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ObjectiveField tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications.MethodsTwenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use.ResultsTourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application.ConclusionField tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

Operation BRAVA (Blast Resuscitation and Victim Assistance) was conceived as a means of conducting humanitarian assistance, education, and training in the acute surgical management of land mine and other blast injuries. The first Operation BRAVA mission was carried out in Sri Lanka during 1998 at a time of civil war between government forces and Tamil separatists. Thirty-seven patients with orthopedic war wounds were seen during this mission because of the fighting. Exploding ordnance injured 24 patients (65%), and 13 patients (35%) sustained gunshot wounds. Sixty-seven percent of explosive injuries were from mortar rounds, and the remainder was from a variety of detonating munitions. Twenty-two patients (59%) sustained injuries to one or both lower limbs, and compartment syndrome of the leg developed in two of these patients as a result of multiple fragment injuries. Nine patients (24%) sustained concomitant neurological or vascular injuries. Operation BRAVA provided a novel approach to enhancing the combat medical skills of U.S. military personnel and was successful in developing working relationships with host country medical professionals, facilitating participation in the care of wounded patients, and establishing a framework upon which future BRAVA teams might build. [ABSTRACT FROM AUTHOR]

Blast and fragment injuries of the musculoskeletal system are the most frequently encountered wounds in modern warfare. Most injuries to the musculoskeletal system involve so-called secondary blast injuries in which casing fragments and other debris become flying projectiles. Nonoperative treatment of selected wounds caused by small-fragment debris has been successful but remains controversial. Successful surgical treatment depends on meticulous wound débridement, with excision of nonviable tissue and foreign material likely to cause infection; adequate drainage; and delayed closure. Advanced internal fixation techniques used in modern trauma centers to treat predominantly blunt trauma may not be appropriate for care of orthopaedic war wounds in a field setting. [ABSTRACT FROM AUTHOR]

The complex anatomy of the posterolateral corner of the knee is due largely to the evolutionary changes in the anatomic relationships of the fibular head, the popliteus tendon, and the biceps femoris muscle. Recent research has improved our understanding of the popliteus complex, particularly the role of the popliteofibular ligament. Biomechanical studies provide a scientific basis for clinical examination of the knee with suspected injury of the posterolateral corner. All grade-I and most moderate grade-II injuries of the posterolateral structures can be treated nonoperatively, but residual laxity may remain, especially in knees with grade-II injury. Acute grade-III isolated or combined injury of the posterolateral corner is best treated early, by direct repair, if possible, or else by augmentation or reconstruction of all injured ligaments. Chronic injury of the posterolateral corner, whether isolated or combined, is probably best treated by reconstruction of the posterolateral corner along with reconstruction of any coexisting cruciate ligament injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a known tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. [ABSTRACT FROM AUTHOR]

The change in the distance of linear separation between each pair of osseous fiber attachment sites of the posterior cruciate ligaments was measured and plotted as a function of the knee flexion angle from 0 degrees to 120 degrees. Data were collected under four sequential test conditions that had in common quadriceps relaxation, absence of tibial rotation forces, and horizontal femoral stabilization. The posterior cruciate ligament fibers were intact or transected (excursion wires left intact) with gravitational joint distraction of the lower leg unconstrained or constrained. The small, posterior oblique fiber region was the most isometric of the four tested fiber regions. Progressively increasing deviations from isometry were seen in the posterior longitudinal, central, and anterior fiber regions, in that order. Transection of the posterior cruciate ligament, combined with unconstrained gravitational distraction of the knee joint, further increased the magnitude of deviation from isometry of the anterior and central fibers, but only changed the pattern of deviation for the more nearly isometric posterior fibers. Under simulated operative conditions, most of the posterior cruciate ligament's anatomic attachment sites exhibit nonisometric behavior, with near isometry demonstrated only by the relatively small posterior fiber attachment sites. If isometry alone is used for bone tunnel placement, the large anterior and central fiber regions will be left largely unreconstructed. Because the normal behavior of most of the fibers of the posterior cruciate ligament involves 4 to 6 mm of end-to-end length increase with progressive knee flexion, this pattern and degree of deviation from isometry should be sought to approximate an anatomic reconstruction of the anterocentral bulk of the ligament. [ABSTRACT FROM AUTHOR]

Purpose: This cross-sectional study investigates the utility of the quantitative ultrashort echo time (UTE) adiabatic T 1ρ (UTE-Adiab-T 1ρ ) magnetic resonance imaging (MRI) in detecting potential differences in Achilles tendons and entheses of patients with psoriatic arthritis disease (PsA) compared with asymptomatic volunteers., Material and Method: The Achilles tendons of forty-four PsA patients (59 ± 15 years old, 38 % female) and thirty-seven asymptomatic volunteers (32 ± 10 years old, 51 % female) were scanned on a 3 T clinical scanner in the sagittal plane using a 3-inch surface coil. The 3D UTE-Adiab-T 1ρ sequences with fat saturation (FS) were used to measure UTE-Adiab-T 1ρ . Tenderness of the tendons, the SF-12 health survey, and visual analog scale (VAS) were recorded for the patients. The Kruskal Wallis test was used to examine the differences in UTE-Adiab-T1 ρ values between asymptomatic volunteers and patients, as well as subgroups of patients with pain in the Achilles tendon region and those treated with Biologics. Spearman's correlation coefficients were calculated between UTE-Adiab-T 1ρ and patient evaluations. P values < 0.05 were considered significant., Results: UTE-Adiab-T 1ρ was significantly higher for the PsA group compared with the asymptomatic group in the enthesis (11.4 ± 2.6 ms vs. 10.4 ± 2.4 ms) and tensile tendon regions (9.8 ± 2.8 ms vs. 7.7 ± 1.7 ms). PsA patients with active Achilles pain showed significantly lower T1ρ in the entheses compared with other patients (10.7 ± 2.6 ms vs. 11.7 ± 2.5 ms). PsA patients treated with Biologics showed significantly lower T 1ρ values in the tendon compared with other patients (9.5 ± 2.5 ms vs. 10.3 ± 3.3 ms). The VAS score of patients showed a significant negative but weak correlation (R = -0.2) with UTE-Adiab-T1ρ of the enthesis. Correlations with SF-12 scores were not significant., Conclusion: This study highlighted the UTE-Adiab-T 1ρ sequence capability in evaluating tendons and entheses and their potential involvement in PsA disease or response to therapies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

We proposed an end-to-end deep learning convolutional neural network (DCNN) for region-of-interest based multi-parameter quantification (RMQ-Net) to accelerate quantitative ultrashort echo time (UTE) MRI of the knee joint with automatic multi-tissue segmentation and relaxometry mapping. The study involved UTE-based T1 (UTE-T1) and Adiabatic T1ρ (UTE-AdiabT1ρ) mapping of the knee joint of 65 human subjects, including 20 normal controls, 29 with doubtful-minimal osteoarthritis (OA), and 16 with moderate-severe OA. Comparison studies were performed on UTE-T1 and UTE-AdiabT1ρ measurements using 100%, 43%, 26%, and 18% UTE MRI data as the inputs and the effects on the prediction quality of the RMQ-Net. The RMQ-net was modified and retrained accordingly with different combinations of inputs. Both ROI-based and voxel-based Pearson correlation analyses were performed. High Pearson correlation coefficients were achieved between the RMQ-Net predicted UTE-T1 and UTE-AdiabT1ρ results and the ground truth for segmented cartilage with acceleration factors ranging from 2.3 to 5.7. With an acceleration factor of 5.7, the Pearson r-value achieved 0.908 (ROI-based) and 0.945 (voxel-based) for UTE-T1, and 0.733 (ROI-based) and 0.895 (voxel-based) for UTE-AdiabT1ρ, correspondingly. The results demonstrated that RMQ-net can significantly accelerate quantitative UTE imaging with automated segmentation of articular cartilage in the knee joint., (© 2024. The Author(s) under exclusive licence to Society for Imaging Informatics in Medicine.)

Background: During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture., Methods: The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement., Results: Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01)., Conclusion: Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: Lower extremity junctional injuries due to explosive blasts are among the most lethal sustained on the battlefield. To help reduce the effects of junctional and perineal trauma from this injury mechanism, a tiered Pelvic Protection System (PPS) was fielded during the war in Afghanistan., Methods: Thirty-six patients with known PPS status who sustained traumatic above knee amputations, with and without perineal injuries, were identified from an operative amputation registry in Helmand Province, Afghanistan, spanning a 12-month period., Results: In Group 1 patients with above knee amputations who wore some tier of the PPS system, 47% (8 of 17) sustained junctional/perineal injuries. Of the patients in Group 2 who wore no PPS, 68% (13 of 19) sustained perineal injuries associated with proximal amputations. Overall, these differences were statistically significant (p = 0.0115)., Conclusion: Use of a PPS may reduce the risk of having severe perineal and lower extremity junctional injury in service members sustaining traumatic above knee amputations from an explosive blast., Competing Interests: Declaration of Competing Interest I have no conflict or declaration of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Case: A 62-year-old man presented with a posterolateral knee dislocation sustained in a motorcycle collision initially managed nonsurgically. His treatment was complicated by recurrent dislocation from noncompliance with bracing and weight-bearing restrictions and by comorbidities including peripheral artery disease, type 2 diabetes, and heavy smoking and drinking. He was treated with a multiplanar knee-spanning external fixator and patellar tendon repair without further ligamentous reconstruction. This treatment provided a stable, functional knee with minimal pain., Conclusions: In this complex, noncompliant patient with a subacute knee dislocation, knee-spanning biplanar external fixation and patellar tendon repair without ligament reconstruction were crucial in achieving a satisfactory outcome.

Objectives: The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft., Materials and Methods: Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5-min crossover period, and then continuous active stimulation until lead removal postoperative Day 14-28. Statistics were not applied to the data due to the small sample size of this feasibility study., Results: During the initial 5-min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5-min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1-3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet., Conclusions: This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103., (© 2018 The Authors. Neuromodulation: Technology at the Neural Interface published by Wiley Periodicals, Inc. on behalf of International Neuromodulation Society.)

Background and Objectives: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period., Methods: Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28., Results: Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported., Conclusions: This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture., Trial Registration Number: NCT02898103., Competing Interests: Competing interests: The University of California San Diego has received funding from SPR Therapeutics for other research studies of BMI, JJF, RAG, ETS, WBA, BK, JFS, MWS, PJ, DCC, and CMR., (© American Society of Regional Anesthesia & Pain Medicine 2019. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Background: Gadopentetate dimeglumine-enhanced magnetic resonance imaging (MRI), or gadolinium-enhanced MRI, was used to prospectively study the postoperative course of bone-patellar tendon-bone (BPTB) and combined semitendinosus and gracilis (STG) tendon autografts following arthroscopically assisted reconstruction of the anterior cruciate ligament (ACL) in humans. Gadopentetate dimeglumine is a contrast agent that has been shown to enhance the signal of vascularized tissue when examined by MRI., Purpose: To prospectively determine and compare the pattern and timing of autograft revascularization following arthroscopically assisted ACL reconstruction by BPTB or STG autografts., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: A total of 73 patients (63 males, 10 females) with ACL tears who were scheduled to undergo reconstruction consented to participate in this study. The patients were randomized to receive arthroscopically assisted reconstruction of the ACL employing either BPTB or STG autografts. Gadolinium-enhanced MRI scans were scheduled at 3-month intervals during the first postoperative year to assess the integrity, timing, and pattern of enhancement of the ACL graft. The temporal sequence and morphologic characteristics of imaged signals were compared for both types of ACL reconstructions., Results: Based on all knees with 1 exception, there were no statistically significant differences in gadopentetate dimeglumine-mediated graft enhancement grade observed between BPTB and STG autografts., Conclusion: The results suggest that autograft revascularization probably varies in intensity and location during the time course of graft healing. The interval signal changes observed 3 to 9 months, but especially 6 to 9 months, postoperatively are due to increased contrast uptake as a reflection of ongoing neovascularization during the process of ligamentization., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This investigation was supported by Naval Medical Research and Development Command (grant B2EW.00095.008.9311). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Case: The medial collateral ligament (MCL) is the most commonly injured ligament of the knee; however, to our knowledge, avulsion fractures of the MCL resulting in an intra-articular fragment have not been reported. We present the case of a 55-year-old woman with a posterior cruciate ligament avulsion fracture and an MCL avulsion fracture with an intra-articular bony fragment., Conclusion: Patients who sustain trauma to the knee should be carefully evaluated for ligamentous avulsion injuries. Avulsion fractures in adults represent substantial traumatic injuries, and associated injuries should be suspected. While the MCL is an extracapsular structure, this case report demonstrates that the MCL femoral-sided osseous attachment can displace intra-articularly.

Case: Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is an often overlooked cause of orthopaedic-related infections despite a well-accepted association in the literature. We present the case of a forty-seven-year-old man with HHT who developed femoral osteomyelitis and a subsequent pathologic femoral fracture from a rare bacterial species associated with HHT., Conclusion: Patients with HHT and extremity pain should be carefully evaluated for orthopaedic infections. If an orthopaedic infection is suspected, fastidious organisms should be considered as a possible etiologic agent. PCR (polymerase chain reaction) is helpful when organisms cannot be isolated from traditional culture media.

Battlefield injuries and high-energy civilian trauma present orthopaedic surgeons with treatment challenges. Despite efforts at limb salvage, some patients elect late amputation. This article reviews risk factors that predispose to late amputation. Using a MEDLINE search, English language peer-reviewed articles from 1993 to 2013 having data on late amputation following limb salvage were included. Late lower extremity amputation after limb salvage varied from 3.9% to 40% in civilian patients and from 5.2% to 15.2% in military patients. Factors influencing a patient's decision to undergo late amputation included a combination of complex pain symptoms with neurologic dysfunction, infection, a desire for improved limb functionality, and unwillingness to endure an often complicated and lengthy course of treatment. In military patients, rank was a significant risk factor since officers were 2.5 times more likely to elect late amputation (p < .05) than enlisted personnel. Despite often extraordinary efforts towardlimb salvage, results maybe disappointing.

Background: After experiencing an unusually high incidence of knee sepsis after anterior cruciate ligament (ACL) reconstruction, we sought to (1) describe how we resolved this problem through temporary discontinuation of the procedure, formation of a multidisciplinary ACL Task Force, systematic investigation of clinical data and institutional care practices, and development and implementation of an evidence-based ACL Clinical Pathway (the Pathway); and (2) report our findings and results., Methods: From 1999 through 2008, thirty-seven cases of knee sepsis after ACL reconstruction were recorded at our institution. In 2008 (yearly incidence, 4.4%), ACL reconstructions were temporarily suspended and a Task Force was assembled to (1) identify infection risk factors or epidemiological links among cases, (2) inspect environment and processes for possible infection sources, and (3) update existing perioperative practices according to current evidence-based guidelines to reduce surgical site infection risk. These actions led to the development of the Pathway for patients and providers. The rates of knee sepsis before and after the Pathway was implemented were compared., Results: There was no consistent risk factor or epidemiologic link among the cases of knee sepsis other than the time and place of the ACL reconstruction. Process review identified shortfalls in decontamination and sterilization of some surgical equipment. Perioperative care practices review revealed wide interprovider variation. Pathway implementation reduced the rate of knee sepsis after ACL reconstruction from 1.96% (twenty-four cases after 1226 ACL reconstructions performed from 2002 to 2008) to 0% (zero cases after 500 ACL reconstructions performed from 2008 to 2011); the difference was significant (p = 0.003)., Conclusions: When a Task Force investigation suggested that knee sepsis after ACL reconstruction was a multifactorial problem, we implemented and standardized evidence-based perioperative care practices via the institution-wide Pathway, which significantly improved the quality and consistency of care for patients undergoing ACL reconstruction, as well evidenced by the elimination of knee sepsis.

The mangled lower extremity is a challenging injury to treat. Orthopaedic surgeons treating patients with these severe injuries must have a clear understanding of contemporary advantages and disadvantages of limb salvage versus amputation. It is helpful to review the acute management of mangled extremity injuries in the civilian and military populations, to be familiar with current postoperative protocols, and to recognize recent advances in prosthetic devices.

Foot and ankle trauma sustained in the Global War on Terror have unique causes and characteristics. At least one-quarter of all battle injuries involve the lower extremity. These severe lower extremity wounds require specialized early treatment. Ballistic mechanisms cause almost all injuries, and as such, most combat foot and ankle wounds are open in nature. Wounds are characteristically caused by blast mechanisms, but high velocity gunshot injuries are also common. The severe and polytraumatic nature of injuries sustained frequently call for damage control orthopaedics to be utilized. Cautious early treatment of irregular and highly exudative ballistic wounds with subatmospheric wound dressings may ease their early management., (Copyright 2010 Elsevier Inc. All rights reserved.)

Blast and fragment injuries are the most frequently encountered wounds in modern warfare. Explosive devices have become the preferred weapon of domestic and foreign terrorists because they are relatively inexpensive to manufacture and can cause substantial casualties. Although blast injuries have traditionally been associated with the battlefield, this type of trauma is being seen more commonly today among noncombatants due to increasing worldwide terrorism.

Necrotizing fasciitis is recognized as a surgical emergency. Early detection and aggressive surgical débridement are crucial to reduce patient mortality and morbidity. There are, however, other causes of subcutaneous emphysema. We present the case of a 64 year-old patient with a history of postsurgical radiation for rectal carcinoma with subcutaneous emphysema of the thigh in the presence of urinary sepsis. Surgical exploration revealed the source of the emphysema to be an enterocutaneous fistula. The patient had an unstable and prolonged hospitalization after débridements of the thigh and abdominal surgery and was readmitted for recurrence of thigh drainage, but eventually was discharged; nine months after the initial diagnosis all wounds had healed and he was walking with a walker. Despite an otherwise benign clinical appearance, the radiographic finding of subcutaneous emphysema in the absence of penetrating trauma must be considered a case of a necrotizing soft tissue infection until proven otherwise.

Musculoskeletal wounds are the most common type of injury among survivors of combat trauma. The treatment of these wounds entails many challenges. Although methods of care are evolving, significant gaps remain as knowledge of civilian trauma is extrapolated to combat injuries. It is important to discuss issues related to the use of portable vacuum-assisted wound closure devices during transport, as well as the prevention of heterotopic ossification and the participation of civilian orthopaedic trauma experts in caring for injured service members through the Distinguished Visiting Scholar Program.

Musculoskeletal injury is the most common type of injury among survivors of combat trauma, and combat-related trauma is challenging for an orthopaedic surgeon to treat. Methods of treatment are evolving, but significant gaps remain as knowledge of civilian trauma is extrapolated to combat trauma.

Background: Recent studies have shown that the posterior cruciate ligament (PCL) is composed of a continuum of fiber regions that display characteristic mechanical behavior under different motion and loading conditions., Hypothesis: The anterior, central, and posterior fiber regions of the PCL differentially contribute to control of posterior translation of the tibia., Study Design: Controlled laboratory study., Methods: Nine intact, fresh-frozen cadaveric knees were instrumented with excursion wires implanted within the anterior, central, and posterior fiber regions of the PCL. In groups of 3, patterns of incremental posterior tibial translation using a 74-N posterior force were analyzed as a function of the variable linear separation distance between tibial and femoral fiber region attachment sites during posterior drawer testing at knee flexion angles of 20 degrees and 90 degrees before and after sequential fiber region section., Results: At 20 degrees of knee flexion, there was no statistical difference in the relatively small amount of posterior tibial translation, regardless of whether the anterior, central, or posterior fibers were alone transected (P = .350). At 90 degrees of knee flexion, whether the posterior fibers were cut first, second, or third (order of section), the incremental difference in posterior tibial translation this produced was significantly different (P = .039). For the fiber regions combined, the third fiber region section resulted in a significantly larger incremental translation than did either the first or second section with the knee flexed 90 degrees (P = .001). After transection of all fiber regions, significantly more total posterior tibial translation occurred at 90 degrees versus 20 degrees of flexion (P = .002)., Conclusions: This study shows that fiber regions within the PCL have unique characteristics and behave differently in response to posterior drawer forces., Clinical Relevance: This study provides additional information on the complex mechanical behavior of the PCL and suggests that some partial tears (ie, those involving 1 or 2 fiber regions) may only result in minimal posterior translation during drawer testing at 90 degrees .

Musculoskeletal war wounds often involve massive injury to bone and soft tissue that differ markedly in character and extent compared with most injuries seen in civilian practice. These complex injuries have challenged orthopaedic surgeons to the limits of their treatment abilities on the battlefield, during medical evacuation, and in subsequent definitive or reconstructive treatment. Newer methodologies are being used in the treatment of these wounds to prevent so-called second hit complications, decrease complications associated with prolonged medical evacuation, reduce the incidence of infection, and restore optimal function. Basic science advances hold the promise of providing foundations for future treatment options that may improve both bone and soft-tissue healing. Research on the treatment of these often devastating wounds also will have broad applicability to trauma resulting from acts of terrorism or from natural disasters.

Approximately 70% of war wounds involve the musculoskeletal system, and military orthopaedic surgeons have assumed a pivotal role in the frontline treatment of these injuries in Iraq. Providing battlefield orthopaedic care poses special challenges; not only are many wounds unlike those encountered in civilian practice, but patients also must be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery, and endure prolonged medical evacuation, often involving ground, helicopter, and fixed-wing transport across continents. Most orthopaedic wounds in Iraq are caused by exploding ordnance--frequently, improvised explosive devices, or IEDs. Because of advances in care, rapid medical evacuation, and modern body armor, many casualties have survived in Iraq who would not have done so in previous wars. Treatment of war wounds, many of which are devastating in the scope of soft-tissue and bony injury, requires a team approach using hypotensive resuscitation, damage-control orthopaedics, new or rediscovered techniques of hemostatic and intravenous hemorrhage control, vacuum-assisted wound closure, and advanced reconstruction. Current challenges include prevention of infection, a better understanding of heterotopic ossification as a sequela of blast injury, and the need for a comprehensive, joint service database that encompasses the multilevel spectrum of orthopaedic care.

Trauma care for military personnel injured in Iraq has become increasingly sophisticated. There are five levels, or echelons, of care, each progressively more advanced. Level I care provides immediate first aid at the front line. Level II care consists of surgical resuscitation provided by highly mobile forward surgical teams that directly support combatant units in the field. Level III care is provided through combat support hospitals--large facilities that take time to become fully operational but offer much more advanced medical, surgical, and trauma care, similar to a civilian trauma center. Level IV care is the first echelon at which definitive surgical management is provided outside the combat zone. Level V care is the final stage of evacuation to one of the major military centers in the United States, where definitive stabilization, reconstruction, or amputation of the injured extremity is performed.

Background: The posterior cruciate ligament has been described as being composed of 2 bands that reciprocally tighten and loosen with knee flexion, but the fiber anatomy and behavior may be more complex., Hypothesis: The mechanical effects of defined loading conditions at discrete knee joint angles can vary significantly within the substance of the posterior cruciate ligament depending on the fiber region tested., Study Design: Controlled laboratory study., Methods: Nine intact, fresh-frozen cadaveric knees were instrumented with excursion filaments implanted within 4 fiber regions of the posterior cruciate ligament. Patterns of fiber behavior were analyzed as a function of the variable linear separation distance between tibial and femoral fiber attachment sites during joint motion under a simulated quadriceps contraction, tibial internal rotation, and tibial external rotation. Analysis of variance, the Newman-Keuls multiple comparisons procedure, and paired t tests were used to evaluate statistical significance., Results: Compared with the control pattern of fiber behavior during unloaded passive knee motion from 0 degrees to 120 degrees , the quadriceps force caused loosening of most ligament fibers at knee flexion of less than 75 degrees . Tibial internal rotation significantly slackened the anterior and central fiber regions near extension and significantly tightened the central and posterior fiber regions with progressive flexion. External rotation had an effect similar to internal rotation on the anterior and central fiber regions but caused significant slackening of the posterior fiber regions from 0 degrees to 45 degrees ., Conclusions: Distinct geographic regions within the posterior cruciate ligament have different functional roles depending on the joint angle and the type of load to which the knee is subjected., Clinical Relevance: The specific graft placement parameters in a given surgical procedure relate to end-to-end length changes of the graft and may have important implications for postoperative rehabilitation and return to specific functional activities.

A series of 51 active duty patients who elected to undergo ambulatory surgery in a Navy Fleet Hospital Training Set (a modified field hospital) over a 2-year period were followed prospectively for perioperative complications. All patients were active duty personnel, ranging in grade from E1 to O5, who voluntarily gave specific informed consent to have their surgery performed in the training set. Patients were offered surgery in the training set only if attending surgeons were confident that the surgery could be done safely and with the same expected outcome as if performed in the hospital. Their entire surgical experience was contained within this tent-based field facility from admission to discharge. There were 12 orthopedic surgery, 4 general surgery, 3 otolaryngology, 2 urology, 1 ophthalmology, and 29 oral and maxillofacial surgery cases. General, regional, or local anesthesia or intravenous conscious sedation were used as indicated. No patients developed wound infections, and there were no anesthetic, bleeding, or other significant perioperative complications. Selected ambulatory surgical procedures can be safely performed on appropriate patients in this field hospital assemblage.

Fleet Hospital FIVE personnel treated more than 24,000 patients during a 1997 military operation other than war in Haiti. Sample data were analyzed for 10,215 Haitians who received humanitarian assistance care at field treatment sites and for 353 military, United Nations personnel, and Haitian nationals who were treated at the fleet hospital. Demographic data, type of encounter, diagnoses, and prescriptions were tabulated. Children aged 1 to 10 years accounted for 31% of humanitarian assistance visits. Females outnumbered males; in adults aged 21 to 30 years, the proportion was almost three to one. Most (97%) were initial encounters. Infectious and parasitic diseases, such as worms or scabies, accounted for 25% of diagnoses. At the fleet hospital, more than 80% of patients were males; these were most often older than 21 years. Injuries and aftercare procedures constituted 51.5% of diagnoses. Of 18,100 prescriptions, 57% were for anti-inflammatories, vitamins, or anti-parasitics. Implications for medical planning are described.

Osteolysis of the distal clavicle has been reported to occur from traumatic, atraumatic (overuse), or systemic causes. Three patients with bilateral osteolysis of the distal clavicles whose osteolysis did not fit these etiologic categories were evaluated. Clinical, imaging, and laboratory evaluations were nonspecific, and histologic sections of the distal clavicle showed evidence of chronic inflammation with reactive change of the articular surface. Patients either had complete resolution or marked improvement of their symptoms after bilateral distal clavicle resection at mean followup of 5 years 3 months. These cases of osteolysis of the distal clavicle represent a category of this disorder not previously described.

At the present time, our understanding of the PCL still lags behind that of the ACL. This knowledge gap has narrowed over the past few years, however, as more basic research has shed new light on the complex anatomy and functional mechanical behavior of the PCL and the nearby capsuloligamentous structures. Recent insights have included recognition that the PCL is composed of a fiber continuum rather than morphologically separate bands or bundles, a better appreciation of the predominantly nonisometric behavior of the intact PCL, and a greater awareness of the PCLs importance in preserving normal articular kinematics. Continued advances in the basic science of the PCL are a prerequisite for improvements in the treatment and rehabilitation of its injury.

Parameters for ideal posterior cruciate ligament graft placement have yet to be convincingly defined. Both anatomic and biomechanical data are reviewed and analyzed with respect to the concepts of isometric and physiometric graft placement. Perhaps elements of both may represent the ultimate solution.

Treatment of osseous defects by induced bone regeneration has yielded promising results in laboratory animals and in preliminary human trials. Two inducing agents, demineralized bone powder and bone morphogenetic protein, are being used clinically to treat some bony defects without the need for an autogenous bone-harvesting procedure. Such off-the-shelf bone-inducing agents may someday become a significant addition to the armamentarium of the military orthopedic surgeon for dealing with the numerous skeletal injuries which occur in today's service environment.

The torsional and compressive biomechanical characteristics of slotted and nonslotted interlocking nails in distal femoral shaft fractures were evaluated. Slotted (Grosse-Kempf) and nonslotted (Russell-Taylor) locked nail systems were implanted in anatomic specimen femora, which were then tested in torsion and axial compression. For torsional studies, each femur was transversely sectioned distal to the isthmus; for axial loading, a distal 3-cm section of bone was removed. The mean peak torsional stiffness of the femora fixed with nonslotted nails was 0.955 Nm per degree, which was significantly greater than that (0.300 Nm per degree) for the femora fixed with the slotted nails. However, when loaded to failure in compression, the nonslotted nail group failed at a mean load of 2490 N compared with 3050 N for the group fixed with the slotted devices. These results could be due in part to the lesser rigidity of the slotted nail, which may have facilitated greater load sharing with bone and increased resistance to compression failure.

As an alternative to intact tetanus toxoid as a carrier for beta-human chorionic gonadotropin (beta-hCG), a fragment of tetanus toxin was sought that had a relatively low molecular weight, yet was highly immunogenic. Purified culture filtrate tetanus toxin was subjected to limited enzymatic digestion with papain, and the resulting fragments separated by column chromatography on Sephadex G-150. Four fractions were thus identified. Fraction II was found to have a molecular weight of 54,000 by SDS-polyacrylamide gel electrophoresis. This fragment was covalently linked to the beta-subunit of hCG (beta-hCG-TTII) using carbodiimide hydrochloride. The ability of beta-hCG-TTII to stimulate production of anti-hCG sera in rabbits was measured by 125I-hCG radioimmunoassay. At sera dilutions of 1:40,000, an average 125I-hCG binding capacity of 34.7 +/- 5.86% (mean +/- SD) was observed 8 weeks after the final immunization. Tetanus toxin Fragment II has the potential for future application in active immunization studies involving hormone-carrier conjugates.

Corynebacterium parvum and Bordetella pertussis were compared with Freund's complete adjuvant (FCA) for their abilities to potentiate the immune response to haptenic beta-human chorionic gonadotropin covalently coupled to an atoxic 54,000-molecular-weight fragment of tetanus toxin (beta-hCG-TTII). The ability of each adjuvant to enhance production of antibodies to hCG in rabbits was measured by 125I-hCG radioimmunoassay. At sera dilutions of 1:10,000, analysis of variance for the 8-week postimmunization course showed that the mean 125I-hCG binding capacities of the C. parvum group was significantly greater overall than the B. pertussis group (P = .0002) and that the FCA-treated group had the greatest binding capacity overall (P less than .018). The mean binding capacities at 1:40,000 dilution again showed the FCA-treated group to have significantly higher anti-hCG titers overall (P less than .0015), with C. parvum potentiating a greater overall antibody response than B. pertussis (P = .001). These results indicate that FCA is the most efficacious of the three tested adjuvants in potentiating antibody production to the hapten component of beta-hCG-TTII. C. parvum was also effective at promoting an anti-beta-hCG response, although not to the same degree as FCA. B. pertussis had only minimal potentiating effect compared to FCA or C. parvum.

Treatment of orthopaedic lesions through induction of bone regeneration has produced promising results in laboratory animals and preliminary human trials. Both demineralized bone powder and bone morphogenetic protein (BMP) are being used clinically to treat bony defects without the need for an autogenous bone harvesting procedure. The historical perspective and laboratory rationale for osteoinduction is presented, as well as current and future clinical applications of demineralized bone powder and BMP.

Antisera to the conjugate of beta-human chorionic gonadotropin and tetanus toxoid (beta hCG-TT) generated in rabbits receiving TT carrier preimmunization were characterized and compared with antisera from rabbits receiving the conjugate without preimmunization. Double immunodiffusion and immunoelectrophoresis were used to identify individual antisera components to the conjugate and its substructures. 125IhCG radioimmunoassay indicated similar antibody titers (P = 0.447) regardless of whether the rabbits were preimmunized with TT. However, bioneutralization of native hCG as measured by inhibition of prepubertal rat uterine weight increase was significantly more effective (P = 0.025) with antisera from rabbits which received carrier presensitization. These results demonstrate that carrier preimmunization provides a method for increasing the efficacy of neutralizing antibody produced against haptenic beta hCG.

A number of adverse consequences can result in the upper limb from parenteral drug abuse. Propylhexedrine, a drug similar to amphetamine, is easily obtained and causes severe injury to the limb when injected intra-arterially. This report describes an inadvertent case of intra-arterial propylhexedrine injection into the radial artery, the natural course of which resulted in digital amputations. The cause and diagnosis of this injury is discussed, and a protocol for treatment is presented.

We review the major advances that have recently occurred in the area of antifertility vaccines by examining the immunogenic potential of gamete, embryonic and placental antigens. In human trials using beta-human chorionic gonadotropin coupled with tetanus toxoid as the immunogen, the major problems with antifertility vaccines relate to specificity and maintaining an adequate antibody titer to disrupt gestation. Possible complications include cross-reaction with other body tissues, immune complex deposition, cytotoxicity, impaired immunologic tumor surveillance and nonreversibility.