Low back pain in the uniformed service member: approach to surgical treatment based on a review of the literature.

The clinical entity of chronic low back pain is not well understood at present. Disparate spinal conditions can result in symptoms of low back pain, and various treatment options have been proposed in the literature including surgical intervention and prolonged nonoperative therapy. Low back pain, as well as lumbar degenerative disc disorders and spondylosis, is common among uniformed service members, and studies, along with treatment recommendations, regarding these entities in the civilian community are not necessarily translatable to military personnel. This literature review endeavors to review the evidence for interventions for low back pain and seeks to formulate a treatment algorithm that takes into account the unique requirements of military personnel. Ultimately, more research must be done, investigating the specific results of treatments for spinal conditions within the military community before definitive recommendations can be made.

PTSD Relief Comes With a Mantra (CME/CE)

Transcendental meditation has potential benefits for combat-related posttraumatic stress disorder (PTSD), a small case series of U.S. military veterans showed.  Five veterans of the Iraq and Afghanistan wars all had significant improvement on the Clinician-Administered PTSD Scale (CAPS) -- the gold standard for the assessment and diagnosis of PTSD -- after eight weeks of meditation (P=0.02), according to Joshua Rosenthal, MD, of Capital Clinical Research Associates in Rockville, Md., and colleagues.

Evidence-based practice in arthroscopic knee surgery

Knee arthroscopy is a minimally-invasive technique that allows intra-articular assessment and treatment of knee joint pathology. It has proven benefits of reduced patient morbidity, earlier recovery and mobilisation, and it is cost-effective. In this paper we review the anatomy of the knee joint, indications and contra-indications to knee arthroscopic use, and consider the main techniques of knee arthroscopy including types of anaesthetic, prophylactic antibiotics, theatre setup and arthroscopic portals, and post-operative care.

Blast-Related Brain Injuries Detected in U.S. Military

An advanced imaging technique has revealed that some U.S. military personnel with mild blast-related traumatic brain injuries have abnormalities in the brain that have not been seen with other types of imaging.
The abnormalities were found in the brain’s white matter, the wiring system that nerve cells in the brain use to communicate with each other.
The study is reported June 2 in The New England Journal of Medicine by scientists at Washington University School of Medicine in St. Louis and the Landstuhl Regional Medical Center in Landstuhl, Germany.

Patient Safety Climate Among Orthopaedic Surgery Residents

Patient safety has attained a higher profile since the Institute of Medicine's report, To Err Is Human: Building a Safer Health System, was distributed in 2000¹. This report suggested that many hospital errors were related to flaws within the health-care delivery system. Many organizations—aviation, nuclear power, the military, and some industries—have realized that safe systems are essential for creating a barrier between human errors and adverse events². Organizations with systems designed to minimize errors, prevent adverse events, and produce reliable outcomes despite intrinsic risks have been termed highly reliable organizations^2,3. Health-care institutions are now being challenged by both internal and external forces to become highly reliable organizations by applying systems-based approaches to address patient safety.

Fracture Prediction Methods May be Useful for Patients with Diabetes

Use of established fracture prediction methods in older patients with type 2 diabetes mellitus (DM) found that scores from these methods were associated with hip and nonspine fracture risk, and a certain score associated with higher risk of fracture compared to persons without DM, according to a study in the June 1 issue of JAMA. Because patients with type 2 DM often have higher levels of bone mineral density (BMD), it has been uncertain the applicability of fracture risk screening methods typically used for patients with lower levels of BMD.

Limb Salvage Team Helps Victims of Haitian Earthquake

A team of plastic and orthopedic surgeons achieved a high success rate in limb salvage—minimizing the need for amputations—among patients injured in last year's devastating earthquake in Haiti, reports a study in the June issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Surgical Radiology app provides high quality training and is a great value

Surgical Radiology is an app that aims to teach appropriate surgical radiology interpretation skills for surgeons and trainees. It emphasizes the clinical implications for imaging findings and prompts the user to identify the imaging abnormality and suggest treatments, where appropriate. It is a free app written for the iOS platform, developed by Drs. Dangleben and Lee at the Lehigh Valley Health Network, a Level I Trama Center in Pennsylvania with a general surgery residency.

External fixation and temporary stabilization of femoral and tibial trauma.

External fixation is an important option in the acute management of unstable femoral and tibial fractures and the temporary stabilization of periarticular injuries of the knee or ankle. The value of external fixation as the modality of choice in selective civilian and military applications is well documented. Primary indications include damage control for multitrauma management in patients with concomitant traumatized integument and/or excessive swelling and/or systemic instability and stabilization for transport in hostile or austere environments. The purpose of this article is to discuss the indications for temporary external fixation of lower extremity long bones and complicated distal femoral, proximal tibia, and tibial plafond fractures; to outline technical considerations in the application of temporary external fixation devices; and to summarize the experience in the use of prepackaged external fixators and their indications in combat.

Breaking the fracture cycle through effective and coordinated models of care

A prior fracture at least doubles a patient's future fracture risk – yet numerous studies from across the world have found that healthcare systems fail to respond to the first fracture to prevent future fractures. Professor Cyrus Cooper, chair of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF) and director of the MRC Lifecourse Epidemiology Unit, University of Southampton in the UK stated, "Studies from the UK, USA and Australia have reported that 45% or more of today's hip fracture patients have a prior fracture history. Healthcare systems are evidently failing to respond to the first fracture – this is, tragically, a missed opportunity for intervention. Worldwide, millions of people go on to experience debilitating and life-threatening hip fractures, at great cost to the individual and to healthcare systems."

A versatile grid holder and grid for miniscrew placement.

The biggest challenge in mini-screw placement is the accuracy and ease of placement, thus avoiding their proximity to the adjacent root structures during insertion. We have designed a very simple and inexpensive grid holder and a grid which can be used on buccal and palatal surfaces of maxillary and mandibular arches, in anterior as well as posterior regions. The grid-holder is effortlessly piggy-backed facially on the existing archwire bracket unit without removing the archwire. The assembly can be easily disengaged when pilot drilling has been done. The grid holder is versatile and can accept most kinds of grids and eyelets available. It is fabricated out of materials routinely available in any orthodontic practice. The same assembly can be reused again after autoclaving on different patients.

Current concepts for the use of platelet-rich plasma in the foot and ankle

Platelet-rich plasma (PRP) injections have been used and studied since the 1970s. Its use has become more popularized over the last several years in the treatment of foot and ankle injuries. Platelets are a normal product found in the clotting cascade and inflammatory process of healing. They produce granules that release growth factors that promote healing. PRP works by increasing the concentration of platelets, thereby increasing the concentration of growth factors and increasing healing potential. PRP has an advantage over many tissue engineering products in that it is autologous. It has been studied and used for the treatment of tendon injuries, chronic wounds, ligamentous injuries, cartilage injuries, muscle injuries, and bone augmentation. The results from in vitro and in vivo studies in foot and ankle injuries are promising. The applications for treatment in the foot and ankle may be broader than once thought.

De Quervain Disease: US Identification of Anatomic Variations in the First Extensor Compartment with an Emphasis on Subcompartmentalization.

Purpose: To demonstrate the usefulness of ultrasonography (US) in the detection of anatomic variations in the first extensor compartment of the wrist in patients with de Quervain disease. Materials and Methods: The institutional review board approved this study protocol and waived the informed consent requirement. Fifteen wrists in 13 women (age range, 41-62 years) in whom de Quervain disease was clinically diagnosed and who underwent surgery for intractable pain were included. A musculoskeletal radiologist performed US before surgery. The absence or presence and extent of subcompartmentalization within the first extensor compartment and the number of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon slips were evaluated and recorded. Preoperative US findings were compared with surgical records and photographs. Results: Subcompartmentalization within the first extensor compartment was observed during surgery in 11 of the 15 wrists (73%), including four (27%) that had subcompartmentalization only in the distal portion of this compartment. US was used to identify all 11 wrists showing subcompartmentalization within this compartment (sensitivity, 100%; 95% confidence interval [CI]: 74%, 100%), as well as three of the four wrists with distal incomplete subcompartmentalization. There was one wrist with false-positive distal incomplete subcompartmentalization. US had a positive predictive value in the detection of subcompartmentalization of 73% (95% CI: 47%, 91%). The number of tendon slips in this compartment detected with US was identical to that identified at surgery with one exception. Conclusion: US can be used to depict various types of anatomic variations in the first extensor compartment in patients with de Quervain disease.

ReachMD MedicalRadio Mobile App

ReachMD MedicalRadio delivers world class medical content from the leader in medical education and information for medical professionals. All programming is broadcast on ReachMD Sirius/XM Satellite Radio Channel XM 167. ReachMD MedicalRadio provides quality peer-to-peer content available in 15-minute programs that cover a broad range of topics for both general practitioners and specialists.  It also has the ability to search for and listen to FREE CME/CE podcasts and take the exam directly on your mobile device.

Arthroscopic treatment of fractures of the lateral malleolus of the tibia: 26 cases.

Arthroscopic removal of fractures of the lateral malleolus of the tibia is technically demanding, but can be performed with minimal complications and with low patient morbidity and short periods of hospitalisation. The majority of horses are able to successfully return to work following the procedure. Potential relevance: The advantages of arthroscopic removal compared to removal via arthrotomy make this the technique of choice for treatment of fractures of the lateral malleolus of the tibia.

Data-driven disaster management requires data: implementation of a military orthopaedic trauma registry.

The Military Orthopaedic Trauma Registry (MOTR) is a comprehensive joint service registry of military orthopaedic injuries. Conceived in 2006, MOTR is now operational for retrospective data entry and prospective data collection of extremity injuries sustained by U.S. service members serving in current Overseas Contingency Operations. Running in tandem with data from the United States Army Institute of Surgical Research's Joint Theater Trauma Registry (JTTR), MOTR augments the casualty data included in JTTR with additional orthopaedic specific data (i.e., the injury patterns, characteristics, treatment, and complications associated with extremity war injuries). Extremity war injuries are the major clinical burden of the current conflicts. However, the scope of the injuries in detail useful to the orthopaedic researcher has never been prospectively collected. MOTR is designed to fill that gap in extremity trauma research. As such, MOTR represents an evolutionary step in the refinement of data-driven disaster management.

Early analysis of the United States Army's telemedicine orthopaedic consultation program.

Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army's telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting were the most common recommended treatments for all orthopaedic consults. Of the 170 consults requesting specific treatment recommendations for patients who likely otherwise would have been evacuated for further evaluation, surgical intervention or medical evacuation was only recommended in 25% and 16% of the consultations, respectively. The novel Army telemedicine orthopaedic consultation program developed for combat-deployed service members provides expert treatment recommendations for a variety of musculoskeletal injuries. Deployed health care providers located in austere combat environments can better determine both the necessity of medical evacuation and appropriate treatments for service members with musculoskeletal injuries when aided by orthopaedic surgery consultants, thereby limiting the number of unnecessary medical evacuations.

Hips take walking in stride; ankles put best foot forward in run

In a first-of-its-kind study comparing human walking and running motions – and whether the hips, knees or ankles are the most important power sources for these motions – researchers at North Carolina State University show that the hips generate more of the power when people walk, but the ankles generate more of the power when humans run. Knees provide approximately one-fifth or less of walking or running power.

New methods for the detection of orthopedic and other biofilm infections.

The detection and identification of bacteria present in natural and industrial ecosystems is now entirely based on molecular systems that detect microbial RNA or DNA. Culture methods were abandoned, in the 1980s, because direct observations showed that <1% of the bacteria in these systems grew on laboratory media. Culture methods comprise the backbone of the Food and Drug Administration-approved diagnostic systems used in hospital laboratories, with some molecular methods being approved for the detection of specific pathogens that are difficult to grow in vitro. In several medical specialties, the reaction to negative cultures in cases in which overt signs of infection clearly exist has produced a spreading skepticism concerning the sensitivity and accuracy of traditional culture methods. We summarize evidence from the field of orthopedic surgery, and from other medical specialties, that support the contention that culture techniques are especially insensitive and inaccurate in the detection of chronic biofilm infections. We examine the plethora of molecular techniques that could replace cultures in the diagnosis of bacterial diseases, and we identify the new Ibis technique that is based on base ratios (not base sequences), as the molecular system most likely to fulfill the requirements of routine diagnosis in orthopedic surgery.

Platelet-derived growth factor applications in periodontal and peri-implant bone regeneration.

INTRODUCTION: Achieving successful tissue regeneration following traditional therapeutic protocols, combining bone grafts and barrier membranes, may be challenging in certain clinical scenarios. A deeper understanding of periodontal and peri-implant wound healing and recent advances in the field of tissue engineering have provided clinicians with novel means to obtain predictable clinical outcomes. The use of growth factors such as recombinant human platelet-derived growth factor-BB (rhPDGF) with biocompatible matrices to promote tissue regeneration represents a promising approach in the disciplines of periodontology and implantology. AREAS COVERED: This review covers the basic principles of bone and periodontal regeneration, and provides an overview of the biology of PDGF and its potential to predictably and reproducibly promote bone regeneration in regular clinical practice. The results of preclinical and clinical human studies evaluating the effectiveness of growth-factor-enhanced matrices are analyzed and discussed. EXPERT OPINION: Current available evidence supports the use of rhPDGF-enhanced matrices to promote periodontal and peri-implant bone regeneration.