Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases.

We evaluated the management of supracondylar paediatric fractures at our institution over a 10-year period in this retrospective cohort study. In total, 762 children with a supracondylar fracture were treated. The mean age of injury was 5.2 years. The incidence of documented nerve and/or vascular injury was 8.3%. A total of 26 patients had early plastic surgeon involvement; of these, 25 had an open exploration. Eight patients required vein grafting for brachial artery reconstruction for intimal tears. There was one nerve rupture requiring repair and 12 children underwent neurolysis. There were 17 late referrals to the plastic surgery service, of which three were explored (two neurolysis, one neuroma resection and sural nerve grafting). In all cases of nerve injury, the deficit took 7.9 months to recover, indicating a more significant injury than neurapraxia. Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention.Level of evidence: IV.

Mass balance of Nehnar glacier from 2000 to 2020, using temperature indexed-IAAR approach.

Glacier mass balance is inextricably linked to annual meteorological conditions and is a key indicator for assessing the ice reserves of a glacier. As a result, a number of studies have estimated glacier mass balance using different methods. Here, we have used the improved accumulation area-ratio (IAAR) method to study the mass balance of the Nehnar glacier from 2000 to 2020. This study also aims to study the spatiotemporal behavior and other dynamics of the glacier. Results have shown that the glacier has continuously lost its ice reserves throughout the studied period though at a lower rate since 2010. Its annual specific mass balance has changed from - 50.10 ± 3 cm w.e in 2000 to - 59.46 ± 3 cm w.e. in 2020. The equilibrium line altitude (ELA) of the glacier rose by 90 m and has shifted from 4260 masl in 2000 to 4350 masl in 2020. The glacier has shrunk from an area of 1.64 km2 in 2000 to 1.38 km2 in 2020 losing nearly 16% of its area. The study highlights the need for continued monitoring of glacier mass balance to better understand and predict the effects of climate change. These findings have important implications for the future of glacier retreat and water reserves of the Jhelum basin.

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair.

INTRODUCTION: Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. METHODS AND ANALYSIS: WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks. TRIAL REGISTRATION NUMBER: ISRCTN identifier: 15052559.

Synchronous circular frame stabilisation and microsurgical soft tissue reconstruction for open lower limb fractures-A cost analysis and description of the surgical technique.

INTRODUCTION: Current surgical paradigms for ortho-plastic management of IIIB open tibial fractures make compromises. Often, definitive circular frame stabilisation is delayed until the soft tissue envelope is secure to allow access for further soft tissue reconstruction if required. This delay has potential clinical and cost implications. A previous study showed acute circular frame stabilisation performed concurrently or before soft tissue reconstruction was feasible without additional soft tissue reconstruction problems. This study examines potential resource savings using this approach. METHODS: All open tibial fractures managed by circular fixator and microsurgical soft tissue reconstruction between April 2015 and June 2019 were identified from a prospectively maintained database. Those receiving circular frame stabilisation with synchronous microsurgical soft tissue reconstruction were considered cases; those in whom the frame stabilisation was delayed were controls. Cost data were derived from the Patient Level Information and Costing System. Salvage cases and those with incomplete treatment were excluded. RESULTS: Nine cases and 25 controls were evaluated. No statistically significant difference was observed between groups in terms of age, sex, injury severity score, time to debridement, time to coverage, length of follow up, or time to union. Median length of stay was 13.3 and 19.7 days for cases and controls respectively (p<0.01). Cases required fewer procedures (2.3) compared to controls (4.5) (p<0.001). The cost of care was less for cases (£25,527) than controls (£32,952) (p <0.05). No cases returned to theatre with flap failure or flap compromise. Complications were similar between groups. CONCLUSION: In suitable patients, synchronous circular frame stabilisation and microsurgical soft tissue reconstruction is a safe, clinically effective, and cost-saving option.

Wrist fusion using an induced membrane technique for forearm salvage in a patient with an infected open injury with segmental bone loss: A case report.

This case report describes the management of a 27-year-old male who, after a quadbike accident, presented with an open, infected, segmental both bone forearm injury with significant bone and soft tissue loss including the radio-carpal joint. Limb salvage was accomplished in the form of a single bone forearm fusion utilising Masquelet's two-stage induced membrane technique to reconstruct the segmental bone defect. The patient proceeded to uneventful bony union by 6 months and returned to driving and riding a quadbike. Despite significant deep infection, successful salvage was achieved using the induced membrane technique. Critical to success was aggressive, repeated debridement alongside restoration of vascular supply and reconstruction of soft tissue defects. We highlight the multidisciplinary approach to management including relevant specialists with a particular interest in limb reconstruction.

Distally Based Sartorius Flap for Soft Tissue Coverage of the Distal Femur.

This case report outlines the use of the distal pedicle of the sartorius muscle in the coverage of a large bony and soft tissue defects of the distal femur in a trauma setting. How to cite this article: McArdle C, Louette S, Wilks D, et al. Distally Based Sartorius Flap for Soft Tissue Coverage of the Distal Femur. Strategies Trauma Limb Reconstr 2021;16(2):120-122.

An overview of mallet finger injuries.

Mallet finger describes a fingertip deformity where the distal interphalangeal joint (DIPJ) of the affected digit is held in flexion, unable to extend the distal phalanx actively. The deformity is typically a consequence of traumatic disruption to the terminal extensor tendon at its insertion at the proximal portion of the distal phalanx or slightly proximally at the level of the DIPJ. Patients typically present with a history describing the event of injury with a typical mallet deformity. Common mechanisms include sport activities causing a direct blow to the finger, low energy trauma while performing simple tasks such as pulling up socks or crush injuries from getting the finger trapped in a door. The DIPJ can be passively extended, but this extension of the joint cannot be maintained once the passive extension is stopped. The Doyle classification can be used to categorise and dictate treatment. The extensor lag associated with the deformity does not improve spontaneously without treatment. Inappropriate management can lead to chronic functional loss and stiffness of the finger. The majority of closed mallet splints are Doyle type I, which can be managed non-surgically with external splints, worn full-time to keep the fingertip straight until the tendon injury or fracture heals. Surgical techniques is considered for other types of mallet injuries. Techniques used include closed reduction and Kirschner wire fixation, open reduction and internal fixation, reconstruction of the terminal extensor tendon and correction of swan neck deformity.

Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle.

Ankle fractures are a common presentation to orthopaedic surgeons, with the lateral malleolus involved in 86% of cases. A soft tissue injury can be a concomitant feature of these injuries as a result of the primary injury or following secondary wound breakdown. The peroneus brevis muscle flap provides a reliable and robust option to cover the distal third of the lower limb. With an understanding of the anatomy and cautious dissection during periosteal elevation, the perforating vessels supplying the peroneus brevis can be preserved ensuring that a valuable reconstructive option is available. HOW TO CITE THIS ARTICLE: Irvine E, Cochrane E, Harwood P, et al. Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle. Strategies Trauma Limb Reconstr 2021;16(3):176-178.

Deciphering the Nature of Caffeic Acid to Inhibit the HSA Aggregation Induced by Glyoxal.

BACKGROUND: Under certain circumstances, the path for protein folding deviates and attains an alternative path forming misfolded states, which are the key precursors for protein aggregation. Protein aggregation is associated with variety of diseases and leads to the cytotoxicity. These protein aggregate related diseases have been untreated so far. However, extensive attempts have been applied to develop anti-aggregating agents as possible approaches to overcome protein aggregation. Different types of substances have been reported to halt or decrease the formation of ordered protein aggregates both in vitro and in vivo, such as polyphenols and metal ions. OBJECTIVE: In the present study the in vitro aggregation of human serum albumin (HSA) by using a reactive dicarbonyl glyoxal has been investigated, simultaneously an attempt has been done to inhibit the glyoxal (GO) induced aggregation of (HSA) by caffeic acid (CA). METHODS: Different methods have been employed to investigate the process, fluorescence spectroscopy, circular dichroism, cango red binding assay, thioflavin T dye binding, turbidimetric analysis, docking study and transmission electron microscopy. RESULTS: Results have shown that elevated concentration of GO forms aggregates of HSA, and the activity of CA suggested the possibility of inhibiting the HSA aggregation at higher concentrations, and this compound was found to have an anti-aggregation property. CONCLUSION: The present study explained that micro molar concentrations of CA inhibits the aggregation of HSA and showed pronounced anti-aggregation effect at increasing concentrations in the presence of GO which is elevated in diabetic and hyperglycaemia conditions.

Glycation induced conformational transitions in cystatin proceed to form biotoxic aggregates: A multidimensional analysis.

Hyperglycaemic conditions facilitate the glycation of serum proteins which may have predisposition to aggregation and thus lead to complications. The current study investigates the glycation induced structural and functional modifications of chickpea cystatin (CPC) as well as biological toxicity of the modified protein forms, using CPC-glucose as a model system. Several structural intermediates were formed during the incubation of CPC with glucose (day 4, 8, 12, & 16) as revealed by circular dichroism (CD), altered intrinsic fluorescence, and high ANS binding. Further incubation of CPC with glucose (day 21) formed abundant ß structures as revealed by Fourier transform infrared spectroscopy and CD analysis which may be due to the aggregation of protein. High thioflavin T fluorescence intensity and increased Congo red absorbance together with enhanced turbidity and Rayleigh scattering by this modified form confirmed the aggregation. Electron microscopy finally provided the valid physical authentication about the presence of aggregate structures. Functional inactivation of glucose incubated CPC was also observed with time. Single cell electrophoresis of lymphocytes and plasmid nicking assays in the presence of modified CPC showed the DNA damage which confirmed its biological toxicity. Hence, our study suggests that glycation of CPC not only leads to structural and functional alterations in proteins but also to biotoxic AGEs and aggregates.

Modification of chickpea cystatin by reactive dicarbonyl species: Glycation, oxidation and aggregation.

Reactive dicarbonyl species such as methylglyoxal (MGO) and glyoxal (GO) have recently received extensive attention due to their high reactivity and ability to modify biological substances such as proteins, phospholipids, and DNA. In case of proteins these reactive species mainly react with lysine and arginine residues to form AGEs, oxidative products, and aggregates. Chickpea cystatin (CPC) was incubated with varying concentrations of glyoxal and methylglyoxal which caused, along with altered secondary and tertiary structures, glycation, functional inactivation, altered redox state, cross-linking and high-molecular-mass aggregation. All these processes were examined and characterized by UV-Vis, fluorescence, and CD spectroscopies. Further characterization of CPC modified by reactive dicarbonyls was done by polyacrylamide gel electrophoresis which also showed alterations in the CPC molecules. Thus, in addition to describing the effects of GO and MGO on structure, conformation and function of CPC, this study also shows the relatively superior modifying effect of methylglyoxal for CPC in terms of glycation, oxidation and aggregation. This model system could shed some more light on the role of the reactive dicarbonyls in the specific alterations of proteins with different biological consequences having implications to ageing and disease such as diabetes.

Interaction of a novel twin-tailed oxy-diester functionalized surfactant with lysozyme: Spectroscopic and computational perspective.

Herein, we have examined the interaction of oxy-diester novel twin tailed (gemini) surfactant, 2,2'-[(oxybis(ethane-1,2-diyl))bis(oxy)]bis(N-hexadecyl-N,Ndimethyl-2-oxoethanaminium) dichloride (C16-E2O-C16) with hen egg white lysozyme (HEWL), utilizing a spectroscopic and molecular docking techniques. Steady-state fluorescence infers ground state C16-E2O-C16-HEWL complex formation. Other spectroscopic results validated the conformational, structural and micro-environmental changes in HEWL upon interaction with C16-E2O-C16. Molecular modeling has shown that C16-E2O-C16 binds in the proximity of hydrophobic moieties (Trp-62/108). We believe the results of the current study will assist in designing the surfactant-enzyme systems for their end use as ingredients in pharmaceutical, cosmetic, drug delivery and industrial compilations. In terms of scientific literature standpoint, it will also enrich and widen the scope of biomacromolecule-surfactant interactions.

Investigating the preventive effects of baicalin and gallocatechin against glyoxal-induced cystatin aggregation.

Several mammalian proteins form pathological deposits under nonphysiological conditions that are associated with many degenerative diseases. Protein aggregation is associated with aging, as well as a variety of diseases, including cystic fibrosis, amyotrophic lateral sclerosis (ALS), and hypertrophic cardiomyopathy. There is a lack of any potential anti-amyloidogenic agents and therapeutics till date. Polyphenols have been accredited with myriad biological effects. An analysis of the effects of natural agents like baicalin (BC) and gallocatechin (GC) on aggregation process can open new avenues for the treatment of protein misfolding diseases. Thus, investigation of the effects of these flavonoids on Buffalo Heart Cystatin (BHC) aggregation induced by a reactive metabolic dialdehyde, glyoxal (GO), was taken up. Results have shown that elevated concentration of GO forms aggregates of BHC, which was characterized by an increase in the ANS fluorescence intensity, an increase in ThT fluorescence intensity, red shift in Congo red absorbance, negative ellipticity peak at 217 nm in the far-UVCD and BHC aggregates displaying by TEM. Using fluorescence spectroscopic analysis with Thioflavin T, CD and electron microscopic studies, anti-aggregation effects of polyphenols, BC and GC were analyzed. The study showed that BC and GC produced concentration-dependent anti-aggregation effects with GC producing a more pronounced effect than BC. The study proposed a mechanistic approach assuming structural constraints and specific aromatic interactions of polyphenols with sheets of BHC aggregates.

Structural and functional studies on a variant of cystatin purified from brain of Capra hircus.

Cystatins, known for their ubiquitous presence in mammalian system are thiol protease inhibitors serving important physiological functions. Here, we present a variant of cystatin isolated from brain of Capra hircus (goat) which is glycosylated but lacks disulphide bonds. Caprine brain cystatin (CBC) was isolated using alkaline treatment, ammonium sulphate fractionation (40-60%) and gel filtration chromatography on Sephacryl S-100HR column with an overall yield of 26.29% and 322-fold purification. The inhibitor gave a molecular mass of ~44 kDa as determined by SDS-PAGE and gel filtration behaviour. The Stokes radius and diffusion coefficient of CBC were 27.14 Å and 8.18 × 10-7 cm2 s-1, respectively. Kinetic data revealed that CBC inhibited thiol proteases reversibly and competitively, with the highest inhibition towards papain (Ki = 4.10 nM) followed by ficin and bromelain. CBC possessed 34.7% α-helical content as observed by CD spectroscopy. UV, fluorescence, CD and FTIR spectroscopy revealed significant conformational change upon CBC-papain complex formation. Isothermal titration calorimetry (ITC) was used to measure the thermodynamic parameters - ΔH, ΔS, ΔG along with N (binding stoichiometry) for CBC-papain complex formation. Binding stoichiometry (N = .97 ± .07 sites) for the CBC-papain complex indicates that cystatin is surrounded by nearly one papain molecule. Negative ΔH (-5.78 kcal mol-1) and positive ΔS (11.01 cal mol-1 deg-1) values suggest that the interaction between CBC and papain is enthalpically as well as entropically favoured process. The overall negative ΔG (-9.19 kcal mol-1) value implies a spontaneous CBC-papain interaction.