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Background: The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). Methods: A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. Results: The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5cm (p <0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. Conclusions: The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Galeazzi fractures traditionally are treated in long arm casts with the wrist fully supinated for 6 weeks after open reduction and internal fixation. Recent literature suggests that early motion can be permitted for a subset of Galeazzi fractures. Defining a safe postoperative protocol that allows immediate elbow motion, immediate platform weight bearing, and early wrist motion might decrease elbow morbidity, increase range of motion, and improve outcomes. A retrospective review of a prospectively collected database of 26 patients at a level I trauma center was conducted. Early motion protocol was assigned to patients who were radiographically and clinically stable after plate and screw fixation. Elbow flexion and platform weight bearing were allowed immediately; increased wrist rotation was allowed at 2-week intervals. Early motion of elbow and wrist seems to be safe during postoperative rehabilitation of repaired Galeazzi fractures. The postoperative protocol might maximize elbow and wrist range of motion.

Warfare-related open fractures with large soft tissue defects create a significant reconstructive challenge. The objective of this article is to review current and evolving treatment strategies for soft tissue coverage of warfare-induced extremity wounds. A review of previously published literature and current data evaluating combat-injured personnel requiring extremity flap reconstruction performed by a single surgeon within the National Capital Area from 2004 to 2009 was performed. Collected data reviewed included injury patterns, methods of reconstruction, and success rates. Seventy-five (59 pedicled flaps and 16 free) extremity reconstructions employing flaps (34 fasciocutaneous, 34 muscle, and 7 adipofascial) were performed in the subacute time period between 7 days and 3 months. One hundred percent of the wounds were associated with open fractures. Early postoperative infections (<6 {\it weeks from reconstruction) occurred in 10 patients (13%). Total flap loss occurred in two flaps (2.8%) and partial flap loss occurred in six flaps (8.3%). Two patients underwent early limb amputation after flap failure. Two additional patients underwent delayed amputation. Flap success was 97% and limb salvage rate was 94%. Based on the location of the extremity wounds, a reconstruction guide for flap type was created. Modern military limb reconstruction strategies in carefully selected patients with soft tissue defects have resulted in low flap loss rates and high limb salvage rates despite reconstruction in the subacute period between 7 days and 3 months. This limb salvage protocol is likely applicable in high-energy civilian motor vehicle accidents or industrial trauma when highly contaminated wounds are present.