Heterotopic Ossification Is Associated with Painful Neuromas in Transtibial Amputees Undergoing Surgical Treatment of Symptomatic Neuromas

BACKGROUND

A relationship between nerve and osseous regeneration has been described. During the surgical treatment of symptomatic neuroma in transtibial amputees, we have noticed that heterotopic ossification (HO) depicted on preoperative radiographs appears to be associated with the location of symptomatic neuromas in both the peroneal and tibial nerve distributions.

METHODS

Data were collected for transtibial amputees who underwent surgical management of symptomatic neuroma and were prospectively enrolled from 2018 through 2023. Preoperative radiographs were assessed for the presence of HO located at the distal fibula and tibia. The presence of a peroneal and/or tibial neuroma was based on findings contained within the operative reports. Pain levels were measured on a numeric rating scale (0-10).

RESULTS

Sixty-five limbs of 62 amputees were include. Peroneal neuroma and presence of fibular HO (P=0.001), and tibial neuroma and presence of tibial HO (P=0.038) demonstrated an association. The odds of having a symptomatic peroneal neuroma with fibular HO present are greater than the odds of a symptomatic peroneal neuroma when fibular HO is absent (OR 9.3; 95%CI [1.9-45.6], P=0.006). Pre-operative pain scores were significantly higher for all patients with HO (P<0.001), those with fibular HO (P<0.001), and those with tibial HO (P<0.001), compared to patients without HO.

CONCLUSIONS

In patients with symptomatic neuromas, preoperative pain was worse when HO was present in the transtibial amputee's residual limb. Further research on the neuroma-HO-complex in symptomatic amputees is required.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Radiographic detection of lateral plateau involvement in medial tibial plateau fractures (AO/OTA 41-B1.2, 1.3, 3.2 and 3.3)

PURPOSE

To assess the accuracy of radiographs in detecting the lateral plateau involvement of medial tibial plateau fractures as well as describe the impact of CT on preoperative planning for this specific fracture morphology.

METHODS

Radiograph and CT imaging of patients with a Schatzker type IV tibial plateau fractures (AO/OTA 41-B1.2, B1.3 h, B2.2. B3.2, and B3.3) between January 2013 and July 2017 were reviewed by three trauma fellowship-trained orthopedic surgeons to identify fractures of the medial condyle with an intact anterolateral articular surface.

RESULTS

Lateral plateau involvement was identified in 16 (37%) radiographs and 26 (61%) CT images (p = 0.051). Radiographic detection of lateral plateau involvement demonstrated a sensitivity of 62% and specificity of 100%, and radiographs were able to predict the recommendation for surgical intervention for lateral plateau involvement with a positive predictive value (PPV) of 75% and a negative predictive value (NPV) of 60% compared to recommendations based on CT imaging. Radiographs predicted a need for a separate surgical approach with PPV of 63% and NPV of 70% when compared to recommendations based on CT images.

CONCLUSIONS

Radiographs are reliable in ruling in lateral plateau involvement of medial plateau fractures, but occult lateral articular extension may only be identified in CT imaging for some cases. Surgical planning may be impacted by CT imaging for this fracture morphology, but further study is warranted to evaluate the correlation between preoperative planning and clinical outcomes.

LEVEL OF EVIDENCE

III.

Injury and treatment patterns of ballistic pelvic fractures by anatomic location

INTRODUCTION

Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries.

METHODS

A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality.

RESULTS

Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance.

CONCLUSIONS

This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement.

LEVEL OF EVIDENCE

IV.

Treatment of Suspected Invasive Fungal Infection in War Wounds

Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. Other recommendations include: (1) early tissue sampling for wound histopathology and fungal cultures, (2) early consultation with infectious disease specialists, and (3) coordination with surgical pathology and clinical microbiology.

Pelvic Fracture Care

While combat-related pelvis fractures are more commonly open, higher energy, and complex in pattern than those seen in the civilian setting, the principles of management are similar. The primary differences are related to the austere setting in which the initial management takes place, and the lack of resources typically available. Initial management consists of cessation of hemorrhage, along with the multi-disciplinary prioritized management of associated injuries, and skeletal stabilization. This is most commonly achieved with a compressive sheet or pelvic binder, with pelvic external fixation when resources allow, and debridement of open wounds as necessary. Definitive, internal fixation is delayed until the patient arrives at a higher echelon of care.

Use of a bioartificial dermal regeneration template for skin restoration in combat casualty injuries

Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.

Regenerative medicine applications in combat casualty care

The purpose of this report is to describe regenerative medicine applications in the management of complex injuries sustained by service members injured in support of the wars in Afghanistan and Iraq. Improvements in body armor, resuscitative techniques and faster transport have translated into increased patient survivability and more complex wounds. Combat-related blast injuries have resulted in multiple extremity injuries, significant tissue loss and amputations. Due to the limited availability and morbidity associated with autologous tissue donor sites, the introduction of regenerative medicine has been critical in managing war extremity injuries with composite massive tissue loss. Through case reports and clinical images, this report reviews the application of regenerative medicine modalities employed to manage combat-related injuries. It illustrates that the novel use of hybrid reconstructions combining traditional and regenerative medicine approaches are an effective tool in managing wounds. Lessons learned can be adapted to civilian care.

Neurovascular entrapment due to combat-related heterotopic ossification in the lower extremity

BACKGROUND

Heterotopic ossification is the ectopic formation of mature lamellar bone in nonosseous tissue. The prevalence of heterotopic ossification following combat injuries is much higher than civilian data would suggest. In certain cases, the aberrant bone formation can envelop major neurovascular structures in the lower extremity, leading to symptomatic neurovascular entrapment.

METHODS

We describe five consecutive cases of heterotopic ossification leading to symptomatic neurovascular entrapment in the lower extremity as a result of blast trauma and present our method of patient assessment, preoperative planning, and surgical excision.

RESULTS

Heterotopic bone was successfully excised without neurovascular injury in all patients. At a mean of twenty months (range, eight to forty-five months) postoperatively, all patients demonstrated continued improvement of their pre-excision function. All patients who had neuropathic pain had a decrease in the pain. Those with decreased joint motion regained motion once their wounds were stable. Sensory deficits resolved before motor deficits did. There was no recurrence of clinically relevant heterotopic ossification in this series.

CONCLUSIONS

Excision of heterotopic bone, particularly with concurrent neurovascular entrapment, can be associated with major short-term and long-term complications. With use of our treatment algorithm, involving careful preoperative planning and meticulous operative excision, heterotopic bone entrapping major neurovascular structures following severe extremity trauma can be safely excised with subsequent clinical improvement.

Use of 3-dimensional stereolithographic polymer models for heterotopic ossification surgical excision

Heterotopic ossification is a known complication of traumatic injuries. To minimize iatrogenic complications during excision, an understanding of anatomic relationships is essential. Current imaging modalities, such as computed tomography and plain radiographs, are limited to providing a 2-dimensional representation of a 3-dimensional problem. This study describes the benefits of 3-dimensional stereolithography in the perioperative management of symptomatic heterotopic ossification using models were that were fabricated based on high-resolution computed tomography scans. The models facilitated heterotopic ossification excision through frequent intraoperative reference, allowing the authors to avoid iatrogenic neurovascular injuries.

Low complication rate associated with raising mature flap for tibial nonunion reconstruction

BACKGROUND

Tibia fractures may require soft tissue coverage with transposed tissue and can develop nonunions. Tibial defects can be approached with a posterolateral approach or by elevating the previously transposed tissue. No literature has previously reported the efficacy or safety of the latter approach. The purpose of this study was to report the flap survival rate and complications from delayed elevation of transposed soft tissue as part of a protocol for the treatment of tibia nonunions.

METHODS

In a retrospective review of patients having local, regional, or free soft tissue transposition for the management of open type III B high-energy tibial fractures and also requiring secondary procedures on the same tibia for treatment of tibial nonunion and/or osteomyelitis that required flap elevation, 23 patients with 24 flaps were identified and studied. The 24 flaps were elevated a total of 72 times as part of a staged protocol for nonunion reconstruction by a single surgeon. Primary end point was flap survival. Mean follow-up after definitive soft tissue coverage was 23.7 months. Mean follow-up after injury was 28.9 months.

RESULTS

One flap failed after elevation. On a per elevation surgery basis, the flap survival rate was 98.6% (71 of 72). On a per flap basis, the flap survival rate was 95.8% (23 of 24).

CONCLUSIONS

This is the first report of the survival and complication rates for delayed elevation of soft tissue flaps for tibial nonunion reconstruction. A total of 95.8% of flaps survived elevation. Flap elevation seems to be an alternative to posterolateral tibial approaches for treatment of tibial nonunions.

Diet and colorectal cancer: implications for the obese and devotees of the Atkins diet

Colorectal cancer (CRC) is the second most common cause of cancer-related death in the Western world and its prevalence is increasing. Potential causes of this increase are changes in diet and the increases in obesity seen. This paper looks at the literature surrounding diet and obesity and the links to this increase in CRC. Heralded as a weight loss miracle we investigate whether the literature suggests the Atkins diet may actually do more harm than good by acting to increase an individual's risk of CRC. Obesity has been demonstrated to be a major factor in the increase in CRC although links to changes in diet are more tenuous. Published studies on diet suggest the Atkins diet may help reduce rather than increase the risk of CRC.

Nucleolar organizer regions in the rabbit (Oryctolagus cuniculus) as shown by silver staining

Nucleolar organizer regions (NOR's) were demonstrated in metaphase chromosomes of the domestic rabbit. Oryctolagus cuniculus (L.) (New Zealand white strain) using silver staining. Sequential quinacrine banding and a modification of the Ag-AS silver precipitation technique with duplicate photography allowed identification of silver staining NOR's on the short arms of chromosomes 13, 16, and 20, as well as the telomeric region of the long arms of number 21 in some cells. Chromosomes 13, 16 and 20 all have subterminal to terminal centromeres, often showed satellites and secondary constrictions, and were sometimes involved in associations.