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.

Navigating the complexity of calf injuries in athletes: a review of MRI findings.

The calf muscle group is a common area for injury within the professional athlete population. Anatomical and biomechanical differences between the different component muscles vary their individual predispositions to and patterns of injury. However, there is a common unifying factor: injuries involving tendinous components have greater clinical implications with regards to rehabilitation, potential intervention, length of time to return to play, and re-injury rates. As such, accurate understanding of the underlying anatomy and subsequent interpretation of the injury patterns carry significant clinical ramifications. Ultrasound is a useful tool but has limitations, particularly when assessing soleus. As such, magnetic resonance imaging remains the workhorse in calf injury investigation.

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.

Paniculitis pancreática como forma de presentación de neoplasia localmente avanzada / Pancreatic panniculitis as an initial manifestation of locally advanced pancreatic cancer

No disponible

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.

A Mouse Noninvasive Intraarticular Tibial Plateau Compression Loading-Induced Injury Model of Posttraumatic Osteoarthritis.

This study sought to develop a noninvasive, reliable, clinically relevant, and easy-to-implement mouse model that can be used for investigation of the pathophysiology of PTOA and for preclinical testing of new therapies of PTOA. Accordingly, we have established a closed intraarticular tibial plateau compression loading-induced injury model of PTOA in C57BL/6J mice. In this model, a single application of a defined loading force was applied with an indenter to the tibial plateau of the right knee to create injuries to the synovium, menisci, ligaments, and articular cartilage. The limiting loading force was set at 55 N with the loading speed of 60 N/s. This loading regimen limits the distance that the indenter would travel into the joint, but still yields substantial compression loading energy to cause significant injuries to the synovium, meniscus, and articular cartilage. The joint injury induced by this loading protocol consistently yielded evidence for key histological hallmarks of PTOA at 5-11 weeks post-injury, including loss of articular cartilage, disorganization of chondrocytes, meniscal hyperplasia and mineralization, osteophyte formation, and degenerative remodeling of subchondral bone. These arthritic changes were highly reproducible and of a progressive nature. Because 50% of patients with meniscal and/or ligament injuries without intraarticular fractures developed PTOA over time, this intraarticular tibial plateau compression loading-induced injury model is clinically relevant. In summary, we have developed a noninvasive intraarticular tibial plateau compression loading-induced injury model in the mouse that can be used to investigate the pathophysiology of PTOA and for preclinical testing for new therapies.

[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.

A third of referrals are unnecessary: Critical review of burn outpatient clinic data.

OBJECTIVES: The purpose of this study was to establish patterns in types of burns referred to the Outpatient Clinic (OP) at Vancouver General Hospital (VGH). METHODS: A 2-year retrospective chart review was conducted of patients presenting to the OP Clinic from June 1, 2016 - June 1, 2018. Data collected included: patient demographics, depth of burn, Total Body Surface Area (TBSA), anatomical location of burn, geographical location of referral, and operative versus non-operative management. RESULTS: The OP Clinic served 470 patients for burn injuries with a total of 1852 visits. Of these, 20% were follow-up visits post-admission, and 73.6% were primary referrals from the emergency department (ED) or elsewhere. The vast majority (69.6%) of burns were less than 5% TBSA. Half involved the hands (50.9%), and half were superficial dermal in depth (45.1%). A third of patients attended only one appointment with the OP Clinic before discharge and 15% did not receive any treatment. CONCLUSIONS: The results of our study demonstrate gaps in current provincial referral guidelines leading to a significant number of "unnecessary referrals." Further research could correlate the results to current provincial referral guidelines to estimate their current efficacy in practical use.

Use of standard musculoskeletal ultrasound to determine the need for fasciotomy in an elevated muscle compartment pressure cadaver leg model.

INTRODUCTION: Acute compartment syndrome (ACS) is a limb-threatening condition often associated with leg injury. The only treatment of ACS is fasciotomy with the purpose of reducing muscle compartment pressures (MCP). Patient discomfort and low reliability of invasive MCP measurements, has led to the search for alternative methods. Our goal was to test the feasibility of using ultrasound to diagnose elevated MCP. METHODS: A cadaver model of elevated MCPs was used in 6 cadaver legs. An ultrasound transducer was combined with a pressure sensing transducer to obtain a B-mode image of the anterior compartment, while controlling the amount of pressure applied to the skin. MCP was increased from 0 to 75 mmHg. The width of the anterior compartment (CW) and the pressure needed to flatten the bulging superficial compartment fascia (CFFP) were measured. RESULTS: Both the CW and CFFP showed high correlations to MCP in the individual cadavers. Average CW and CFFP significantly increased between baseline and the first elevated MCP states. Both Inter-observer and intra-observer agreements for the ultrasound measurements were good to excellent. DISCUSSION: Ultrasound indexes showed excellent correlations in compartment pressures, suggesting that there is a potential for the clinical use of this modality in the future.

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.

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.

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.

Prevalence of lameness and leg lesions of lactating dairy cows housed in southern Brazil: Effects of housing systems.

Within the last few decades, the North American and European dairy industries have been collecting information about lameness and leg injury prevalence on dairy farms and have tried to develop solutions to mitigate these ailments. Few published articles report the prevalence of lameness and leg lesions in areas outside of those 2 regions, or how alternative housing systems, such as compost-bedded packs, affect the prevalence of these maladies. The objectives of this study were to compare the prevalence of lameness and leg lesions on confined dairies that used freestall, compost-bedded packs, or a combination of these 2 systems in Brazil. Data were collected in the autumn and winter of 2016 from 50 dairy farms located in Paraná state, including 12 compost-bedded pack dairies (CB), 23 freestall dairies (FS), and 15 freestall dairies that used compost-bedded packs for vulnerable cows (FS+C). A visit to the farm consisted of a management questionnaire, an inspection of the housing areas as well as the milking parlor, and an evaluation of all lactating cows as they exited the parlor for lameness (score 1-5), hygiene (score 0-2), body condition score (score 1-5), and hock and knee lesions (score 0-1). Median 1-way chi-squared test was used to compare production systems. We found no difference between farm types in management practices related to hoof health management or average daily milk production per cow [31 (29-33.9) kg/d; median (quartile 1-3)], percentage of Holstein cattle in the herd [100% (90-100%)], conception rate [35.8% (30.2-38%)], or pregnancy rate [15% (13.7-18%)]. The CB farms were smaller [85 (49.5-146.5) milking cows] than both the FS [270 (178-327.5) milking cows] and FS+C farms [360 (150-541.5) milking cows). The overall prevalence of severe lameness (score 4 and 5) across all farms was 21.2% (15.2-28.5%) but was lower on the CB farms [14.2% (8.45-15.5%)] in comparison to the FS [22.2% (16.8-26.7%)] and the FS+C farms [22.2% (17.4-32.8%)]. Less than 1% of all cows scored on CB farms were observed with swollen or wounded knees (or both), which was lower than either the FS or FS+C farms [7.4% (3.6-11.9%) and 6.4% (2.6-11.8%) of all cows scored, respectively]. The same pattern was found for hock lesions, where the farm-level prevalence within the 3 different housing types was 0.5% (0-0.9%), 9.9% (0.8-15.3%), and 5.7% (2.6-10.9%) for CB, FS, and FS+C farms, respectively. No differences between farm systems were observed for hygiene or body condition score. On average, 2.7% (0.8-10.9%) of lactating cows had a soiled side, 15.4% (2.1-37.4%) had dirty legs and 1.7% (0-9.3%) had dirty udders. The average herd-level body condition score across farms was 2.9 (2.9-3), with 0.86% of the all cows scored having a body condition score <2.5. These results indicate that lameness prevalence on confined dairies in Brazil is high and highlight the need for remedial changes in environmental design and management practices. We found that CB farms in this region had reduced lameness and lesions in relation to FS or FS+C dairies.