John Keeling - Academia.edu (original) (raw)
Papers by John Keeling
Journal of Trauma-injury Infection and Critical Care, Mar 1, 2008
Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause ... more Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause of mortality. Given the long term complications and rehabilitation needs after initial recovery from the acute burns, these patients are often cared for in dedicated burn units such as the Department of Defense referral burn center at the United States Army Institute of Surgical Research in San Antonio, TX. This review highlights the evidence-based recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for burned casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage.
Journal of Orthopaedic Trauma, 2021
Objectives: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress dis... more Objectives: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. Design: A retrospective cohort study. Setting: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. Patients/Participants: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. Intervention: Not applicable. Main Outcome Measurements: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. Results: Military extremity trauma and amputation/limb salva...
Prescribed by ANSI Std. Z39.18
Journal of surgical orthopaedic advances, 2010
Damage control orthopaedics is well described for civilian trauma. However, significant differenc... more Damage control orthopaedics is well described for civilian trauma. However, significant differences exist for combat-related extremity trauma. Military combat casualty care is defined by levels of care. Each level of care has a specific role in the care of the wounded patient. Because of lack of equipment, austere environments, and significant soft tissue wounds, most combat fractures are stabilized with external fixation even in a stable patient, unlike civilian trauma. External fixation allows for rapid stabilization of fractures and easy access to wounds and requires little shelf stock of implants. Unique situations exist in the care of the combat-injured casualty, which include working in an isolated facility, caring for enemy combatants, large soft tissue wounds, and the need to rapidly transport patients out of the theater of operations.
The Journal of bone and joint surgery. American volume, Jan 15, 2010
Trauma is the most common reason for amputation of the upper extremity. The morphologic and funct... more Trauma is the most common reason for amputation of the upper extremity. The morphologic and functional distinctions between the upper and lower extremities render the surgical techniques and decision-making different in many key respects. Acceptance of the prosthesis and the outcomes are improved by performing a transradial rather than a more proximal amputation. Substantial efforts, including free tissue transfers when necessary, should be made to salvage the elbow. Careful management of the peripheral nerves is critical to minimize painful neuroma formation while preserving options for possible future utilization in targeted muscle reinnervation and use of a myoelectric prosthesis. Rapid developments with targeted muscle reinnervation, myoelectric prostheses, and composite tissue allotransplantation may dramatically alter surgical treatment algorithms in the near future for patients with severe upper-extremity trauma.
The journal of trauma and acute care surgery, 2012
Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluat... more Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly...
Journal of Trauma: Injury, Infection & Critical Care, 2008
Management of combat-related trauma is derived from skills and data collected in past conflicts a... more Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.
The Journal of Hand Surgery, 2013
High-energy blasts can lead to complex intra-articular distal humerus fractures with extensive so... more High-energy blasts can lead to complex intra-articular distal humerus fractures with extensive soft tissue loss, and treatment is fraught with complications. We describe 2 patients with such injuries treated successfully with the use of aggressive wound management followed by distal humerus fracture stabilization with a circular external fixator. We chose this circular external fixator over the Ilizarov frame because of our experience and success in the treatment of open tibia fractures with negligible malalignment and high union rate. This circular external fixator allows for indirect reduction of fracture fragments over time to improve final alignment with great control to fine-tune the reduction postoperatively. In our humerus cases, fracture union was achieved with good alignment and acceptable functional range of motion. Symptomatic heterotopic ossification did not develop despite the presence of multiple risk factors.
Foot & Ankle International, 2008
Fracture of the neck of the talus is a rare injury making up only 0.14% to 0.32% of all fractures... more Fracture of the neck of the talus is a rare injury making up only 0.14% to 0.32% of all fractures.14,15 It is usually a high energy fracture historically diagnosed by plain radiography. Fractures of the talar neck, due to the tenuous blood supply, are prone to the complication of avascular necrosis. Nondisplaced (Hawkins I) fractures have a very low complication rate. However, missed diagnosis and subsequent improper treatment puts the patient at higher risk for progression to a displaced fracture and related complications. We present the following case of a nondisplaced (Hawkins I) fracture of the talar neck not visible on plain film and CT. The fracture was diagnosed by MRI, which significantly influenced treatment.
Journal of Surgical Orthopaedic Advances, 2013
A retrospective review was performed to evaluate the outcomes and complications following heterot... more A retrospective review was performed to evaluate the outcomes and complications following heterotopic ossification (HO) resection and lysis of adhesion procedures for posttraumatic contracture, after combatrelated open elbow fractures. From 2004 to 2011, HO resection was performed on 30 blast-injured elbows at a mean 10 months after injury. Injuries included 8 (27%) Gustilo-Anderson type II fractures, 8 (27%) type III-A, 10 (33%) III-B, and 4 (13%) III-C. Mean preoperative flexion-extension range of motion (ROM) was 36.4°, compared with mean postoperative ROM of 83.6°. Mean gain of motion was 47.2°. Traumatic brain injury, need for flap, and nerve injury did not appear to have a significant effect on preoperative or postoperative ROM. Complications included one fracture, six recurrent contractures, and one nerve injury. The results and complications of HO resection for elbow contracture following high-energy, open injuries from blast trauma are generally comparable to those reported for HO resection following lower energy, closed injuries.
Journal of surgical orthopaedic advances, 2010
Injury to the lower extremity is common in the current conflicts, often severely affecting the fo... more Injury to the lower extremity is common in the current conflicts, often severely affecting the foot and ankle. Secondary to continued surgical advances, many lower extremities are able to undergo limb salvage procedures. However, scoring systems still do not reliably predict which patient will be best served with an amputation or limb salvage. Because of this, limb salvage should be attempted whenever possible, awaiting definitive treatment at a later time. Treatment begins at the time and location of injury with aggressive debridement, with reduction and external fixation of fractures when possible. Serial debridements are often necessary until the traumatic wounds are ready for coverage or closure. Forefoot injuries are treated with varying techniques depending on the location of the injury. Amputation of toes and/or flap coverage is often necessary secondary to tenuous soft tissues. Midfoot injury patterns are complex, possibly requiring arthrodesis, antibiotic spacers, soft tiss...
Foot and ankle clinics, 2010
Determining whether to perform limb salvage or amputation in the traumatized lower extremity cont... more Determining whether to perform limb salvage or amputation in the traumatized lower extremity continues to be a difficult problem in the military and civilian sectors. Numerous predictive scores and models have failed to provide definitive criteria for prediction of limb-salvage success. Excellent support is available in the military health care system for soldiers electing to undergo either limb salvage or amputation. Recent experience with soldiers who sustained limb-threatening injuries has shown that delayed amputation after limb-salvage attempts is a viable option for soldiers wounded in combat.
Journal of surgical orthopaedic advances, 2010
Since the onset of combat activity in Iraq and Afghanistan, there have been over 1100 major limb ... more Since the onset of combat activity in Iraq and Afghanistan, there have been over 1100 major limb amputations among United States service members. With a sustained military presence in the Middle East, continued severe lower extremity trauma is inevitable. For this reason, combat surgeons must understand the various amputation levels as well as the anatomic and technical details that enable an optimal functional outcome. These amputations are unique and usually result from blast mechanisms and are complicated by broad zones of injury with severe contamination and ongoing infection. The combat servicemen are young, previously healthy, and have the promising potential to rehabilitate to very high levels of activity. Therefore, every practical effort should be made to perform sound initial and definitive trauma-related amputations so that these casualties may return to their highest possible level of function.
The Journal of Bone and Joint Surgery-American Volume, 2013
Background: The prevalence of penetrating wartime trauma to the extremities has increased in rece... more Background: The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). Methods: A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. Results: The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p < 0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. Conclusions: The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. S evere lower-extremity injuries remain frequent as a result of penetrating wartime trauma sustained in combat, often resulting in traumatic or surgical amputation. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be used to obtain the most functional transtibial amputation 1-9. To date, to Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. Government. We certify that all individuals who qualify as authors have been listed; each has participated in the conception and design of this work, the analysis of data, the writing of the document, and the approval of the submission of this version; that the document represents valid work; that if we used information derived from another source, we obtained all necessary approvals to use it and made appropriate acknowledgements in the document; and that each takes public responsibility for it. Nothing in the presentation implies any Federal/Department of Defense/Department of the Navy endorsement.
Clinical Orthopaedics and Related Research, 1996
A sheep model was developed for the implantation of 84 bicylindrical stainless steel external fix... more A sheep model was developed for the implantation of 84 bicylindrical stainless steel external fixation pins. One-half of the pins were coated with hydroxyapatite, and the rest remained uncoated. A set of 6 pins with the same coating was implanted in the lateral side of the left tibias of 14 sheep, the final insertion torque was measured, and a monolateral external fixator was assembled on the pins. The medial tibia1 middiaphysis then was exposed and a 5-mm resection osteotomy was done. Sheep were euthanized 6 weeks after surgery, radiographs were taken, and the initial extraction torque was measured on 4 pins from each sheep. Undecalcified sectioning and histologic and histomorphometric analyses were done on the remaining 2 pins. Radiographic pin tract rarefaction was significantly lower in the hydroxyapatite coated pins compared with the uncoated pins. Group average insertion torque was 960 f 959 Nmm in the hydroxyapatite coated pins and 709 f 585 Nmm in the uncoated pins. Group average initial extraction torque was 1485 f 1308 Nmm and 298 f 373 Nmm, respectively. Bone pin contact was 85.7% & 8.9% and 50.3% f 20.4%, respec
The Journal of Bone and Joint Surgery-American Volume, 2013
Background: The study was performed to examine the hypothesis that functional outcomes following ... more Background: The study was performed to examine the hypothesis that functional outcomes following major lowerextremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. Methods: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/ free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. Results: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to continued Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
The Journal of Trauma: Injury, Infection, and Critical Care, 2008
During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related inj... more During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related injuries. Rates of infection vary based upon organ of injury with the highest rates noted for trauma to the colon. This review focuses on the management and prevention of infections related to injuries of the thoracic and abdominal cavity. The evidence upon which these recommendations are based included military and civilian data from prior published guidelines, clinical trials, where available, reviews, and case reports. Areas of focus include antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound closure. Overall, there are limited data available from the modern battlefield regarding the prevention or treatment of these infections and further efforts are needed to answer best treatment strategies.
Blast-related lower extremity trauma presents many challenges in its management that are not freq... more Blast-related lower extremity trauma presents many challenges in its management that are not frequently experienced in high-energy civilian trauma. The large amount of kinetic energy imparted from irregularly shaped projectiles creates a wide zone of soft tissue and bone injury. 1-4 Moreover, the ''outside-in'' mechanism of the blast frequently results in a considerable amount of wound contamination from clothing, footwear, and environmental contaminants. Also, the bony component of these
The journal of trauma and acute care surgery, 2012
Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluat... more Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly...
Journal of Trauma-injury Infection and Critical Care, Mar 1, 2008
Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause ... more Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause of mortality. Given the long term complications and rehabilitation needs after initial recovery from the acute burns, these patients are often cared for in dedicated burn units such as the Department of Defense referral burn center at the United States Army Institute of Surgical Research in San Antonio, TX. This review highlights the evidence-based recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for burned casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage.
Journal of Orthopaedic Trauma, 2021
Objectives: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress dis... more Objectives: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. Design: A retrospective cohort study. Setting: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. Patients/Participants: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. Intervention: Not applicable. Main Outcome Measurements: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. Results: Military extremity trauma and amputation/limb salva...
Prescribed by ANSI Std. Z39.18
Journal of surgical orthopaedic advances, 2010
Damage control orthopaedics is well described for civilian trauma. However, significant differenc... more Damage control orthopaedics is well described for civilian trauma. However, significant differences exist for combat-related extremity trauma. Military combat casualty care is defined by levels of care. Each level of care has a specific role in the care of the wounded patient. Because of lack of equipment, austere environments, and significant soft tissue wounds, most combat fractures are stabilized with external fixation even in a stable patient, unlike civilian trauma. External fixation allows for rapid stabilization of fractures and easy access to wounds and requires little shelf stock of implants. Unique situations exist in the care of the combat-injured casualty, which include working in an isolated facility, caring for enemy combatants, large soft tissue wounds, and the need to rapidly transport patients out of the theater of operations.
The Journal of bone and joint surgery. American volume, Jan 15, 2010
Trauma is the most common reason for amputation of the upper extremity. The morphologic and funct... more Trauma is the most common reason for amputation of the upper extremity. The morphologic and functional distinctions between the upper and lower extremities render the surgical techniques and decision-making different in many key respects. Acceptance of the prosthesis and the outcomes are improved by performing a transradial rather than a more proximal amputation. Substantial efforts, including free tissue transfers when necessary, should be made to salvage the elbow. Careful management of the peripheral nerves is critical to minimize painful neuroma formation while preserving options for possible future utilization in targeted muscle reinnervation and use of a myoelectric prosthesis. Rapid developments with targeted muscle reinnervation, myoelectric prostheses, and composite tissue allotransplantation may dramatically alter surgical treatment algorithms in the near future for patients with severe upper-extremity trauma.
The journal of trauma and acute care surgery, 2012
Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluat... more Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly...
Journal of Trauma: Injury, Infection & Critical Care, 2008
Management of combat-related trauma is derived from skills and data collected in past conflicts a... more Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.
The Journal of Hand Surgery, 2013
High-energy blasts can lead to complex intra-articular distal humerus fractures with extensive so... more High-energy blasts can lead to complex intra-articular distal humerus fractures with extensive soft tissue loss, and treatment is fraught with complications. We describe 2 patients with such injuries treated successfully with the use of aggressive wound management followed by distal humerus fracture stabilization with a circular external fixator. We chose this circular external fixator over the Ilizarov frame because of our experience and success in the treatment of open tibia fractures with negligible malalignment and high union rate. This circular external fixator allows for indirect reduction of fracture fragments over time to improve final alignment with great control to fine-tune the reduction postoperatively. In our humerus cases, fracture union was achieved with good alignment and acceptable functional range of motion. Symptomatic heterotopic ossification did not develop despite the presence of multiple risk factors.
Foot & Ankle International, 2008
Fracture of the neck of the talus is a rare injury making up only 0.14% to 0.32% of all fractures... more Fracture of the neck of the talus is a rare injury making up only 0.14% to 0.32% of all fractures.14,15 It is usually a high energy fracture historically diagnosed by plain radiography. Fractures of the talar neck, due to the tenuous blood supply, are prone to the complication of avascular necrosis. Nondisplaced (Hawkins I) fractures have a very low complication rate. However, missed diagnosis and subsequent improper treatment puts the patient at higher risk for progression to a displaced fracture and related complications. We present the following case of a nondisplaced (Hawkins I) fracture of the talar neck not visible on plain film and CT. The fracture was diagnosed by MRI, which significantly influenced treatment.
Journal of Surgical Orthopaedic Advances, 2013
A retrospective review was performed to evaluate the outcomes and complications following heterot... more A retrospective review was performed to evaluate the outcomes and complications following heterotopic ossification (HO) resection and lysis of adhesion procedures for posttraumatic contracture, after combatrelated open elbow fractures. From 2004 to 2011, HO resection was performed on 30 blast-injured elbows at a mean 10 months after injury. Injuries included 8 (27%) Gustilo-Anderson type II fractures, 8 (27%) type III-A, 10 (33%) III-B, and 4 (13%) III-C. Mean preoperative flexion-extension range of motion (ROM) was 36.4°, compared with mean postoperative ROM of 83.6°. Mean gain of motion was 47.2°. Traumatic brain injury, need for flap, and nerve injury did not appear to have a significant effect on preoperative or postoperative ROM. Complications included one fracture, six recurrent contractures, and one nerve injury. The results and complications of HO resection for elbow contracture following high-energy, open injuries from blast trauma are generally comparable to those reported for HO resection following lower energy, closed injuries.
Journal of surgical orthopaedic advances, 2010
Injury to the lower extremity is common in the current conflicts, often severely affecting the fo... more Injury to the lower extremity is common in the current conflicts, often severely affecting the foot and ankle. Secondary to continued surgical advances, many lower extremities are able to undergo limb salvage procedures. However, scoring systems still do not reliably predict which patient will be best served with an amputation or limb salvage. Because of this, limb salvage should be attempted whenever possible, awaiting definitive treatment at a later time. Treatment begins at the time and location of injury with aggressive debridement, with reduction and external fixation of fractures when possible. Serial debridements are often necessary until the traumatic wounds are ready for coverage or closure. Forefoot injuries are treated with varying techniques depending on the location of the injury. Amputation of toes and/or flap coverage is often necessary secondary to tenuous soft tissues. Midfoot injury patterns are complex, possibly requiring arthrodesis, antibiotic spacers, soft tiss...
Foot and ankle clinics, 2010
Determining whether to perform limb salvage or amputation in the traumatized lower extremity cont... more Determining whether to perform limb salvage or amputation in the traumatized lower extremity continues to be a difficult problem in the military and civilian sectors. Numerous predictive scores and models have failed to provide definitive criteria for prediction of limb-salvage success. Excellent support is available in the military health care system for soldiers electing to undergo either limb salvage or amputation. Recent experience with soldiers who sustained limb-threatening injuries has shown that delayed amputation after limb-salvage attempts is a viable option for soldiers wounded in combat.
Journal of surgical orthopaedic advances, 2010
Since the onset of combat activity in Iraq and Afghanistan, there have been over 1100 major limb ... more Since the onset of combat activity in Iraq and Afghanistan, there have been over 1100 major limb amputations among United States service members. With a sustained military presence in the Middle East, continued severe lower extremity trauma is inevitable. For this reason, combat surgeons must understand the various amputation levels as well as the anatomic and technical details that enable an optimal functional outcome. These amputations are unique and usually result from blast mechanisms and are complicated by broad zones of injury with severe contamination and ongoing infection. The combat servicemen are young, previously healthy, and have the promising potential to rehabilitate to very high levels of activity. Therefore, every practical effort should be made to perform sound initial and definitive trauma-related amputations so that these casualties may return to their highest possible level of function.
The Journal of Bone and Joint Surgery-American Volume, 2013
Background: The prevalence of penetrating wartime trauma to the extremities has increased in rece... more Background: The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). Methods: A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. Results: The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p < 0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. Conclusions: The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. S evere lower-extremity injuries remain frequent as a result of penetrating wartime trauma sustained in combat, often resulting in traumatic or surgical amputation. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be used to obtain the most functional transtibial amputation 1-9. To date, to Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. Government. We certify that all individuals who qualify as authors have been listed; each has participated in the conception and design of this work, the analysis of data, the writing of the document, and the approval of the submission of this version; that the document represents valid work; that if we used information derived from another source, we obtained all necessary approvals to use it and made appropriate acknowledgements in the document; and that each takes public responsibility for it. Nothing in the presentation implies any Federal/Department of Defense/Department of the Navy endorsement.
Clinical Orthopaedics and Related Research, 1996
A sheep model was developed for the implantation of 84 bicylindrical stainless steel external fix... more A sheep model was developed for the implantation of 84 bicylindrical stainless steel external fixation pins. One-half of the pins were coated with hydroxyapatite, and the rest remained uncoated. A set of 6 pins with the same coating was implanted in the lateral side of the left tibias of 14 sheep, the final insertion torque was measured, and a monolateral external fixator was assembled on the pins. The medial tibia1 middiaphysis then was exposed and a 5-mm resection osteotomy was done. Sheep were euthanized 6 weeks after surgery, radiographs were taken, and the initial extraction torque was measured on 4 pins from each sheep. Undecalcified sectioning and histologic and histomorphometric analyses were done on the remaining 2 pins. Radiographic pin tract rarefaction was significantly lower in the hydroxyapatite coated pins compared with the uncoated pins. Group average insertion torque was 960 f 959 Nmm in the hydroxyapatite coated pins and 709 f 585 Nmm in the uncoated pins. Group average initial extraction torque was 1485 f 1308 Nmm and 298 f 373 Nmm, respectively. Bone pin contact was 85.7% & 8.9% and 50.3% f 20.4%, respec
The Journal of Bone and Joint Surgery-American Volume, 2013
Background: The study was performed to examine the hypothesis that functional outcomes following ... more Background: The study was performed to examine the hypothesis that functional outcomes following major lowerextremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. Methods: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/ free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. Results: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to continued Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
The Journal of Trauma: Injury, Infection, and Critical Care, 2008
During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related inj... more During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related injuries. Rates of infection vary based upon organ of injury with the highest rates noted for trauma to the colon. This review focuses on the management and prevention of infections related to injuries of the thoracic and abdominal cavity. The evidence upon which these recommendations are based included military and civilian data from prior published guidelines, clinical trials, where available, reviews, and case reports. Areas of focus include antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound closure. Overall, there are limited data available from the modern battlefield regarding the prevention or treatment of these infections and further efforts are needed to answer best treatment strategies.
Blast-related lower extremity trauma presents many challenges in its management that are not freq... more Blast-related lower extremity trauma presents many challenges in its management that are not frequently experienced in high-energy civilian trauma. The large amount of kinetic energy imparted from irregularly shaped projectiles creates a wide zone of soft tissue and bone injury. 1-4 Moreover, the ''outside-in'' mechanism of the blast frequently results in a considerable amount of wound contamination from clothing, footwear, and environmental contaminants. Also, the bony component of these
The journal of trauma and acute care surgery, 2012
Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluat... more Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly...