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Kauta N, Bott A, Majirija ET, Du Plessis JP, Vrettos B, Maqungo S, Roche S. Surgical management of distal humerus gunshot fractures: descriptive case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3711-3716. [PMID: 37322263 PMCID: PMC10651556 DOI: 10.1007/s00590-023-03611-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa. METHODS A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification. RESULTS Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months. CONCLUSIONS These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | | | | | - Basil Vrettos
- Vincent Pallotti Private Hospital, Cape Town, South Africa
| | - Sithombo Maqungo
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Stephen Roche
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Raherinantenaina F, Randriantsoa MP, Avotsihoarana TH, Harioly Nirina MOJ, Rakoto Ratsimba HN, Rajaonanahary TMA. Surgical repair of brachial artery injuries. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:142-145. [PMID: 37914459 DOI: 10.1016/j.jdmv.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 11/03/2023]
Affiliation(s)
- F Raherinantenaina
- Vascular Surgery Department, Faculty of Medicine, University of Antananarivo, CHUJRA Antananarivo, Madagascar.
| | - M P Randriantsoa
- General Surgery Department, University Hospital Center, Tulear, Madagascar
| | - T H Avotsihoarana
- Vascular Surgery Department, Faculty of Medicine, University of Antananarivo, CHUJRA Antananarivo, Madagascar
| | - M O J Harioly Nirina
- Anesthesia-Resuscitation Department, Faculty of Medicine, University of Toamasina, CHU Morafeno, Toamasina, Madagascar
| | - H N Rakoto Ratsimba
- General and Vascular Surgery Department, Faculty of Medicine, University of Antananarivo, CHUJRA Antananarivo, Madagascar
| | - T M A Rajaonanahary
- Vascular Surgery Department, Faculty of Medicine, University of Antananarivo, CHUJRA Antananarivo, Madagascar
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Lewis RH, Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg 2022; 92:21-27. [PMID: 34670960 DOI: 10.1097/ta.0000000000003430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE Prognostic study, Level IV.
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Affiliation(s)
- Richard H Lewis
- From the Department of Surgery University of Tennessee Health Science Center, Memphis, Tennessee
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Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:395-403. [PMID: 34050819 PMCID: PMC8924095 DOI: 10.1007/s00590-021-03008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage. METHODS A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO. RESULTS A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities. CONCLUSIONS Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.
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Affiliation(s)
- Sandeep Krishan Nayar
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Harry M F Alcock
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Dafydd S Edwards
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, London, UK
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Abstract
Humeral shaft fractures are relatively common, representing approximately 1% to 5% of all fractures. Conservative management is the treatment of choice for most humeral shaft fractures and offers functional results and union rates that are not inferior to surgical management. Age and oblique fractures of the proximal third are risk factors for nonunion. Surgical indication threshold should be lower in patients older than 55 years presenting with this type of fracture. Functional outcomes and union rates after plating and intramedullary nailing are comparable, but the likelihood of shoulder complications is higher with intramedullary nailing. There is no advantage to early exploration of the radial nerve even in secondary radial nerve palsy.
Cite this article: EFORT Open Rev 2021;6:24-34. DOI: 10.1302/2058-5241.6.200033
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Affiliation(s)
- Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, Canada
| | - Frédéric Vauclair
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Riccelli V, Pontell M, Gabrick K, Drolet BC. Outcomes Following Mangling Upper Extremity Trauma. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Seo JB, Heo K, Yang JH, Yoo JS. Clinical outcomes of dual 3.5-mm locking compression plate fixation for humeral shaft fractures: Comparison with single 4.5-mm locking compression plate fixation. J Orthop Surg (Hong Kong) 2020; 27:2309499019839608. [PMID: 30955460 DOI: 10.1177/2309499019839608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Recently, several in vitro biomechanical studies that used dual small locking plate fixation for humeral shaft fractures have investigated. However, in vivo studies about dual plate fixation for humeral shaft fractures are limited. The purpose of our study was to report the outcomes of dual small plating for humeral shaft fractures in comparison with those of single large fragment plating. METHODS Sixty consecutive patients who underwent an open reduction internal fixation for humeral shaft fractures at our institution from September 2014 to December 2017 were included. Single 4.5-mm locking compression plate (LCP) fixation was used in the first 40 cases, and dual 3.5-mm LCP fixation was used in the final 20 consecutive cases. Data were collected to define patient characteristics, injury mechanism, clinical outcomes, time to surgery, operative time, estimated blood loss, and complications. Using simple radiography during the follow-up period (6, 12, 24, and 52 weeks after surgery), the shoulder and elbow joint ranges of motion (ROM) were also evaluated. RESULTS Demographic data, time to surgery, surgical time, and estimated blood loss had no significant differences between the two groups. No significant differences were observed in nonunion rate and union rate 3 months after surgery. However, two patients (5%) in the single 4.5-mm LCP fixation group showed metal failure and breakage. No significant differences were found in postoperative shoulder and elbow ROM. Three patients (7.5%) in the single plating group and one patient (5%) in the dual plating group developed radial nerve palsy after surgery. No vascular injury and deep infection were observed in either group. CONCLUSION For diaphyseal humeral fractures, dual 3.5-mm LCP fixation to the humerus is a possible treatment choice. This method showed satisfactory union rate, ROM, and complication rate, without increasing surgical time, in comparison with the conventional single 4.5-mm LCP fixation. Level of evidence: III.
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Affiliation(s)
- Joong-Bae Seo
- Department of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Kang Heo
- Department of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jong-Heon Yang
- Department of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jae-Sung Yoo
- Department of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
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Yang J, Zheng C, Wang H, Hacquebord JH, Qin B, Zhou X, He B, Wang D, Li P, Liu X, Gu L, Qi J, Zhu Q. Cross limb vessel transfer for salvage of the extremity with irreparable artery injury. Injury 2019; 50 Suppl 5:S111-S116. [PMID: 31759618 DOI: 10.1016/j.injury.2019.10.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Complex injuries of the extremity can be very challenging to treat. In the setting of soft tissue infection and vascular defect, arterial reconstructions are at high risk of failure. Historically, there have not been good options to successfully salvage limbs with these serious injuries. We describe our experience of utilizing a cross limb vessel transfer to salvage the limb. METHODS Patients were identified retrospectively with complex vascular injuries of the extremity and wound infection, who were treated with a cross limb vessel transfer. Once the infection has successfully been cleared, flow-through flap transfer was performed for definitive reconstruction of the arterial injury. Data collated included patient demographics, injury and operation details, and post-operative outcomes including blood supply of the limb, wound infection and complications. RESULTS Between April 2014 and January 2017, 3 patients with an average age of 21 years (range, 16-29) were admitted. The median length of hospital stay was 62 days (range, 26-122). The average number of operation was 7.3 times (range, 6-10). Two patients' upper limb had survived with limited movement, relatively minor donor site morbidity and confirmed flow through the vessel reconstruction using CTA, while one patient had lower limb amputation due to severe infection and prolonged ischemia time. CONCLUSIONS This series of patients demonstrates that cross limb vessel transfer is an invaluable technique to salvage the limb in patients with complex vascular injury and wound infection. However, for lower limb with prolonged ischemia time and severe infection, limb salvage is not recommended.
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Affiliation(s)
- Jiantao Yang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Canbin Zheng
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Honggang Wang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | | | - Bengang Qin
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Xiang Zhou
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Bo He
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Dong Wang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Ping Li
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Xiaolin Liu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Liqiang Gu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China
| | - Jian Qi
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China.
| | - Qingtang Zhu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, China.
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Mitchell SL, Hayda R, Chen AT, Carlini AR, Ficke JR, MacKenzie EJ. The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma. J Bone Joint Surg Am 2019; 101:1470-1478. [PMID: 31436655 PMCID: PMC7406140 DOI: 10.2106/jbjs.18.00970] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stuart L. Mitchell
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Roman Hayda
- Department of Orthopaedic Surgery, Brown University Warren Alpert School of Medicine, Providence, Rhode Island
| | - Andrew T. Chen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anthony R. Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James R. Ficke
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen J. MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Kish AJ, Pensy RA. The Mangled Extremity: An Update. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Updegrove GF, Mourad W, Abboud JA. Humeral shaft fractures. J Shoulder Elbow Surg 2018; 27:e87-e97. [PMID: 29292035 DOI: 10.1016/j.jse.2017.10.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/09/2017] [Accepted: 10/18/2017] [Indexed: 02/01/2023]
Abstract
Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard nonoperative management as the standard of care; however, as the understanding of these injuries increases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoulder arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.
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Affiliation(s)
| | - Wassim Mourad
- Division of Orthopedic Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Govaert GAM, Glaudemans AWJM, Ploegmakers JJW, Viddeleer AR, Wendt KW, Reininga IHF. Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol. Eur J Trauma Emerg Surg 2017; 44:417-426. [PMID: 28331952 PMCID: PMC6002444 DOI: 10.1007/s00068-017-0783-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/10/2017] [Indexed: 12/17/2022]
Abstract
Introduction Posttraumatic osteomyelitis (PTO) is a feared complication after surgical fracture care. Late diagnosis can result in interrupted and prolonged rehabilitation programmes, inability to work, medical dependency, unnecessary hospital admissions, and high medical and non-medical costs. Primary aim of this study was to assess preferred diagnostic imaging strategies for diagnosing PTO amongst orthopaedic and trauma surgeons, radiologists, and nuclear medicine physicians. Secondary aims were to determine the preferred serum inflammatory marker for diagnosing PTO and the existence of a local hospital protocol to diagnose and manage PTO. Materials and methods This study utilised an online survey based on four clinical scenarios, varying from early to late onset of PTO. It was designed to assess individual practitioners’ current preferred diagnostic strategy for diagnosing PTO. Eligible study participants were medical specialists and registrars in orthopaedic and trauma surgery, musculoskeletal (MSK) radiology, and nuclear medicine. Results There were 346 responders: 155 trauma surgeons, 102 orthopaedic surgeons, 57 nuclear medicine physicians, and 33 MSK radiologists. Trauma surgeons favour FDG-PET to image PTO, while orthopaedic surgeons prefer WBC scintigraphy. A similar difference was seen between radiologists and nuclear medicine physicians (MRI versus nuclear medicine imaging). CRP was regarded as the most useful serum inflammatory marker. Only one-third of all responders was aware of a local hospital protocol for the treatment of osteomyelitis. Conclusions The availability of and awareness towards local protocols to diagnose and treat PTO is poor. The results of this study support the need for future randomised controlled trials on optimal diagnostic strategies for PTO.
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Affiliation(s)
- G A M Govaert
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands. .,Department of Trauma Surgery, University Medical Center Utrecht, Internal mail no G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - A W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - J J W Ploegmakers
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - A R Viddeleer
- Department of Radiology, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - K W Wendt
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - I H F Reininga
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
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Zheng DW, Li ZC, Shi RJ, Sun F, Xu L, Shou KS. Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury. Injury 2016; 47:364-71. [PMID: 26772451 DOI: 10.1016/j.injury.2015.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVES Salvage repair after complex upper limb traumatic injury is surgically challenging due to underlying major arterial impairment with complicating a large-sized soft tissue defect. The purpose of this study was to evaluate the effectiveness and safety of using a giant-sized (≥100 cm(2)) flow-through venous flap for reconstruction of dual or multiple forearm, metacarpal, or digital arteries after complex upper limb traumatic injury. METHODS Seven patients were consecutively hospitalized for emergency salvage repair after complex upper limb traumatic injury between March 2012 and May 2014. The forearm and palmar artery defects were repaired using the calf great saphenous vein flap and the volar forearm venous flap, respectively. RESULTS The flow-through venous flap ranged from 9.5 cm × 12.0 cm to 12.0 cm × 20.0 cm (mean, 158.4 cm(2)) in size. The flaps and affected limbs survived uneventfully in five patients, with one patient experiencing distal flap marginal necrosis and a second patient requiring amputation of the affected limb. Computed tomography angiography showed patent vessels in all patients. The mean total active motion of the repaired fingers was 199.5° versus 258.8° for the contralateral counterpart (77.1%). The sensory return was determined to be S2 in 2 patients, S3 in 3 patients and S3+ in 1 patient. The disability scores for the arm, shoulder, and hand ranged from 4.6-18.2 (mean, 11.3), and the mean Michigan hand outcomes questionnaire score was 7.8 ± 0.9. CONCLUSIONS The flow-through venous flap is an effective and safe treatment alternative for salvage therapy of a ≥100-cm(2) complex upper limb traumatic injury with dual or multiple major arterial impairment. This technique allows simultaneous reconstruction of dual or multiple artery injuries and an extensive soft tissue defect. Serious surgical site infection remains a major safety concern and necessitates radical debridement in complicating cases.
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Affiliation(s)
- Da-Wei Zheng
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China.
| | - Zhang-Can Li
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Rong-Jian Shi
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Feng Sun
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Li Xu
- Department of Hand Surgery, Xuzhou Renci Hospital, Xuzhou 221004, Jiangsu Province, P. R. China
| | - Kui-Shui Shou
- Department of Hand Surgery, Wuxi Hand Surgery Hospital, Wuxi 214062, Jiangsu Province, P. R. China
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