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Chung BH, Shaw KA, Burke JS, Jackson KL, Schmitz MR, Boomsma S, Hurvitz AP, Moreland CM, O'Brien FP, Antosh IJ, Huh J, Waterman BR, Wheatley BM, Potter BK. Consensus and Equipose in the Management of Military Trainee Femoral Neck Stress Fractures: A Survey of Military Surgeons. Mil Med 2024; 189:e82-e89. [PMID: 37261898 DOI: 10.1093/milmed/usac426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/25/2022] [Accepted: 12/23/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Femoral neck stress fractures (FNSFs) are a unique injury pattern not commonly treated in the civilian trauma population; however, it is particularly high with military trainees engaged in basic combat training. To date, no study has surveyed a population of military orthopedic surgeons on treatment preferences for military service members (SMs) with FNSF. QUESTIONS We aim to evaluate the extent of clinical equipoise that exists in the management of these injuries, hypothesizing that there would be consensus in the factors dictating surgical and non-surgical intervention for FNSF. PATIENTS AND METHODS A 27-question survey was created and sent to U.S. military orthopedic surgeon members of the Society of Military Orthopaedic Surgeons. The survey was designed in order to gather the experience among surgeons in treating FNSF and identifying variables that play a role in the treatment algorithm for these patients. In addition, seven detailed, clinical vignettes were presented to further inquire on surgeon treatment preferences. Binomial distribution analysis was used to evaluate for common trends within the surgeon's treatment preferences. RESULTS Seventy orthopedic surgeons completed the survey, the majority of whom were on active duty status in the U.S. Military (82.86%) and having under 5 years of experience (61.43%). Majority of surgeons elected for a multiple screw construct (92.86%), however the orientation of the multiple screws was dependent on whether the fracture was open or closed. Management for compression-sided FNSF involving ≥50% of the femoral neck width, tension-sided FNSF, and stress fractures demonstrating fracture line progression had consensus for operative management. Respondents agreed upon prophylactic fixation of the contralateral hip if the following factors were involved: Complete fracture (98.57%), compression-sided fracture line >75% (88.57%), compression-sided fracture line >50-75% with hip effusion (88.57%), contralateral tension-sided fracture (87.14%), and compression-sided fracture line >50-75% (84.29%). An FNSF < 50% on the contralateral femoral neck or a hip effusion was indeterminate in surgeons indicating need for prophylactic fixation. Majority of surgeons (77.1%) utilized restricted toe-touch weight-bearing for postoperative mobility restrictions. CONCLUSIONS Consensus exists for surgical and non-surgical management of FNSF by U.S. military orthopedic surgeons, despite the preponderance of surgeons reporting a low annual volume of FNSF cases treated. However, there are certain aspects in the operative and non-operative management of FNSF that are unanimously adhered to. Specifically, our results demonstrate that there is no clear indication on the management of FNSF when an associated hip effusion is involved. Additionally, the indications for surgically treating contralateral FNSF are unclear. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - K Aaron Shaw
- Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 30905, USA
| | - Joseph S Burke
- University of Kentucky College of Medicine, Lexington, KY 40506, USA
| | - Keith L Jackson
- Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 30905, USA
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Matthew R Schmitz
- University of Kentucky College of Medicine, Lexington, KY 40506, USA
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Shawn Boomsma
- University of Kentucky College of Medicine, Lexington, KY 40506, USA
- Jackson Memorial Hospital, Miami, FL 33136, USA
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | | | | | | | - Ivan J Antosh
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- San Antonio Military Medical Center, San Antonio, TX 78219, USA
| | - Jeannie Huh
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- San Antonio Military Medical Center, San Antonio, TX 78219, USA
| | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, NC 27109, USA
- U.S. Ski & Snowboard, Park City, UT 84060, USA
| | | | - Benjamin K Potter
- Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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Ring M, Friemert B, Hackenbroch C, Achatz G. [Stress fractures in the military context]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:856-862. [PMID: 37910187 DOI: 10.1007/s00113-023-01375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist. OBJECTIVE Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities. MATERIAL AND METHODS A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options. RESULTS There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated. CONCLUSION Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.
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Affiliation(s)
- Matthias Ring
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
| | - Benedikt Friemert
- Zentrales Klinisches Management, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Carsten Hackenbroch
- Klinik für Radiologie und Neuroradiologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Gerhard Achatz
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
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