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Six clinical databases were analysed from inception through 2023 to assess the trajectory of orthoplastic surgery research and provide a scoping review of concentrations and gaps in the literature. The literature grew exponentially since 2010, with 66 % of identified studies published between 2020 and 2024. The United Kingdom emerged as the primary contributor, accounting for 47 % of publications following national guideline implementation that demonstrated improved patient outcomes. While meta-analyses support the clinical benefits of orthoplastic management for complex fractures, showing reduced surgical interventions and infection rates, the evidence base relies predominantly on retrospective studies, with no randomized controlled trials identified. Key opportunities to strengthen the field include conducting prospective studies, expanding research beyond lower extremity trauma to areas such as upper extremity reconstruction, oncologic applications, and paediatric care, addressing healthcare access disparities, evaluating cost-effectiveness across different healthcare systems, and developing standardized guidelines beyond the UK. more...

Background: Traumatic injury of popliteal artery records the highest risk of lower extremity loss with amputation rates of 10% to 15%. A method to investigate the predictors of amputation is needed because previous scores could not be validated. The goal of this review is to investigate if POPSAVEIT (popliteal scoring assessment for vascular extremity injuries in trauma) may be used as a preoperative indicator of amputation risk in patients with traumatic injury of popliteal vessel. Methods: From 2017 to 2022, all patients who underwent surgical repair of popliteal arterial traumatic injuries at Zagazig University Hospitals were included in this retrospective study. Patients who needed amputation were assessed to those with limb salvage. Based on univariate analysis, the significant predictors of POPSAVEIT variables for amputation were included in a multivariable analysis. To determine low vs. high-risk scores, receiver operating characteristic (ROC)curve are created. Results: 76 patients were included in the study, with an overall amputation rate of 18.4%. The following risk factors were shown to be independently related with amputation: systolic blood pressure <90 mm Hg (OR, 5.3; P = 0.05), associated orthopedic injury (OR, 6.1; P = 0.009), and a lack of preoperative pedal Doppler signals (OR, 8.3; P = 0.001). For a high risk of amputation, a score of ≥3 was determined to have the best sensitivity (78.6%) and specificity (59%). Conclusions: POPSAVEIT is a preoperative simple and practical way to classify patients into low- and high-risk major amputation categories. [ABSTRACT FROM AUTHOR] more...

Introduction: Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery, such as pain exacerbations, reduced functional recovery, and lowered patient satisfaction. However, the influence of pre-existing mental health conditions on orthopaedic trauma outcomes has not been thoroughly investigated. The objective of this study was to systematically review literature addressing the association between pre-existing mental health conditions and patient outcomes following surgical interventions for lower extremity fractures in non-geriatric populations. Methods: A systematic literature review was conducted using Medline, Embase, and Scopus databases following PRISMA-ScR guidelines to select studies that examined lower extremity orthopaedic trauma outcomes in relation to pre-existing mental health conditions. Studies that evaluated patients with surgically treated lower extremity fractures and a history of mental health conditions such as anxiety, depression, or mood disorders were included. Studies with a mean patient age above 65 years of age were excluded to focus on non-geriatric injury patterns. Results: The systematic review identified 12 studies investigating the relationship between surgical outcomes of orthopaedic lower extremity fractures and pre-existing mental health disorders in non-geriatric populations. Studies included patients with pelvis, femur, tibia, and ankle fractures. A majority (83%) of these studies demonstrated that patients with pre-existing mental health diagnoses had inferior functional outcomes, heightened pain levels, or an increase in postoperative complications. Discussion: The presence of pre-existing mental health conditions, particularly anxiety and depression, may predispose orthopaedic trauma patients to an elevated risk of suboptimal functional outcomes, increased pain, or complications after surgical intervention for lower extremity fractures. Future research should focus on interventions that mitigate the impact of mental health conditions on orthopaedic outcomes and patient wellness in this population. [ABSTRACT FROM AUTHOR] more...

Lower extremity trauma is one of the most common injury patterns seen in emergency medical and surgical practice. Vascular injuries occur in less than one percent of all civilian fractures. However, if not treated promptly, such injuries can lead to ischemia and death. Computed tomography angiography (CTA) is the non-invasive imaging gold standard and plays a crucial part in the decision-making process for treating lower extremity trauma. A novel, FDA-approved 3D reconstruction technique known as cinematic rendering (CR) yields photorealistic reconstructions of lower extremity vascular injuries depicting clinically important aspects of those injuries, aiding in patient workup and surgical planning, and thus improving patient outcomes. In this article, we provide clinical examples of the use of CR in evaluating lower extremity vascular injuries, including the relationship of these injuries to adjacent osseous structures and overlying soft tissues, and its role in management of lower extremity trauma. [ABSTRACT FROM AUTHOR] more...

Limb-threatening injuries can have a profound impact on patient lives. The impact on a patient's psychosocial well-being is widespread yet not well understood. This study aims to explore which psychosocial elements are central to patient experiences after limb-threatening lower extremity trauma. This is a qualitative interview-based study to identify psychosocial experiences after limb-threatening lower extremity trauma in a patient-centered manner. Data were collected via semi-structured qualitative interviews and analyzed via an interpretive description approach. Interviews were performed until content saturation was reached. A total of 33 interviews were performed until reaching content saturation. Eleven participants underwent early amputation, 7 delayed amputation after an attempt at limb salvage, and 15 underwent limb salvage. A total of 533 unique psychosocial codes were identified, comprised of eight concepts: acceptance, body image, coping, distress, positive impact, emotional support, isolation, and intrapsychic. This study identified the concerns central to this patient population and developed a conceptual framework for how patients cope with these psychosocial experiences. These findings underscore the importance of developing resilience by actively practicing acceptance and reaching more positive mental health outcomes. Additionally, these findings highlight the importance of increasing access to early and routine psychological and social support for patients with severe lower extremity trauma. [ABSTRACT FROM AUTHOR] more...

BackgroundExtensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness.MethodsFrom January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed.ResultsThe size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin.ConclusionFree transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage. more...

Acute compartment syndrome (ACS) of the lower extremity is a surgical emergency, often secondary to severe crush injury, and requires immediate fascial release. In treatment of ACS, the underlying fascia is left unrepaired and the subsequent fascial defect does not generally cause negative consequences. Here, we present a 24-year-old man who developed symptomatic muscle herniation 3-years after undergoing fascial release secondary to ACS of the anterior thigh. Given the size of the defect, reconstruction was performed using Acellular Dermal Matrix (ADM). The patient did well, with no complications 6 months postoperatively. Symptomatic muscle herniation following fasciotomy can be treated with hernia reduction and fascial repair. When primary closure is not possible, Acelluar Dermal Matrix (ADM) is an option for successful fascial reconstruction. more...

Introduction: Compartment syndrome of the lower extremity following arterial vascular trauma can cause irreversible damage to muscle as well as nerve tissue leading to long-term functional impairment of the extremity or worse limb loss. Prompt diagnosis and treatment of compartment syndrome is mandatory to preserve muscle tissue and prevent limb loss. The aim of the study was to analyze the fasciotomy rate of our patient cohort and to perform a predictors analysis for the need of fasciotomy.Material and Methods: In a retrospective study all patients treated for arterial vascular trauma since 1990 were identified. Demographics, clinical data and outcome were analysed. After separation in a fasciotomy and non-fasciotomy group, a Bayes Network was used to arrive at a predictor ranking for the need of fasciotomy via a gain ratio feature evaluation.Results: In the period of 28 years, 88 (73.9%) of a total of 119 patients, predominantly male (80.7%) and aged under 40 years (37.5 ± 17.5), required fasciotomy after arterial vascular trauma. Patients of the fasciotomy group presented at higher Rutherford categories (grade III 34.1% vs. 9.7%, p = 0.005), varied in terms of the type of arterial vascular injury (dissection 25% vs. 61.3%, p <0.001, occlusion 15.9% vs. 0%, p = 0.011) and showed prolonged hospitalization (35.17 ± 29.3 vs. 21.48±25.4, p = 0.002). Ischaemia duration exceeding 2.5 h followed by the Rutherford grade IIa and greater, the site (popliteal artery segment 3), type (transection and occlusion), and mechanism of vascular trauma (work related accident over traffic and sports accidents), as well as the male gender presented as strong predictors for fasciotomy.Conclusions: Arterial vascular trauma requiring fasciotomy for compartment syndrome accounted for 73.9% of all cases. Immediate diagnosis and treatment is mandatory to prevent long-term functional impairment or limb loss. The above mentioned predictors should help identifying patients at risk for developing a compartment syndrome to provide best possible treatment. [ABSTRACT FROM AUTHOR] more...

Objective: Patient compliance with weight bearing and physical therapy recommendations is critical following an orthopedic injury. Proper compliance requires knowledge of the postinjury plan, but there is little published data regarding comprehension of postinjury recommendations among orthopedic trauma patients. We hypothesized that patient knowledge of weight bearing and physical therapy instructions following an orthopaedic injury would be poor.Design: Prospective Observational Cohort SETTING: Level I Trauma Center PATIENTS: 194 prospectively enrolled patients completed a questionnaire testing their knowledge of their weight bearing status and physical therapy plan at their first clinic visit following an inpatient admission with an orthopedic injury RESULTS: Despite the fact that 73% of patients were participating in physical therapy following hospital discharge, only 66% (95% CI 60-73%) of patients correctly identified their postinjury weight bearing status. A multivariate analysis found no significant correlation between chance of knowing postoperative weightbearing status or physical therapy plan and any of the socioeconomic patient factors we collected.Conclusions: Orthopedic trauma patients had a relatively poor understanding of even basic postinjury physical therapy instructions. This did not appear to be affected by age, gender, or socioeconomic factors. Orthopedic trauma surgeons should be aware of the significant potential for knowledge deficits among their patients and should make specific efforts to identify and correct those deficits. [ABSTRACT FROM AUTHOR] more...

Abstract In the reconstruction of the mangled lower extremity, muscle flaps are well known for their reliable use in soft tissue coverage, however very few reports document their functional reconstruction potential as neurotized muscle flaps. This case illustrates that free neurotized latissimus dorsi flaps are a good option for long-term functional reconstruction in the mangled lower extremity. Our report is the first case in the literature to date describing a subacute reconstruction with a functional latissimus dorsi in lower extremity trauma. more...

Abstract Background In the context of major trauma, the rate of wound infection in surgical incisions created during fracture fixation amongst patients with closed high-energy injuries is high. One of the factors which may reduce the risk of surgical site infection is the type of dressing applied over the closed incision. The WHIST trial evaluates the effects of negative-pressure wound therapy (NPWT) compared with standard dressings. Methods/design The WHIST trial is a multicentre, parallel group, randomised controlled trial. The primary outcome is the rate of deep surgical site infection at 30 days after major trauma. Secondary outcomes are measured at 3 and 6 months post-randomisation and include the Disability Rating Index, the EuroQoL EQ-5D-5 L, the Doleur Neuropathique Questionnaire, a patient-reported scar assessment, and record of complications. The analysis approaches for the primary and secondary outcomes are described here, as are the descriptive statistics which will be reported. The full WHIST protocol has already been published. Discussion This paper provides details of the planned statistical analyses for this trial and will reduce the risks of outcome reporting bias and data driven results. Trial registration International Standard Randomised Controlled Trials database, ISRCTN12702354. Registered on 9 December 2015. more...

Background: Grade III open fractures of the lower extremity are serious injuries and are difficult to reconstruct. The optimal treatment for such injuries is unclear. We aimed to determine the safety and efficacy of orthoplastic reconstruction, using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation for Gustilo grade IIIB/C open tibial fractures.Methods: From April 2018 to April 2019, 15 patients, ranging from 19 to 72 years old, with Gustilo grade IIIB/C open fractures were treated using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation. This involved wound debridement and removal of free bone fragments, followed by bone cement packing of the defect, external fixation, and vacuum sealing drainage treatment. The final stage involved switching from external to internal fixation and wound repair using a free anterolateral thigh flap. Repair time ranged from 2 to 7 days. Flap size ranged from 25 × 15 cm2 to 13 × 7cm2. Hospital stay ranged from 11 to 50 days (mean, approximately 33.3 days). Bone cement was removed after 6-19 weeks and replaced with autogenic cancellous bone.Results: All flaps survived without incident. One patient experienced a wound infection, but there were no deep infections. For all patients, bone union was achieved after 4 to 7 months.Conclusion: The use of a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation is a safe and effective procedure for reconstruction of Gustilo grade IIIB/C open fractures. [ABSTRACT FROM AUTHOR] more...

Perioperative anxiety increases postoperative pain and the risk of complications in hospitalized children. Nonpharmacologic pain resources provided by Certified Child Life Specialists (CCLS) are a viable adjunct for pain management. A routine CCLS consult was implemented for patients admitted to the orthopedic service with traumatic lower extremity injuries requiring surgery. A retrospective chart review compared patients who did not receive a CCLS consult. Daily pain rating scores, total doses of opioid and nonopioid pain medication, number of physical therapy attempts, length of stay, and demographics were compared for both groups. A clinically significant improvement was seen for decreased pain rating scores and opioid use after a routine CCLS consult was implemented. Adopting a routine CCLS consult for children with unplanned admissions because of trauma reduces the number of opioids used, provides children with pain management resources, and promotes coping skills that may be used in the future. [ABSTRACT FROM AUTHOR] more...

Background: The medial sural artery perforator (MSAP) flap provides a thin, pliable and durable soft tissue reconstruction with adequate pedicle length and low donor morbidity. It is an ideal choice for small-to-moderate defects of the lower extremity, although it does have limitations. We report our experience of the flap in a three-pronged anatomical, clinical and patient reported outcome-based study.Methods: Cadaveric fresh frozen lower limbs (n = 10) were used for anatomical dissections to assess pertinent and clinically relevant findings. Data relating to MSAP flaps was collected from a prospectively maintained database over a 2-year period. Both clinical data and modified Enneking scores were analysed.Results: Anatomical study: A mean of 2.1 ± 0.99 perforators arose from the medial sural artery, located 11.9 cm ± 2.07 along the line between the popliteal fossa and medial malleolus. The largest perforator was located 13.58 cm ± 2.01 from the popliteal artery. The distance from the dominant perforator to the first branching point within the gastrocnemius was 7.39 ± 1.50 (range 5-9.2 cm). The short saphenous vein was located on average 3.08 cm ± 0.77 from the dominant perforator. Clinical study: Twenty free and nine pedicled MSAPs were included (n = 29). Open lower limb fractures (n = 18, 62%) and infection (n = 10, 35%) were the most common aetiologies. Defects sites included: foot-and-ankle (n = 12, 55%), knee (n = 9, 31%) and anterior leg (n = 4, 14%). Four patients (14%) required SSG to for donor site coverage. Venous congestion was responsible for partial flap necrosis in 6.9%(n = 2) of patients. All wounds were healed at discharge. At 14 months, the mean Enneking score was 72.5%. All patients were ambulant, 96% returned to work and 87% were using pre-operative footwear.Conclusions: The MSAP provides robust foot-and-ankle reconstruction, whilst permitting glide when over the knee. Patient satisfaction and functional outcomes are excellent with careful patient selection. Care should be taken to avoid compression or kinking of the large, thin walled veins as the most commonly observed complication was venous congestion. We advocate MSAP as a first choice flap for small-to-moderate foot, ankle or knee defects. [ABSTRACT FROM AUTHOR] more...

Background  Venous outflow problems are the most common reasons for perioperative flap complications. Size mismatch in venous anastomoses poses a theoretical problem by promoting turbulent flow and subsequent thrombus formation. The purpose of this study was to determine if increased vein size mismatch is predictive of flap failure. Methods  Retrospective review of our institutional flap registry from 1979 to 2016 identified 410 free flaps performed for reconstruction of lower extremity trauma. Patient demographics, flap characteristics, and flap outcomes were examined. Venous size mismatch was defined as a difference in size ≥ 1 mm between the recipient vein and flap vein. Results  Vein size mismatch ≥ 1mm was present in 17.1% (n  = 70) of patients. The majority of anastomoses were end-to-end (n  = 379, 92.4%), and end-to-side anastomoses were preferentially used in the presence of vein size mismatch (p  < 0.001). Major complications occurred in 119 (29%) flaps, with 35 (8.5%) partial flap losses and 34 (8.3%) total flap losses. Looking specifically at flaps with end-to-end venous anastomoses, venous size mismatch was associated with increased total flap failure (p  = 0.031) and takeback for vascular compromise (p  = 0.030). Recipient vein size relative to flap vein size (larger or smaller) had no effect on flap outcomes. Multivariable regression analysis controlling for age, sex, flap type, number of veins, recipient vein size, flap vein size, venous coupler use, and vein size mismatch demonstrated that flaps with ≥ 1 mm vein mismatch were predictive of total flap failure (p  = 0.045; odds ratio: 2.58). Conclusion  Flaps with vein size mismatch ≥ 1 mm demonstrated increased flap complication rates in the setting of end-to-end venous anastomoses. End-to-side anastomosis was preferentially used in vein size mismatch and carried a higher risk of flap failure. Our results support using veins of similar size for anastomosis whenever feasible to protect against flap complications. [ABSTRACT FROM AUTHOR] more...

Background  Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases. Methods  We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance. Results  Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications (p  = 0.051) and flap-specific complications (p  = 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance. Conclusion  Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient. [ABSTRACT FROM AUTHOR] more...

• Time to brake was prolonged and functional outcome measurements denoted dysfunction among patients released to full weightbearing and driving following lower extremity injury. • When MFA scores worsened by one point, time to brake increased. • When PROMIS pain interference scores worsened by one point, time to brake increased. • When PROMIS mobility scores worsened by one point, time to brake increased. Inability to drive a motor vehicle due to lower extremity injury is a major inconvenience. Timing of safe return to driving has not been much studied. Objective measurements such as time to brake (TTB) have been proposed; however, utility and concordance of functional outcome measurements have not been previously evaluated. The purpose of this project is to measure these parameters and to assess for associations with ability to safely return to driving, improving the ability of clinicians to assess for measurements of driving readiness without specifically measuring TTB. A prospective, cohort study of 232 patients with complex lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia, ankle, and foot was performed. Time to brake (TTB) was measured once weightbearing was allowed. Function was assessed by the Musculoskeletal Function Assessment (MFA) questionnaire, and pain, mobility, and physical functions, via patient reported outcome measurement information system (PROMIS) surveys. Patients with longer TTB had significantly elevated MFA scores indicating increased musculoskeletal dysfunction post-injury. As the MFA score increased by 1 point, TTB increased by 0.013 s (p <0.001). PROMIS metrics were also significantly associated with patients experiencing more pain and worse mobility as TTB increased. Many patients continue to exhibit musculoskeletal dysfunction several months post-treatment for complex lower extremity injuries. Patients with better PROMIS metrics and MFA scores, and shorter TTB are more appropriate to return to driving. Surgeons may be better informed about safe driving ability by considering these measurements. II [ABSTRACT FROM AUTHOR] more...

Soft-tissue coverage after complex distal lower extremity trauma is often difficult due to limited local flap options and injury to potential recipient vessels when considering microsurgical reconstruction. Therefore, obtaining recipient vessels outside the zone of injury to optimize successful free tissue transfers remains a basic tenet of microsurgery. We present a case of a crush injury to the lower extremity with open tibia and fibula fractures and a large soft-tissue defect that required reconstruction for limb salvage. Due to recipient vessel thrombosis within the affected extremity even well proximal to the zone of injury, contralateral lower extremity recipient vessels were used as an alternative for cross-leg flap limb salvage. We performed flap pedicle division 6 weeks after inset. Follow-up 9 months after reconstruction showed the patient achieving independent ambulation. In conclusion, cross-leg free flaps may be used as a last resort to successfully salvage flaps in the setting of poor ipsilateral recipient vessels and repeatedly occluding anastomoses. more...

Background  February of 2016 marked 30 years since the passing of Marko Godina, a pioneer and prodigy in the field of reconstructive microsurgery. Most noteworthy among his many contributions was his method of radical debridement of contaminated compound fractures followed by early free tissue transfer for wound closure. In the last three decades, the landscape of reconstructive surgery has undergone significant transformation owing to advances in reconstructive techniques and wound care technology, as well as new data. Methods  Dr. Godina's work and legacy are reviewed, compared and contrasted with new and evolving data regarding lower extremity trauma reconstruction. Results  Advancements in technique and technology have greatly molded lower extremtiy reconstruction over the past thirty years. Nonetheless, Dr. Godina's principles of timely care and early vascularized soft tissue coverage have withstood the test of time. Conclusion  Marko Godina's contribution to reconstructive microsurgery cannot be overstated and his groundbreaking work continues to serve as the foundation of lower extremity trauma reconstruction. Three decades after his seminal work, we honor Dr. Godina's legacy and explore how his principles have endured, evolved, or been replaced. [ABSTRACT FROM AUTHOR] more...

Introduction: Compression ultrasound is a non-invasive technique allowing for qualitative visualization and quantitative measurements of mechanical tissue properties. In acute compartment syndrome (ACS), cadaver studies have proven that the intra-compartmental pressure (ICP) measured by compression sonography correlates with the ICP measured invasively. This study aimed to evaluate compression sonography for compartment pressure measurements in an animal model.Material and Methods: The pressure in the anterior tibial compartment of 6 domestic pig legs was increased from baseline to 40mmHg in 5mmHg steps. Using compression sonography, the compartment diameter was measured without external pressure and during manual application of five levels of external pressure. The elasticity ratio (ER) was computed as the ratio of the compartment diameter with and without external pressure. At 40mmHg of external pressure the ERs at different ICP levels were compared using repeated ANOVA measurements. Post-hoc comparisons evaluated the lowest detectable ICP fulfilling the definition of ACS (ICP≥30mmHg) by starting from each pressure below 30mmHg (baseline, 20mmHg and 25mmHg, respectively). Receiver operator characteristic analyses defined ER limits with appropriate sensitivity and specificity to detect ACS.Results: The ER increased from 79.0% at baseline ICP to 89.3% at 40mmHg ICP. The ER at baseline and at 20mmHg ICP significantly differed from the ER at 30mmHg ICP (p=0.007 and 0.002, respectively); the ER at 25mmHg ICP significantly differed from the ER at 40mmHg ICP (p=0.001). An ER less than 87.1% had a sensitivity of 94.4% and a specificity of 88.9% to proper diagnosis of ACS.Conclusion: Compression sonography might offer a non-invasive technique to guide treatment in cases of uncertain acute compartment syndrome. Further studies are needed to collect elasticity ratio data in humans and to clinically validate compression sonography for compartment pressure measurements. [ABSTRACT FROM AUTHOR] more...

Background Treatment algorithms for large soft tissue defects in lower extremity trauma are not clearly defined. The aim of this study is to determine if there are geographic or demographic differences in themanagement of open tibia fractures with soft tissue defects requiring either soft tissue reconstruction or amputation in the United States (US). Methods A retrospective analysis was performed on the Nationwide Inpatient Sample (NIS), 2000 to 2011.We evaluated flap and amputation rates in the open tibia fractures with soft tissue defects based on geographic and socioeconomic factors. Results From 2000 to 2011, there were 175,283 open tibia fractures in the US; 7.2% (n = 12,620) had a concomitant soft tissue defect requiring either flap or amputation. The overall flap rate was 73.2% (n = 9,235). When compared with the South at 68%, flap rates were highest in the West at 79% (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI] = 1.49, 2.86; p < 0.0001), followed by the Northeast at 77% (AOR = 1.63; 95% CI = 1.22, 2.19; p = 0.001), and the Midwest at 74% (AOR = 1.76; 95% CI = 1.25, 2.47; p = 0.001). Flap rates were lower in the rural hospitals in theWest (AOR = 0.24; 95% CI = 0.07, 0.84; p = 0.03) and Northeast (AOR = 0.55; 95% CI = 0.37, 0.82; p = 0.003) when compared with the urban hospitals. Flap rates were highest in the highest income quartile at 77% (AOR = 1.53; 95% CI = 1.05, 2.25; p = 0.03) compared with 72% in the lowest income quartile. Conclusions Reconstruction rates were significantly higher in three major US regions when compared with the South, urban hospitals in the West and Northeast, and the highest income quartile. [ABSTRACT FROM AUTHOR] more...

Multidetector computed tomography angiography (MDCTA) of the upper and lower extremities is the standard of care in the assessment of trauma patients with vascular trauma of the upper and lower extremities. A MDCTA of the extremities is typically integrated into multiphasic whole-body computed tomography trauma protocols in patients with suspected vascular injury. MDCTA has replaced catheter-directed digital subtraction angiography (DSA) as the modality of choice for the initial detection and characterization of vascular injuries because it is readily available, noninvasive, and faster than DSA. Understanding the imaging findings and pitfalls of upper and lower extremity MDCTA is essential in the diagnosis of vascular injuries such as active hemorrhage, vasospasm and stenosis, hematoma, occlusion and thrombosis, posttraumatic arteriovenous fistula, pseudoaneurysm, and patterns of intimal injury including dissection. We discuss the diagnosis and characterization of vascular injuries of the upper and lower extremities using MDCTA including derived multiplanar reconstructions,maximumintensity projection, and three-dimensional volume rendering techniques. [ABSTRACT FROM AUTHOR] more...

The aim of the present study was to examine changes of sera levels of C-reactive protein (CRP), interleukin- 10 (IL-10), phospholipase A2 (PLA2) and fibrinogen β polypeptide chain gene (Fbg) in patients with traumatic fracture of lower limb, and to evaluate their association with prognosis. The changes in sera levels of CRP, IL-10, PLA2 and Fbg were observed at the time of injury, 24 h, and 5 and 7 days after surgery in 90 patients with traumatic fracture of lower limb. In addition, 50 cases, who presented for health examination, were included as the normal controls. The expression of sera levels of CRP, IL-10, PLA2 and Fbg in patients with traumatic fracture of lower limb, was markedly higher than that in the normal controls prior to surgery (P<0.05). The concentration of CRP significantly increased within 24 h after emergency, but decreased gradually as the wound healed, compared to the controls. Pre- and postoperative IL-10 levels increased within 24 h and then decreased gradually. The level of PLA2 in patients before and after surgery was increased, and then decreased gradually. The level of Fbg in patients with trauma was increased after 24 h and then decreased, and increased gradually. The correlation of serum CRP and IL-10 levels (r=0.634, P<0.05), and that of PLA2 and IL-10 levels (r=0.617, P<0.05) were positive. In conclusion, the expression of CRP, IL-10, PLA2 and Fbg levels in traumatic fracture of lower limb markedly increased and was closely associated with prognosis. CRP, IL-10, PLA2 and Fbg levels may therefore serve as useful indexes in determining the progression and prognosis of patients with traumatic fracture of lower limb. [ABSTRACT FROM AUTHOR] more...

Summary Fillet flaps are traditionally harvested from nonsalvagable extremities to reconstruct complex soft tissue defects. This method results in minimal donor site morbidity, and can be effective in reconstructing large pelvic wounds requiring significant soft tissue coverage. Here, we present their application in three young patients with extensive pelvic wounds secondary to trauma and its sequelae. In each case, neurologic injury limited limb function, and fillet flaps were used to fill soft tissue defects and pad bony prominences. The fillet flaps have been successful in providing wound coverage in all cases, and have all remained intact to date, with a mean follow up time of 29 months. These results demonstrate a role for fillet flaps in the management challenging pelvic wounds, as they can provide both satisfactory tissue coverage and improved functional outcomes. [ABSTRACT FROM AUTHOR] more...

Background Venous outflow problems are the most common reasons for perioperative flap complications. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation. Materials and methods Retrospective review of our institutional flap registry from 1979 to 2014 identified 464 free flaps performed for lower leg trauma reconstruction. Patient demographics, flap characteristics, and outcomes were examined. Results A total of 219 flaps were randomly selected for preliminary analysis. Single-vein outflow was more common (72.6%) than dual-vein (27.4%); most of the recipients were in deep venous system (83.6%) versus superficial (11.9%) or both (4.6%). Two-vein anastomoses were more likely in fasciocutaneous flaps than muscle flaps ( P = 0.001) and in smaller (<300 cm 2 ) flaps ( P = 0.002). Complications occurred in 98 flaps (44.7%); with 54 partial flap losses (24.7%), and 11 complete flap losses (5.0%). Multivariable regression analysis controlling for age, sex, flap type, presence of bone gap, flap size, vein size mismatch, and time since injury demonstrated dual-vein outflow to be protective against complications (relative risk [RR] = 0.269, P = 0.001), partial flap failure (RR = 0.351, P = 0.031), and any flap failure (RR = 0.31, P = 0.010). No significant difference in operative time was found ( P = 0.664). Conclusions Dual-vein outflow demonstrated 73% reduction in overall complications and 69% reduction in flap failure rate compared to single-vein flaps. These results suggest a protective effect of a dual-vein outflow system, and when considered together with our findings of unchanged operative time, provide evidence for preferential use of two venous anastomoses when possible for free flap reconstruction of lower extremity trauma. [ABSTRACT FROM AUTHOR] more...

Background The anterolateral thigh (ALT) flap has a key role regarding limb salvage and has facilitated the preservation of function and esthetics in lower extremity reconstruction. The purpose of this study is to review the advantages of the ALT flap when used early in the reconstruction of the trauma patient; specifically, its long-term viability when ALT flap reconstruction is followed by recurrent flap elevation performed to allow a variety of sequential orthopedic operations including washout, antimicrobial disc placement, and reinstrumentation. Methods A retrospective analysis was performed to review all ALT flaps performed by the authors from January 2009 to October 2012 at the Orlando RegionalMedical Center. A total of 69 patients with an average age of 38 years were included in the study leading to a total of 69 ALT flaps indicated for traumatic orthopedic wounds. Out of these, 29 flaps were elevated at least once leading to a total of 49 flap elevations. Results Themedian number of days to flap elevation was 117 with aminimumof 1 day and a maximum of 540 days. A total of 42% flaps were elevated at least once after initial placement for reinstrumentation, washout, or antibiotic disk placement. Overall, 52% of the flaps were lifted once, 34% were lifted twice, and 14% were lifted more than thrice. There is no statistically significant difference in the complication rate between elevating the flap compared with primary ALT placement. Conclusion We conclude, therefore, there is no elevated risk to long-term viability by elevating the ALT flap. This combined with the ease of elevation makes it a safe procedure to be performed as needed for access to the deep tissues. [ABSTRACT FROM AUTHOR] more...

Introduction: Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. Methods: From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. Results: Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. Conclusions: The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition. [ABSTRACT FROM AUTHOR] more...

Introduction: Isolated fractures of the lower extremity are relatively common injuries while multifocal injuries resulting from high-energy trauma are less frequently encountered. Our objectives are to characterise patients who sustained multiple noncontiguous fractures and open fractures of the lower extremity, report the incidence of major complications, and identify factors that may contribute to complications and unplanned re-operations.Patients and Methods: A retrospective review of patients was performed at a Level 1 trauma centre from 2000 to 2013. Patients who sustained two or more noncontiguous operative fractures in an ipsilateral lower extremity, with at least one open fracture were included. Noncontiguous was defined as fractures in the same lower limb that were not in continuity on preoperative radiographs or intra-operatively. Demographic, injury characteristics, and hospitalisation data were collected. Primary outcomes included non-union, deep infection, and the need for unplanned surgeries.Results: 257 patients sustained a total of 876 lower extremity fractures with an average of 1.7 open and 2.7 operative fractures in the qualifying limb. Ninety-nine patients (38.5%) sustained bilateral lower extremity injuries. Following their initial stay, 22.6% of patients had planned procedures (definitive fixation, skin, or planned bone grafting). Nearly half (45.9%) required one or more unplanned re-operation. Complications included deep infections (19.5%), non-unions (19.5%), and mal-unions (2.7%). 17.5% of the patients had at least one procedure for removal of painful implants. A deep infection was predictive of having a non-union (odds ratio, OR 7.5). The presence of a Gustilo-type IIIB/IIIC (OR 24.6/16.0) fracture was predictive of having a deep infection. After excluding painful implant removal, a type IIIB fracture was associated with an unplanned procedure (OR 13.8).Conclusions: Patients with multiple non-contiguous lower extremity injuries associated with open fractures can expect complications including non-unions, deep infections, and painful implants. Nearly half of the patients will need further operative treatment. [ABSTRACT FROM AUTHOR] more...

The article focuses on the study of the orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway including high-intensity functional rehabilitation with a custom energy-storing orthosis. It focuses on severe lower extremity musculoskeletal injuries were treated with a combined intervention. more...

We report the sequential use of a pedicled fillet foot flap in a clinical case of complex bilateral lower extremity trauma to achieve stable wound closure, maximizing length preservation and gait rehabilitation. In addition, we perform a literature review of the use of fillet foot flaps in lower extremity trauma. [ABSTRACT FROM PUBLISHER] more...

Multi-detector computed tomography angiography (MDCTA) of the lower extremities is an integral part of the decision-making process of lower extremity trauma. MDCTA can be integrated into multiphasic whole-body trauma MDCT and has replaced the traditional gold standard of catheter-based angiography as the preferred technique for the initial assessment of lower extremity trauma in many institutions worldwide. Advances in MDCT technology enable high speed simultaneous evaluation of both complete lower extremities, rapid image reconstruction, and advanced image visualization for the noninvasive and accurate diagnosis of vascular, including hematoma, active extravasation, vasospasm, stenosis, external compression, occlusion, intimal injury and dissection, arteriovenous fistulas, and pseudoaneurysm formation. In this exhibit, we outline the role of MDCTA in the management of lower extremity trauma, review current MDCT protocols and the practical use of advanced visualization techniques, and illustrate typical MDCTA findings, pearls, and pitfalls, which help to accurately characterize vascular injury and guide management. [ABSTRACT FROM AUTHOR] more...

Acute compartment syndrome (ACS) is a surgical emergency. Diagnosis depends on a high clinical suspicion and an understanding of risk factors, pathophysiology and subtle physical exam findings. The typical high risk scenario for ACS is a male patient younger than 35 years of age, involved in a high energy sport or roadway collision, resulting in a tibial shaft fracture. He will go on to develop acute compartment syndrome of the leg in less than 10 hours and require emergent fasciotomy. Diagnosis of ACS in this patient is primarily a clinical one but can be confirmed with invasive intracompartmental pressure monitoring or non-invasive near infrared spectroscopy (NIRS). Delaying the diagnosis will likely result in some degree of permanent disability and places the surgeon at high risk for litigation. This article reviews the salient features of acute compartment syndrome that should be understood by all orthopaedic residents and surgeons. [ABSTRACT FROM AUTHOR] more...

Abstract: Fractures of the distal tibia are potentially devastating injuries fraught with many complications and poor outcomes, including financial hardships. The purpose of this study was to examine the financial outcomes in the short term of pilon fractures. Sixty patients who sustained pilon fractures were prospectively assessed on financial criteria and injury characteristics. This included various scores and also introduced a financial data sheet and outcome form. Twenty-five patients met inclusion/exclusion criteria and were available for follow-up. The mean age was 46.3 ± 12.0 years (19–61 years), with a mean follow-up of 11.8 ± 4.8 months (6–20 months). Only 7 patients (29.2%) returned to work at latest follow-up. Seven of 19 patients (36.8%) reported selling possessions to meet financial obligations, and 8 of 19 patients (42.1%) used social assistance programs. All 4 white-collar workers returned to work whereas only 3 (14.3%) of 21 blue-collar workers had returned to work at last follow-up (P = .001). Five (62.5%) of 8 patients who had graduated from college returned to work, but only 2 (14.3%) of 14 patients who did not attend college returned to work (P = .01). Because there are no widely used measures of financial status change in the literature, we have introduced some in this article including preinjury financial preparedness and postinjury strategies to fulfill financial obligations. These may be useful in evaluating outcomes and counseling patients. In addition, we have again demonstrated that there is a significantly higher return to work outcome in white collar jobs and higher education. [Copyright &y& Elsevier] more...

Tibial shaft fractures are the commonest cause of compartment syndrome. Intramedullary nails have been the most common treatment for such fractures. Raised pressures after nailing do not necessarily imply compartment syndrome, but are an important factor to consider when deciding on the appropriate treatment. A clinical study was performed that included 80 cases diagnosed with tibial shaft fractures and treated with reamed intramedullary nails. Compartment pressure was measured with a slit catheter. The pressure was calculated before and just after surgery. Delta P values were also calculated. Patients with overpressure but no clinical suspicion of compartment syndrome were monitored for 24 h. Patients diagnosed with compartment syndrome were treated via fasciotomy. A descriptive and statistical study was performed with 95% confidence intervals and significant difference p < 0.05. A statistically significant increase in pressure was observed after surgery. Delta P values only decreased after nailing in the anterior compartment, although the decrease was not significant (p ≥ 0.05). Four cases required monitoring for 24 h. Eleven patients were diagnosed with compartment syndrome after surgery, with absolute pressures of over 30 mmHg and delta P values of less than 40 mmHg. Reamed intramedullary nails can increase compartment pressures in tibial shaft fractures. The delta P value can influence the decision about whether to perform a fasciotomy. The diagnosis of compartment syndrome must be based on clinical findings. If there is any doubt, we recommend measuring the pressure and using a cut-off value for fasciotomy of delta P ≤ 40 mmHg. A delay in definitive treatment is suggested until pressure values are secure. [ABSTRACT FROM AUTHOR] more...

Complete dislocation of the knee is a rare injury, and is frequently associated with injuries to other structures in the popliteal fossa. Prompt recognition of associated popliteal artery disruption and early revascularization is paramount for successful and functional results. The necessity for emergency vascular reconstruction markedly complicates an already difficult orthopaedic problem. Arteriography is recommended in all cases of complete dislocation of the knee. [ABSTRACT FROM AUTHOR] more...

A retrospective, quantitative, long-term evaluation of patients with a free flap transfer to the lower extremity was carried out with respect to functional, socioeconomic, and esthetic outcome. The study included 57 patients who were examined by questionnaire filled out by both an examiner and the patients themselves. Indications for the free flaps were acute trauma or osteomyelitis and unstable scars arising from a previous trauma to the lower leg. The flap success rate was 94.7%. The period between the operation and evaluation was at least 3 years. A local, flap-specific functional impairment was found in 17 patients (30%) and a general impairment of the lower extremity in 56% of the subjects. With respect to the socioeconomic outcome more than two-thirds of the patients returned to their previous occupation with no restrictions; approximately 20% of subjects had to switch to a less strenuous job. Although from the viewpoint of the examiner the esthetic appearance was satisfactory in 44 free flaps (77%), the majority of the patients were conscious of pigmental, textural, or contour changes which produced a subjective esthetic compromise in 56% of cases. In conclusion, despite a considerably high rate of local functional impairment the majority of patients (89%) were satisfied and judged the application of a free flap as having been beneficial in preventing a loss in socioeconomic status. The high rate of esthetic problems demonstrates the importance of including esthetic considerations in designing the free flap, in particular with regard to (a) meticulously tailoring the flap, (b) aiming at a homogeneous skin surface, and (c) thoroughly shaping the affected lower extremity. [ABSTRACT FROM AUTHOR] more...

Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P <.05) for amputation on univariate analysis were included in a multivariable analysis. A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect. [ABSTRACT FROM AUTHOR] more...

Abstract Today, skeletal tibial traction remains a mainstay of initial management following high-energy, major orthopaedic lower extremity trauma. Historically utilized as definitive fracture management, recent advances in surgical technology have moved skeletal tibial traction into the realm of temporary management, with benefits including fracture reduction, pain relief, and restoration of disturbed surrounding soft tissues, lowering wound complication and compartment syndrome rates. However, no procedure is without its risks. Here, we present a case of common peroneal palsy following skeletal tibial traction placement, which resolved with subsequent pin removal. Indications, proper placement, potential etiologies, and a review of the literature are also discussed. more...

Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. A method to evaluate the predictors of amputation is needed because previous scores could not be validated. In the present study, we aimed to provide a simplified scoring system (POPSAVEIT [popliteal scoring assessment for vascular extremity injuries in trauma]) that could be used preoperatively to risk stratify patients with traumatic popliteal vascular injuries for amputation. A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared with those with limb salvage at the last follow-up. Of these patients, 80% were randomly assigned to a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (P <.1) on univariate analysis were included in a multivariable analysis. Those with P <.05 on multivariable analysis were assigned points according to the relative value of their odds ratios (ORs). Receiver operating characteristic curves were generated to determine low- vs high-risk scores. An area under the curve of >0.65 was considered adequate for validation. A total of 355 patients were included, with an overall amputation rate of 16%. On multivariate regression analysis, the risk factors independently associated with amputation in the final model were as follows: systolic blood pressure <90 mm Hg (OR, 3.2; P =.027; 1 point), associated orthopedic injury (OR, 4.9; P =.014; 2 points), and a lack of preoperative pedal Doppler signals (OR, 5.5; P =.002; 2 points [or 1 point for a lack of palpable pedal pulses if Doppler signal data were unavailable]). A score of ≥3 was found to maximize the sensitivity (85%) and specificity (49%) for a high risk of amputation. The receiver operating characteristic curve for the validation group had an area under the curve of 0.750, meeting the threshold for score validation. The POPSAVEIT score provides a simple and practical method to effectively stratify patients preoperatively into low- and high-risk major amputation categories. [Display omitted] [ABSTRACT FROM AUTHOR] more...

Background: In the context of major trauma, the rate of wound infection in surgical incisions created during fracture fixation amongst patients with closed high-energy injuries is high. One of the factors which may reduce the risk of surgical site infection is the type of dressing applied over the closed incision. The WHIST trial evaluates the effects of negative-pressure wound therapy (NPWT) compared with standard dressings.Methods/design: The WHIST trial is a multicentre, parallel group, randomised controlled trial. The primary outcome is the rate of deep surgical site infection at 30 days after major trauma. Secondary outcomes are measured at 3 and 6 months post-randomisation and include the Disability Rating Index, the EuroQoL EQ-5D-5 L, the Doleur Neuropathique Questionnaire, a patient-reported scar assessment, and record of complications. The analysis approaches for the primary and secondary outcomes are described here, as are the descriptive statistics which will be reported. The full WHIST protocol has already been published.Discussion: This paper provides details of the planned statistical analyses for this trial and will reduce the risks of outcome reporting bias and data driven results.Trial Registration: International Standard Randomised Controlled Trials database, ISRCTN12702354 . Registered on 9 December 2015. [ABSTRACT FROM AUTHOR] more...