Utility of severity scoring systems for mangled upper limb salvage: A systematic review and meta-analysis.

BACKGROUND: The purpose of scoring systems is to aid in the decision-making process of whether to salvage or amputate mangled extremities, but their efficacy for upper limbs is uncertain. In this study, we examined the predictive potential of scoring systems for upper limb salvage. METHODS: Two investigators undertook a systematic search of 3 leading databases for English or Japanese literature from 1985, when the first scoring system to evaluate mangled extremities was proposed, until January 2022. To be eligible, studies must have had upper extremity limb salvage or amputation as an outcome, and identified the scoring system used and treatment outcome in individual cases. RESULTS: Ten studies (N = 338) of the Mangled Extremity Scoring System (MESS) were ultimately included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95 % CI = 0.69-0.99) and 0.81 (0.65-0.91), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.95 (0.93-0.97). A subgroup analysis showed lower specificity in isolated vascular injuries. Scoring systems other than MESS were ineligible for the quantitative synthesis because none were examined in an adequate number of publications. CONCLUSION: The pooled sensitivity and specificity for MESS were comparable to those reported for the lower extremities. The specificity suggests that limb salvage was achieved in at least 20 % of the patients whose MESS was above the threshold beyond which amputation is indicated. Given the likelihood of upper extremity functional limitations following amputation and the drawbacks of prostheses, we conclude that current scoring systems poorly predict salvageability of a mangled upper extremity and should not be used to justify amputation.

Outcomes of spring-locking plate fixation method using locking mesh plate/box plate for posterior wall fractures of the acetabulum: a retrospective single-centre study.

INTRODUCTION: This retrospective study evaluated the outcomes of variable-angle locking compression plate, mesh plate, or footplate box fixation for posterior acetabular wall fractures. PATIENTS AND METHODS: The study included nine patients with unstable posterior acetabular wall fractures who underwent internal fixation with the "spring-locking plate fixation method" between January 2015 and December 2019. Patient demographics, fracture classifications, surgical details, radiological and clinical evaluations, and complications were collected from electronic medical records. Statistical analyses were performed to assess the relationship between preoperative and postoperative dislocations. RESULTS: The mean age of the patients was 46 years, and the majority were men (88.9%). Fracture types included posterior wall fractures and posterior column plus posterior wall fractures. The mean operative time was 246 min and the mean blood loss was 663 mL. The surgical approaches included the Kocher-Langenbeck, Ganz trochanteric flip, and transtrochanteric approaches. Variable-angle locking compression plate mesh plates and footplate box type implants were used for fixation. The mean preoperative dislocation was 23 mm, which was significantly reduced to 1 mm immediately post-operation and at the final observation. The bone fusion rate was 100% and radiological and clinical evaluations revealed favourable outcomes. Complications were minimal, with mild heterotopic ossification observed in four patients. CONCLUSION: The spring-locking plate fixation method demonstrated satisfactory outcomes for the treatment of posterior acetabular wall fractures. This technique provides rigid fixation. Furthermore, the use of variable-angle locking screws minimizes the risk of intra-articular perforations. Despite limitations such as a small sample size and the absence of a control group, the results suggest that the spring-locking plate fixation method may be valuable in managing these fractures.

Effectiveness of Specific Single-Use Incisional Negative Pressure Wound Therapy (PICO System) After Major Lower Extremity Amputation.

Lower extremity amputation (LEA), particularly in patients with diabetes or peripheral vascular disease, often results in complications such as surgical site infections (SSIs) and wound dehiscence. This study examined whether utilizing the portable and user-friendly PICO system (Smith and Nephew Medical Ltd, Hull, UK) as incisional negative-pressure wound therapy can reduce post-LEA complications. This study was conducted at a Japanese tertiary medical center and involved a retrospective analysis of LEA cases (n = 32) between January 2021 and December 2022. The PICO dressing group (n = 16) was compared to the conventional dressing group (n = 16) for post-LEA wound management. The primary outcome was the incidence of postoperative wound complications, including SSI and wound dehiscence, within 15 days of LEA. Superficial/deep SSI and wound dehiscence occurred less frequently in the PICO dressing group than in the conventional dressing group (12.5% vs 43.8%; p = .054). There were no cases of deep SSIs in the PICO dressing group. Although this study has limitations owing to its retrospective design and small sample size, the results suggest the potential of the PICO system for improving outcomes in post-LEA wound management.

A nerve-to-implant distance as a novel predictor for lateral femoral cutaneous nerve injuries after anterior subcutaneous pelvic internal fixation.

Although anterior subcutaneous pelvic internal fixation is a valuable tool for the reduction and fixation of unstable pelvic ring injuries, lateral femoral cutaneous nerve irritation by the implant is the most common complication. This study aimed to investigate the association between the nerve-to-implant distance and the postoperative lateral femoral cutaneous nerve symptom. Patients who underwent anterior subcutaneous pelvic internal fixation between 2016 and 2019 were retrospectively analyzed. Lateral femoral cutaneous nerve status was defined as follows: not identified, nerve-to-implant distance <13 mm, and ≥13 mm. The proportion of patients who experienced postoperative nerve disorders was compared using the nerve status. Nerve-to-implant distances were compared using the presence or absence of postoperative lateral femoral cutaneous nerve disorders. The predictive value of a nerve-to-implant distance of 13 mm for postoperative nerve disorders was assessed. Overall, 26 lateral femoral cutaneous nerves were included. Ten patients had postoperative nerve disorders, of which seven had an nerve-to-implant distance <13 mm, while the other three occurred in patients whose nerves were not identified. A nerve-to-implant distance ≥13 mm was significantly associated with a decreased risk of postoperative nerve disorder compared to a nerve-to-implant distance <13 mm (p = 0.017). A nerve-to-implant distance ≥13 mm had a perfect sensitivity (100%) and modest specificity (58.3%). Nerve-to-implant distance was ≥13 mm. Nerve disorders were frequently observed when the nerve-to-implant distance was <13 mm or the nerve was not identified intraoperatively. Efforts to identify the lateral femoral cutaneous nerve may be useful to avoid internal fixation-related nerve disorders.

A rare case of the axillary necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection that needs acute surgical intervention and other types of supportive care. The upper extremities are a less frequent site for this infection than the lower extremities. Axillary necrotizing fasciitis is quite rare and bears a high risk of iatrogenic neurovascular injuries. We report a severe case of a 39-year-old man with a right axillary necrotizing fasciitis caused by Streptococcus pyogenes. While dealing with important nerves and blood vessels at the initial emergency surgery, we marked and preserved them with vascular tapes. The patient underwent several surgical interventions for infection control in addition to supportive care to avoid limb loss and to survive. Intraoperatively, the locations of nerves and vessels could be easily found by checking the vessel tapes. Twelve months after the initial admission, the patient had no symptoms of nerve injuries and resumed work. With necrotizing fasciitis, the risk of an iatrogenic nerve injury exists even if limb amputation is avoided due to repeated debridement. We report that marking and preserving nerves and blood vessels with vascular tapes at the initial surgery may make the subsequent ones easier and may reduce iatrogenic neurovascular injury.

Mid-term outcomes of digital nerve injuries treated with Renerve® synthetic collagen nerve conduits: A retrospective single-center study.

BACKGROUND: Biodegradable synthetic nerve conduits have become widely used for peripheral nerve injuries. Recently, bioabsorbable collagen conduits filled with collagen fibers (Renerve®) are commercially available in Japan. We investigated the clinical efficacy and safety of Renerve® conduits for digital nerve repair. PATIENTS AND METHODS: We retrospectively reviewed data of patients who underwent digital nerve repair using Renerve® conduits between August 2017 and February 2022 at our hospital and were followed up for at least 12 months. Seventeen patients (20 nerves) with a median age of 46.5 years (interquartile rage: 26-48 years) were included in the analysis. We analyzed sensory nerve function recovery and residual pain or uncomfortable tingling, as well as safety outcomes. The relationship between nerve defect length and sensory function data was assessed using Spearman's rank correlation. RESULTS: Sensory nerve function at 12 months postoperatively was excellent in six, good in 10, and poor in four nerves, and that at the final follow-up (median period, 24 months; range, 12-30 months) was excellent in nine, good in 10, and poor in one nerve. All nerves with a defect length of <12 mm had excellent or good sensory outcomes. At 12 months postoperatively, the correlation coefficients between nerve defect length and Semmes-Weinstein monofilament test results, static two-point discrimination, and dynamic two-point discrimination were 0.35 (p = 0.131), 0.397 (p = 0.0827), and 0.451 (p = 0.0461), respectively. Residual pain or tingling sensation were observed in four nerves at the final follow-up. No postoperative complications were observed in any of the patients. CONCLUSIONS: This study demonstrated the clinical efficacy and safety of Renerve® conduits for digital nerve repair. Our results will be useful in clinical practice because of the scarcity of real-world data on the use of Renerve® conduits for digital nerve repair.

Posterior sternoclavicular joint dislocation with thoracic costovertebral joints fracture-dislocations: A case report.

Case: A 59-year-old man presented with posterior sternoclavicular joint dislocation concomitant with fracture-dislocations of multiple thoracic costovertebral joints caused by traumatic injury. The posterior sternoclavicular joint dislocation was treated using an ultra-high molecular weight polyethylene fiber cable and the joint was stabilized. The degree of malpositioning of the thoracic costovertebral joints was difficult to reduce. Conclusion: The patient achieved an excellent shoulder range of motion at 12 months postoperatively; however, chronic shoulder stiffness and posterior neck discomfort persisted.

Total Hip Arthroplasty With Impacted Bone Graft on Acetabulum for Osteoporotic Acetabular Fractures: A Report of 3 Cases.

Osteoporotic acetabular fractures in elderly patients have recently been increasing, but the best treatment remains uncertain due to the difficulty in stabilizing these fractures with osteosynthesis. We performed total hip arthroplasty with an impacted bone graft on the acetabula of 3 elderly patients with comminuted acetabular fractures after confirming acetabular callus formation via radiographic imaging 2 months following the patients' initial injuries. Two of the patients presented in the subacute phase after conservative treatment, and 1 patient had no history of trauma or quadrilateral surface destruction. Two patients achieved good functional results at the 3-year follow-up. Furthermore, no loosening of the prosthesis components or subsidence of the acetabular cemented cup was evident on radiographic imaging in any of the patients.

Use of Triceps Tendon and Paratenon Composite Graft for Extensor Tendon Reconstruction in the Hand: A Case Report.

An extensor tendon defect in the hand requires reconstruction to restore extension. We report a 44-year-old woman with a 24-mm extensor tendon defect of the middle finger over the dorsum of the hand that was reconstructed using a composite graft consisting of the triceps tendon and paratenon. This composite graft from the posterior aspect of the distal arm is simple, safe and may be considered in extensor tendon reconstruction. Level of Evidence: Level V (Therapeutic).

Satisfactory mid- to long-term clinical and radiographic outcomes after surgical treatment of radial neck fracture in 10 children.

Complications after surgical treatment of pediatric radial neck fractures are common. The purpose of this study was to evaluate the mid- to long-term clinical and radiographic outcomes after surgical treatment of pediatric radial neck fractures. We assessed 10 children who had been surgically treated for radial neck fractures. We mainly performed percutaneous intrafocal pinning to reduce the fracture; where this was inappropriate, we performed open reduction. Mid- to long-term clinical and radiographic outcomes were assessed, as well as whether these affected patient-related outcomes (Hand 20 questionnaire) at the final follow-up. Of the 10 patients (seven boys; mean age, 9 years; age range, 5-14 years; four fractures on the right-hand side, six on the left), four each were grades II and III, and two were grade IV, according to the Judet classification. The mean follow-up time was 6.7 (range, 3.6-11.2) years. Eight patients had restricted forearm pronation. The mean radial neck angulation on the fractured side was 36° (range, 5°-96°), preoperatively, and 2° (range, 0°-11°) at the final follow-up. There were eight cases of radial head overgrowth, three of premature physeal closure, two of notching of the radial neck, and one of heterotopic ossification. According to the Leung/Peterson Classification, four patients had "excellent," three had "good," and three had "fair" functionality. Eight patients had a perfect score upon completing the Hand 20 questionnaire. In conclusion, postsurgical patient-related outcomes for the 10 cases were satisfactory despite slightly restricted forearm range of motion and complications detected using radiography.

Peripherally Inserted Central Catheter-Related Infectious Myositis: A Case Report.

BACKGROUND Peripherally inserted central catheters (PICCs) are commonly used by clinicians in daily practice as a safe and reliable alternative to central venous catheters. While there are advantages to the use of PICCs, such as a low insertion-related complication rate and cost-effectiveness, using PICCs may expose patients to life-threatening severe complications such as a central line-associated bloodstream infection and deep venous thrombosis (DVT). There have been no reports of infectious myositis associated with PICC insertion. CASE REPORT We report a case of infectious myositis related to PICC insertion complicated by brachial DVT in a 43-year-old immunocompromised patient with myelodysplastic syndrome. Despite the administration of broad-spectrum antibiotics, the patient's condition did not improve. He developed septic shock and required emergency excision of the infected and necrotic muscles. Although the pathogen responsible for the infection was unknown, infectious myositis and myonecrosis were observed intraoperatively. Furthermore, histopathological examination revealed evidence of infectious myositis in the biceps brachii and brachial muscles. The septic shock resolved with treatment and the patient survived with residual elbow joint dysfunction. CONCLUSIONS We present a case of infectious myositis related to PICC insertion. We believe that urgent resection of infected and necrotic tissues, rather than broad-spectrum antimicrobial therapy alone, was essential to save the patient's life.

Surgical fixation of ulnar coronoid process fractures via mesh plate: A case report.

Introduction: The coronoid process of the ulna is the primary stabilizer of the elbow joint. There has not yet been an accurate off-the-shelf dedicated implant because fragments of coronoid process fractures are often small and diverse. The variable angle locking compression mesh plate 2.4/2.7 (Depuy Synthes, West Chester, PA, USA) acts as a versatile, low-profile implant that can be cut to suit the specific fracture pattern and fits anatomically. Case presentations: We report two cases of Regan-Morrey type II ulnar coronoid process fractures in terrible triad elbow injuries. In both cases, persistent instability was fluoroscopically diagnosed after repair of the lateral structures. We performed osteosynthesis for the ulnar coronoid process fractures using a mesh plate, which we cut into a rhombus-like shape and used as a buttress plate. Here we report the good results obtained thereof. Conclusion: Considering our positive experience with using mesh plates, the mesh plate may be a good method of fixation for ulnar coronoid process fractures.

The First Fatal Case of Chromobacterium violaceum Infection in Japan.

BACKGROUND Chromobacterium violaceum (C. violaceum) is a gram-negative and facultative anaerobic oxidase-positive bacillus generally seen in tropical or subtropical areas (latitudes between 35°N and 35°S). C. violaceum infection is a rare but serious infection with high morbidity and mortality rates. Most clinicians practicing in non-tropical counties, such as Japan, are unfamiliar with it. CASE REPORT We report the first fatal case of a 49-year-old man infected with C. violaceum after a traffic accident in Japan (latitude 34.8°N). The patient reported brief submergence in a marshy muddy rice field after the accident. There was some evidence of soil and water contamination of the patient's skin and clothing, but he denied swallowing water or soil. There were no findings of pneumonitis or severe open wounds on admission. Until the night of the 7th day of hospitalization, his general conditions remained stable despite a persistent fever. However, he suddenly collapsed on the 8th day of hospitalization and died. C. violaceum bacteremia led to fatal sepsis on dissemination to the iliopsoas abscess, which is a rare combination for this infection. CONCLUSIONS Episodes of exposure to contaminated water or soil, especially in summer, are important predisposing factors for C. violaceum infection. Thus, it is vital to include C. violaceum infections as a differential diagnosis, since the mortality rate of C. violaceum infections is high and the cases of this infection have increased in non-tropical counties.

An intraoperative small distractor for non-open reduction and intramedullary fixation of pediatric displaced diaphyseal forearm fractures.

This report describes technical tools for the treatment of pediatric displaced and unstable diaphyseal forearm fractures, which are difficult to treat by manual closed reduction. During intramedullary fixation with Kirchner wires, we propose our original small distractor as an intraoperative distraction apparatus without open reduction. This apparatus is made using parts of the Ilizarov external fixator. Apart from general external fixation devices, our apparatus is adequate for the effective shortening and lateral dislocation of the fracture site. This adequacy is not only because of the three-dimensional control by ball joints but also owing to the gradual adjustment structure of the Quick adjust strut (Orthofix, Verona, Italy), which allows tight and fine stretching, thus making the distractor an effective reduction tool. Our findings show the feasibility and usefulness of our reduction technique and small distractor. Our small distractor is a useful intraoperative distraction apparatus without open reduction for pediatric displaced and unstable diaphyseal forearm fractures that cannot be treated by manual closed reduction. In this report, we describe the distractor, the closed reduction technique, and the clinical results of four representative cases.

Ulnar Parametacarpal Flap for Small Finger Avulsion Injury.

In difficult cases of replantation following small finger avulsion injury, in which amputation occurs at the proximal interphalangeal joint, the ulnar parametacarpal island flap, rotated 180° (propeller flap), can be used as an alternative method for covering a skin defect of the proximal phalanx. This flap can prevent metacarpophalangeal joint dysfunction and additional finger shortening. We propose the use of an ulnar parametacarpal flap for this purpose and report the outcomes of two successful cases treated with this method and followed up for 12 months.