Publications by authors named "Mark E Fleming"

26 Publications

  • Page 1 of 1

Standard Versus Low-Dose Computed Tomography for Assessment of Acetabular Fracture Reduction.

J Orthop Trauma 2020 09;34(9):462-468

Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA.

Objective: First, to assess the impact of varying computed tomography (CT) radiation dose on surgeon assessment of postfixation acetabular fracture reduction and malpositioned implants. Second, to quantify the accuracy of CT assessments compared with the experimentally set displacement in cadaver specimens. We hypothesized that a CT dose would not affect the assessments and that CT assessments would show a high concordance with known displacement.

Methods: We created posterior wall acetabular fractures in 8 fresh-frozen cadaver hips and reduced them with varying combinations of step and gap displacement. The insertion of an intra-articular screw was randomized. Each specimen had a CT with standard (120 kV), intermediate (100 kV), and low-dose (80 kV) protocols, with and without metal artifact reduction postprocessing. Reviewers quantified gap and step displacement, overall reduction, quality of the scan, and identified intra-articular implants.

Results: There were no significant differences between the CT dose protocols for assessment of gap, step, overall displacement, or the presence of intra-articular screws. Reviewers correctly categorized displacement as anatomic (0-1 mm), imperfect (2-3 mm), or poor (>3 mm) in 27.5%-57.5% of specimens. When the anatomic and imperfect categories were condensed into a single category, these scores improved to 52.5%-82.5%. Intra-articular screws were correctly identified in 56.3% of cases. Interobserver reliability was poor or moderate for all items. Reviewers rated the quality of most scans as "sufficient" (60.0%-72.5%); reviewers more frequently rated the low-dose CT as "inferior" (30.0%) and the standard dose CT as "excellent" (25%).

Conclusion: A CT dose did not affect assessment of displacement, intra-articular screw penetration, or subjective rating of scan quality in the setting of a fixed posterior wall fracture.
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http://dx.doi.org/10.1097/BOT.0000000000001778DOI Listing
September 2020

Injury and treatment patterns of ballistic pelvic fractures by anatomic location.

Eur J Orthop Surg Traumatol 2021 Jan 27;31(1):111-119. Epub 2020 Jul 27.

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Introduction: Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries.

Methods: A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality.

Results: Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance.

Conclusions: This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00590-020-02744-wDOI Listing
January 2021

Treatment of Suspected Invasive Fungal Infection in War Wounds.

Mil Med 2018 09;183(suppl_2):142-146

Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX.

Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. Other recommendations include: (1) early tissue sampling for wound histopathology and fungal cultures, (2) early consultation with infectious disease specialists, and (3) coordination with surgical pathology and clinical microbiology.
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http://dx.doi.org/10.1093/milmed/usy079DOI Listing
September 2018

Pelvic Fracture Care.

Mil Med 2018 09;183(suppl_2):115-117

Joint Trauma System, 3698 Chambers Pass, Building 3611, JBSA Fort Sam Houston, San Antonio, TX.

While combat-related pelvis fractures are more commonly open, higher energy, and complex in pattern than those seen in the civilian setting, the principles of management are similar. The primary differences are related to the austere setting in which the initial management takes place, and the lack of resources typically available. Initial management consists of cessation of hemorrhage, along with the multi-disciplinary prioritized management of associated injuries, and skeletal stabilization. This is most commonly achieved with a compressive sheet or pelvic binder, with pelvic external fixation when resources allow, and debridement of open wounds as necessary. Definitive, internal fixation is delayed until the patient arrives at a higher echelon of care.
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http://dx.doi.org/10.1093/milmed/usy111DOI Listing
September 2018

Restoring full-thickness defects with spray skin in conjunction with dermal regenerate template and split-thickness skin grafting: a pilot study.

J Tissue Eng Regen Med 2017 12 22;11(12):3523-3529. Epub 2017 Mar 22.

Plastic Surgery, The Ohio State Wexner Medical Center, Columbus, OH, USA.

Complex, full-thickness soft tissue defects secondary to large burns, trauma and war-related injuries continue to challenge reconstructive surgeons. To achieve positive surgical outcomes in these patient populations, novel approaches are needed to restore the functional, protective and aesthetic properties of skin. Herein, we provide the first report describing the staged use of a dermal regenerate template (DRT) with a spray-on epidermal regenerative modality (spray skin) in addition to autologous split-thickness skin grafting (STSG) in non-burn trauma and compare these results with those of patients treated with DRT and STSG alone. A pilot study was performed to evaluate whether the use of spray skin technology (ReCell, Avita Medical) as an adjunct to DRT (Integra, Integra Lifesciences) and autologous skin grafting in the treatment of patients with large full-thickness soft tissue losses impacts donor site burden as well as recipient and donor site re-epithelialization. In this retrospective study, two patients who were treated with DRT and STSG alone (control group) were compared with two patients who were treated with DRT and spray skin/STSG in combination (experimental group). The mechanisms of injury, total defect and treatment sizes, time to complete re-epithelialization, lengths of follow-up, outcomes and complications were reviewed. Our group observed that using a DRT in conjunction with spray skin/STSG can reduce donor site burden and decrease time to complete healing. It can also permit greater or larger meshing ratios, while aiding in improved re-pigmentation when compared with similar wounds treated with a DRT and autologous skin grafting alone. Copyright © 2017 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/term.2264DOI Listing
December 2017

A Case Report of the First Nonburn-related Military Trauma Victim Treated with Spray Skin Regenerative Therapy in Combination with a Dermal Regenerate Template.

Plast Reconstr Surg Glob Open 2016 Dec 27;4(12):e1174. Epub 2016 Dec 27.

Department of Plastic Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio.; and Departments of Oral and Maxillofacial Surgery, Plastic and Reconstructive Surgery, and Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, Md.

Massive soft tissue and skin loss secondary to war-related traumas are among the most frequently encountered challenges in the care of wounded warriors. This case report outlines the first military nonburn-related trauma patient treated by a combination of regenerative modalities. Our case employs spray skin technology to an established dermal regenerate matrix. Our patient, a 29-year-old active duty male, suffered a combat blast trauma in 2010 while deployed. The patient's treatment course was complicated by a severe necrotizing fasciitis infection requiring over 100 surgical procedures for disease control and reconstruction. In secondary delayed reconstruction procedures, this triple-limb amputee underwent successful staged ventral hernia repair via a component separation technique with biologic mesh underlay although this resulted in a skin deficit of more than 600 cm. A dermal regenerate template was applied to the abdominal wound to aid in establishing a "neodermis." Three weeks after dermal regenerate application, spray skin was applied to the defect in conjunction with a 6:1 meshed split thickness skin graft. The dermal regenerate template allowed for optimization of the wound bed for skin grafting. The use of spray skin allowed for a 6:1 mesh ratio, thus minimizing the donor-site size and morbidity. Together, this approach resulted in complete healing of a large full-thickness wound. The patient is now able to perform activities of daily living, walk without a cane, and engage in various physical activities. Overall, our case highlights the potential that combining regenerative therapies can achieve in treating severe war-related and civilian traumatic injuries.
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http://dx.doi.org/10.1097/GOX.0000000000001174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5222667PMC
December 2016

Erratum: Light-Activated Sealing of Acellular Nerve Allografts following Nerve Gap Injury.

J Reconstr Microsurg 2016 11 24;32(9):e1. Epub 2016 Jun 24.

Wellman Centre for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1055/s-0036-1584882DOI Listing
November 2016

Introduction.

J Orthop Trauma 2016 Oct;30 Suppl 3:S1

*OTA, Military Committee †Department of Orthoapedic Surgery, San Antonio Military Medical Center, San Antonio, TX ‡Department of Extremity Trauma and Regenerative Medicine, United States Army Institute of Surgical Research, San Antonio, TX §Navy Trauma Training Center, Los Angeles County + USC Medical Center, Los Angeles, CA.

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http://dx.doi.org/10.1097/BOT.0000000000000679DOI Listing
October 2016

Light-Activated Sealing of Acellular Nerve Allografts following Nerve Gap Injury.

J Reconstr Microsurg 2016 Jul 15;32(6):421-30. Epub 2016 Feb 15.

Wellman Centre for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts.

Introduction Photochemical tissue bonding (PTB) uses visible light to create sutureless, watertight bonds between two apposed tissue surfaces stained with photoactive dye. In phase 1 of this two-phase study, nerve gaps repaired with bonded isografts were superior to sutured isografts. When autograft demand exceeds supply, acellular nerve allograft (ANA) is an alternative although outcomes are typically inferior. This study assesses the efficacy of PTB when used with ANA. Methods Overall 20 male Lewis rats had 15-mm left sciatic nerve gaps repaired using ANA. ANAs were secured using epineurial suture (group 1) or PTB (group 2). Outcomes were assessed using sciatic function index (SFI), gastrocnemius muscle mass retention, and nerve histomorphometry. Historical controls from phase 1 were used to compare the performance of ANA with isograft. Statistical analysis was performed using analysis of variance and Bonferroni all-pairs comparison. Results All ANAs had signs of successful regeneration. Mean values for SFI, muscle mass retention, nerve fiber diameter, axon diameter, and myelin thickness were not significantly different between ANA + suture and ANA + PTB. On comparative analysis, ANA + suture performed significantly worse than isograft + suture from phase 1. However, ANA + PTB was statistically comparable to isograft + suture, the current standard of care. Conclusion Previously reported advantages of PTB versus suture appear to be reduced when applied to ANA. The lack of Schwann cells and neurotrophic factors may be responsible. PTB may improve ANA performance to an extent, where they are equivalent to autograft. This may have important clinical implications when injuries preclude the use of autograft.
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http://dx.doi.org/10.1055/s-0035-1571247DOI Listing
July 2016

Use of a bioartificial dermal regeneration template for skin restoration in combat casualty injuries.

Regen Med 2016 Jan 18;11(1):81-90. Epub 2015 Dec 18.

Department of Plastic Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Ste 2100, Columbus, OH 43212, USA.

Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.
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http://dx.doi.org/10.2217/rme.15.83DOI Listing
January 2016

Combat-Related Hemipelvectomy: 14 Cases, a Review of the Literature and Lessons Learned.

J Orthop Trauma 2015 Dec;29(12):e493-8

*Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD; †Norman M. Rich Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD; and ‡Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN.

Objectives: Trauma-related hemipelvectomy is a rare and often fatal injury that poses a number of challenges to the treating surgeon. Our objective was to identify patient and injury characteristics that have proven difficult to treat, and to describe management techniques.

Design: Retrospective review.

Setting: Level II trauma center.

Patients: Thirteen consecutive patients who underwent 14 combat-related hemipelvectomies between 2001 and 2013.

Intervention: We reviewed our prospective trauma registry, along with the patients' medical records, radiographs, and clinical photographs.

Main Outcome Measurements: Injury severity scores, required surgical procedures, ambulatory status, and bowel and bladder function.

Results: Hemipelvectomy was indicated for insufficient soft tissue coverage, complicated by life-threatening local infection and/or a dysvascular hemipelvis. Five patients underwent resection for angioinvasive fungal infections. All patients sustained a genitourinary injury, with 7 requiring suprapubic catheters and all undergoing diverting colostomy. After a median of 2 years of follow-up, 2 patients had normal urinary continence and 3 regained fecal continence. The surviving patients required a mean of 44 operations. One patient returned to community ambulation.

Conclusions: This is the largest published series of trauma-related hemipelvectomies. Our lessons learned may benefit civilian surgeons who are confronted with high-energy open injuries to the pelvic girdle. Although the decision to perform hemipelvectomy should not be taken lightly, this procedure can be lifesaving and should be performed in a timely fashion when indicated.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000398DOI Listing
December 2015

Heterotopic Ossification following Tissue Transfer for Combat-Casualty Complex Periarticular Injuries.

Plast Reconstr Surg 2015 Dec;136(6):808e-814e

Bethesda and Baltimore, Md.; and Columbus, Ohio From the Departments of Orthopedics and Surgery and the Plastic and Reconstructive Surgery Service, Department of Surgery, Walter Reed National Military Medical Center; the Department of Surgery, Uniformed Services University of the Health Sciences; the Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine; and the Department of Plastic and Reconstructive Surgery, Division of Burn, Wound, and Trauma, The Ohio State University Wexner Medical Center.

Background: Although mechanisms underlying heterotopic ossification remain unknown, certain risk factors can influence heterotopic bone formation. The purpose of this study was to determine whether flaps used in periarticular reconstruction had any effect on heterotopic ossification formation.

Methods: A retrospective review of periarticular injuries requiring flap coverage from 2003 through 2014 was performed. Flap types, Injury Severity Scores, functional outcomes, and complications were reviewed. Radiology findings were assessed to determine heterotopic ossification rates and grades.

Results: Three hundred eighty-nine flaps were performed for traumatic extremity coverage over the 13-year study period. Sixty-nine of these flaps were used for periarticular coverage. The rate of periarticular heterotopic ossification was 47 percent for fasciocutaneous versus 54 percent for muscle-based flap coverage (p = 0.88). There were no significant differences in Injury Severity Score (p = 0.44) or overall heterotopic ossification formation (p = 0.97) between groups; however, the grade of heterotopic ossification within muscle-based flap cohort was significantly higher (1.70 for muscle versus 1.06 for the fasciocutaneous cohort; p = 0.002).

Conclusions: Combat-related trauma is associated with high rates of heterotopic ossification, with an overall formation rate exceeding 85 percent for our patients requiring periarticular flap coverage. Although no difference in the rate of heterotopic ossification formation was found between fasciocutaneous and muscle flap coverages, a significantly increased severity of heterotopic ossification was seen in periarticular muscle-based flaps. These findings suggest that flap composition might not affect the rate of heterotopic ossification formation but may have an effect on ectopic bone formation severity.
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http://dx.doi.org/10.1097/PRS.0000000000001796DOI Listing
December 2015

Light-Activated Sealing of Nerve Graft Coaptation Sites Improves Outcome following Large Gap Peripheral Nerve Injury.

Plast Reconstr Surg 2015 Oct;136(4):739-750

Boston, Mass.; and Bethesda, Md. From the Division of Plastic Surgery and the Wellman Center for Photomedicine, Massachusetts General Hospital; and the Plastic Surgery Service and the Department of Orthopedics, Walter Reed National Military Medical Center.

Background: Nerve repair using photochemically bonded human amnion nerve wraps can result in superior outcomes in comparison with standard suture. When applied to nerve grafts, efficacy has been limited by proteolytic degradation of bonded amnion during extended periods of recovery. Chemical cross-linking of amnion before bonding may improve wrap durability and efficacy.

Methods: Three nerve wraps (amnion, cross-linked amnion, and cross-linked swine intestinal submucosa) and three fixation methods (suture, fibrin glue, and photochemical bonding) were investigated. One hundred ten Lewis rats had 15-mm left sciatic nerve gaps repaired with isografts. Nine groups (n = 10) had isografts secured by one of the aforementioned wrap/fixation combinations. Positive and negative control groups (n = 10) were repaired with graft and suture and no repair, respectively. Outcomes were assessed using sciatic function index, muscle mass retention, and histomorphometry. Statistical analysis was performed using analysis of variance and the post hoc Bonferroni test (p < 0.05).

Results: Cross-linking improved amnion durability. Photochemically bonded cross-linked amnion recovered the greatest sciatic function index, although this was not significant in comparison with graft and suture. Photochemically bonded cross-linked amnion recovered significantly greater muscle mass (67.3 ± 4.4 percent versus 60.0 ± 5.2 percent; p = 0.02), fiber diameter, axon diameter, and myelin thickness (6.87 ± 2.23 μm versus 5.47 ± 1.70 μm; 4.51 ± 1.83 μm versus 3.50 ± 1.44 μm; and 2.35 ± 0.64 μm versus 1.96 ± 0.47 μm, respectively) in comparison with graft and suture.

Conclusion: Light-activated sealing of cross-linked human amnion results in superior outcomes when compared with conventional suture.
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http://dx.doi.org/10.1097/PRS.0000000000001617DOI Listing
October 2015

Regenerative medicine applications in combat casualty care.

Regen Med 2014 Mar;9(2):179-90

Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA.

The purpose of this report is to describe regenerative medicine applications in the management of complex injuries sustained by service members injured in support of the wars in Afghanistan and Iraq. Improvements in body armor, resuscitative techniques and faster transport have translated into increased patient survivability and more complex wounds. Combat-related blast injuries have resulted in multiple extremity injuries, significant tissue loss and amputations. Due to the limited availability and morbidity associated with autologous tissue donor sites, the introduction of regenerative medicine has been critical in managing war extremity injuries with composite massive tissue loss. Through case reports and clinical images, this report reviews the application of regenerative medicine modalities employed to manage combat-related injuries. It illustrates that the novel use of hybrid reconstructions combining traditional and regenerative medicine approaches are an effective tool in managing wounds. Lessons learned can be adapted to civilian care.
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http://dx.doi.org/10.2217/rme.13.96DOI Listing
March 2014

Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length.

Ann Plast Surg 2014 Aug;73(2):183-9

From the *Department of Orthopaedics, Walter Reed National Military Medical Center; †Uniformed Services University of the Health Sciences; and ‡Plastic and Reconstructive Service, Walter Reed National Military Medical Center, Bethesda, MD.

Background: A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation.

Methods: A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length.

Results: Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers.

Conclusions: The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.
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http://dx.doi.org/10.1097/SAP.0b013e3182a638d8DOI Listing
August 2014

Neurovascular entrapment due to combat-related heterotopic ossification in the lower extremity.

J Bone Joint Surg Am 2013 Dec;95(24):e195(1-6)

Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19), 2nd Floor-Ortho, Bethesda, MD 20889. E-mail address:

Background: Heterotopic ossification is the ectopic formation of mature lamellar bone in nonosseous tissue. The prevalence of heterotopic ossification following combat injuries is much higher than civilian data would suggest. In certain cases, the aberrant bone formation can envelop major neurovascular structures in the lower extremity, leading to symptomatic neurovascular entrapment.

Methods: We describe five consecutive cases of heterotopic ossification leading to symptomatic neurovascular entrapment in the lower extremity as a result of blast trauma and present our method of patient assessment, preoperative planning, and surgical excision.

Results: Heterotopic bone was successfully excised without neurovascular injury in all patients. At a mean of twenty months (range, eight to forty-five months) postoperatively, all patients demonstrated continued improvement of their pre-excision function. All patients who had neuropathic pain had a decrease in the pain. Those with decreased joint motion regained motion once their wounds were stable. Sensory deficits resolved before motor deficits did. There was no recurrence of clinically relevant heterotopic ossification in this series.

Conclusions: Excision of heterotopic bone, particularly with concurrent neurovascular entrapment, can be associated with major short-term and long-term complications. With use of our treatment algorithm, involving careful preoperative planning and meticulous operative excision, heterotopic bone entrapping major neurovascular structures following severe extremity trauma can be safely excised with subsequent clinical improvement.
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http://dx.doi.org/10.2106/JBJS.M.00212DOI Listing
December 2013

Use of 3-dimensional stereolithographic polymer models for heterotopic ossification surgical excision.

Orthopedics 2013 Apr;36(4):282-6

Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.

Heterotopic ossification is a known complication of traumatic injuries. To minimize iatrogenic complications during excision, an understanding of anatomic relationships is essential. Current imaging modalities, such as computed tomography and plain radiographs, are limited to providing a 2-dimensional representation of a 3-dimensional problem. This study describes the benefits of 3-dimensional stereolithography in the perioperative management of symptomatic heterotopic ossification using models were that were fabricated based on high-resolution computed tomography scans. The models facilitated heterotopic ossification excision through frequent intraoperative reference, allowing the authors to avoid iatrogenic neurovascular injuries.
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http://dx.doi.org/10.3928/01477447-20130327-06DOI Listing
April 2013

Injury severity score underpredicts injury severity and resource utilization in combat-related amputations.

J Orthop Trauma 2013 Jul;27(7):419-23

Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.

Objective: Assess effectiveness of Injury Severity Score (ISS) in predicting injury severity in combat-related amputations.

Design: Retrospective evaluation of prospectively collected data.

Setting: Military medical center.

Patients: One hundred and nine patients with major extremity amputations sustained in overseas combat.

Intervention: Standard combat casualty care.

Main Outcome Measurements: Difference in injury severity as measured by ISS, numbers of extremity(s) amputated, number of associated injuries, blood products used, intensive care unit length of stay, hospital length of stay in those with an upper extremity amputation (UEA) compared with those with an isolated lower extremity amputation.

Results: Thirteen patients (11.9%) sustained at least one UEA. Patients with an UEA had a greater number of amputations per casualty compared with patients with a lower extremity alone (2.5 vs. 1.5; P < 0.001). The mean hospital length of stay (P = 0.02) and intensive care unit length of stay (P = 0.02) were significantly greater in those with an UEA. Mean blood product utilization was also significantly greater in those with an upper extremity amputation (P < 0.05). There was no difference in ISS between the two groups (P > 0.05).

Conclusions: The presence of an UEA is associated with increased injury severity as evident by increased intensive care unit requirements, blood product utilization, and hospital length of stay. ISS underestimates the severity of injury and therefore resource utilization in patients with multiple combat-related amputations. Recognition of this limitation in addition to the development of a military-specific ISS is required for more effective resource utilization to continue to improve combat casualty care.

Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0b013e318279fa4fDOI Listing
July 2013

Reprioritization of research for combat casualty care.

J Am Acad Orthop Surg 2012 ;20 Suppl 1:S99-102

Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX, USA.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.
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http://dx.doi.org/10.5435/JAAOS-20-08-S99DOI Listing
September 2012

Evolution of orthopaedic reconstructive care.

J Am Acad Orthop Surg 2012 ;20 Suppl 1:S74-9

Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, USA.

The patterns and severity of injury sustained by service members have continuously evolved over the past 10 years of combat in Iraq and Afghanistan. The 2010 surge of combat troops into Afghanistan, combined with a transition to counterinsurgency tactics with an emphasis on dismounted operations, resulted in increased exposure of US service members to improvised explosive devices and a new pattern of injury termed dismounted complex blast injury. This constellation of injuries typically includes multiple extremity injuries, high bilateral transfemoral amputations, amputated or mangled upper extremities, open pelvis fractures, and injury to the perineal and/or genital regions. These polytraumatized patients frequently present with head, abdominal, and genitourinary injuries, as well. Traditional methods of reconstruction must be optimized because tissue availability may be limited.
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http://dx.doi.org/10.5435/JAAOS-20-08-S74DOI Listing
September 2012

Moderators' summary: outcomes data driving technological advances (session I).

J Am Acad Orthop Surg 2012 ;20 Suppl 1:S1-2

Department of Orthopaedics and Rehabilitation, United Hospital Center, Bridgeport, WV, USA.

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http://dx.doi.org/10.5435/JAAOS-20-08-S1DOI Listing
September 2012

Use of the Vertical Rectus Abdominis Muscle Flap for an Open Pelvic Fracture Secondary to a Blast Injury: A Case Report.

JBJS Case Connect 2012 Jul-Sep;2(3):e39

Integrated Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for K.N. Evans:

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http://dx.doi.org/10.2106/JBJS.CC.K.00126DOI Listing
December 2017

Low complication rate associated with raising mature flap for tibial nonunion reconstruction.

J Trauma 2011 Dec;71(6):1709-14

Department of Orthopaedic Surgery, Multicare Health Systems, Tacoma, Washington, USA.

Background: Tibia fractures may require soft tissue coverage with transposed tissue and can develop nonunions. Tibial defects can be approached with a posterolateral approach or by elevating the previously transposed tissue. No literature has previously reported the efficacy or safety of the latter approach. The purpose of this study was to report the flap survival rate and complications from delayed elevation of transposed soft tissue as part of a protocol for the treatment of tibia nonunions.

Methods: In a retrospective review of patients having local, regional, or free soft tissue transposition for the management of open type III B high-energy tibial fractures and also requiring secondary procedures on the same tibia for treatment of tibial nonunion and/or osteomyelitis that required flap elevation, 23 patients with 24 flaps were identified and studied. The 24 flaps were elevated a total of 72 times as part of a staged protocol for nonunion reconstruction by a single surgeon. Primary end point was flap survival. Mean follow-up after definitive soft tissue coverage was 23.7 months. Mean follow-up after injury was 28.9 months.

Results: One flap failed after elevation. On a per elevation surgery basis, the flap survival rate was 98.6% (71 of 72). On a per flap basis, the flap survival rate was 95.8% (23 of 24).

Conclusions: This is the first report of the survival and complication rates for delayed elevation of soft tissue flaps for tibial nonunion reconstruction. A total of 95.8% of flaps survived elevation. Flap elevation seems to be an alternative to posterolateral tibial approaches for treatment of tibial nonunions.
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December 2011

Prevention of infections associated with combat-related extremity injuries.

J Trauma 2011 Aug;71(2 Suppl 2):S235-57

Infectious Disease Service, San Antonio Military Medical Center, Fort Sam Houston, Texas 78234, USA.

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.
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August 2011

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

J Trauma 2011 Aug;71(2 Suppl 2):S210-34

Infectious Disease Service, San Antonio Military Medical Center, Fort Sam Houston, Texas 78234, USA.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.
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August 2011

Executive summary: Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

J Trauma 2011 Aug;71(2 Suppl 2):S202-9

San Antonio Military Medical Center, US Army Institute of Surgical Research, Fort Sam Houston, Texas 78234, USA.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.
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August 2011
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