IntroductionThe military includes lower extremity amputees requiring arthroplasty; however, there is little literature on this population. The primary aim of this study was to report demographics and clinical factors in amputees who undergo total hip or knee arthroplasty (THA/TKA) in the Military Health System (MHS). Second, patient-reported outcome measures (PROMs) are reported.MethodsThe Military Data Repository was queried for patients with lower extremity amputations and TKA or THA between 1 October 2014 and 12 October 2020. The medical records were reviewed and patients were contacted to complete PROMs. Mean follow-up for TKA and THA was 5.5 and 2.5 years, respectively.ResultsNineteen TKAs (76%) and eight THAs (28%) were performed in 25 patients. Mean age of TKA and THA patients at the time of arthroplasty was 57 years old. A majority of TKA (68%) and THA (57%) patients underwent amputations secondary to trauma. Nearly all TKAs were performed on the contralateral side to the amputation (95%), while half of THAs were performed on the ipsilateral side (50%). Two THAs (29%) were revised due to periprosthetic fractures, whereas six TKAs (32%) were revised or reoperated on due to infection. Ten TKA patients completed PROMs. The mean score on Knee Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) was 41.8 and Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) was 41.6 (Global Physical Health) and 49.6 (Global Mental Health).ConclusionsMost TKAs were performed on the contralateral limb, suggesting increased demand on the joint. The most common indication for amputation and post-TKA complication was trauma and infection, respectively. KOOS JR may not accurately capture the outcomes of this population, or they simply do worse. However, PROMIS-10 scores were similar to the non-amputee population, suggesting that the PROMIS-10 may be more useful than the KOOS JR.

IntroductionWhile civilian opioid prescriptions have seen a dramatic decline in recent years, there are few studies investigating trends in opioid prescription in the active duty military population. We evaluated oral opioid prescribing patterns to active duty military personnel in the Military Health System (MHS) from 2017 to 2020 to determine the incidence of opioid prescriptions as well as demographic and military-specific risk factors for receiving an oral opioid prescription.MethodsThe MHS Data Repository was queried from 2017 to 2020 to identify all outpatient oral opioid prescriptions to active duty military personnel in August of each year as well as demographic information on the study population. Data were evaluated in a logistic regression model, and ORs of receiving an oral opioid prescription were calculated for each factor.ResultsThe proportion of active duty military personnel receiving an oral opioid prescription declined from 2.71% to 1.26% (53% relative reduction) over the study period. Within the logistic regression model, female military personnel were significantly more likely to receive opioid prescriptions compared with men, and there was a stepwise increase in likelihood of an opioid prescription with increasing age. Army and Marine personnel, personnel without a history of military deployment and those stationed within the continental USA were significantly more likely to receive an opioid prescription.DiscussionThe substantial decrease in oral opioid prescriptions to active duty military personnel mirrors data published in the civilian community. The identified risk factors for receiving an opioid prescription may be potential targets for future interventions to further decrease prescribing.

Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA. A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up. 5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up. The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Nasal obstruction, rhinorrhea, and epistaxis are common presenting concerns in primary care clinics. Nasal disorders affect the quality of life for many children and families. Rarely, these complaints may represent a life-threatening condition among infant obligate nasal breathers or cases of unusual pathology. The most common causes of rhinorrhea and nasal obstruction vary by age and include physiologic, infectious, allergic, foreign body, irritant, and traumatic causes. Less commonly, children may have congenital malformations, sinonasal masses, or autoimmune disease. The most common causes of epistaxis are inflammatory, environmental, and traumatic causes and medication misuse, but rarely, children may have predisposing anatomic, hematologic, or vascular abnormalities or even sinonasal tumors. In this article, we provide a thorough review of the common nasal disorders treated every day in primary care clinics and mention briefly some of the rare but serious cases that may be overlooked without considering a full differential diagnosis.

To determine the rate of and risk factors for clinical failure and return to military duty following primary patellar tendon repair with either transosseous trunnel repair or suture anchor repair. The Military Health System Data Repository (MDR) was queried to identify all adult patients undergoing surgical treatment of a patellar tendon rupture in the Military Health System from 2014 to 2018. Patients who underwent either transosseous tunnel repair or suture anchor repair were included. Health records were examined to collect additional data. Univariate analysis and multivariate logistic regression models were used to determine independent risk factors for rerupture. A total of 450 knees in 437 patients were included. Transosseous tunnel repair was the most frequently used technique (314/450, 77%), followed by suture anchor repair (113/450, 25%). Rerupture occurred in 33 knees (7%). There was no difference in rerupture rate between transosseous tunnel repair and suture anchor repair (P= .15), and this result persisted within the multivariate logistic regression model. Among transosseous tunnel repairs, use of low tensile strength suture was an independent risk factor for repair failure (odds ratio [OR], 3.4; P= .016). Among suture anchor repairs, use of anchors 5.0 mm in diameter or greater (OR, 12.0; P= .027) was an independent risk factor for repair failure. There is no statistically significant difference in failure rate between transosseous tunnel repair and suture anchor repair in primary patellar tendon ruptures. However, the use of low tensile strength suture with transosseous tunnels and the use of suture anchors 5.0 mm in diameter or greater resulted in significantly higher failure rates. These data suggest that use of high tensile strength suture in transosseous tunnel repair and use of suture anchors less than 5.0 mm in diameter in suture anchor repair result in lower failure rate in primary patellar tendon repair. Level III, retrospective cohort study.

Patient demographics, such as sex and age, are known risk factors for undergoing revision following primary total hip arthroplasty (THA). The military population is unique because of the increased rates of primary and secondary osteoarthritis of the hip. Treatment options are limited for returning patients to their line of duty; however, THA has been shown to be an effective option. The primary purpose of this study was to evaluate and contrast the demographic differences of patients undergoing primary THA between the U.S. active duty military population and the general population. The secondary goal was to identify the proportion of primary THA performed at the MTF within the military health system (MHS). This was an exempt study determined by the local institutional review board. A retrospective analysis of the MHS Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP) was performed. The databases were used to identify the patients who underwent THA from January 1, 2015 to December 31, 2020. The MDR was used to identify demographics such as sex, age, setting of surgery, geographic location, previous military deployments, history of deployment-related injuries, branch of service, and rank. The NSQIP database was queried for sex and age. The median age of the population was compared using the Mann-Whitney U test and gender was compared using the Chi-square test. The MDR was used to evaluate 2,734 patients, whereas the NSQIP database was used to evaluate 223,832 patients. In the military population, patients who underwent THA were 87.7% male with an average age of 45 years, whereas in the general population as measured via the NSQIP database, 45.2% patients were male with an average age of 66.0 years. Comparing the two groups, we demonstrated that the military patients were significantly more likely to be younger (P < .001) and males (P < .001). Only 29.6% of primary THAs were performed within the MTF. Patients in the MHS are undergoing THA at a younger age and are more likely to be male compared to the general population. A significant portion of primary THAs in the MHS are also being performed at civilian institutions. These demographics may result in increased risk of revision; however, long-term studies are warranted to evaluate survivorship in this unique population.

Ventral hernia repair cost the U.S. healthcare system nearly 3 billion dollars annually. Surgical repair is a critical competency for residents yet hernia recurrence rates following mesh-based repair range from 0.8% to 24%. Improving surgical techniques using cadavers is often cost-prohibited for many education programs and limited research exists using simulation models with a corresponding hernia repair curriculum in the graduate medical education setting. This pilot project aimed to develop a low cost, easily reproducible novel abdominal wall reconstruction model and pilot-test the ventral hernia repair curriculum to inform further refinement prior to formal evaluation. This descriptive study pilot-tested the newly refined Abdominal Wall Surgical Skills Operative Model (AWSSOM) simulator for ventral hernia repair with mesh and its corresponding 2-h training curriculum for use at all levels of general surgery graduate medical education. The AWSSOM is a 3D printed synthetic anatomically realistic abdominal wall model consisting of silicone cured layers of skin, fat, rectus abdominis and a posterior rectus sheath fascia, and silicone tubules to simulate lateral neurovascular bundles. The curriculum incorporated didactic content reflecting surgical practice guidelines, hands-on practice, and faculty guidance promoting interactive critical thinking development during task performance. A pre-/post-assessment included a 10-item knowledge test, a 19-item psychomotor assessment, and 4-items confidence survey to examine changes in performance, knowledge, and confidence in competently completing the ventral hernia repair technique. Descriptive statistics were used to report the limited results of six military surgical resident participants and inform further model and curriculum refinement prior to formal evaluation. The five-layer AWSSOM model was manufactured in 65 h at a material cost of $87 per model frame, is reusable model, and secure base. Six surgical residents were recruited; only four completed both pre- and post-tests due to resident schedule conflicts. The average increase in knowledge was 25%, although variable changes in confidence were observed over the four program year participants. A larger sample size and a control group are needed to demonstrate curriculum effectiveness at improving knowledge, performance, and confidence in ventral hernia repair with mesh and better delineate if high scores translate to better operative skills. A key improvement requested by residents was a more secure model base for dissection and performance of the hernia repair. The novel abdominal wall surgical skills operative model fills an important proof of concept gap in simulation training. It is low cost with the potential to improve cognitive and psychomotor skills, as well as confidence to competently complete ventral hernia repair with mesh in the graduate medical education setting. Prior to formal effectiveness testing, our lessons learned should be addressed in both the model and curriculum. Future studies must include an adequately powered statistical evaluation with a larger sample across all levels of training.

A 15-month-old boy who was being followed for developmental dysplasia of the hip because of breech presentation was discovered to have a solitary infantile myofibroma in the left femoral neck. The patient was avoiding weight-bearing on the affected extremity; thus, stabilization of the femoral neck was performed using a proximal femur locking plate. Postoperatively, he achieved all gross motor developmental milestones. This report is the first to describe a solitary infantile myofibroma in the femoral neck and demonstrates the utility of operative stabilization of these lesions.

This case report summarizes an envenomation by the Mangshan pit viper (Protobothrops mangshanensis), a rare, endangered, venomous snake endemic to Mount Mang of China, and the first reported use of Hemato Polyvalent antivenom (HPAV) for this species. The snakebite occurred in a United States zoo to a 46-year-old male zookeeper. He presented via emergency medical services to a tertiary center after sustaining a single P. mangshanensis bite to the abdomen and was transported with antivenom from the zoo. Within 2 hours of envenomation, he developed oozing of sanguineous fluid and ecchymosis at the puncture site, and about 4 hours post-bite, was treated with HPAV. His coagulation profile fluctuated with the following pertinent peak/nadir laboratory values and corresponding hospital day (HD): undetectable fibrinogen levels, d-dimer 8.89 mg/L and 7.43 mg/L, and INR 2.97 and 1.46 on HD zero and three, respectively. Other peak/nadir values included hemoglobin 9.7 g/dL and creatinine phosphokinase 2410 U/L on HD four and platelets 81 × 109/L on HD seven. The patient received a total of 30 vials of HPAV over 5 days and 1 unit of cryoprecipitate on HD six. Upon discharge on HD eight, laboratory studies were normalizing, except for platelets, and edema stabilized. This case describes an acute, recurrent, and prolonged venom-induced consumptive coagulopathy despite prompt administration and repeated doses of HPAV.