, which have traditionally been seen as supporting dual-processing models of reasoning, are consistent with a single-process model that assumes a common evidentiary scale for induction and deduction. (PsycINFO Database Record

State-trace analysis (STA) was introduced by Bamber (J Math Psychol 19(2):137–181, 1979) as a general method to determine properties of the latent structure that mediates the effects of one or more independent variables on two or more dependent variables. STA offers a principled way of adjudicating between theories proposing different numbers of latent variables under very general conditions and with minimal assumptions we introduce the concept of the general structure which provides a framework for representing the functional relationships between sets of independent, latent, and dependent variables. Within this framework, we distinguish between the observational structure that consists of the physical components that can be observed and the theoretical structure that consists of the theoretical components that must be inferred. We discuss the dimensionality of the state-trace and show how it can be used to infer properties of the theoretical structure. We derive the central idea of STA that the dimensionality of the theoretical structure—the number of latent variables—cannot be less than the dimensionality of the state-trace.

We demonstrate the application of STA to mixed designs with continuous dependent variables using the STACMR software package that we have developed. Mixed designs involve a combination of independent observations (“between-participants” or randomized factors) and related observations (“within-participants” or repeated measure factors) on continuous variables. We begin with the mixed design because of its generality—fully randomized and fully repeated measure designs are easily seen as special cases.