Definitive internal fracture fixation followed by staged free flap coverage ("fix followed by flap" protocol) for open Gustilo type IIIB fractures.

BACKGROUND: Although the concept of the "fix and flap" approach, in which definitive fracture fixation and flap coverage are completed in a single procedure at the earliest opportunity may seem ideal for the treatment of Gustilo type IIIB open fractures, the individual circumstances of patients, such as polytrauma or multiple fracture cases may not allow for the immediate fracture fixation and flap coverage ("fix and flap" approach). In our hospital, patients with Gustilo type IIIB open fractures are treated with definitive internal fixation of the fracture followed by staged flap coverage ("fix followed by flap" protocol) when the "fix and flap" approach was not feasible due to the patient's condition or difficulty in coordinating surgery schedules. The "fix followed by flap" protocol provides benefits in terms of flexibility in adjusting the surgical timetable, simplifying the planning of flap coverage following fracture fixation, and minimizing individual surgical invasion. METHODS: We reviewed 10 cases of severe open fractures treated with the "fix followed by flap" protocol and evaluated their outcomes. All surgical procedures, including wound debridement, fracture fixation, and flap coverage, were performed by orthoplastic surgeons specializing in both fracture surgery and microsurgery including soft tissue reconstruction. RESULTS: All free flaps survived, and no partial necrosis was observed. None of the patients developed postoperative deep infection up to the last follow-up. Fracture union was achieved in all patients with or without autologous bone grafts. The median time for union was 9.4 months (range, 4-12 months). CONCLUSIONS: This study presents favorable outcomes of treatment for Gustilo type IIIB open fractures with fracture fixation followed by staged flap coverage ("fix followed by flap" protocol). Despite a delay in flap coverage, the consistency of treatment provided by orthoplastic surgeons may have contributed to the favorable outcomes in this study.

Gorham-Stout Syndrome of the Shoulder Girdle Successfully Controlled by Antiresorptive Agents: A Report of 2 Cases.

CASE: Gorham-Stout disease (GSD) is a rare disorder characterized by massive bone destruction. Consensus is lacking on the effective treatment strategies for GSD. This report presents 2 cases of GSD, a 47-year-old man and a 72-year-old woman, involving the shoulder girdle which were successfully controlled by antiresorptive agents including bisphosphonates and denosumab, the antireceptor activator of nuclear factor-κB ligand antibody. CONCLUSIONS: These 2 cases suggest that antiresorptive agents targeting osteoclasts can be efficacious therapeutic options for GSD. This is the first case of GSD we are aware of which showed good response to denosumab treatment.

Radiologic Patterning of Hallux Deformity in Rheumatoid Arthritis and Its Relationship to Flatfoot.

Hallux deformities other than hallux valgus, especially those in the sagittal plane, have not yet been elucidated in the feet of patients with rheumatoid arthritis. The objectives of the present study were to classify rheumatoid arthritis hallux deformity in both the horizontal and the sagittal planes and investigate its relationship with flatfoot. Using a cross-sectional study design, we assessed patients with rheumatoid arthritis (527 feet in 274 patients) using radiographs and classified the deformity patterns of the great toes using cluster analysis. Of the 274 patients, the range of motion in the metatarsophalangeal joint was clinically investigated in 44 (16.1%) patients. The great toes could be divided into 5 clusters according to the characteristic configuration as follows: cluster I (normal type), cluster II (hallux valgus type), cluster III (boutonniere type), cluster IV (boutonniere with hallux valgus type), and cluster V (swan-neck type). Radiographic measurements revealed the characteristic deformities of each cluster, including splayed foot for cluster II; flat foot, metatarsal primus elevatus, and plantar displacement of the proximal phalanx for cluster III; and a mixture of these characteristics for cluster IV. Plantar displacement of the proximal phalanx, which was a specific characteristic of the boutonniere deformity, correlated significantly with the decreased dorsiflexion in the metatarsophalangeal joint. Our classification method revealed the relationship of hallux deformity in the sagittal plane to flatfoot and also demonstrated the usefulness of measuring basal phalanx displacement in predicting the range of motion of the metatarsophalangeal joint.

Correlation between knee and hindfoot alignment in patients with rheumatoid arthritis: The effects of subtalar joint destruction.

OBJECTIVES: Compensatory hindfoot alignment for deformities at the knee level has been demonstrated in patients with knee osteoarthritis. However, this phenomenon has not been elucidated in patients with rheumatoid arthritis (RA). The aim of this study is to investigate the relationship between knee deformity and hindfoot alignment and the effect of subtalar joint destruction in patients with RA. METHODS: We retrospectively investigated RA patients (110 patients, 205 limbs) using radiographs in the standing anteroposterior knee, standing lateral foot, and hindfoot alignment views. The grade of destruction at the knee and subtalar joints was assigned using Larsen's grading system. The correlation between the femorotibial and tibiocalcaneal angles and the effect of joint destruction on this correlation were analyzed using Pearson's correlation coefficients. RESULTS: There was moderate correlation between the femorotibial and tibiocalcaneal angles in a group of knees with a Larsen grade of ≥ 4 (r = 0.544, p = 0.0239). This correlation was stronger in a group with less damaged subtalar joints with a Larsen grade of ≤ 3 (r = 0.705, p = 0.0049). CONCLUSION: These findings emphasized the importance of examining foot and ankles in patients with RA who undergo total knee arthroplasty.

A surgical treatment for adult muscular torticollis.

Adult presentation of neglected congenital muscular torticollis (CMT) is rare. Therefore, efficacy of surgical treatment for adult CMT is unclear. We experienced a case of neglected CMT in a 28-year-old male patient and report the surgical result here. We conducted unipolar resection at the distal end of the sternocleidomastoid muscle (SCM). After surgery, the range of neck movement and head tilt improved, and his appearance was cosmetically improved despite the long-standing nature of the deformity. We concluded that surgical management of adult patients with neglected congenital muscular torticollis may be a treatment option.

Delayed surgical treatment for a traumatic bilateral cervical facet joint dislocation using a posterior-anterior approach: a case report.

INTRODUCTION: There have been few reports of patients with bilateral cervical facet dislocations that remain untreated for eight weeks or more. We report the case of a 76-year-old man with an old bilateral cervical facet joint dislocation fracture that was treated by posterior-anterior reduction and fixation. CASE PRESENTATION: A 76-year-old Asian man was involved in a road traffic accident. He presented with neck pain and arm pain on his right side, but motor weakness and paralysis were not observed. He was treated conservatively; however, instability and spondylolisthesis at the C5 to C6 joint increased eight weeks after the injury. We performed a posterior-anterior reduction and fixation. After surgery, bony union was achieved, and his neck pain and arm pain disappeared. CONCLUSION: We recommend reduction and fixation surgery if a patient has an old bilateral facet joint dislocation fracture in the cervical spine.

[Preoperative adjuvant therapy for primary malignant bone tumors].

In primary bone sarcomas, the efficacy of chemotherapy varies according to the histological types. Prognoses are poor in patients with osteosarcoma or Ewing's sarcoma, when surgery alone is performed. However, because these sarcomas are chemosensitive, their prognoses have been improved with adjuvant chemotherapy. Nowadays, in highgrade bone sarcomas, especially in osteosarcoma, Ewing.s sarcoma and malignant fibrous histiocytoma of bone, adjuvant chemotherapy including neoadjuvant or preoperative chemotherapy is usually performed. The purpose of the neoadjuvant chemotherapy is (I) to prevent distant metastases, (II) to reduce the size of the primary tumor and (III) to evaluate the efficacy of the chemotherapeutic agents. Reducing the tumor size facilitates easier excision with less risk of local recurrence. In addition, not only limb-saving but also function-preserving surgery is made possible. Evaluating the efficacy of the chemotherapeutic agents in preoperative chemotherapy facilitates rational selection of postoperative chemotherapeutic agents. Several kinds of anticancer agents are used, and many authors have reported various kinds of protocols and their clinical results. Commonly used drugs include adriamycin, ifosfamide, cisplatin, methotrexate and vincristine in osteosarcoma, and vincristine, adriamycin, cyclophosphamide, ifosfamide, actinomycin-D and etoposide in Ewing's sarcoma. In contrast, chondrosarcomas are chemoresistant, and chemotherapy is rarely performed. Low-grade bone sarcomas, e. g., parosteal osteosarcoma, central low-grade osteosarcoma, are well cured only by surgical excision, and adjuvant chemotherapy is not performed for these low-grade sarcomas. To enhance the efficacy of preoperative chemotherapy, various modalities have been used e. g., intraarterial infusion, caffeine-assisted chemotherapy, and local perfusion with hyperthermia. Good clinical results have been reported.