Simultaneous sequential anterolateral thigh free flaps with interposition comitant vein graft for one-stage lower extremity reconstruction: A case report.

Developments in the microsurgery have made perforator fasciocutaneous free flaps more popular in lower extremity reconstructions. They have acceptable donor site morbidities when compared to traditional methods. However; there are some possible limitations with these flaps such as anatomical variations and insufficiency to cover large and/or complex defects with a single flap. Anterolateral thigh flap (ALT), which has proven its advantages in the reconstruction of many regions of the body, is one of the versatile perforator fasciocutaneous flap options. We present our experience of using sequential double ALTs for complex lower extremity reconstruction. A 44-year-old patient, who had a history of multiple traumas as a result of a traffic accident, had interconnected anterior tibial (6 × 4 cm) and bimalleolar defects (4 × 4 cm, 4 × 5 cm) in his left lower extremity. Double ALT flaps (16 × 9 cm, 17 × 10 cm) were used to reconstruct three individual defects. The posterior tibial artery was the only uninjured artery perfusing the lower extremity, so the already occluded anterior tibial artery was chosen as the recipient to avoid disturbing the posterior tibial vessels. The dominant comitant vein of one of the flaps was leaving the pedicle too early and following an aberrant path with increased diameter. As it was understood that the other comitant vein had poor drainage, it was taken as an interposition vein graft to lengthen the dominant aberrant vein. The two flaps were customized as one by flow-through anastomoses on the operating table. The anterior tibial artery was washed and debrided distal to proximal until arterial spurting was seen. At the distance of 8 cm superior, the artery was found as feasible and anastomoses were performed. The proximal flap was inset vertically and the distal flap was inset on the horizontal axis to reach the bilateral malleolar defect. No complications were observed in both flaps. The patient was followed-up for 8 months. Despite the successful reconstruction, the patient is still unable to walk unaided due to multiple traumas and the rehabilitation process continues. We believe that the use of sequential double ALT may be a useful alternative to reconstruct large lower extremity defects with minimal donor site morbidity when a suitable single recipient vessel is available.

Is interferential current effective in the management of pain, range of motion, and edema following total knee arthroplasty surgery? A randomized double-blind controlled trial.

OBJECTIVE: To investigate the effectiveness of interferential current implementation following total knee arthroplasty surgery. DESIGN: Double-blind randomized controlled study. SETTING: Orthopedics and traumatology in-patient clinic. PARTICIPANTS: From an initial enrollment of 132 patients, 113 who met the study inclusion criteria were randomly separated into two groups: the interferential current group ( n = 57) and the sham current group ( n = 56). A total of 98 patients completed the study: 49 in the interferential current group and 49 in the sham group. INTERVENTION: Patients in the interferential current group received interferential current treatment for 30 minutes, twice a day for five days postoperatively. For the patients in the sham interferential current treatment group, the same pads were applied to the patients for the same time periods but no electrical stimulation was applied. MAIN OUTCOME MEASURES: Patients were assessed in respect of pain, range of motion (ROM), edema, and the amount of paracetamol used at baseline and on the 5th and 30th days after surgery. RESULTS: No significant difference was determined between the groups in respect of pain, ROM, and edema at days 0, 5, and 30. At the end of the 5th day, the amount of paracetamol used was significantly lower in the interferential current group ( P < 0.05). CONCLUSION: In this study, both groups showed significant improvements in pain, ROM, and edema with no significant difference between the groups. Although there was a significant difference in paracetamol intake of the two groups, this cannot be argued as showing the effectiveness of interferential current.

Comparison of dynamic compression system versus multiple cancellous screws in the treatment of femoral neck fractures in young adults.

INTRODUCTION: Femoral neck fractures have posed a significant global healthcare challenge and had notable impacts on the quality of life. Current treatment strategies for femoral neck fractures in young individuals have varied, emphasizing the need for optimal fixation methods. This study compared the clinical and radiological outcomes of the dynamic compression system (DCS) and multiple cancellous screws (MCS) methods. METHODS: This retrospective study included a total of 275 young adults with fresh femoral neck fractures treated with DCS and MCS. A matching analysis with a 1:1 ratio based on age, gender, fracture classification, and reduction quality was conducted. Demographic data were recorded, and comparisons were made according to follow-up time (FUT), hospitalization period, operation duration, femoral neck shortening, caput-collum-diaphysis (CCD) angle, Harris Hip Score (HHS), and post-operative complications. RESULTS: A total of 42 fractures were matched with a median age of 42 years (range, 22-48). In the DCS group, vertical neck shortening (median 1.92) was significantly lower than that in the MCS group (median 4.53) (P < 0.05). In the DCS group, horizontal femoral neck shortening, resultant femoral neck shortening, the amount of change in CCD angle, and HHS were 0.57 mm (0.43, 4.74 mm), 1.82 mm (0.40, 3.53 mm), 0.13° (-0.78°, 1.80°), and 91 (85-93), respectively. They were all non-significant than 1.00 mm (0.56, 6.23 mm), 2.74 mm (1.59, 6.71 mm), -0.18° (-1.11°,1.85°), and 91 (75, 93) in the MCS group, respectively (P > 0.05). There was no statistical difference in FUT, hospitalization period, operation time, and post-operative complications at the latest follow-up (P > 0.05). There were no complications such as pulmonary embolism, deep vein thrombosis, and incision infection reported. CONCLUSION: DCS and MCS demonstrated effectiveness in treating femoral neck fractures in young adults. The DCS implant provides additional stability in the vertical axis. A prospective randomized controlled study with a large sample size was needed to validate these findings.

An investigation into the frequency and risk factors of low back pain following surgical treatment of isolated calcaneal fractures.

OBJECTIVE: This study aimed to determine the frequency of low back pain after calcaneal fractures treated with open reduction internal fixation (ORIF) and the risk factors that cause this condition. METHODS: Thirty-one patients (27 males and 4 females) who underwent surgery for a unilateral calcaneal fracture between 2016 and 2020 and had no complaints of low back pain before fracture surgery were included in the study. The patients were divided into 2 groups: those who developed low back pain after the operation and those who did not. Patients were evaluated with the Life Quality Short Form SF-36, the Oswestry Disability Index (ODI), and American Orthopedic Foot-Ankle Association Score (AOFAS). Sanders' fracture type, joint range of motion (ROM) measurements of injured and uninjured limbs, maximal isometric muscle strength measurements, balance on 1 leg with pedobarographic measurements, and walking time were evaluated. The obtained data were compared among the 2 groups. RESULTS: Low back pain was observed in 71% of the patients and was detected after an average of 6 months from the operation. In ODI, 59.1% of the patients reported that low back pain limited their lives slightly. Patients with low back pain have lower AOFAS scores and worse SF-36 physical functionality than those without low back pain (P < .001, P=.016). Balance time on 1 foot in pedobarographic measurements, foot in ROM, ankle in ankle active, passive plantar flexion, inversion, active hip, passive internal, external rotation, muscle is the foot eversion force. In these measurements, the values of the injured side are intact. It was statistically significantly lower than the other side (interaction P < .1). CONCLUSION: Low back pain may occur after unilateral calcaneal fractures treated by ORIF. This may be caused by decreased angles of ankle dorsi and plantar flexion, foot inversion, hip abduction, and internal and external rotation. In the rehabilitation program, not only the ankle region but also the hip joint of the affected side should be included, and the kinetic chain that describes the interaction mechanism of the human body should not be forgotten. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

Comparative analysis of radiological outcomes among cephalomedullary nails: helical, screw and winged screw.

Objective: Cephalomedullary nails (CMN) are implants with a high success rate in the surgical treatment of trochanteric fractures. The aim of this study is to compare the radiological outcomes and mechanical complications of femoral trochanteric fractures treated with three different CMNs. Methods: Intertrochanteric fractures in patients aged 50 years and older treated with CMN between January 2016 and December 2021 were reviewed retrospectively. A total of 158 cases meeting the criteria were included to final analysis. Cases were divided into three groups based on the type of nail used (helical blade: group 1, n = 54; screw: group 2, n = 53; winged screw: group 3, n = 51). Demographic characteristics, mechanical complications, reduction quality, tip-apex distances (TAD) and Cleveland zones were compared between the groups. Femoral neck shortening, varus collapse, lag sliding, changes in abductor length were compared between study groups. Factors affecting mechanical complications were also analyzed. Results: Study groups were homogenic in terms of demographic characteristics, fracture type and reduction quality. Regarding mechanical complications, no statistically significant difference was found between groups. All three implants had similar outcomes on femoral neck shortening, varus collapse and lag sliding. Pooled analysis of 158 cases showed that mechanical complications increase as the quality of reduction decreases (p = 0.000) same applies when TAD alters from the desired range (p = 0.025) and with non-optimally implanted blade according to Cleveland zones (p = 0, 000). Conclusion: The radiological outcomes and mechanical complications of helical blade, screw type blade and winged screw type blade proximal femoral nails are similar in selected group. Regardless of the device type, it is necessary to obtain high reduction quality, obtain TAD within described range and optimally place the blade according to Cleveland Zones to reduce the failure rate and avoid complications.

Unilateral Spinal Anesthesia in Hip Fracture Surgery for Geriatric Patients With High Cardiovascular Risk due to Aortic Stenosis is Safe and Effective.

Introduction: Aortic stenosis is a cause of mortality or morbidity. It complicates the selection and management of anesthetic procedures. The aim of this study was to evaluate the efficacy, hemodynamic effects and postoperative outcome of unilateral spinal anesthesia in geriatric patients with hip fractures with moderate or severe aortic stenosis. Material and Method: A retrospective observational study was conducted on geriatric high-risk patients with cardiac conditions who underwent surgery for hip fractures under unilateral spinal anesthesia with low-dose hyperbaric bupivacaine. The study period spanned from January 2018 to December 2021. The inclusion criteria were individuals with moderate to severe aortic stenosis, as defined by the American Heart Association Criteria. Data on demographic information, cardiac pathologies, hemodynamic data, data on motor and sensory block, perioperative complications, and mortality rates at 30th and 180th days were collected. Results: Mortality rates at the 30th day and 180th day were 8.9% (n:4) and 24.4% (n:11), respectively. T6 level was predominantly obtained level of anesthesia (44.4%). Motor and sensory block formation times averaged 7.6 and 4.8 minutes, respectively. Surgical procedures were performed mostly within 1 hour (66.7%), and complications were rare (11.1% hypotension). Initial analgesic effect showed a rapid resolution, with 64.4% of patients requiring analgesic within the first hour postoperatively. Conclusion: In elderly patients with moderate to severe aortic stenosis scheduled for hip fracture surgery, we posit that unilateral spinal anesthesia with ultra-low dose is safe and effective option.

Preoperative cardiology consultations for geriatric patients with hip fractures rarely provide additional recommendations and are associated with prolonged hospital stays and delayed surgery: a retrospective case control study.

OBJECTIVES: Hip fractures are increasingly common among the elderly population, who often present with a high burden of comorbidities necessitating preoperative stabilization. As a result, preoperative cardiology consultations are frequently conducted in clinical practice. The aim of this study was to investigate the additional recommendations provided by preoperative cardiology consultations and the impact of consultations on the management and outcomes of elderly patients undergoing hip fracture surgery. PATIENTS AND METHODS: This matched cohort study was performed to retrospectively assess the clinical data of patients who were treated for hip fractures at our institution between January 2016 and December 2017. Individuals who were 60 years old or older with available clinical and radiological data were included. A total of 262 patients who met these criteria were included, with 192 undergoing cardiology consultation and 70 not. Through matching for age, sex, ASA grade, fracture type, and surgery type, two groups (Group A, preoperative cardiology consultation requested; Group B, preoperative cardiology consultation not requested) of 50 patients each were formed. The duration between hospital admission and surgery, recommendations provided by cardiology consultation, type of anaesthesia and surgery, length of hospital stay, incidence of medical and orthopaedic complications, and one-year mortality status were compared between the groups. RESULTS: The mean age of Group A was 78.5 (± 7.4) years, whereas that of Group B was 78.4 (± 7.4) years (p = 0.99). Both groups included 30 female patients and 20 male patients each. There were no significant differences in anaesthesia type or the incidence of medical or orthopaedic complications between the groups. However, Group A experienced a significantly longer duration between admission and surgery (5 [1/9] days vs. 3 [0/7] days; p = 0.00) and a longer hospital stay (7 [3/15] days vs. 5 [1/19] days; p = 0.01) than did Group B. The one-year mortality rate did not significantly differ between the groups (30% vs. 20%; p = 0.36). Notably, only 3 out of 50 patients received additional treatments following cardiology consultation beyond routine recommendations. CONCLUSION: Preoperative cardiology consultations before hip fracture surgery rarely leads to a change in treatment. Additionally, these evaluations delay surgery and extend the hospital stay.

Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail?

BACKGROUND: Reverse obliquity fractures of the proximal femur have biomechanical characteristics distinct from other intertrochanteric fractures and high implant failure rate when treated with sliding hip screws. Intramedullary hip nailing for these fractures reportedly has less potential for cut-out of the lag screw because of their loadbearing capacity when compared with extramedullary implants. However, it is unclear whether nail length influences healing. QUESTIONS/PURPOSES: We compared standard and long types of intramedullary hip nails in terms of (1) reoperation (fixation failure), (2) 1-year mortality rate, (3) function and mobility, and (4) union rate. METHODS: We conducted a pilot prospective randomized controlled trial comparing standard versus long (≥ 34 cm) intramedullary hip nails for reverse obliquity fractures of the proximal femur from January 2009 to December 2009. There were 15 patients with standard nails and 18 with long nails. Mean age was 79 years (range, 67-95 years). We determined 1-year mortality rates, reoperation rates, Parker-Palmer mobility and Harris hip scores, and radiographic findings (fracture union, blade cut-out, tip-apex distance, implant failure). Minimum followup was 12 months (mean, 14 months; range, 12-20 months). RESULTS: We found no difference in reoperation rates between groups. Two patients (both from the long-nail group) underwent revision surgery because of implant failure in one and deep infection in the other. There was no difference between the standard- and long-nail groups in mortality rate (17% versus 18%), Parker-Palmer mobility score (five versus six), Harris hip score (74 versus 79), union rate (100% in both groups), blade cut-out (zero versus one), and tip-apex distance (22 versus 24 mm). CONCLUSIONS: Our preliminary data suggest reverse obliquity fractures of the trochanteric region of the femur can be treated with either standard or long intramedullary nails.

Management of complex pilon fractures: Is it necessary to fix all the columns in AO/OTA type 43-C fractures?

INTRODUCTION: Surgical treatment of AO/OTA 43-C pilon fractures has not yet taken a standard form. We aimed to evaluate whether patients that appeared to be labelled as unsupported columns according to the four-column theory would affect long-term clinical and radiological outcomes. MATERIALS AND METHODS: Patients with AO/OTA 43-C type who were treated surgically between January 2010 and December 2019 were included in the study. 53 fractures in 52 patients who received osteosynthesis were categorized based on the fixed columns. These groups were formed as fully supported columns (FSC- Group A), partly supported columns (PSC-Group B), Ankle range of motions (ROM), Burwell Charnley's reduction evaluation criteria, Kellgren-Lawrence ankle osteoarthritis staging system, and American Orthopedic Foot and Ankle Society (AOFAS) Scoring System, Olerud-Molander Ankle Score, Visual Analog Scale were used for evaluating radiological and functional outcomes. RESULTS: The mean follow-up period was 72.6 (12-131) months. Mean age was 42.6 (18-76). Two groups were homogenously distributed in terms of age (p = 0.785), sex (p = 0.376), laterality (p = 0.732), smoking status (p = 0.488) and reduction quality. There was no difference in AOFAS score (p = 0.452), Olerud-Molander score (p = 0.354) and VAS scores (p = 0.589). TAS, TLS and TT angle measurements suggested no difference between groups (p = 0.493, p = 0.834, p = 0.577). There was no difference between groups in terms of infection (p = 0.734), malunion (p = 0.688) and arthritis (p = 0.483) CONCLUSION: We presented findings that contradicted the hypothesis positing the existence of four distinct columns in pilon fractures, as well as the notion that each fractured column requires support from distinct implants. LEVEL OF EVIDENCE: Level III.

Single dose of intra-muscular platelet rich plasma reverses the increase in plasma iron levels in exercise-induced muscle damage: A pilot study.

BACKGROUND: Platelet rich plasma (PRP) therapy is widely used in enhancing the recovery of skeletal muscle from injury. However, the impact of intramuscular delivery of PRP on hematologic and biochemical responses has not been fully elucidated in exercise-induced muscle damage. The purpose of this investigation the effects of intramuscular delivery of PRP on hematologic and biochemical responses and recovery strategy muscle damage induced by high intensity muscle exercise (exercise-induced muscle damage, EIMD). METHODS: Moderately active male volunteers participated in this study and were assigned to a control group (control, n = 6) and PRP administration group (PRP, n = 6). The subjects performed exercise with a load of 80% one repetition maximum (1RM) maximal voluntary contraction of the elbow flexors until point of exhaustion of the non-dominant arm was reached. The arms were treated with saline or autologous PRP post-24 h EIMD. Venous blood samples were obtained in the morning to establish a baseline value and 1-4 days post-exercise and were analyzed for serum ferritin, iron, iron binding capacity (IBC), creatinine kinase (CK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). RESULTS: The baseline levels of plasma iron, ferritin, IBC, CK, LDH, AST, and ALT were similar in both the control and PRP groups. However, 24-h following exercise a significant increase in these parameters was observed in both groups between 1 and 4 days during the recovery period. Interestingly, PRP administration decreased plasma iron levels compared to the control on the second day post-exercise. Plasma IBC increased in PRP group from Days 2 to 4 post-exercise compared to the control group whilst PRP administration had no effect on plasma ferritin, CK, AST, ALT, or LDH. CONCLUSION: Acute exhaustive exercise increased muscle damage markers, including plasma iron, IBC, and ferritin levels, indicating muscle damage induced by exercise. PRP administration improves inflammation by reversing the increase in the iron levels post-exercise without displaying any myotoxicity and may have a role to play in the recovery of exercise-induced muscle damage.