Surgical treatment results in patients with defects of the integumentary tissues of the trunk and limbs of mechanical origin.

This study aimed to develop and implement a universal method for the quantitative assessment of treatment effectiveness in patients with skin and underlying soft tissue defects of the trunk and extremities. The study involved 242 patients, including 46 patients with upper extremity injuries, 179 with lesions of lower extremity tissues, and 17 patients with defects of the integumentary tissues of the trunk. The greatest treatment effectiveness was observed in patients with upper limb injury: excellent result - 60.0%, good - 33.3%, unsatisfactory - 6.7% of patients. In the group of patients with lower extremity injuries, an excellent result was recorded in 19.6% of cases, good (58.1%), satisfactory (15.1%), and unsatisfactory in 7.2% of patients. In patients with trunk injuries, an excellent treatment result was obtained in 23.5%, good - 35.5%, satisfactory - 23.5%, and unsatisfactory - 17.6%. The universal quantitative method for evaluating treatment effectiveness in patients with various types of damage to the trunk and extremities tissues was proposed. This method makes it possible to objectively determine the level of medical service provided to each patient, which is of great importance in the context of medical service reorganization in the state.

The timing of amputation of mangled lower extremities does not predict post-injury outcomes and mortality: A retrospective analysis from the ACS TQIP database.

BACKGROUND: While limb salvage does not result in improved functional outcomes among patients with a mangled lower extremity, the impact of attempted limb salvage on mortality and complications is poorly understood. The objective of this study was to evaluate the relationship between attempted limb salvage and in-hospital outcomes among patients with a mangled lower extremity. METHODS: We performed a retrospective cohort study of adults, 16 years or older, with a mangled lower extremity. Data were derived from the American College of Surgeons' Trauma Quality Improvement Program (2012-2017). We compared mortality, complications (severe sepsis, acute kidney injury [AKI], decubitus ulcers) and length of stay between patients managed with the intention of limb salvage (amputation beyond 24 hours or no amputation) and those who underwent early amputation (within 24 hours of presentation). Instrumental variable analysis was used to evaluate the relationship between management strategy and outcomes. RESULTS: We identified 5,527 patients with a mangled lower extremity, of which 901 (16.3%) underwent early amputation. Among those managed with attempted limb salvage, 42.5% underwent amputation prior to discharge. After adjusting for patient and hospital characteristics, there was no association between initial management strategy and mortality (odds ratio, 1.20; 95% confidence interval [CI], 0.83-1.74 early amputation vs. attempted limb salvage). Early amputation was associated with lower odds of AKI (OR, 0.59; 95% CI, 0.39-0.88) and a trend toward shorter length of stay (relative risk, 0.77; 95% CI, 0.52-1.14). CONCLUSION: Over half of patients who sustain a mangled lower extremity undergo amputation during their initial hospital course. While a limb salvage strategy is associated with an elevated risk of AKI, there is no association between attempted limb preservation and mortality. These findings suggest that in patients in which there is no clear indication for early amputation, attempts at limb salvage do not come at the cost of increased mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites.

BACKGROUND The purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity. MATERIAL AND METHODS From January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed. RESULTS External iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery. CONCLUSIONS Although limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon's best efforts.

Factors associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome.

INTRODUCTION: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. METHODS: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy. RESULTS: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001). CONCLUSIONS: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.

Dual energy CT can aid in the emergent differentiation of acute traumatic and pathologic fractures of the pelvis and long bones.

PURPOSE: To determine whether dual energy CT (DECT) scanning can aid in the differentiation between acute traumatic and pathologic fractures of the pelvis and long bones. METHODS: Retrospective review of 11 patients with 15 pathologic fractures proven by biopsy and/or other advanced imaging modalities. Age- and sex-matched patients with non-pathologic traumatic fractures were used as controls. Studies were reviewed by two readers on syngo.via software before and after the creation of virtual bone marrow color maps. Hounsfield units (HU) of the marrow space at the level of the fracture were recorded on both reviews. Differences between the HU of the bone marrow of traumatic and pathologic fractures were compared using two-tailed unpaired t-test. RESULTS: A statistically significant difference was found in the HU of the affected bone marrow on DECT virtual noncalcium bone marrow color maps between the pathologic group (mean HU:4.89) and the non-pathologic group (mean HU: - 286.2) (p = 0.0177). HU measurements on the mixed kVp images were 150.4 for the pathologic and 94.1 for the non-pathologic fracture groups, respectively, with no statistical significance (p = 0.272). CONCLUSIONS: DECT scanning can aid in the differentiation between hematoma at acute traumatic fracture sites and neoplasm at pathologic fracture sites. HU of the bone marrow is higher for pathologic fractures, and the difference in bone marrow attenuation is more evident on the virtual bone marrow color maps.

Risk factors for death and amputation in acute leg compartment syndrome.

INTRODUCTION: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. METHODS: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. RESULTS: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. CONCLUSIONS: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. LEVEL OF EVIDENCE: Level III Prognostic.

[Coverage in the management of loss of skin substances on the lower third of the leg: about 9 cases]. / La couverture des pertes de substances cutanées du tiers inférieur de la jambe: à propos de 09 cas.

Coverage of loss of skin substances on the lower third of the leg is a challenging problem. This is due to adjacent soft tissues impairment, shortage of local vascularization and bone exposure. We conducted a retrospective study of a series of 9 cases of skin coverage of the lower third of the leg treated at the University Hospital Hassan II of Fez from 2016 to 2018. This study aims to highlight the characteristic of the loss of skin substances on the lower third of the leg, while emphasizing the difficulty of management.

Reconstruction of the Distal Leg and Foot Using Free Anterolateral Thigh Flaps in Patients With High-Voltage Electrical Burns.

In a patient with a high-voltage electrical burns, the extent of burning is greatest at the entrance and exit points of the electric current. As the exit point is usually the ankle and/or foot, these areas may be the most severely damaged. As local tissue is limited in this region, free tissue transfer is usually required for reconstruction. Eleven anterolateral thigh free flaps were placed for the reconstruction of foot and ankle defects caused by electrical burns. When the defects were large, we placed the flaps with two or three perforators. In six patients, recipient vessels were prepared in the trauma region or immediately adjacent thereto. Reconstructions were performed at an average of 23.18 days after the burns, and the average hospitalization time was 42.27 days. Patients with burns on the dorsum of the foot often required toe amputations. In patients who underwent direct reconstruction (without debridement), re-operations were required because of graft loss in other burnt areas. The foot and ankle are the regions most damaged by electrical burns. Vessels in the trauma zone or immediately proximal thereto can serve as recipient vessels. Even when the defect is sizeable, a large anterolateral thigh flap with multiple perforators can be harvested. No vascular problem was encountered during early or late reconstruction. The free flap is very reliable when used to reconstruct foot tissue defects caused by electrical burns.

Reduced Anterolateral Thigh Flap Donor-Site Morbidity Using Incisional Negative Pressure Therapy.

BACKGROUND: Primary closure of the donor-site after harvest of a large anterolateral thigh flap (ALT) is associated with significant morbidity. Incisional negative pressure therapy (INPT) may decrease complications in high-risk incisions. This study assessed if the incidence of complications after primary closure of the ALT flap donor-site decreases with INPT. METHODS: Retrospective cohort study of a prospectively maintained database including patients who underwent upper and lower limb reconstruction, using an ALT free flap with primary closure of the donor-site. Two groups were defined: primary closure and INPT (study group) and primary closure with traditional dressings (control group). Nonparametric statistics were employed to identify prognostic factors, p < 0,05. RESULTS: Fifty-eight free ALT flaps in 58 patients (study group n = 28; control group n = 30) were included. Median flap width and length were 9 cm (range: 5-14) and 25 cm (range: 10-48), respectively. Median follow-up was 19 months (range: 3-78 months). No significant differences in age or flap size were identified in both groups (p > 0.05). The global complication rate was 7.14% (n = 2) in the INPT group, and 37% (n = 11) in the control group (p = 0.007). The study group had a lower dehiscence and skin necrosis rate (p < 0.05). Multivariate logistic regression analysis showed IPNT was associated with a significant reduction of donor-site complications (p = 0.006), especially in patients with defects > 8 cm (p = 0.003). CONCLUSION: In this cohort study the use of INPT significantly reduced the donor-site morbidity after ALT flap harvest.

Two cases of unidentified acute compartment syndrome.

Acute compartment syndrome (ACS) is a surgical emergency that requires urgent fasciotomy to prevent irreversible sequelae. We report two cases of unidentified ACS, which did not result from traumatic injuries such as fractures or crush injury, iatrogenic injury or diseases such as haematological malignancies. Both patients complained of severe pain and swelling of their extremity. No bite marks, blisters or skin necrosis was noted. They also complained of marked symptoms of third cranial nerve injury, including divergent squint and diplopia. The diagnosis of ACS was made following continuous intracompartmental pressure measurement, and both patients underwent urgent fasciotomy with partial incision. Considering the season and location of the injuries, together with the rapid progression of signs and symptoms that included thrombocytopaenia, acute renal failure, rhabdomyolysis and especially that of third cranial nerve injury, we postulate that these two cases may have developed following mamushi (Gloydiusblomhoffii) bites.

Medial sural artery perforator free flap for the reconstruction of leg, foot and ankle defect: an excellent option.

BACKGROUND: The defects over the leg, foot and ankle are best covered with a thin pliable flap. The use of muscle flap for the reconstruction of these defects leaves a grafted, aesthetically inferior result. The medial sural artery perforator (MSAP) free flap gives a thin pliable tissue for the reconstruction with better aesthesis. METHODS: The study design was retrospective case analysis over a period of 2 years. All the patients who underwent flap for leg, foot and ankle defect reconstruction in the form of MSAP free flap were included in the study. The flap characteristics and aesthesis were assessed along with the patient satisfaction. The flap complication and donor site morbidity were also analysed. RESULTS: A total of seven MSAP free flaps were done for leg, foot and ankle reconstruction. The mean flap size was 14.29 × 6.6 cm and mean pedicle length was 9.71 cm. One flap had venous congestion post-operatively resulting in marginal flap loss. All the flaps had acceptable aesthesis with good patient satisfaction. There was donor site morbidity in two patients, in the form of wound dehiscence. CONCLUSION: MSAP free flap is a reliable choice for leg, foot and ankle defect reconstruction.

Extra-Articular Soft-Tissue Calcification After Burn Injury: A Case Study.

Soft-tissue calcifications after burn injury commonly develop in periarticular regions, especially in the elbow joint. They can be easily recognized in patients because calcification in the joint limits range of motion and brings about tingling sensation due to compression of ulnar nerve. However, the incidence of extra-articular soft-tissue calcification after burn injury has rarely been reported. We present a patient with massive soft-tissue calcification in extra-articular burn scar with nonhealing ulcer after a long latency period of 40 years. We recommended wide excision and skin grafting, for prevention of recalcification and recurrence of ulceration, which could transform into a malignant case, if left untreated. Furthermore, we propose that such patients with burn injury should undergo follow-up in outpatient clinic and x-ray evaluation.

The spreaded gracilis flap revisited: Comparing outcomes in lower limb reconstruction.

BACKGROUND: In lower limb reconstruction, the free gracilis muscle flap is usually chosen for coverage of small- to medium-sized defects. Aim of this study was a re-appraisal regarding the reconstructive indications of the gracilis muscle flap with a focus on postoperative complications in order to evaluate if it can also be routinely used to reconstruct large-size lower limb defects. METHODS: A total of 204 patients underwent free gracilis muscle transfers for lower limb reconstruction at our institution. Cases were divided according to the size of the defect into two groups (<150 cm2 versus ≥150 cm2 ). The small- to medium defect size group included 150 patients and the large defect size group included 54 patients. In the large defect size group, the muscle was enlarged as needed by careful dissection of the epimysium and all connective tissue surrounding the intrinsic vessels under loupe magnification to protect the muscle perfusion. Surgical complications were accounted for and the two groups compared accordingly. RESULTS: Overall, there were no significant differences between the two groups of patients regarding the rate of major (15.72% versus 10.91%; P = .506) and minor surgical complications (6.92% versus 3.64%; P = .522). The total percentage of flap losses in the small to medium defect size group was 5.03%. There were no total flap losses in the large defect size group (P = .117). CONCLUSION: The use of the spreaded gracilis flap provides a valuable option for the microsurgeon, especially also to reconstruct large size lower limb defects.

Medical Missions in the Middle East: An Orthopaedic Surgeon's Experience of a Series of Lower Extremity Cases.

Orthopaedic trauma accounts for a great deal of disability worldwide. There are many impoverished nations affected by war wherein victims suffer blast injuries associated with mines, missiles, high-powered gunshots, and bombings. One way to address this is through international medical missions sponsored by industrialized nations. It is imperative that practitioners have a basic understanding of the type of injuries that may be encountered in these nations impacted by war and conflict. Therefore, we described a small number of various lower extremity injuries seen by one orthopaedic surgeon during his volunteer medical mission to Jordan. Frequently, these injuries did result in the loss of a limb and/or function as the patients were treated without appropriate instrumentation or facilities in a suboptimal environment. Treatment was frequently delayed, and many of the surgeons involved lacked optimal training. It is our hope that this case series will lead to studies which may give guidance regarding how to best treat these complex injuries with optimal outcomes and minimal complications.

[Amputation of a limb secondary to snakebite in a child]. / Amputation de membre secondaire à une morsure de vipère.

Amputation of a limb is a serious consequence of snakebite poisoning. It is caused by the toxicity of the venom and often the use of a tourniquet in some patients, which can lead to limb ischemia. Management of the victim aims to ensure survival and preserve the function of the bitten limb. Antivenom immunotherapy is the only specific treatment for ophidian envenomation. It is indicated in cases of general symptoms and signs related to the bite, but also if local damage could lead to the loss of limb function. The authors report on a case of snakebite that led to amputation at the thigh.

[THE METHOD CHOICE OF OPERATIVE INTERVENTION IN PATIENTS WITH POSTTRAUMATIC DEFECTS OF COVERING TISSUES OF TRUNK AND EXTREMITIES].

Results of 242 patients treatment, suffering the trunk and extremities covering tissues defects, which have had occur as a consequence of mechanical injury in a 2008 ­ 2016 yrs period, were analyzed. There were 697 оperative interventions performed, of them 492 (70.6%) ­ aiming to restore the tissues injured. The choice of method of the correcting intervention and the tissues defects covering have depended upon the wound dimension and depth, as well as peculiarities of hemodynamics in the area injured. Application of differentiated approach to choice of method for the wound surfaces closure, which were created as a consequence of mechanical injury, have had permitted to achieve satisfactory results in 98.75% of patients.

The posteromedial thigh (PMT) flap for lower extremity reconstruction.

BACKGROUND: The posteromedial thigh (PMT) perforator flap is a new reliable flap with versatility. The purpose of this article was to report our experience with the use of free PMT flaps for reconstruction of defects of the lower extremity. PATIENTS AND METHODS: From July 2014 to May 2015, 8 patients received reconstruction with 8 free PMT flaps. The defect locations included the heel (1 case), dorsal foot (2 cases), plantar foot (1 case), lateral malleolus (1 case), Achilles tendon (1 case), and tibia (2 cases). Flaps were raised based on the first medial perforator of the profunda femoris artery (PFA) (7 cases) and medial circumflex femoral artery (LCFA) perforator (1 case). The dorsalis pedis artery (3 cases), anterior tibia artery (1 cases), posterior tibial artery (3 cases), and medial sural pedicle (1 case) were dissected as recipient vessels. RESULTS: The flap sizes varied from 10 × 10 to 30 × 11 cm. All the flaps survived completely after surgery. The donor sites were all primarily closed with minimal morbidities. Follow-up observations were conducted for 3-12 months, and all patients had good functional recovery with satisfactory cosmetic results. CONCLUSION: Perforators arising from the PFA in the posterior medial thigh can be used to design pliable fasciocutaneous flaps. The pedicle length and the vessel diameter are adequate for microvascular anastomosis to the lower extremities recipient vessels. The free PMT flap serves as a good new option for reconstructing lower extremity defects. © 2016 Wiley Periodicals, Inc. Microsurgery 37:865-872, 2017.

[Anterolateral thigh flap for distal lower leg reconstruction]. / Place du lambeau libre antérolatéral de cuisse dans la reconstruction des pertes de substance distales des membres inférieurs.

CONTEXT: Soft tissue defects of lower leg are still a challenge for the plastic surgeon. It should provide an effective and functional coverage with a minimal morbidity on the donor site. Free anterolateral thigh flap present in these areas many advantages over the pedicled local flaps and free muscle flaps used conventionally. We try to define its place through our experience with a bicentric retrospective study. MATERIALS AND METHODS: A retrospective analysis of all cases of reconstruction of the lower leg using the free ALT flap was performed in two centers of reconstructive surgery. The characteristics of the defect and reconstructions were collected. The rate of success and complication has been reported as well as long term aesthetic and functional outcomes. RESULTS: Forty-one patients were reconstructed between 2008 and 2013 for post-traumatic care in 58.5% of cases. The average size of the defect was 191.4cm2, their location was mainly on the foot and ankle (61%) and bone exposure was most frequently found (82.9%). Success rate was 92.8%. Functional results were judged as very good and good in 75.5% of cases and aesthetic results as very good and good for 63.6% of cases. Three "lost sight" 7.3% and 3 fails (7.3%) patients were not included in the result analysis. CONCLUSION: Showing functional results at least similar to other flaps, ALT flap demonstrated its reliability and its low morbidity on the donor site. Its versatility allows adaptation to the vast majority of defects of the lower leg.

Management of Open Lower Extremity Wounds With Concomitant Fracture Using a Porcine Urinary Bladder Matrix.

BACKGROUND: Open wounds of the distal third of the leg and foot with exposed bone, fractures, and hardware are challenging wounds for which to achieve stable coverage. The orthopedic advances in lower extremity fracture management over the last 30 years have allowed a rethinking of the standard operative approach to close these complex wounds. MATERIALS AND METHODS: The ability of extracellular matrix (ECM) products to facilitate constructive remodeling of a wound seemed a reasonable approach for treatment, especially in patients who are often poor surgical candidates for more advanced reconstructive procedures. RESULTS: The authors reviewed 9 patients with 11 open fractures of the leg, ankle, or foot treated with a newer ECM wound healing device to total closure. The clinical course and patient management are reviewed. CONCLUSION: The authors conclude that newer ECM products can provide a reasonable method of management for patients who have wounds with exposed hardware, distal leg wounds, and open foot fractures compared to prolonged negative pressure wound therapy or complex reconstructive operative procedures.

Postoperative negative pressure therapy significantly reduces flap complications in distally based peroneus brevis flaps: Experiences from 74 cases.

BACKGROUND: The distally based peroneus brevis muscle flap is a valuable therapeutic option for coverage of tissue defects around the ankle and the distal lower leg. However, the rate of postoperative flap complications requiring revisional surgery is high due to an impaired venous drainage and oedema formation. The purpose of this study was to evaluate if postoperative negative pressure therapy is able to reduce flap complications. METHODS: From April 2010 until March 2014, we treated 74 patients with distally based peroneus brevis muscle flaps for defect coverage at the lower leg. In four cases, an osteomuscular composite flap has been used to treat partly stability-relevant bone defects. In 43 cases, negative pressure therapy (75mmHg, continuous) with a circular dressing was initiated after the flap procedure for 7 days. In 31 cases no negative pressure therapy was initiated. We retrospectively analysed those two groups of patients. The primary endpoint was the incidence of flap complications with a need for revision surgery, which were classified in three grades. RESULTS: The group treated with negative pressure therapy had significantly less flap complications when compared to the control group (p<0.0001). Concerning the single grades of complication, the negative pressure therapy-group had a significantly smaller rate of skin graft necrosis (Grade 1; p=0.014) and partial flap loss (Grade 2; p=0.002) compared to the control group. There were no statistically significant differences concerning complete flap loss (Grade 3) between both groups. CONCLUSION: Postoperative negative pressure therapy for 7 days reduces flap complications in distally based peroneus brevis flaps.