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INTRODUCTION: The incidence of open fractures in super-old patients has increased. "Fix and flap" procedures using early internal fixation and free flap reconstruction in super-old patients are rarely reported. PRESENTATION OF CASE: A 97-year-old woman presented to our emergency department after a car accident. She was diagnosed with an open fracture of the lower leg, and the open wound could not be closed after debridement. The tibia was fixed using an intramedullary nail on the day of injury, and the open wound was closed using a free latissimus dorsi myocutaneous flap on the sixth day. The flap was engrafted at the 1-year follow-up after the injury, and the patient was able to walk using a cane. DISCUSSION: To facilitate flap elevation and shorten the operative time, a flap with fewer vascular variants should be selected, and flow-through anastomosis that does not obstruct peripheral blood flow with a high patency rate is preferable. Reconstructive free flap surgery is preferably performed within 1 week of the initial injury to prevent fibrosis or scarring of recipient vessels. CONCLUSION: The "fix and flap" procedure, composed of early internal fixation and free flap reconstruction, is possible even in super-old patients through careful considerations of flap selection, methods of anastomosis of blood vessels, and timing of surgery. However, it is necessary to determine whether the affected limb can be preserved or amputated, and prolonged treatment must be avoided.
RESUMO
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To develop a grading method for cervical paraspinal soft tissue damage after cervical spinal cord injury (CSCI) without major fracture based on the short T1 inversion recovery (STIR) mid-sagittal magnetic resonance image (MRI) for prediction of neurological improvements. METHODS: This study included 34 patients with CSCI without major fracture, treated conservatively for at least 1 year and graded using the STIR-MRI Grade. This system consists of anterior grades; A0: no high-intensity area (HIA), A1: linear HIA, and A2: fusiform HIA, and posterior grades; P0: no HIA, P1: HIA not exceeding the nuchal ligament, and P2: HIA exceeding the nuchal ligament, within 24 hours postinjury. The American Spinal Injury Association impairment scale (AIS) and the Japanese Orthopedic Association (JOA) scores were examined. RESULTS: Anterior grades were not significantly correlated with the AIS and JOA score. At both injury and final follow-up, the AIS in P2 patients was significantly more severe (P = 0.007, P = 0.015, respectively) than that in P0 patients. At the injury, the AIS in P2 patients was significantly more severe (P = 0.008) than that in P1 patients. Among P2 patients only, the JOA score at the injury (1.4 points) did not improve by the final follow-up (3.9 points). The final follow-up JOA score (3.9 points) in P2 patients was significantly lower than that (13.6 points) in P0 patients (P = 0.016). CONCLUSIONS: Grade P2 led to poor neurological outcomes. The STIR-MRI Grade is a prognostic indicator for neurological improvements past-CSCI.
