Life does not end after a major lower extremity amputation. With advances in surgical technique and in sophistication and capabilities of prosthetics, patients should be reasonably expected to return to most of their pre-amputation physical capabilities. This article highlights management and operative principles that will optimize patients' physical function and quality of life following a major lower extremity amputation.
Heterotopic ossification is a pathological condition characterized by the formation of mature, lamellar bone in the soft tissues. There are a number of causes of heterotopic ossification, including trauma and neurogenic injury. Surgical resection is a known effective form of treatment in patients experiencing decreased motion. Concurrently, it has been described in the literature that a multidisciplinary approach to orthopedic surgical procedures has been shown to allow for better patient safety and outcomes. In this manuscript we highlight a case that displays these principles.
This case involves a 49-year-old man who developed severe extensive heterotopic ossification of his left hip and thigh after a motor vehicle collision. For the treatment of this patient, a multidisciplinary team of orthopedic, plastic, and vascular surgeons, and radiation oncology was utilized to proceed with the surgical resection of the heterotopic ossification. The use of this multidisciplinary team allowed for adequate patient treatment and restoration of normal range of motion. This case report aims to highlight the effectiveness of both surgical resection of heterotopic ossification as well as the multidisciplinary team approach.
The anterior pelvic external fixator is widely used in the emergency management of unstable pelvic fractures. Management of pelvic ring injuries is difficult in limited resource settings where the diagnostic and therapeutic means required for intervention are not readily available. We aimed to identify the therapeutic challenges and to evaluate the outcome of unstable pelvic fractures managed definitively by external fixation in an environment with limited human, technical, and financial resources.
A hospital-based prospective observational and cross-sectional study carried out from the 1st of January 2016 to the 31st of December 2021 at the Limbe Regional Hospital, a regional referral hospital that serves as a teaching hospital for the Faculty of Health Sciences of the University of Buea.
A total of 45 patients were included in the study. The indications of maintaining the pelvic external fixators as definitive treatment were financial constraints and inadequate technical resources needed for surgery in almost half of the cases. The overall average functional outcome in this study was fair. Good to excellent scores were recorded in only one-quarter of the cases.
Definitive pelvic external fixation of unstable pelvic fractures in resource-limited settings needs thorough improvements to meet the standards as the outcome was fair in half of the cases, and good to excellent in only 25% of the cases. Locally available human, technical and financial resources should be considered in the decision to perform definitive pelvic external fixation as an alternative to internal fixation of unstable pelvic fractures.
A walking cross-leg flap is a cross-leg flap that reaches its destination not in one but in several steps. It may be the last option before leg amputation. Knowledge on the perfusion of these flaps may optimize its use, reduce the risk for complications and improve our knowledge on flap survival. Dynamic infrared thermography (DIRT) was used to evaluate the perfusion during the critical steps of flap transfer of a walking cross-leg flap. DIRT showed that a perforator at the recipient site had connected to the fasciocutaneous perforator vasculature of the walking cross-leg flap. Flap perfusion during transfer of the walking cross-leg flap to its destination was based on this perforator and led to a reversed blood flow direction within the walking cross-leg flap through this perforator. DIRT also helped to define the time of pedicle division as it showed the location and the hemodynamics of the newly formed perforator.
A complex traumatic hand injury may pose a challenge for the reconstructive surgeon. Perforator flaps provide the surgeon with an option in managing such injuries. Securing perfusion of the perforator flap is essential, as partial, or total flap loss yield poor functional and cosmetic outcome, often requiring reoperation. We report a case of a 28-year-old male suffering a mutilating hand injury after a car accident. Reconstruction was performed with a free microvascular lateral arm flap, and perfusion of the flap was monitored pre-, intra-, and postoperatively with dynamic infrared thermography (DIRT).The purpose of this report is to highlight the usefulness of DIRT as a novel perfusion imaging modality in the management of complex traumatic hand injury.
The study aimed to compare the short and long-term functional outcomes of the displaced 5th metacarpal neck fractures treated by conservative and intramedullary Kirschner wire fixation.
A retrospective cohort study was conducted between 2016 and 2018, analyzing 41 patients with displaced 5th metacarpal neck fractures. The patients were divided into surgical (intramedullary Kirschner wire fixation) and conservative groups (no fracture reduction, plaster of paris immobilization, and followed with a functional brace). The functional outcome was assessed and compared at six weeks and 12 months of follow-up.
There were 22 patients in the surgical group and 19 in the conservative group. All fractures united in both groups. The age, gender, flexion, extension at the MCP joint, grip strength, VAS, time to union, and return to work were comparable between the two groups. There was no significant difference in the outcome at six weeks and 12 months between surgical and conservative groups. The surgical group's quick DASH score was significantly better (p < 0.05). The radiological outcomes (palmar angulation, shortening) improved in the surgical group but persisted in the conservative groups in the follow-up.
The displaced 5th metacarpal neck fractures managed by intramedullary or conservative with a functional brace produce similar functional results. The patient's satisfaction, aesthetics, and functionality are superior in the surgical group.
IV.
To investigate the incidence, risk factors, demographics, and association in the analysis of acute compartment syndrome of the forearm.
A retrospective review of the Trauma Quality Programs data from the American College of Surgeons. This includes 120,556 patients who sustained a forearm fracture from 2015 to 2018 (4 calendar years). The main outcome measurements are fasciotomies performed after sustaining a forearm fracture, thus suggesting acute compartment syndrome.
Fasciotomies were performed in 1.6% of all forearm fractures. Open fractures were 5 times more likely to lead to fasciotomies. Being a male was associated with an increased likelihood of fasciotomies of 64%. Complex fractures (OTA type C) exhibited 74% stronger likelihood of fasciotomies compared to simple fractures. Patients with a history of substance abuse disorder (SAD) were 45% more likely to undergo a fasciotomy compared to patient with no SAD. Multiple other factors were addressed while controlling for cofounders.
This big data analysis provided a holistic perspective on the risk factors, demographics, and clinical association of ACS in the forearm. There is a clear need for a gold standard diagnosis for ACS to provide better care for the patients: whether it is continuous pressure monitoring, validated biomarkers, or other biomarkers.
III, retrospective database cohort study.
Deficiency of the knee extensor mechanism may result from severe injury, loss of structural tissues after tumor resection or complications due to joint replacement surgery. Current treatment options for extensive defects are limited, yielding unsatisfactory functional results and high complication rates. Here, we propose for the first time the use of a free vascularized tissue transfer to reconstruct the extensor mechanism of the knee. The tensor fasciae latae free flap provides sufficient vascularized muscle and fascia as well as a large skin paddle. We present the anatomical concept and long-term outcomes in a patient.
Gender and racial disparities remain prevalent in academic surgery. Moreover, reports on racial distributions are scarce. We aim to assess the state of diversity among faculty and fellowship trainees in academic hand surgery and identify if program faculty diversity correlates with trainee diversity.
Working from the American Society for Surgery of the Hand (ASSH) fellowship list, a database of 84 hand fellowship programs, 622 faculty, and 582 recently graduated fellows was created. ASSH and American Association for Hand Surgery (AAHS) membership databases and clinical and research websites were accessed to determine gender, race (white or person of color [POC]), and practice and training details, for each faculty and fellow.
Women comprise 17% of the faculty cohort and 25% of fellows. Gender disparity was similar between orthopedic surgery-trained and plastic surgery-trained faculty and fellows. Women represented 24% assistant, 16% associate, and 9% full professor faculty positions (p = 0.002). White race was assigned to 75% and 71% of faculty and fellows, respectively. POC accounted for 28%, 27%, and 21% of assistant, associate, and professor positions, respectively (p > 0.05). Female and POC leadership correlated with significantly more female and POC faculty/fellows, respectively.
Relative to medical school and academic medicine, females and racial minorities are under-represented in academic hand surgery, especially with higher academic rank and in leadership positions. Diversity in leadership and related allyship may be an important strategy for increasing diversity at all levels.
The decision between limb salvage or amputation in patients with severely injured lower extremities has major consequence to patients. There is a paucity of data on socioeconomic and institutional factors that affect this decision. We aim to evaluate the association of institutional and payment factors on management of Gustilo III lower extremity trauma.
Patients with Gustilo III lower extremity injuries were identified from the National Trauma Data Bank (NTDB) from 2016 through 2017. Amputation and limb salvage outcomes were analyzed in relation to patient demographics, comorbidities, payment type, and hospital characteristics. Independent T-tests, Chi squared tests, and multivariate logistic regression was performed with statistical significance set at p < 0.05.
A total of 587 patients were identified, of which 81.4% were men and 18.6% were women. Sex, race, BMI, and injury severity score were not statistically different. Compared with amputation, limb salvage patients were younger (39.2 years versus 44.9 years, p = 0.001), had government-assisted health insurance (34.0% versus 14.5%, p = <.001), and were evaluated at an academic medical center (68.7% versus 53.8%, p = 0.003) or level I trauma center (73.3% vs. 64.3%, p = 0.049). Limb salvage was 1.73 times more likely at teaching hospitals versus nonteaching hospitals and 4.47 times more likely with public government-assisted insurance versus private insurance.
This study presents data on lower extremity care following Gustilo III injuries from the NTDB. Patients are more likely to undergo limb salvage if they are evaluated at an academic center or have government-assisted health insurance.
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