Cost-effectiveness analysis of routine computed tomography angiography (CTA) for lower extremity penetrating trauma.

BACKGROUND: Routine evaluation with CTA for patients with isolated lower extremity penetrating trauma and normal ankle-brachial-indices (ABI) remains controversial. While prior literature has found normal ABI's (≥0.9) and a normal clinical examination to be adequate for safe discharge, there remains concern for missed injuries which could lead to delayed surgical intervention and unnecessary morbidity. Our hypothesis was that routine CTA after isolated lower extremity penetrating trauma with normal ABIs and clinical examination is not cost-effective. METHODS: We performed a decision-analytic model to evaluate the cost-effectiveness of obtaining a CTA routinely compared to clinical observation and ABI evaluation in hemodynamically normal patients with isolated penetrating lower extremity trauma. Our base case was a patient that sustained penetrating lower extremity trauma with normal ABIs that received a CTA in the trauma bay. Costs, probability, and Quality-Adjusted Life Years (QALYs) were generated from published literature. RESULTS: Clinical evaluation only (no CTA) was cost-effective with a cost of $2056.13 and 0.98 QALYs gained compared to routine CTA which had increased costs of $7449.91 and lower QALYs 0.92. Using one-way sensitivity analysis, routine CTA does not become the cost-effective strategy until the cost of a missed injury reaches $210,075.83. CONCLUSIONS: Patients with isolated, penetrating lower extremity trauma with normal ABIs and clinical examination do not warrant routine CTA as there is no benefit with increased costs.

The association of pre-existing mental health conditions and patient outcomes after lower extremity orthopaedic trauma: a scoping review.

INTRODUCTION: Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery, such as pain exacerbations, reduced functional recovery, and lowered patient satisfaction. However, the influence of pre-existing mental health conditions on orthopaedic trauma outcomes has not been thoroughly investigated. The objective of this study was to systematically review literature addressing the association between pre-existing mental health conditions and patient outcomes following surgical interventions for lower extremity fractures in non-geriatric populations. METHODS: A systematic literature review was conducted using Medline, Embase, and Scopus databases following PRISMA-ScR guidelines to select studies that examined lower extremity orthopaedic trauma outcomes in relation to pre-existing mental health conditions. Studies that evaluated patients with surgically treated lower extremity fractures and a history of mental health conditions such as anxiety, depression, or mood disorders were included. Studies with a mean patient age above 65 years of age were excluded to focus on non-geriatric injury patterns. RESULTS: The systematic review identified 12 studies investigating the relationship between surgical outcomes of orthopaedic lower extremity fractures and pre-existing mental health disorders in non-geriatric populations. Studies included patients with pelvis, femur, tibia, and ankle fractures. A majority (83%) of these studies demonstrated that patients with pre-existing mental health diagnoses had inferior functional outcomes, heightened pain levels, or an increase in postoperative complications. DISCUSSION: The presence of pre-existing mental health conditions, particularly anxiety and depression, may predispose orthopaedic trauma patients to an elevated risk of suboptimal functional outcomes, increased pain, or complications after surgical intervention for lower extremity fractures. Future research should focus on interventions that mitigate the impact of mental health conditions on orthopaedic outcomes and patient wellness in this population.

Cinematic rendering in the evaluation of complex vascular injury of the lower extremities: how we do it.

Lower extremity trauma is one of the most common injury patterns seen in emergency medical and surgical practice. Vascular injuries occur in less than one percent of all civilian fractures. However, if not treated promptly, such injuries can lead to ischemia and death. Computed tomography angiography (CTA) is the non-invasive imaging gold standard and plays a crucial part in the decision-making process for treating lower extremity trauma. A novel, FDA-approved 3D reconstruction technique known as cinematic rendering (CR) yields photorealistic reconstructions of lower extremity vascular injuries depicting clinically important aspects of those injuries, aiding in patient workup and surgical planning, and thus improving patient outcomes. In this article, we provide clinical examples of the use of CR in evaluating lower extremity vascular injuries, including the relationship of these injuries to adjacent osseous structures and overlying soft tissues, and its role in management of lower extremity trauma.

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center.

BACKGROUND: Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. METHODS: A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. RESULTS: Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P = 0.001), high body mass index (P = 0.001), blunt injury (P = 0.001), associated fractures (P = 0.005), significant soft tissue injury (P = 0.007), delayed repair after shunt placement (P = 0.003), bypass revascularization (P = 0.001), initial revascularization failure (P = 0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n = 7), revascularization failure (n = 9), bleeding (n = 3), and vascular surgical wound complications (n = 5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. CONCLUSION: Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.

Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study.

OBJECTIVE: Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. METHODS: A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis. RESULTS: A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. CONCLUSIONS: Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.

Popliteal scoring assessment for vascular extremity injuries in trauma study.

OBJECTIVE: Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. A method to evaluate the predictors of amputation is needed because previous scores could not be validated. In the present study, we aimed to provide a simplified scoring system (POPSAVEIT [popliteal scoring assessment for vascular extremity injuries in trauma]) that could be used preoperatively to risk stratify patients with traumatic popliteal vascular injuries for amputation. METHODS: A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared with those with limb salvage at the last follow-up. Of these patients, 80% were randomly assigned to a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (P < .1) on univariate analysis were included in a multivariable analysis. Those with P < .05 on multivariable analysis were assigned points according to the relative value of their odds ratios (ORs). Receiver operating characteristic curves were generated to determine low- vs high-risk scores. An area under the curve of >0.65 was considered adequate for validation. RESULTS: A total of 355 patients were included, with an overall amputation rate of 16%. On multivariate regression analysis, the risk factors independently associated with amputation in the final model were as follows: systolic blood pressure <90 mm Hg (OR, 3.2; P = .027; 1 point), associated orthopedic injury (OR, 4.9; P = .014; 2 points), and a lack of preoperative pedal Doppler signals (OR, 5.5; P = .002; 2 points [or 1 point for a lack of palpable pedal pulses if Doppler signal data were unavailable]). A score of ≥3 was found to maximize the sensitivity (85%) and specificity (49%) for a high risk of amputation. The receiver operating characteristic curve for the validation group had an area under the curve of 0.750, meeting the threshold for score validation. CONCLUSIONS: The POPSAVEIT score provides a simple and practical method to effectively stratify patients preoperatively into low- and high-risk major amputation categories.

Yield of CT angiography in penetrating lower extremity trauma.

PURPOSE: CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided. METHODS: A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined. RESULTS: A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001). CONCLUSION: There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

Dual venous outflow improves lower extremity trauma free flap reconstructions.

BACKGROUND: Venous outflow problems are the most common reasons for perioperative flap complications. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation. MATERIALS AND METHODS: Retrospective review of our institutional flap registry from 1979 to 2014 identified 464 free flaps performed for lower leg trauma reconstruction. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: A total of 219 flaps were randomly selected for preliminary analysis. Single-vein outflow was more common (72.6%) than dual-vein (27.4%); most of the recipients were in deep venous system (83.6%) versus superficial (11.9%) or both (4.6%). Two-vein anastomoses were more likely in fasciocutaneous flaps than muscle flaps (P = 0.001) and in smaller (<300 cm(2)) flaps (P = 0.002). Complications occurred in 98 flaps (44.7%); with 54 partial flap losses (24.7%), and 11 complete flap losses (5.0%). Multivariable regression analysis controlling for age, sex, flap type, presence of bone gap, flap size, vein size mismatch, and time since injury demonstrated dual-vein outflow to be protective against complications (relative risk [RR] = 0.269, P = 0.001), partial flap failure (RR = 0.351, P = 0.031), and any flap failure (RR = 0.31, P = 0.010). No significant difference in operative time was found (P = 0.664). CONCLUSIONS: Dual-vein outflow demonstrated 73% reduction in overall complications and 69% reduction in flap failure rate compared to single-vein flaps. These results suggest a protective effect of a dual-vein outflow system, and when considered together with our findings of unchanged operative time, provide evidence for preferential use of two venous anastomoses when possible for free flap reconstruction of lower extremity trauma.

Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series.

OBJECTIVES: Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis. METHODS: Three consecutive male patients, aged 21-23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function. RESULTS: Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis. DISCUSSION: Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.

Compartment Syndrome of the Lower Limb in Adults and Children and Effective Surgical Intervention and Post-surgical Therapies: A Narrative Review.

Compartment syndrome (CS) can be defined as an acutely painful condition that occurs due to increased pressure within a compartment, resulting in reduced blood flow and oxygen to nerves and muscles within the limb. It is considered a surgical emergency, and a delayed diagnosis may result in ischemia and eventual necrosis of the limb. The majority of cases in adults are associated with high-energy trauma, more specifically, long bone fractures of the lower limb, while supracondylar fractures of the humerus are highly associated with CS in pediatric patients. CS may also develop gradually as a result of prolonged and ongoing physical activity such as running. In this narrative review, we discuss the anatomy, pathophysiology, methods of diagnosis, and effective management of CS in adults and children.

Associations of musculoskeletal dysfunction, time to brake, and patient reported outcomes following lower extremity trauma.

INTRODUCTION: Inability to drive a motor vehicle due to lower extremity injury is a major inconvenience. Timing of safe return to driving has not been much studied. Objective measurements such as time to brake (TTB) have been proposed; however, utility and concordance of functional outcome measurements have not been previously evaluated. The purpose of this project is to measure these parameters and to assess for associations with ability to safely return to driving, improving the ability of clinicians to assess for measurements of driving readiness without specifically measuring TTB. METHODS: A prospective, cohort study of 232 patients with complex lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia, ankle, and foot was performed. Time to brake (TTB) was measured once weightbearing was allowed. Function was assessed by the Musculoskeletal Function Assessment (MFA) questionnaire, and pain, mobility, and physical functions, via patient reported outcome measurement information system (PROMIS) surveys. RESULTS: Patients with longer TTB had significantly elevated MFA scores indicating increased musculoskeletal dysfunction post-injury. As the MFA score increased by 1 point, TTB increased by 0.013 s (p<0.001). PROMIS metrics were also significantly associated with patients experiencing more pain and worse mobility as TTB increased. DISCUSSION: Many patients continue to exhibit musculoskeletal dysfunction several months post-treatment for complex lower extremity injuries. Patients with better PROMIS metrics and MFA scores, and shorter TTB are more appropriate to return to driving. Surgeons may be better informed about safe driving ability by considering these measurements. LEVEL OF EVIDENCE: II.

Lower Extremity Injuries Due to Chainsaw During Four-Year Periods.

Background Chainsaws cause injuries mostly on the upper extremities, then on the face and lower extremities. In the literature, there are many studies about hand and face injuries; however, articles about lower extremity injuries are limited. The aim of the study is to define injury patterns, treatments, and results of the cases that we have encountered in our hospital and to evaluate precautions after reviewing the literature. Methods Patients admitted to our hospital's Emergency Department with chainsaw-related lower extremity injuries between 2016 and 2021 are evaluated. Patients' demographic data, pathologies, treatments, length of stay in hospital, return to work time, and functional scores are calculated retrospectively. Results There were 39 male and two female patients, with a minimum follow-up of 12 months. Their mean age was 42.6 ± SD (16-62). Thirty-two patients (78.04%) had injuries on the left lower extremity, and nine patients (21.9%) had injuries on the right lower extremity. 93.75% (30/32) of the patients with left lower extremity injuries had the right hand as the dominant extremity. The most frequently observed injury pattern was extensor hallucis longus (EHL) tendon disruption, with a percentage of 58.5% (24/41). 29.2% (13/41) of the cases had bone pathologies present as well. Patients' average AOFAS score was 97.4 ± 4.4 (74-100) at the end of one year. The average hospitalization length of stay was 2.95 ± 2.7 (0-15) days, and the time interval of return to work was 6.17 ± 1.4 (2-15) weeks, excluding one patient who had to change his workplace. Conclusion Saw-related injuries of the lower extremities are the injuries that can be seen mostly in male patients. Among the right dominant-handed patients, left foot dorsum injuries were the most common EHL tendon disruptions observed. We have seen that the reason for this is foot injuries remaining in the projection of the saw due to incorrect positioning of the foot. Protective gear and shoes must be used as precautions. More preventive measures could be taken while using chainsaws and similar tools, as they may cause serious injuries. Requirements for the use and sale of this tool should be introduced, and training should be given as it can be easily purchased by the public.

Outpatient Treatment of Refractory Morel-Lavallée Lesion Infection With Retention Sutures: A Case Report.

We report the case of a 41-year-old man with a Morel-Lavallée lesion (MLL) that developed an infection. The patient was initially treated with intravenous antibiotics, but the infection persisted. He was then treated with outpatient cleansing and retention sutures, which resulted in successful wound healing. This case report demonstrates the efficacy of outpatient cleansing and retention sutures for the treatment of MLL infection. This treatment modality is less expensive than inpatient treatment, and it allows the patient to return to their normal activities sooner.

Consideration for Limb Salvage in Place of Amputation in Complex Tibial Fracture With Neurovascular Injury: A Case Report.

High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV.

Resilience through practicing acceptance: A qualitative study of how patients cope with the psychosocial experiences following limb-threatening lower extremity trauma.

INTRODUCTION: Limb-threatening injuries can have a profound impact on patient lives. The impact on a patient's psychosocial well-being is widespread yet not well understood. This study aims to explore which psychosocial elements are central to patient experiences after limb-threatening lower extremity trauma. PATIENTS AND METHODS: This is a qualitative interview-based study to identify psychosocial experiences after limb-threatening lower extremity trauma in a patient-centered manner. Data were collected via semi-structured qualitative interviews and analyzed via an interpretive description approach. Interviews were performed until content saturation was reached. RESULTS: A total of 33 interviews were performed until reaching content saturation. Eleven participants underwent early amputation, 7 delayed amputation after an attempt at limb salvage, and 15 underwent limb salvage. A total of 533 unique psychosocial codes were identified, comprised of eight concepts: acceptance, body image, coping, distress, positive impact, emotional support, isolation, and intrapsychic. CONCLUSIONS: This study identified the concerns central to this patient population and developed a conceptual framework for how patients cope with these psychosocial experiences. These findings underscore the importance of developing resilience by actively practicing acceptance and reaching more positive mental health outcomes. Additionally, these findings highlight the importance of increasing access to early and routine psychological and social support for patients with severe lower extremity trauma.

Correlation of Time to Soft Tissue Coverage With Clinical Outcome in Lower Extremity Trauma in the Modern Era: A Single-Center Retrospective Review.

Background: Lower extremity salvage in the setting of severe trauma requires the consideration of multiple surgical specialties and treatment algorithms. We hypothesized that time to first ambulation, ambulation without an assistive device, chronic osteomyelitis, and delayed amputation were not affected by the time to soft tissue coverage in Gustilo IIIB and IIIC fractures at our institution. Methods: We evaluated all patients treated for open tibia fractures at our institution from 2007 to 2017. Patients requiring any form of soft tissue coverage to the lower extremity during their initial hospitalization and who had at least 30 days of follow-up from time of hospital discharge were included. Univariable and multivariable analysis was performed for all variables and outcomes of interest. Results: Of 575 patients included, 89 required soft tissue coverage. On multivariable analysis, the time to soft tissue coverage, length of negative pressure wound therapy treatment, and number of wound washouts were not found to be associated with development of chronic osteomyelitis, decreased 90-day return to any ambulation, decreased 180-day return to ambulation without assistive device, or delayed amputation. Conclusions: Time to soft tissue coverage in open tibia fractures did not affect time to first ambulation, ambulation without an assistive device, chronic osteomyelitis, or delayed amputation in this cohort. It remains difficult to definitively prove that time to soft tissue coverage meaningfully impacts lower extremity outcomes.

Seven-Compartment Fascial Release of the Lower Extremity: A Case Report.

Compartment syndrome of the lower extremities is a condition that can lead to permanent nerve and muscle damage if not treated in an emergent fashion. Fasciotomy of the medial compartment of the thigh is exceedingly rare, and a review of the literature revealed only one reported case where compartment syndrome was present in both the thigh and lower leg compartments simultaneously. Given the rarity of compartment syndrome in all seven compartments of the leg, in this case, we report the development of full leg compartment syndrome in a 29-year-old male who fell asleep on a hard surface for an extended period following heroin intoxication, which was treated with seven compartment fasciotomies. We conclude with a discussion about how medial release of the thigh for compartment syndrome is rare enough that careful consideration of the anatomy must be made before proceeding with the procedure. Additionally, wound closure has many proposed options, but current literature favors skin staples with an interlaced elastic band to minimize delays in wound closure.

Morel-Lavallée Lesions: A Diagnostic and Clinical Dilemma.

Morel-Lavallée lesions (MLL) occur following closed degloving injuries in trauma and appear as subcutaneous fluid collections. These lesions provide a diagnostic dilemma due to their resemblance to other subcutaneous lesions, including post-traumatic or post-procedural hematomas, and malignant entities such as soft tissue sarcomas. Magnetic resonance imaging (MRI) remains the diagnostic test of choice to diagnose MLL. Here we present a single case of MLL in a 40-year-old female who sustained an injury to her left thigh months earlier after falling through a pier as well as a review of literature on the diagnostic findings typically seen in this type of injury.

Promotion of a damage control concept in repairing orthopedic lower limb trauma.

OBJECTIVE: To explore the application value of the concept of damage control orthopaedics (DCO) in clinical treatment of lower limb fractures. METHODS: In this retrospective analysis, 157 patients with lower extremity fracture, who received surgery in Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine (Cangzhou Orthopaedic Hospital) during March 2019 and August 2020, were chosen as research subjects. Among them, 73 patients admitted from March to December 2019 were included in the control group, and the other 84 patients admitted from January to August 2020 were included in the observation group. The control group received conventional fracture treatment scheme, and the observation group was treated under the DCO concept. The operation time, postoperative hospital stay, fracture reduction quality, incidence of complications, and bone metabolism and bone healing pre- and post-treatment were compared between the groups. RESULTS: The operation time, time to achieve stable vital signs and hospital stay of the observation group were apparently shorter than those of the control group (P<0.05). Visual analog score (VAS) of patients in both groups on postoperative day 3 and 7 were substantially lower than those on postoperative day 1 (P<0.05), and VAS scores of patients in the observation group were markedly lower than those in the control group (P<0.05). Serum Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in the two groups were significantly reduced on 14th day after surgery compared to those before surgery (P<0.05), and the indexes of observation group were lower than those of control group (P<0.05). Serum Osteocalcin (BGP), carboxyterminal of type I procollagen (PICP), alkaline phosphatase (ALP), Soluble intercellular adhesion molecule-1 (sICAM-1) and Insulin like growth factor-1 (IGF-1) in the two groups postoperative day 14 were obviously higher than those before operation (P<0.05), and the indicators in the observation group were higher than those of the control group (P<0.05). The incidence of complications in the control group was significantly higher than that in the observation group (P<0.05). CONCLUSION: The application of the DCO concept in the clinical treatment of lower extremity trauma can effectively promote the rehabilitation of patients with lower extremity trauma, minimize their complications, improve the bone metabolism and bone healing degree, and reduce the degree of pain.

Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient.

Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.