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BACKGROUND: The evolution of warfare has resulted in a surge of high-energy blast injuries predominantly involving the lower extremities. Once thought to impact only forward-deployed military, such mechanisms of injury are becoming a harsh reality even in civilian territory. Proficiency in surgical techniques for extremity damage control is vital for surgeons, regardless of specialty. To evaluate and train surgical residents and attending surgeons in critical limb-salvage techniques, Theater Hospital Operations Replication (THOR) has been proposed as a high-fidelity training platform to enhance extremity surgery teaching practices and assess proficiency in fasciotomy, vascular shunting, and knee-spanning external fixation in a simulated, resource-limited environment. QUESTIONS/PURPOSES: Given the importance of proficiency and efficiency in surgeon ability to perform fasciotomies, vascular shunting, and placement of external fixators, in this study, we proposed two research questions: (1) Does repetition-based training within the THOR model improve surgeon knowledge and technical skill? (2) Are there differences in skill outcome when utilizing the THOR model based on surgical specialty (orthopaedic versus general) and/or level in training (attending versus resident)? METHODS: This was an observational learning outcome study performed in the bioskills lab at a single institution, the Naval Medical Center Portsmouth, in which 26 surgeons completed a same-day course consisting of pretraining assessment, cadaver training on three damage-control surgery techniques in a high-fidelity THOR environment, and post-training assessment. The surgeons were either general surgeons or orthopaedic surgeons and consisted of both residents and attending surgeons. Subjects underwent a pretraining knowledge assessment, followed by two rounds of performing simulated surgery. The first round of surgery included guidance and instruction from board-certified orthopaedic surgeons. After a short break for the subjects to review the material, the second round was completed without instruction. To answer our first question of how repetition-based training impacts surgical skill, our metrics included: Objective Structured Assessment of Technical Skills (OSATS) scores (range 1 to 5, scored lowest to highest, where higher scores represent optimal skill performance), procedural accuracy, a 10-question knowledge assessment administered before and after training (scored 0 to 10, where higher scores represent competency of the anatomy and procedure steps), and total procedure time. To address our second question, data on demographic characteristics were collected on all participants, which included surgical specialty, year in training, and gender. RESULTS: The general surgery residents' cohort demonstrated improvement in both mean ± SD OSATS scores (2.4 ± 0.7 before training versus 3.6 ± 0.6 after training, mean difference 1.2 [95% CI 0.4 to 2.0]; p = 0.01) and procedure duration (23 ± 7 minutes before training versus 16 ± 5 minutes after training, mean difference 6 minutes [95% CI 4 to 9]; p = 0.001) for external fixator procedures after THOR. Similar results were seen in fasciotomies after THOR. The orthopaedic surgery residents' cohort showed similar improvements in reducing procedure duration when performing knee-spanning external fixator surgery, as well as exhibited improvements during vascular shunting procedures in both mean ± SD OSATS scores (previously 3.3 ± 0.9 versus 4.0 ± 0.9, mean difference 0.7 [95% CI 0.2 to 1.2]; p = 0.01) and procedure duration (23 ± 5 minutes versus 14 ± 8 minutes, mean difference 10 minutes [95% CI 4 to 15]; p = 0.003) after THOR. When we compared the cohorts, general surgery attending surgeons demonstrated an improvement in vascular shunting procedure duration after instruction with the THOR model (19 ± 3 minutes versus 12 ± 4 minutes, mean difference 7 minutes [95% CI 1 to 13]; p = 0.03) and in overall knowledge scores (4.3 + 0.5 versus 8.0 ± 1.6, mean difference 3.8 [95% CI 0.5 to 7.0]; p = 0.04). The orthopaedic surgery attending surgeons yielded no improvement for any metric, pretraining and post-training. Using the prescores as a covariate, for almost all metrics analyzed, there were no differences between surgeon groups based on specialty after completing the repeated training. CONCLUSION: Use of the high-fidelity THOR training model improved proficiency in the examined sample of extremity damage-control procedures, thus demonstrating its efficacy in enhancing surgical skills and short-interval knowledge retention while simultaneously highlighting the importance of cadaver simulation training in enhancing surgical preparedness for complex trauma. CLINICAL RELEVANCE: The high-fidelity THOR training model represents a promising modality for preparing surgeons for extremity combat trauma management in resource-limited, high-stress environments. Whether in a wartime environment or in the civilian sector, efficient and skilled intervention are crucial in managing patient morbidity. Differences of a few minutes per procedure can mean all the difference in damage control, especially when compounded in situations where vascular shunting, knee-spanning external fixation, and lower leg four-compartment fasciotomy have to be performed together by both orthopaedic and general surgeons. The observational period in this study spanned 1 day and thus does not provide information on retention of long-term skills or knowledge. A follow-on study can assess how time from initial training to final evaluation impacts overall skill competency and knowledge.

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OBJECTIVE: To define relative increases in visual bony surface area and access to critical landmarks with the addition of a trochanteric slide osteotomy to a Kocher-Langenbeck approach. METHODS: A Kocher-Langenbeck approach followed by a trochanteric slide osteotomy was sequentially performed on 10, fresh-frozen, hemipelvectomy cadaveric specimens. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J. RESULTS: The acetabular surface area exposed was 27.66 (±6.67) cm2 for a Kocher-Langenbeck approach. This increased to and 41.82 (±7.97) cm2 with the addition of a trochanteric osteotomy. The exposed surface area was increased by 51.2% for the trochanteric osteotomy (P < 0.001). The superior margin of the acetabulum could be visualized and palpably accessed in both exposures. Access to the more anterosuperior portions of the acetabulum was consistently possible in the trochanteric osteotomy but not with the Kocher-Langenbeck approach. CONCLUSIONS: A trochanteric osteotomy may visually improve access to the most anterosuperior acetabulum but does not significantly improve surgical access to relevant portions of the superior acetabulum when compared with a Kocher-Langenbeck approach.

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CASE: A 21-year-old woman presented with a chronic fracture dislocation of her left shoulder after striking a submerged tree during a watersport activity. She was initially treated at an outside hospital, where she underwent open reduction and internal fixation of her posterior scapula. She presented 8 weeks after index procedure with pain and severely decreased range of motion. Her comminuted and displaced fracture comprising 70% of the anterior superior glenoid was surgically reconstructed using a distal tibia allograft (DTA), resulting in a functional shoulder. CONCLUSION: A DTA is a feasible option to reconstruct the glenoid surface in fracture dislocations of the shoulder with a significant loss of the articular surface.

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BACKGROUND: Debate exists over the optimal approach for addressing fractures of the proximal humerus. The purpose of this study was to objectively quantify the surface area of the humerus exposed using the deltopectoral (DP) and anterolateral acromial (ALA) approaches and to compare visualized and palpable anatomic landmarks. METHODS: Ten arms on five fresh-frozen torsos underwent the DP and ALA approaches. The arms were positioned to simulate a supine patient and held in a fixed position. Visual and/or palpable access to relevant surgical landmarks and the myotendinous junctions were recorded. The myotendinous junctions were used as a rough approximation of consistent proximal exposure of a clinically retracted tuberosity. Landmarks were grouped into quadrants based on the location. Calibrated digital photographs of each approach were analyzed to calculate the surface area and the length of the exposed bone. RESULTS: The DP and ALA approaches exposed 22.9 ± 6.3 cm2 and 16.3 ± 6.4 cm2, respectively (P = 0.03). The DP and ALA approaches provided equivalent visual and palpable access to all landmarks in the superior and inferior quadrants. The ALA allowed improved visual (80% versus 70%) and palpable (100% versus 70%) access to the myotendinous junction of the infraspinatus in the posterior quadrant. The DP approach allowed better access to anterior quadrant structures, including improved ability to visualize the myotendinous junction of the subscapularis (100% versus zero), the subscapularis insertion (100% versus 80%), and the medial anatomic neck (100% versus 20%). Palpable access to the myotendinous junction of the subscapularis (100% versus 70%) and medial anatomic neck (100% versus 60%) was also improved with the DP. CONCLUSIONS: In a cadaver model with fixed arm position, the DP provides increased exposure to the proximal humerus and more reliable access to anterior surgical landmarks, whereas the ALA allows improved access to the most posterior aspect of the shoulder.

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Extensile approaches to the humerus are often needed when treating complex proximal or distal fractures that have extension into the humeral shaft or in those fractures that occur around implants. The 2 most commonly used approaches for more complex fractures include the modified lateral paratricipital approach and the deltopectoral approach with distal anterior extension. Although the former is well described and quantified, the latter is often associated with variable nomenclature with technical descriptions that can be confusing. Furthermore, a method to expose the entire humerus through an anterior extensile approach has not been described. Here, we illustrate and quantify a technique for connecting anterior humeral approaches in a stepwise fashion to form an aggregate anterior approach (AAA). We also describe a method for further distal extension to expose 100% of the length of the humerus and compare this approach with both the AAA and the lateral paratricipital in terms of access to critical bony landmarks, as well as the length and area of bone exposed.

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OBJECTIVES: A debate exists over the optimal approach for addressing fractures of the scapula and glenoid. The purpose of this study is to (1) quantify and compare osseous exposure using modified Judet (MJ) and classic Judet (CJ) approaches and (2) assess the change in scapular exposure after triceps release from the inferior glenoid. METHODS: Ten arms on 5 fresh-frozen torsos underwent MJ and CJ approaches. A triceps release was performed following the CJ approach in all specimens. Visual and/or palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J (NIH, Bethesda, MD) to calculate the surface area of exposed bone. RESULTS: The MJ and CJ approaches exposed 16.8 (±7.58) cm(2) and 98.6 (±25.39) cm(2) of bone, respectively (P < 0.001). The full medial and lateral borders of the scapula were visualized in all approaches with mobilization of the teres minor. Palpable access to the full scapular spine was possible in all cadavers. Although the MJ and CJ approaches only allowed the inferior gleniod neck to be visualized in 1 and 2 specimens, respectively, performing a triceps release provided access to this structure. It also increased the CJ exposure by 12.6 cm(2) (P < 0.001) and allowed palpation of the anterior glenoid margin in 100% of specimens. CONCLUSIONS: In conclusion, the MJ approach allows similar access to landmarks important for reduction and fixation while exposing only 20% of the surface area typically visualized with the CJ approach.

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PURPOSE: Fiberglass casts are frequently valved to relieve the pressure associated with upper extremity swelling after a surgical procedure or when applied after reduction of a displaced fracture in a child. Although different opinions exist regarding the valving of casts, no research to date has explored the biomechanical effects of this commonly used technique. As cast integrity is essential for the maintenance of fracture reduction, it is important to understand whether casts are structurally compromised after valving. Understanding the effects of valving on cast integrity may help guide clinicians in the technique of valving while minimizing the potential for a loss of fracture reduction. METHODS: Thirty standardized cylindrical fiberglass cast models were created. Ten models were left intact, 10 were univalved, and 10 were bivalved. All the models were mechanically tested by a 3-point bending apparatus secured to a biaxial materials testing system. Load to failure and bending stiffness were recorded for each sample. Differences in load of failure and bending stiffness were compared among the groups. RESULTS: Unvalved cast models had the highest failure load and bending stiffness, whereas bivalved casts showed the lowest value for both failure load and bending stiffness. Univalved casts had a failure load measured to be between those of unvalved and bivalved cast models. Analysis of variance showed significance when failure load and bending stiffness data among all the groups were compared. A post hoc Bonferroni statistical analysis showed significance in bending stiffness between intact and bivalved models (P < 0.01), intact and univalved models (P < 0.01), but no significant difference in bending stiffness between univalved and bivalved models (P > 0.01). Differences in measured failure load values were found to be statistically significant among all cast models (P < 0.01). CONCLUSIONS: Valving significantly decreases the bending stiffness and load to failure of fiberglass casts. Univalved casts have a higher load to failure than bivalved casts. CLINICAL RELEVANCE: Valving adversely alters the structural integrity of fiberglass casts. This may impair a cast's ability to effectively immobilize an extremity or maintain a fracture reduction.

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