Gym and Fitness Injuries amongst those Aged 16-64 in New Zealand: Analysis of Ten Years of Accident Compensation Corporation Injury Claim Data

BACKGROUND

To provide epidemiological data for minor and moderate-to-serious injury claims for gym and fitness related injuries amongst those aged 16-64 in New Zealand, to inform the development of an injury prevention program.

METHODS

Retrospective analytical review of gym and fitness related injury entitlement minor and moderate- to-serious Accident Compensation Corporation (ACC) claims from 1 July 2011 to 30 June 2020. Data were analysed by cause of injury, geographical region, sex, age, body site and injury type. Qualitative analysis of free text describing the activity causing the injury was conducted.

RESULTS

Over the ten-year period, 16-64 year olds made 345,254 injury claims, costing ACC NZ$241,298,275 in treatment charges. Soft tissue injuries were the most prevalent making up 96% (331,343) of all claims and 88% (NZ$213,049,197) of the total charges. Strenuous movement with lifting (n = 154,467, 47%), strenuous movement without lifting (n = 84,469, 25%), impact/contact with object (n = 39,610, 12%) and impact/contact with ground (n = 25,351, 8%) were the top four mechanisms resulting in injury, accounting for 92% of soft tissue injuries. Males and females aged 21 to 30 years old were most frequently injured. The four most injured body sites (lower back/spine, shoulder, knee, neck/back of head) accounted for 63% of injuries in females, and 65% in males.

CONCLUSIONS

The most common cause of injury from gym and fitness activity claims in 16-64 year olds in New Zealand was lifting/carrying/strain resulting in lower back/spine and shoulder (including clavicle/blade) soft tissue injuries. Soft tissue injuries accounted for 96% of the total claims. Males and females aged 21 to 30 years old were most frequently injured age group.

Delayed reconstruction of the combat-related mandibular defects with non-vascularized iliac crest grafts: Defining the optimal conditions for a positive outcome in the retrospective study

BACKGROUND

Reconstruction of mandibular defects caused by combat injuries is challenging for clinicians due to soft tissue defects and high complication risk. This study evaluated the outcomes of mandibular continuous defects reconstruction with non-vascularized iliac crest graft (NVICG) in patients with combat injuries.

MATERIAL AND METHODS

Patients with continuous mandibular defects acquired by high-velocity agents, who received NVICG reconstruction with or without microvascular-free soft tissue or regional flaps, were included in the study. The outcome variable was graft loss due to postoperative complications or full (more than 90 %) resorption. The primary predictor variable was soft tissue defect in the recipient area. The secondary predictor variable was the length of the defect. Variables related to patients, defect site, surgery, and other complications were also evaluated. Statistical analysis was performed with the usage of independent sample t-test, Pearson's chi-squared and Fisher's exact tests with a significance level of P < 0.05 RESULTS: The study included 24 patients with 27 mandibular defects. Overall, the general success rate of reconstructions was 59.3 %. Soft tissue defects were significantly associated with graft failure and other complications (p < 0.05), which were mostly related to soft tissue defects. The graft success rate was only 14.3 % even in minor soft tissue defects. In turn, in reconstructions with sufficient soft tissue coverage, the graft survived in 75.0 % of the cases. In addition, patients with more delayed reconstruction had significantly fewer graft failures than those with earlier surgery (p < 0.05). No associations were found between defect size and complications.

CONCLUSION

The sufficient soft tissue coverage is essential in the reconstruction of mandibular defects caused by combat injuries. Also, minor soft tissue defects should be covered with soft tissue flaps to avoid complications and graft loss in these specific injuries. Even large defects can be reconstructed with NIVICG if the soft tissue coverage is sufficient.

Tibiotalocalcaneal nail and primary closure for the management of open ankle fractures in the elderly patient; results from a major trauma centre

INTRODUCTION

Open ankle fractures in elderly patients are challenging injuries to manage. The aim of this study was to assess the outcome of elderly patients with open ankle fractures treated with a tibiotalocalcaneal nail and primary wound closure.

METHODS

We identified all open ankle fractures in patients over 65 referred to our major trauma centre managed with a tibiotalocalcaneal nail and primary wound closure over 10 years. We recorded patient demographics, comorbidities, injury mechanism, length of stay, operation, weightbearing status, re-operations, infections and mortality.

RESULTS

We included 34 patients with an average age of 87 (73-99). We found 56 % of patients' mobility status declined post-operatively and 21 % of patients were discharged directly home. Four patients required further unplanned surgery including two deep infections requiring amputation. We had a 6 % three month mortality rate.

CONCLUSION

Use of a tibiotalocalcaneal nail with primary wound closure offers a reasonable treatment option for open fractures of the ankle in the elderly patient.

Pediatric Facial Soft Tissue Repair and Reconstruction

There are unique considerations for the management, repair, and reconstruction of pediatric facial soft tissue injuries. Conventional methods for the repair and reconstruction of facial soft tissue injuries can be successfully applied in children with considerations for anatomic and physiologic differences and the growth potential of a child. Attention to correct form, framework, and esthetics guides the proper reconstruction of individual regions on the face. Choice of approach ultimately depends on and the size, severity, location of injury, and surgeon's preferences.

Management of Injuries in Agility Dogs

Agility is a physically demanding sport, and injuries are common. An understanding of the common clinical presentations, frequent injuries, and risk factors for injury is critical when seeing this population of patients in practice. Shoulder injuries and other soft tissue injuries including iliopsoas muscle strains are commonly seen. The Border Collie seems to be at higher risk of developing agility-related injuries. The key to rehabilitation of the agility dog is accurate and expedient diagnosis of the injury, which often involves advanced diagnostics such as musculoskeletal ultrasound, arthroscopy, and/or MRI.

The Effect of Anterior-Only, Posterior-Only, and Combined Anterior Posterior Fixation for Cervical Spine Injury with Soft Tissue Injury: A Finite Element Analysis

OBJECTIVE

This finite element analysis aimed to investigate the effects of surgical procedures for cervical spine injury.

METHODS

A three-dimensional finite element model of the cervical spine (C2-C7) was created from computed tomography. This model contained vertebrae, intervertebral discs, anterior longitudinal ligament, and posterior ligament complex. To create the cervical spine injury model, posterior ligament complex and anterior longitudinal ligament at C3-C4 were resected and the center of the intervertebral disc was resected. We created posterior-only fixation (PF), anterior-only fixation (AF), and combined anterior-posterior fixation (APF) models. A pure moment with a compressive follower load was applied, and range of motion, annular/nucleus stress, instrument stress, and facet forces were analyzed.

RESULTS

In all motion except for flexion, range of motion of PF, AF, and APF models decreased by 80%-95%, 85%-93%, and 97%-99% compared with the intact model. C3-C4 annulus stress of PF, AF, and APF models decreased by 28%-72%, 96%-100%, and 99%-100% compared with the intact model. Facet contact forces of PF, AF, and APF models decreased by 77%-79%, 97%-99%, and 77%-86% at C3-C4 compared with the intact model. Screw stress in the PF model was higher than in the APF model, and plate stress in the AF model was lower than in the APF model, but bone graft stress in the AF model was higher than in the APF model.

CONCLUSIONS

Cervical stabilization was preserved by the APF model. Regarding range of motion, the PF model had an advantage compared with the AF model except for flexion. An understanding of biomechanics provides useful information for the clinician.

[Acute compartment syndrome of the extremities]

Acute compartment syndrome of the extremities is a surgical emergency and a rapid diagnosis and immediate surgical treatment are essential for the outcome. The cause is an increase in the tissue pressure inside a muscle compartment enclosed by fasciae and the resulting disruption of microperfusion. This can have potentially disastrous consequences, such as loss of the extremity due to extensive tissue necrosis or a threat to life due to infectious complications. Although mostly triggered by trauma, a multitude of other causes can lead to the formation of a compartment syndrome, so that a basic knowledge of this condition is of great importance not only for trauma surgeons. This is particularly true because a timely treatment necessitates rapid diagnosis and evaluation of the indications. This article provides an overview of the underlying pathophysiology, the causes, the symptoms and the treatment of acute compartment syndrome.

Pathophysiology in patients with polytrauma

The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.

Complex facial degloving injury: a case report of a complication and its management

Facial degloving injuries are due to separation between the skin and subcutaneous tissues from the underlying muscles, bones, and fascia. These injuries often create a reconstructive challenge for surgeons especially when there are associated complications like wound infection or necrosis of the avulsed flap. This case report presents management of a case of facial degloving injury with full thickness necrosis of the avulsed flap. The authors concluded that treatment of such complex wounds requires a multi-disciplinary approach along with proper planning and staging of the surgical procedures for optimum aesthetic and functional outcomes.

The local soft tissue status and the prediction of local complications following fractures of the ankle region

INTRODUCTION

Well-known risk factors (RF) for soft tissue complications following surgical treatment of fracture of the ankle region include diabetes, smoking, and the local soft tissue status. A weighted analysis might provide a risk profile that guides the surgical treatment strategy. The aim of this meta-analysis was to provide a risk profile for soft tissue complications following closed fractures of the ankle region.

METHODS

This review provides a meta-analysis of studies that investigate potential risk factors for complications in fractures of the ankle region.

INCLUSION CRITERIA

Original articles that were published between 2000 and 2020 in English or German language that calculated odds ratios (OR) of RF for soft tissue complications. Further, this study only includes articles that investigated fractures of the ankle region including pilon fracture, calcaneal fractures, and fractures of the malleoli. This study excluded articles that provide exploratory analyses, narrative reviews, and case reports. RF were stratified as patient specific systemic RF (PSS), patient specific local RF (PSL), and non-patient specific RF (NPS). PSS RF includes comorbidities, American society of anaesthesiology (ASA), requirement of medication, additional injuries, and smoking or substance abuse. PSL RF includes soft tissue status, wounds, and associated complications. NPS RF includes duration of surgery, staged procedure, or time to definitive surgery. Random effect (RE) models were utilized to summarize the effect measure (OR) for each group or specific RF.

RESULTS

Out of 1352 unique articles, 34 were included for quantitative analyses. Out of 370 complications, the most commonly assessed RF were comorbidities (34.6%). Local soft tissue status accounted for 7.5% of all complications. The overall rate for complication was 10.9% (standard deviation, SD 8.7%). PSS RF had an OR of 1.04 (95%CI 1.01 to 1.06, p = 0.006), PSL an OR of 1.79 (95% 1.28 to 2.49, p = 0.0006), and NPS RF an OR of 1.01 (95%CI 0.97 to 1.05, p = 0.595). Additional injuries did not predict complications (OR 1.23, 95%CI 0.44 to 3.45, p = 0.516). The most predictive RF were open fracture (OR 3.47, 95%CI 1.64 to 7.34, p < 0.001), followed by local tissue damage (OR 3.05, 95%CI 1.23 to 40.92, p = 0.04), and diabetes (OR 2.3, 95%CI 1.1 to 4.79, p = 0.26).

CONCLUSION

Among all RFs for regional soft tissue complications, the most predictive is the local soft tissue status, while additional injuries or NPS RF were less predictive. The soft tissue damage can be quantified and outweighs the cofactors described in previous publications. The soft tissue status appears to have a more important role in the decision making of the treatment strategy when compared with comorbidities such as diabetes.

Soft Tissue Injury in Cervical Spine Is a Risk Factor for Intersegmental Instability: A Finite Element Analysis

OBJECTIVE

Soft tissue cervical spine injury (CSI) has the possibility of causing cervical segmental instability, which can lead to spinal cord injury. There is a lack of certainty in assessing whether soft tissue CSI is unstable or not. This biomechanical study aimed to investigate the risk factors of soft tissue CSI.

METHODS

A 3-dimensional finite element model of the ligamentous cervical spine (C2-C7) was created from medical images. Three soft tissue injury models were simulated at C4-C5: 1) posterior ligament complex (PLC) injury, 2) intervertebral disk (ID) with anterior longitudinal ligament injury (IDI), and 3) anterior longitudinal ligament, PLC, and ID injury (API) model. Pure moment with compressive follower load was applied, and the range of motion, annular stress, nucleus stress, and facet forces were analyzed.

RESULTS

For the IDI and API models, the range of motion increased at the injury level in extension (by 101%) and left/right axial rotations (>30%) compared with the intact model. The IDI and API models showed an increase of >50% in annular and nucleus stresses at the injury level in extension and left/right rotations compared with the intact model. The PLC injury showed similar stresses as the intact model except for flexion. The facet contact forces of IDI and API models increased more than 100% compared with other models in all motions.

CONCLUSIONS

In CSI, all soft tissues have a key role in stabilizing cervical spine, but ID is the most important component of all.

A Technique of Immobilization of Digits by Spinal or Intracath Needle Following Soft Tissue Surgery

After release of post burn flexion contracture and repair of soft tissue injury of digits, it is desirable to maintain the digits in full extension. This is conventionally done by insertion of Kirschner wires across the interphalangeal or metacarpophalangeal joints. We have been inserting a spinal or intracath needle in a dorsal supra-periosteal plane for immobilizing digits after release of post burn contractures or repair of soft tissue injury. The needle is maintained for 2-3 weeks, and all patients achieved stable immobilization of digits. There were no major complications. This procedure is minimally invasive, simple to perform, and provides stable immobilization. Level of Evidence: Level V (Therapeutic).

Dual split and dislocation----a variant of Schatzker type-I tibial plateau fracture: A case report

Schatzkter type-I tibial plateau fracture is a split fracture of the lateral tibial plateau in sagittal plane, consequent to valgus impaction caused by low velocity of trauma. However, a deep understanding of the different columns of the tibial plateau and patho-mechanisms of the injury led to the unmasking of atypical fractures around the tibial plateau. We have encountered 2 cases with unusual fracture pattern of the lateral tibial condyle caused by road traffic accidents. The fracture pattern and severity of injury deviate from the original description of Schatzker type 1; in view of dual plane split, there is rotation of the posterolateral column fragment along its sagittal plane plus grade-III medial collateral ligament injury. The patients were initially treated with knee spanning external fixator and after a latency of 5 days, definitive fracture specific fixation was done, combined with repair of grade-III medial collateral ligament injury. At the 6 months follow-up both the patients achieved satisfactory knee functions (knee society score case 1: 100 and case 2: 92) and returned to their jobs. The severity of fracture pattern and displacement as described should prompt for examination of associated ligament injury. Because of timely diagnosis, early and appropriate care promised an excellent function outcome even in such a severe nature of knee injury. To prompt the description of injury pattern we coined the name "dual split and dislocation" of lateral tibial plateau, as a complex injury variant of split fracture of lateral tibial plateau fracture.

[A systematic approach to plastic surgical foot reconstruction]

BACKGROUND

Soft tissue defects of the foot are very common sequelae after trauma and require an individual reconstructive approach.

OBJECTIVE

Recommendations for the treatment of soft tissue injuries to the foot are given.

MATERIAL AND METHODS

The criteria of soft tissue reconstruction, postoperative follow-up and complications are first discussed before the therapeutic approach is explained depending on the reconstruction site. Case examples are given for illustration.

RESULTS

Decision making for soft tissue reconstruction of the foot is based on the location, the 3‑dimensional extent of the defect, the patient requirements and concomitant diseases. Standardized treatment algorithms are usually applied that need to be adapted according to individual patient factors. Randomized and local pedicled flaps can be applied for foot reconstruction; however, these options involve a significant risk of complications. Consequently, free flaps are frequently indicated after appropriate preoperative diagnostics of the perfusion of the foot. Due to the vast variety of donor sites, free flaps allow an individualized reconstruction, which is adapted to local and patient requirements.

CONCLUSION

Precise preoperative reconstructive planning and analysis of the vascularization form the foundation for a successful soft tissue reconstruction of the foot. The aims of the individualized approach to soft tissue reconstruction of the foot are stable soft tissue coverage, resistance to weight bearing of the sole of the foot, the ability to wear normal shoes and maintenance of sensibility.

Long-term prognoses of patients with and without re-rupture after arthroscopic rotator cuff repair

[Purpose] We followed-up patients who underwent arthroscopic rotator cuff repair (ARCR) for 2 years to assess the prognosis of rotator cuff tears and compared the outcomes of the patients with and without re-rupture. We also examined the usefulness of Shoulder36, a self-assessment tool, for assessing the long-term prognosis in patients undergoing ARCR. [Participants and Methods] We included 28 patients who received occupational therapy pre- and post-ARCR between April 2012 and August 2015 and categorized them based on the occurrence of re-rupture. We followed-up on their prognoses for 2 years using physical examination and Shoulder36 assessment. [Results] Re-rupture occurred in five patients within 3 months of treatment. During the 2 year follow-up, the control group showed a significant improvement in pain and bi-directional active range of motion during physical assessment and in five out of six domains during Shoulder36 assessment. In contrast, the re-rupture group showed significant differences for only three domains of the Shoulder36 assessment twelve months after surgery. [Conclusion] We confirmed the long-term functional improvement and maintenance in the re-rupture group, suggesting that continued rehabilitation, compensatory movements, and detailed guidance on daily life activities are required for patients after ARCR. Furthermore, Shoulder36 can be useful for assessing the prognosis of patients with and without re-rupture.

Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?

Cold therapy has been used regularly as an immediate treatment to induce analgesia following acute soft-tissue injuries, however, a prolonged ice application has proved to delay the start of the healing and lengthen the recovery process. Hyperbaric gaseous cryotherapy, also known as neurocryostimulation, has shown the ability to overcome most of the limitations of traditional cold therapy, and meanwhile promotes the analgesic and anti-inflammatory effects well, but the current existing studies have shown conflicting results on its effects. Traditional cold therapy still has beneficial effect especially when injuries are severe and swelling is the limiting factor for recovery after soft-tissue injuries, and therefore no need to be entirely put out to pasture in the rehabilitation practice. Strong randomized controlled trials with good methodological quality are still needed in the future to evaluate the effects of different cryotherapy modalities.

Soft Tissue Trauma: Management of Lip Injury

Repair of soft tissue trauma to the lips requires careful attention to both function and esthetics. This article outlines basic lip anatomy, goals in managing lip injury, and appropriate workup and ultimate treatment of various types of trauma to the lips.

Soft tissue injury in the limbs increased regional bone turnover

BACKGROUND

Pathological conditions after skeletal tissue injury such as trauma and surgical intervention are often accompanied with regional osteoporotic changes, which are recognized to be mainly caused by limb immobility after injury. However, the mechanisms for the progression of regional osteoporotic changes related to the injury remains unknown. Previous studies reported that the pathophysiological conditions related to tissue injury include the acidic micro-environment formation and increased ATP levels. In addition, we previously demonstrated that those changes in the micro-environment induced a high bone turnover state through the activation of TRPV1, ASICs and P2X expressed in bone cells. We, therefore, hypothesized that tissue injury could enhance a high bone turnover state due to those pathophysiological changes in soft tissue in the injured limb. The aim of this study was to examine whether soft tissue injury associated with cutaneous incisions in a limb affects regional bone turnover.

METHODS

Eight-week-old male C57BL/6 J mice underwent soft tissue injury associated with cutaneous incisions in the right femoral skin. During the 14 days after the incision, changes in the expression of osteoblast and osteoclast differentiation regulators and ATP were evaluated in comparison with those in uninjured mice. The pain-like behaviors and the expression of those differentiation regulators with and without treatment with bisphosphonate and Cox2 inhibitor were assessed in the injured limb.

RESULTS

Consistent with the wound healing process, the expression levels of Osterix, osteocalcin and RANKL in the femur of the incised limb were significantly increased up to 7 days, and then decreased to the same level as those in the control limbs by 14 days after the incisions. The levels of TRAP 5b and ATP were initially significantly increased, and then decreased to the same level as before injury by day 14. Bisphosphonate significantly improved the pain-like behaviors in the injured limb associated with the inhibition of osteoblast and osteoclast differentiation regulators.

CONCLUSION

We believe that the pathophysiological changes in soft tissue resulting from cutaneous incisions could be related to the induction of osteoblast and osteoclast differentiation regulators.

Minimizing treatment complexity of combat-related soft tissue injuries using a dedicated tension relief system and negative pressure therapy augmented by high-dose in situ antibiotic therapy and oxygen delivery: a retrospective study

BACKGROUND

Following combat-related, extensive soft tissue injury from gunshot wounds or blasts, prolonged duration from injury to full wound closure is associated with infection, increased morbidity and mortality, failure to mobilize, poor functional outcome and increased cost. The purpose of this study was to evaluate a novel treatment enabling early primary closure of combat wounds.

METHODS

This was a retrospective study of 10 soldiers and civilians with extensive combat-related soft tissue limb injuries (5 gunshot wounds, 5 blasts) treated using the TopClosure^® Tension Relief System (TRS) with simultaneous administration of regulated oxygen-enriched and irrigation negative pressure-assisted wound therapy (ROINPT) via the Vcare α^® device.

RESULTS

Nine patients were treated during the acute phase of injury and one was treated following removal of a flap due to deep infection 20 years after injury and flap reconstruction. Two patients had upper limb injury and the rest lower limb injury. With the aid of the TRS and/or ROINPT, immediate primary closure during reconstruction was achieved in 6 patients and delayed primary closure in three. Only one patient required a skin graft to close a small area of the wound after most of the wound had been closed by delayed primary closure. Wound closure was achieved within 0-37 days (median: 12.5 days, interquartile range: 2.75-19.75) from injury.

CONCLUSIONS

The TRS is a novel device for effective, early skin stretching and secure wound closure through the application of stress relaxation and mechanical creep, achieving primary closure of large defects using a simplified surgical technique and reducing the need for closure using skin grafts and flaps and the use of tissue expanders. Delivering supplemental oxygen to the wound by ROINPT reverses the reduced oxygen levels inherent in conventional negative pressure-assisted wound therapy, mitigating anaerobic contamination and reducing infection. Irrigation may accelerate the evacuation of infectious material from the wound and provide a novel method for antibiotic administration. The combination of TRS and ROINPT devices allow for early primary closure with improved functionality of combat-related limb injuries.

Minimally invasive treatment of forearm double fracture in adult using Acumed forearm intramedullary nail: A case report

BACKGROUND

Currently, open reduction internal fixation is the conventional surgical method for treatment of double ulna and radius fracture. However, open reduction is associated with a high risk of complications. This case of forearm double fracture involved a patient treated using an Acumed intramedullary nail. The patient experienced good follow-up outcomes. The Acumed forearm intramedullary nail enables early functional exercise and hastens healing of the fracture. Few studies have reported on the use of this approach for the treatment of fractures.

CASE SUMMARY

A 23-year-old male patient was admitted to hospital after 5 h of pain, swelling, and limited activity of left forearm caused by a careless fall. Physical examination showed stable basic vital signs, swelling of the left forearm, and severe pain when pressing on the injured part of the forearm. Further, friction was felt at the broken end of the bone; the skin was not punctured. Movement of the left hand was normal, and the left radial artery pulse was normal. Three-dimensional computed tomography examination showed an ulna fracture of the left forearm and comminuted fracture of the radius. The fracture was located in the upper third of the radius, with significant displacement on the fracture side. Clinical diagnosis further confirmed the left radius comminuted fracture and ulna fracture. After analyzing the fracture pattern, age, and other patient characteristics, we chose an Acumed nail for treatment and achieved good follow-up outcomes.

CONCLUSION

Acumed forearm intramedullary nail for fixation of ulna and radius fracture reduced complication risk and resulted in good follow-up outcomes.

A prospective randomized controlled trial comparing the systemic inflammatory response in conventional jig-based total knee arthroplasty versus robotic-arm assisted total knee arthroplasty

AIMS

The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups.

METHODS

This prospective randomized controlled trial included 30 patients with osteoarthritis of the knee undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localized knee temperature were collected preoperatively and postoperatively at six hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned postioning of the components in both groups.

RESULTS

Patients undergoing conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory and localized thermal response at six hours, day 1, day 2, and day 28 after surgery. Robotic TKA had significantly reduced levels of interleukin-6 (p < 0.001), tumour necrosis factor-α (p = 0.021), ESR (p = 0.001), CRP (p = 0.004), lactate dehydrogenase (p = 0.007), and creatine kinase (p = 0.004) at day 7 after surgery compared with conventional TKA. Robotic TKA was associated with significantly improved preservation of the periarticular soft tissue envelope (p < 0.001), and reduced femoral (p = 0.012) and tibial (p = 0.023) bone trauma compared with conventional TKA. Robotic TKA significantly improved the accuracy of achieving the planned limb alignment (p < 0.001), femoral component positioning (p < 0.001), and tibial component positioning (p < 0.001) compared with conventional TKA.

CONCLUSION

Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (< 48 hours) or late (day 28) postoperative systemic inflammatory response compared with conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced femoral and tibial bone trauma, and improved accuracy of component positioning compared with conventional TKA. Cite this article: Bone Joint J 2021;103-B(1):113-122.

Fracture blisters: pathophysiology and management

Open fractures are considered an orthopaedic emergency due to the severe soft tissue disruption that might potentially lead to devastating complications. On the other hand, closed fractures, and especially those resulting from high-energy mechanisms, are also often accompanied by severe soft tissue trauma. Soft tissue envelope compromise can have a detrimental effect on the final outcome of the patients. Fracture blisters in particular, develop as a sign of significant local tissue trauma and appear in a time period between 6 to 72 hours post-injury. They can delay the definitive fracture treatment for a considerable amount of time and at the same time they also increase the risk for post-operative wound complications. Awareness of fracture blisters pathophysiology and their management options are crucial for orthopaedic surgeons, in order to achieve a favorable clinical outcome. In the herein study we present a concise synopsis of the pathophysiology pathways and management options of fracture blisters.

Soft Tissue Injury Considerations in the Treatment of Tibial Plateau Fractures

Tibial plateau fractures represent a highly variable spectrum of injury that requires a multifaceted diagnostic and therapeutic approach in order to adequately treat. Constant vigilance is required to consider all the injured structures and avoid focusing only on the bony aspect of the injury. Management of the soft tissue envelope and repair/reconstruction of critical stabilizing structures of the knee should be at the forefront of the thought process when approaching these complex injuries. This article aims to emphasize the high incidence of injury to associated soft tissue structures and provide general approach considerations to these complex injuries.

[External fixator of the wrist-temporary fixation]

OBJECTIVE

a) Fixed-angle bridging of the wrist between radius diaphysis and metacarpus by percutaneous or minimally invasively inserted threaded pins and a frame (fixator) placed above the skin level (external); b) retention of fracture fragments by ligamentotaxis; c) temporary stabilization after bone loss at wrist and distal forearm.

INDICATIONS

a) Initial treatment of fractures near the wrist or soft tissue injuries in multiple trauma patients; b) fractures of the distal radius and the distal ulna; c) dislocation of the carpus; d) infections of the wrist; e) instability after resection in the wrist area; f) fractures with impending or manifest compartment syndrome; g) fractures with extensive loss of soft tissues and lacking coverage of implants.

CONTRAINDICATIONS

a) Pathological changes at the site of pin application, as long as no alternative site is possible: infections, fractures, osteoporosis, tumors; b) fractures that are closed and not reduceable; c) exclusively intra-articular distal radius fractures; d) lack of compliance by the patient.

SURGICAL TECHNIQUE

Insertion of two threaded pins into the radial shaft proximal to the radiocarpal joint and two pins into the second metacarpal bone. Assembly of the fixator frame in advance of the definitive reduction. Subsequently, final reduction and fixation in the desired position by tightening of the screws on the fixator frame.

POSTOPERATIVE MANAGEMENT

Pin care and changes of wound dressing every 2-3 days RESULTS: Reliable, low complication procedure for temporary fixation of the wrist for many indications.

A novel arthroscopically assisted reduction technique for three patterns of posterolateral tibial plateau fractures

Background

Posterolateral tibial plateau fractures (PTPF) remain a challenge for orthopedics surgeons because the special anatomical structures of the posterolateral corner of knee joint including the fibular head, the lateral collateral ligament, and the peroneal nerve, which impedes the exposure of the fracture fragments and need irregular implants to get a stable fixation. The purpose of present study was to introduce a new articular fracture fragments restoration technique for three patterns of PTPF and investigate the relationship between associated soft injuries and fracture patterns.

Methods

From May 2016 to April 2018, 31 patients with PTPF who had undertaken arthroscopically assisted reduction and fixation (AARF) were enrolled in present study. Demographic data, pre-operation, and post-operation X plan films, three-dimensional computed tomography (CT) scans and magnetic resonance imaging (MRI) were reviewed. Present samples were divided into three patterns with lateral inclination (LI), posterior inclination (PI), and parallel compression (PC) according to the orientation of the articular fragment inclination. Rasmussen anatomical score was used to assess the radiological results. Rasmussen functional score, Hospital for Special Surgery knee-rating Score (HSS), and range of motion (ROM) of the knee joint at the final follow-up were measured to evaluate the clinical outcomes.

Results

In this series, the post-operation tibial plateau angle (TPA) was 9.7° ± 3.5°(range 4.0°–15.8°) and the Rasmussen anatomical score was 17.7 ± 0.7(range 16–18); clinical outcomes showed that the HSS score was 92.7 ± 21.8 (range 90–96) and the Rasmussen functional score was 27.9 ± 1.0 (range 26–30). Of all the patients, the anterior cruciate ligament (ACL) injuries including the ACL tibial attachment ruptures occurred in 16 patients (51.6%), meniscus lesions happened in 19 patients (61.3%), medial collateral ligament (MCL) injuries were founded in 13 patients (41.9%). The number of ACL injuries including the ACL tibial attachment ruptures in the PI fracture pattern (12 cases) is significantly higher than LI (2 cases) and PC (2 cases) fracture pattern (p < 0.05).

Conclusion

Profound understanding the different patterns of PTPF and using our reduction technique will facilitate to restore the main articular fracture fragments. The PI fracture patterns have a significant high incidence of the ACL ruptures.

Level of evidence

Therapeutic study, Level IV.

Does low body mass index constitute a risk of damage to the soft tissues during reaming for proximal femoral nailing? a cadaveric study

BACKGROUND

The purpose of this cadaveric study was to evaluate the damage to the gluteus medius muscle, tendon and superior gluteal nerve in low BMI patients during the reaming of the greater trochanter tip for proximal femoral nailing.

MATERIALS AND METHODS

The study used 19 femurs of 10 fresh femur intact cadavers [mean BMI: 22.79 (17.60-28.70)]. A guidewire was placed in the tip of greater trochanter under C-arm fluoroscopy, and a 17-mm reamer was advanced over the wire. After the reaming was completed, the hips were dissected and the gluteus medius muscle, tendon and superior gluteal nerve were inspected to evaluate the amount of injury.

RESULTS

BMI was < 18.50 in 3 cadavers. The gluteus medius muscle was injured in all hips. The superior gluteal nerve was intact in all hips, but the thickness of gluteus medius muscle mass that remained intact was thicker in the cadavers with a higher BMI (3.86 mm for low BMI, 9.08 mm for high BMI group). The percentage of the tendon insertion disrupted by the reamer was an average of 36.20% in the low BMI group and an average of 26.93% in the high BMI group. The percentage of the tendon insertion disrupted by the reamer showed a statistically significant difference between low and high BMI cadavers.

CONCLUSION

The injury to the gluteus medius muscle and tendon after proximal femoral nailing through the greater trochanter tip may be higher in patients with low BMI. It must be kept in mind that gluteal muscle could be damaged during proximal femoral nailing and this could result in limping.

Scapholunate, lunotriquetral and TFCC ligament injuries associated with intraarticular distal radius fractures: Arthroscopic assessment and correlation with fracture types

The aim of this study was to evaluate the prevalence of arthroscopic scapholunate (SL) and/or lunotriquetral (LQ) laxity and triangular fibrocartilaginous complex (TFCC) injuries in patients who have an intraarticular fracture of the distal radius and to correlate these lesions with fracture type. Fifty-seven intraarticular radius fractures, whether or not they were associated with an ulnar styloid fracture, were evaluated and treated by arthroscopy. Scapholunate and lunotriquetral ligament injuries were classified according to the EWAS classification. TFCC lesions were assessed according to Palmer's classification. Each injury was documented through preoperative X-rays and a CT scan. Fracture type and soft tissue injury were not significantly associated one to another. Arthroscopic examination revealed at least one soft tissue injury in 39 intraarticular fractures of the distal radius (68.4%). Twenty-five percent of arthroscopic SL laxities (including severe EWAS 3 injuries) were not detected on standard radiographs. Arthroscopic SL laxity was present in 8 of 11 cases (72.7%) of radial styloid fracture and in 15 of 25 cases (60%) of fractures with at least one radial styloid component. There was no association between LQ integrity and fracture type. Ulnar styloid fractures (base or tip) and TFCC lesions were significantly correlated (P<0.0001). The prevalence of soft tissue lesions secondary to intraarticular fractures of the distal radius was 68.4%. However, there was no statistically significant relationship between the different types of radius fractures and soft tissue injuries. On the other hand, ulnar styloid fracture was predictive of TFCC injury.

A novel rat model of tibial fracture for trauma researches: a combination of different types of fractures and soft tissue injuries

BACKGROUND

The outcomes for open tibial fractures with severe soft tissue injury are still a great challenge for all the trauma surgeons in the treatment. However, most of the existing open tibial fracture models can only provide minimal soft tissue injury which cannot meet the requirement of severe trauma research. Our goal is to investigate a novel tibial fracture model providing different fractures combined with soft tissue injury for better application in trauma research.

METHODS

A total of 144 Sprague-Dawley rats were randomly divided into 4 groups. With group 1 as control, the other groups sustained different right tibial fractures by the apparatus with buffer disc settings either 3 mm, 10 mm, or 15 mm. X-ray and computed tomography angiography (CTA) were performed at 6 h to evaluate the fracture patterns and vascular injuries. Peripheral blood and tibialis anterior muscle were harvested at 6 h, 1 day, 3 days, 7 days, 14 days, and 28 days for ELISA and histological analysis.

RESULTS

X-ray and μCT results indicated that different fractures combined with soft tissue injuries could be successfully provided in this model. According to OTA and Gustilo classification, the fractures and soft tissue injuries were evaluated and defined: 36 type I in group 2, 34 type II in group 3, and 36 type III in group 4. The CTA confirmed no arterial injuries in groups 1 and 2, 2 arterial injuries in group 3, and 35 in group 4. ELISA indicated that the levels of pro-inflammatory cytokines TNF-α and IL-1β were significantly higher in group 4 than in other groups, and the levels of anti-inflammatory cytokines TGF-β and IL-10 were significantly higher in surgery groups than in group 1 in later stage or throughout the entire process. HE, Masson, and caspase-3 stains confirmed the most severe inflammatory cell infiltration and apoptosis in group 4 which lasted longer than that in groups 2 and 3.

CONCLUSIONS

The novel apparatus was valuable in performing different fractures combined with soft tissue injuries in a rat tibial fracture model with high reproducibility and providing a new selection for trauma research in the future.

[Reduction techniques for minimally invasive plate osteosynthesis]

The technique of fracture treatment by minimally invasive plate osteosynthesis (MIPO) is today part of the treatment repertoire of any experienced trauma surgeon. The minimization of any additional iatrogenic damage to the tissues and the preservation of the osteogenic fracture hematoma are the decisive differences to open reduction and internal fixation (ORIF). The MIPO technique is particularly applied in metaphyseal and diaphyseal fractures, which cannot be treated with intramedullary nails as well as in fractures with critical soft tissue covering and complex fractures with metaphyseal extension fractures. In metaphyseal and diaphyseal fractures a distinction must always be made between relatively simple (A/B1 type) and more complex (B2/3 and C type) fracture forms. In simple fracture forms, which are treated with minimally invasive plate osteosynthesis, an anatomical (or at least gap-free) reduction should be strived for. In contrast, in more complex metaphyseal and diaphyseal fractures achievement of correct functional alignment (correct axis, length and rotation) is the goal of reduction. The minimally invasive approach by the trauma surgeon in MIPO fracture treatment is mainly defined by the selected gentle reduction technique. Because the fracture zone cannot be directly viewed, good knowledge of the anatomy and careful surgical planning including reduction on an adequate image basis are of decisive importance. This article introduces the principles of the reduction techniques in minimally invasive plate osteosynthesis and their practical application is described in detail.

Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review

BACKGROUND

Acute compartment syndrome (ACS) is characterised by abnormal pressure inside a compartment, resulting in ischemia of muscles and nerves. Most orthopaedic surgeons, especially those who work in major trauma centres, have been or will be facing a case of ACS in their clinical activity. Fortunately, complications related to untreated compartment syndrome have become less frequent thanks to a better understanding of pathogenesis and to early recognition and prompt surgical treatment. The aim of this study is to identify the existing evidence regarding aetiology of trauma-related ACS of the leg.

METHODS

A systematic review of the literature was undertaken using PubMed Medline, Ovid Medline and the Cochrane library, extended by a manual search of bibliographies. Retrieved articles were eligible for inclusion if they reported data about aetiology of trauma-related compartment syndrome of the tibia.

RESULTS

Ninety-five studies that fulfilled the inclusion criteria were identified. By dividing the studies into three groups according to the traumatic aetiology, we were able to classify traumatic ACS as fracture related, soft tissue injury related and vascular injury related. Fracture related was the most represented group, comprising 58 papers, followed by the soft tissue injury related group which includes 44 articles and vascular injury related group with 24 papers.

CONCLUSIONS

Although traditionally ACS has been associated mainly with fractures of tibial diaphysis, literature demonstrates that other localisations, in particular in the proximal tibia, are associated with an increased incidence of this serious condition. The forms of ACS secondary to soft tissues injuries represent an extremely variable spectrum of lesions with an insidious tendency for late diagnosis and consequently negative outcomes. In the case of vascular injury, ACS should always be carefully considered as a priority, given the high incidence reported in the literature, as a result of primitive vascular damage or as a result of revascularisation of the limb. Knowledge of aetiology of this serious condition allows us to stratify the risk by identifying a population of patients most at risk, together with the most frequently associated traumatic injuries.

Use of oral screen for preventing soft tissue injuries associated with use of arch bars: a prospective randomized clinical study

PURPOSE

The purpose of the present study was to access the efficacy of oral screen in protection of arch bar-induced soft tissue injury after achieving maxillomandibular fixation (MMF).

MATERIALS AND METHODS

This study is a randomized clinical trial. The study sample was derived from the population of patients who required MMF and reported from January 2017 to December 2017. A total of 60 patients in whom application of an Erich arch bar was indicated for MMF were selected for the study. The patients were divided into two groups. In group I, only MMF was done; however, in group II, oral screen was used after MMF. The patients were assessed for soft tissue injury, pain, and maintenance of oral hygiene. All parameters were compared statistically using the chi-square test and Student's t test.

RESULTS

The soft tissue injury in group I (73.33%) was greater than that in group II (3.33%). The pain was worse in group I than in group II. The mean value of plaque index in group II is 1.20 and in group I is 2.89. It signifies that plaque deposition was more in group I.

CONCLUSION

Soft tissue injury and pain were less, as well as oral hygiene maintenance is better in patients who used oral screen after the placement of Erich arch bars.

High-energy tibial pilon fractures: an instructional review

High-energy tibial pilon fractures continue to represent a significant challenge to the treating orthopaedic surgeon. Pre-operative evaluation includes a careful clinical assessment of the associated soft tissue injury, which frequently dictates surgical management. Staged surgical reconstruction remains the standard treatment protocol at most trauma centres. This includes application of a temporary spanning external fixator for approximately one to four weeks, followed by open reduction and internal fixation once the surrounding soft tissues are amendable. Despite careful soft tissue management protocols, the risk of wound complications continues to be relatively high compared to other orthopaedic trauma procedures. The functional long-term outcomes of these injuries remain limited, and recent data has emphasised that the majority of patients do not regain their pre-operative work status. In addition, the health-related quality of life scores fare poorly when compared to other orthopaedic and non-orthopaedic patient populations, and many patients develop post-traumatic arthritis within the tibiotalar joint. It has been shown that the quality of fracture reduction may significantly correlate with the long-term functional outcomes. While the orthopaedic community has come a long way with regard to safe management of high-energy tibial pilon fractures, the clinical outcomes continue to remain limited. In particular, the persistently high rates of wound complications and the limited functional long-term outcomes leave significant room for improvement. Future investigators may focus on further innovations to minimise the risk of wound complications. The surgical team may emphasise the quality of fracture reduction as an important treatment goal.

Gastric pentadecapeptide body protection compound BPC 157 and its role in accelerating musculoskeletal soft tissue healing

There is a current need for a therapy that can alleviate the social and economic burden that presents itself with debilitating and recurring musculoskeletal soft tissue injuries and disorders. Currently, several therapies are emerging and undergoing trials in animal models; these focus on the manipulation and administration of several growth factors implicated with healing. However, limitations include in vivo instability, reliance on biocompatible and robust carriers and restricted application procedures (local and direct). The aim of this paper is therefore to critically review the current literature surrounding the use of BPC 157, as a feasible therapy for healing and functional restoration of soft tissue damage, with a focus on tendon, ligament and skeletal muscle healing. Currently, all studies investigating BPC 157 have demonstrated consistently positive and prompt healing effects for various injury types, both traumatic and systemic and for a plethora of soft tissues. However, to date, the majority of studies have been performed on small rodent models and the efficacy of BPC 157 is yet to be confirmed in humans. Further, over the past two decades, only a handful of research groups have performed in-depth studies regarding this peptide. Despite this, it is apparent that BPC 157 has huge potential and following further development has promise as a therapy to conservatively treat or aid recovery in hypovascular and hypocellular soft tissues such as tendon and ligaments. Moreover, skeletal muscle injury models have suggested a beneficial effect not only for disturbances that occur as a result of direct trauma but also for systemic insults including hyperkalamia and hypermagnesia. Promisingly, there are few studies reporting any adverse reactions to the administration of BPC 157, although there is still a need to understand the precise healing mechanisms for this therapy to achieve clinical realisation.

The epidemiology of work-related musculoskeletal injuries among chiropractors in the eThekwini municipality

Background

Chiropractors are a unique group of health care professionals who are at risk for developing work-related musculoskeletal injuries. Diversity of daily practice imposes different physical demands on the chiropractor. This study aimed to determine the prevalence of work-related musculoskeletal injuries in chiropractors in eThekwini municipality and selected risk factors associated with these work-related musculoskeletal injuries.

Methods

The design was a quantitative, cross-sectional, descriptive study utilising a self-administered questionnaire, developed specifically for this research. The questionnaire contained sections on personal and practice demographics, with questions pertaining to the single most severe work-related musculoskeletal injury, as well as the second and third most severe work-related musculoskeletal injury.

Results

A response rate of 64% was obtained (n = 62). The life-time prevalence of work-related musculoskeletal injuries was 69% with a predominance of injuries to the upper extremity (50%) and lower back (28.3%). The hand/wrist was the most common anatomical site of injury (31.5%) followed by the lower back (28.3%). Number of years in practice was considered a risk factor as most injuries occurred within the first five years of practice (41.6%). The majority of injuries affected the soft tissue, including ligament sprains (27.5%) and muscle strains (26.6%) and occurred while the practitioner was performing manipulation (38.2%) of the lumbosacral (80.8%) area with the patient in the side posture (61.5%).

Conclusions

The results concur with other studies on work-related musculoskeletal injuries in chiropractors and add insight into risk factors predisposing this population to injury.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0238-y) contains supplementary material, which is available to authorized users.

Diagnosis of Soft Tissue Injury in the Sport Horse

For successful diagnosis of soft tissue injuries in the sport horse, localizing the area of injury during clinical and lameness evaluation will be followed in most cases by an ultrasonographic examination. With MRI more available in equine veterinary clinics, this modality can allow for a complete evaluation of soft tissue and osseous structures and is especially useful for evaluation of structures within the hoof capsule. This article discusses special ultrasonographic techniques, an overview of MRI image generation, and the use of contrast computed tomography for diagnosis of soft tissue injuries.

Subcutaneous and Intramuscular Injection of Petrol (Hydrocarbon): A Case Report and Review of the Literature

Deliberate injection of hydrocarbon remains an uncommon method of self harm. There is a paucity of information pertaining to soft tissue toxicity throughout the literature. Prompt recognition of the potential ramifications is needed to try salvage limb function. Hydrocarbon toxicity can result in multi organ failure. This case report demonstrates the recommended diagnostic approach, work up and treatment involved in such a case. A 26 year old male deliberately injected petrol into the anterior compartment of his non dominant forearm in a suicide attempt. Multidisciplinary involvement from surgeons, psychiatrists and hand therapists was needed to maximize functional outcome. He avoided systemic toxicity but required an urgent fasciotomy. He required significant follow up with hand therapy to regain usage of the limb. However his long term outcomes were poor with a power grading 3/5 in the anterior compartment muscles.

Degloving injuries with versus without underlying fracture in a sub-Saharan African tertiary hospital: a prospective observational study

Background

Degloving injuries are surgical conditions in which an extensive portion of skin and subcutaneous tissue is detached from the underlying fasciae, muscles, or bone surface. Frequently, there is an association of fracture underlying the degloved area. We aimed to compare the short-term outcomes of degloving injuries with and without underlying fracture.

Methods

A prospective cohort study was conducted. We recruited patients with degloving injuries, and followed them up for 30 days to assess the outcomes. We collected data on socio-demography, cause and mechanism of injury, presence of underlying fracture, presence of shock at admission, injury severity score, location and size of degloving injuries, their management, and short-term outcomes. There were two comparison groups of degloving injuries based on the presence or absence of underlying fracture. We analyzed the differences between the two groups by using Fisher exact test for categorical variables and Student’s t test for continuous variables; p values < 0.05 were considered to be significant. Risk ratio was calculated for the short-term outcomes.

Results

There were 1.56% (n = 51) of degloving injuries among 3279 admitted trauma patients during the study period of 5 months; 1% (n = 33) with and 0.56% (n = 18) without underlying fracture. For the overall degloving injuries, male-female ratio was 2 and mean age was 28.8 years; they were caused by road traffic crashes in 84%, and resulted in shock at admission in 29%. In the group with underlying fracture, lower limbs were frequently affected in 45% (p = 0.0018); serial debridement and excision of the avulsed flap were the most performed surgical procedures in 22% (p = 0.0373) and 14% (p = 0.0425), respectively; this same group had 3.9 times increased risk of developing poor outcomes (mainly infections) after 30 days and longer hospital stay (26.52 ± 31.31 days, p = 0.0472).

Conclusion

Degloving injuries with underlying fracture are frequent in the lower limbs, and have increased risk of poor short-term outcomes and longer hospital stay. We recommend an early plastic surgery review at admission of patients with degloving injuries with underlying fracture to improve the flap viability and reduce the infection risk.

Electronic supplementary material

The online version of this article (10.1186/s13018-017-0706-9) contains supplementary material, which is available to authorized users.

A prospective, observational cohort study of patients presenting to an emergency department with acute shoulder trauma: the Manchester emergency shoulder (MESH) project

Background

Fracture and dislocation of the shoulder are usually identifiable through the use of plain radiographs in an emergency department. However, other significant soft tissue injuries can be missed at initial presentation. This study used contrast enhanced magnetic resonance arthrography (MRA) to determine the pattern of underlying soft tissue injuries in patients with traumatic shoulder injury, loss of active range of motion, and normal plain radiography.

Methods

A prospective, observational cohort study. Twenty-six patients with acute shoulder trauma and no identifiable radiograph abnormality were screened for inclusion. Those unable to actively abduction their affected arm to 90° at initial presentation and at two week’s clinical review were consented for MRA.

Results

Twenty patients (Mean age 44 years, 4 females) proceeded to MRA. One patient had no abnormality, three patients showed minimal pathology. Four patients had an isolated bony/labral injury. Eight patients had injuries isolated to the rotator cuff. Four patients had a combination of bony and rotator cuff injury. Four patients were referred to a specialist shoulder surgeon following MRA and underwent surgery.

Conclusions

Significant soft tissue pathology was common in our cohort of patients with acute shoulder trauma, despite the reassurance of normal plain radiography. These patients were unable to actively abduct to 90° both at initial presentation and at two week’s post injury review. A more aggressive management and diagnostic strategy may identify those in need of early operative intervention and provide robust rehabilitation programmes.

Acute Compartment Syndrome of Upper Extremities with Tendon Ruptures

BACKGROUND

It is well known that acute compartment syndrome is associated with fracture of the forearm, while involvement of soft tissue injury including musculotendinous injury remains unclear. The purpose of this study was to evaluate the soft tissue involvement, including musculotendinous ruptures, in acute compartment syndrome of the upper limb.

METHODS

We retrospectively enrolled 16 patients who underwent surgical treatment for acute compartment syndrome of the upper extremity. The average age of the patients was 47 years (range, 14 to 79) and the mean follow-up period after the surgery was 15 months (range, 12 to 29). Complications included at least one presentation at the final follow up of sensory disturbances or motor disturbances. We examined the presence of musculotendinous injury mechanism of injury, presence of fracture, the performance of skin grafting, and complications.

RESULTS

Mechanism of injury of "caught in a machine" was found in six cases. Three of these patients had musculotendinous ruptures and all muscle tears were revealed by intraoperative findings. No patients had muscle ruptures with other injury mechanisms. Seven out of 16 patients (44%) developed complications at final follow-up. Skin grafting was performed in six patients, and five of these patients developed complications. Only one of the nine patients without complications underwent skin grafting.

CONCLUSIONS

In cases of high-energy injuries, the surgeon should suspect the presence of a musculotendinous injury prior to surgery.

Pronounced and sustained cutaneous vasoconstriction during and following cyrotherapy treatment: Role of neurotransmitters released from sympathetic nerves

Cryotherapy is a therapeutic technique using ice or cold water applied to the skin to manage soft tissue trauma and injury. While beneficial, there are some potentially detrimental side effects, such as pronounced vasoconstriction and tissue ischemia that are sustained for hours post-treatment. This study tested the hypothesis that this vasoconstriction is mediated by 1) activation of post-synaptic α-adrenergic receptors and/or 2) activation of post-synaptic neuropeptide Y1 (NPY Y1) receptors. 8 subjects were fitted with a commercially available cryotherapy unit with a water perfused bladder on the lateral portion of the right calf. Participants were instrumented with four intradermal microdialysis probes beneath the bladder. The following conditions were applied at the four treatment sites: 1) control (Ringer solution), 2) combined post-synaptic β-adrenergic receptors and neuropeptide (NPY) Y₁ receptors blockade (P+B site), 3) combined post-synaptic α-adrenergic receptor, β-adrenergic receptor, and NPY Y₁ receptor blockade (Y+P+B site), and 4) blockade of pre-synaptic release of all neurotransmitters from the sympathetic nerves (BT site). Following thermoneutral baseline data collection, 1°C water was perfused through the bladder for 30min, followed by passive rewarming for 60min. Skin temperature (T_skin) fell from ~34°C to ~18.5°C during active cooling across all sites and there was no difference between sites (P>0.05 vs. control for each site). During passive rewarming T_skin rose to a similar degree in all sites (P>0.05 relative to the end of cooling). In the first 20min of cooling %CVC was reduced at all sites however, this response was blunted in the BT and the Y+P+B sites (P>0.05 for all comparisons). By the end of cooling the degree of vasoconstriction was similar between sites with the exception that the reduction in %CVC in the Y+B+P site was less relative to the reduction in the control site. %CVC was unchanged in any of the sites during passive rewarming such that each remained similar to values obtained at the end of active cooling. These findings indicate that the initial vasoconstriction (i.e. within the 1st 20min) that occurs during cryotherapy induced local cooling is achieved via activation of post-synaptic α-adrenergic receptors; whereas nonadrenergic mechanisms predominate as the duration of cooling continues. The sustained vasoconstriction that occurs following cessation of the cooling stimulus does not appear to be related to activation of post-synaptic α-adrenergic receptors or NPY Y1 receptor.

Intraoperative arthroscopy of the TMJ during surgical management of condylar head fractures: A preliminary report

PURPOSE

The purpose of this preliminary study was to evaluate intraarticular soft tissues of the temporomandibular joint (TMJ) using intraoperative arthroscopy during open reduction and internal fixation (ORIF) of condylar head fractures (CHF).

MATERIALS AND METHODS

26 patients (29 joints) were diagnosed in period of 5 years (2011-2015) with CHF, 5 patients had concomitant mandibular fracture. Fractures were diagnosed on basis of conventional orthopantomogram (OPG) and computed tomography (CT).

RESULTS

Intraoperative arthroscopy revealed hyperemia and hypervascularity in all 29 joints, anterior disc dislocation in 26 joints, cartilage erosion in 21 joints and hemorrhagic clots were present in 10 joints. Major hemarthrosis or tear of the posterior band, as often described in MRI, could not be shown in our patients. Data from the study further the understanding of intraarticular pathology of the TMJ after acute trauma in a group with CHF.

CONCLUSION

Intraoperative arthroscopy is useful for direct evaluation and accurate diagnosis of the extent of soft tissue damage to TMJ in CHF. Larger and more long-term studies including comparison to MRI findings should be helpful to refine the treatment and postoperative management of patients after CHF.

Recurrent Dislocation of the Proximal Interphalangeal Joint of the Finger: A Rare Issue in Hand Surgery

Recurrent dislocation is not common in small joints. This report presents a recurrent dislocation of the proximal interphalangeal joint of the ring finger in a 23-years-old man. Recurrent dislocation was addressed successfully by repairing the avulsed volar plate to the base of the middle phalanx, followed by 6 weeks of splint immobilization.

Should hydrogen therapy be included in a musculoskeletal medicine routine?

Molecular hydrogen (H ₂) has recently been recognized as a potential novel therapeutic agent in biomedicine. Initially proposed to be a possible treatment for certain types of neuromuscular disorders, cardio-metabolic diseases and cancer, H ₂ improved clinical end-points and surrogate markers in several clinical trials, mainly acting as an anti-inflammatory agent and powerful antioxidant. In this paper, the medicinal properties of H ₂ in musculoskeletal medicine are discussed with the aim to provide an updated and practical overview for health professionals working in this field.

Clinical Experiences with the Scapular Fascial Free Flap

Background

The goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissue for optimal restoration of form and function. Here, we present our clinical experience with the use of the scapular fascial free flap to correct facial asymmetry and to reconstruct soft tissue defects of the extremities.

Methods

We used a scapular fascial free flap in 12 cases for soft tissue coverage of the extremities or facial soft tissue augmentation.

Results

The flaps ranged in size from 3×12 to 13×23 cm. No cases of total loss of the flap occurred. Partial loss of the flap occurred in 1 patient, who was treated with a turnover flap using the adjacent scapular fascial flap and a skin graft. Partial loss of the skin graft occurred in 4 patients due to infection or hematoma beneath the graft, and these patients underwent another skin graft. Four cases of seroma at the donor site occurred, and these cases were treated with conservative management or capsulectomy and quilting sutures.

Conclusions

The scapular fascial free flap has many advantages, including a durable surface for restoration of form and contours, a large size with a constant pedicle, adequate surface for tendon gliding, and minimal donor-site scarring. We conclude that despite the occurrence of a small number of complications, the scapular fascial free flap should be considered to be a viable option for soft tissue coverage of the extremities and facial soft tissue augmentation.

The versatility of the medial thigh lift for defect coverage in the genito-perineal region

Soft tissue defects in the genito-perineal region are predominantly because of trauma, infections, neoplasms or iatrogenic causes. As a result of the region's urological, reproductive and gastrointestinal function, defects in this area may cause devastating physical and psychological consequences as well as diminished sexual functioning. The purpose of this study was to examine the efficacy of implementing a medial thigh lift for defect coverage in the perineal region. A retrospective analysis of all medial thigh lift procedures for defect coverage in the genito-perineal region between November 2010 and March 2015 was conducted at three institutions. Ten consecutive patients underwent a medial thigh lift for defect coverage in the genito-perineal region. Nine patients were male, and one was female. The causative factors were Fournier's gangrene in eight patients, one patient had a straddle injury, and one suffered from extramammary Paget's disease. The mean follow-up time was 19·8 months. The average total defect size was 11·1 × 11 cm (length × width). The medial thigh lift procedure is a safe, technically easy and reliable technique with discrete scars. Outstanding aesthetic and functional outcomes result in a high rate of patient satisfaction. Through immediate wound closure, a reduction of recovery time can be achieved.

Patterns and management of degloving injuries: a single national level 1 trauma center experience

Background

Degloving soft tissue injuries (DSTIs) are serious surgical conditions. We aimed to evaluate the pattern, management and outcome of DSTIs in a single institute.

Methods

A retrospective analysis was performed for patients admitted with DSTIs from 2011to 2013. Presentation, management and outcomes were analyzed according to the type of DSTI.

Results

Of 178 DSTI patients, 91 % were males with a mean age of 30.5 ± 12.8. Three-quarter of cases was due to traffic–related injuries. Eighty percent of open DSTI cases were identified. Primary debridement and closure (62.9 %) was the frequent intervention used. Intermediate closed drainage under ultrasound guidance was performed in 7 patients; however, recurrence occurred in 4 patients who underwent closed serial drainage for recollection and ended with a proper debridement with or without vacuum assisted closure (VAC). Closed DSTIs were mainly seen in the lower extremity and back region and initially treated with conservative management as compared to open DSTIs. Infection and skin necrosis were reported in 9 cases only. Open DSTIs were more likely involving head and neck region and being treated by primary debridement/suturing and serial debridement/washout with or without VAC. All-cause DSTI mortality was 9 % that was higher in the closed DSTIs (19.4 vs 6.3 %; p = 0.01).

Conclusion

The incidence of DSTIs is 4 % among trauma admissions over 3 years, with a greater predilection to males and young population. DSTIs are mostly underestimated particularly in the closed type that are usually missed at the initial presentation and associated with poor outcomes. Treatment guidelines are not well established and therefore further studies are warranted.