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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]

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]

ObjectiveTraumatic 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.MethodsA 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.ResultsA 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.ConclusionsTraumatic 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.

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]

ObjectiveTraumatic 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.MethodsA 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.ResultsA 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

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]

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.

Ankle fractures are a common intra-articular trauma. The gold standard treatment for unstable ankle fractures has been Open Reduction Internal Fixation with plating and lag screw(s). Advocates for intramedullary nailing of the fibula note decreased wound complications and greater biomechanical strength. We hypothesized that time to union and time to weight bearing would be decreased with a fibular intramedullary nail compared to prior ankle ORIF literature. A retrospective cohort study was conducted of 65 consecutive ankle fracture patients treated with a fibular nail. The median follow-up time was 18.3 months (IQR: 55.4 - 97.6 days). All patients (100%) achieved clinical and radiographic union at a median of 9.6 (IQR: 54 - 78 days) and 10.8 weeks (IQR: 58 - 95 days), respectively. Post-operatively patients bore weight in walking boot and athletic shoe at a median 6.1 and 9.4 weeks, respectively. Fifteen patients suffered complications (23.1%). Patients with history of prior or active smoking were significantly correlated to longer time to union (p=0.016). Time to union also took 0.43 days longer for each additional year of age (t-value 2.13, p-value = 0.038). Nineteen out of 65 patients (29.2%) participated in the Olerud-Molander Ankle Scoring and the median functional outcome score was 71 (IQR: 56 - 93). While fibular nailing has advanced passive range of motion and weight bearing in our institution, time to weight bearing is clouded by surgeon comfort. Further study comparing fibular fracture healing and weight bearing status in regards to intramedullary and plate fixation in needed. LEVEL OF EVIDENCE: IV., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Calcaneal fractures are rare injuries constituting 2% of all fractures. Fractures of calcaneum correspond to nearly 60-75% of the tarsal bone fractures. The calcaneum is the most commonly fractured tarsal bone 90% occur in males between 21 and 45 years of age. The calcaneal fracture may be extra-articular (sparing the subtalar joint) and intra-articular involving the subtalar joint. Intra-articular fractures account for approximately 75% of calcaneal fractures and have been associated with poor functional outcomes. In this study, we aim to assess the functional outcome of internal fixation in displaced intra-articular calcaneal fractures., Materials and Methods: A prospective interventional study was conducted on patients with only intra-articular calcaneal fractures admitted to Chettinad Hospital and Research Institute, Kelambakkam during the period from May 1, 2022, to February 29, 2024, and a total of 32 patients were considered. The functional outcome was assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scoring System., Results: The average age of the patients in our study was 39 years of which all were male. Fall from height is the most common mode of injury. The right calcaneum is more commonly involved than the left. The mean duration of hospital stay was around 10 days. The fracture classification was based on the sanders and Essex-Lopresti classification of which 17 patients were sanders type 3 and 13 patients were sanders type 2 and 1 patient was sanders type 4. The mean time for radiological union is 12 weeks. The Bohler's angle and Gissane's angle preoperatively 16.16 ± 8.87 and 121.48 ± 7.47 restored to near normal values after fixation 27.77 ± 6.02 and 113.485 ± 44, respectively. Heel height and heel width restored to near normal values of (pre-operative heel height - 24.74 ± 3.71 and heel width - 39.97 ± 4.11 and post-operative heel height - 31.55 ± 3.38 and heel width - 34.0 ± 3.1), respectively. The most common complications were wound-related complications (superficial wound infection - 9.7%, deep wound infection - 3.2%, and wound margin necrosis and wound dehiscence 6.4%) and the most common late complications were complex regional pain syndrome - 9.7% and subfibular lateral impingement with peroneal tendinitis - 6.5%. AOFAS grading of functional outcome had shown good to excellent results in 83.8% (26 patients) of the cases. The mean AOFAS score was 83.39 in our study., Conclusion: The present study shows that open reduction and internal fixation give superior radiographic results as shown by the restoration of Bohler's and Gissane's angle and height and width of the calcaneus to near normal values, indicating anatomical restoration of calcaneal shape. The functional outcome by AOFAS score showed good to excellent results in most of the patients with minimal wound complications., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

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.

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]

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.

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]

Compartment syndrome (CS) can be defined as an acutely painful condition that occurs due to increased pressure within a compartment, resulting in reduced blood flow and oxygen to nerves and muscles within the limb. It is considered a surgical emergency, and a delayed diagnosis may result in ischemia and eventual necrosis of the limb. The majority of cases in adults are associated with high-energy trauma, more specifically, long bone fractures of the lower limb, while supracondylar fractures of the humerus are highly associated with CS in pediatric patients. CS may also develop gradually as a result of prolonged and ongoing physical activity such as running. In this narrative review, we discuss the anatomy, pathophysiology, methods of diagnosis, and effective management of CS in adults and children., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Hobbs et al.)

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.

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]

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]

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]

• 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]

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]

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]

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.

High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV., Competing Interests: Disclosures: DM discloses speaker’s bureau with Skeletal Dynamics and Axogen, DC discloses education with Smith and Nephew. HN/ WC/JH have nothing to disclose., (Copyright © The Iowa Orthopaedic Journal 2023.)

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]

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]

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]

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]

Background Chainsaws cause injuries mostly on the upper extremities, then on the face and lower extremities. In the literature, there are many studies about hand and face injuries; however, articles about lower extremity injuries are limited. The aim of the study is to define injury patterns, treatments, and results of the cases that we have encountered in our hospital and to evaluate precautions after reviewing the literature. Methods Patients admitted to our hospital's Emergency Department with chainsaw-related lower extremity injuries between 2016 and 2021 are evaluated. Patients' demographic data, pathologies, treatments, length of stay in hospital, return to work time, and functional scores are calculated retrospectively. Results There were 39 male and two female patients, with a minimum follow-up of 12 months. Their mean age was 42.6 ± SD (16-62). Thirty-two patients (78.04%) had injuries on the left lower extremity, and nine patients (21.9%) had injuries on the right lower extremity. 93.75% (30/32) of the patients with left lower extremity injuries had the right hand as the dominant extremity. The most frequently observed injury pattern was extensor hallucis longus (EHL) tendon disruption, with a percentage of 58.5% (24/41). 29.2% (13/41) of the cases had bone pathologies present as well. Patients' average AOFAS score was 97.4 ± 4.4 (74-100) at the end of one year. The average hospitalization length of stay was 2.95 ± 2.7 (0-15) days, and the time interval of return to work was 6.17 ± 1.4 (2-15) weeks, excluding one patient who had to change his workplace. Conclusion Saw-related injuries of the lower extremities are the injuries that can be seen mostly in male patients. Among the right dominant-handed patients, left foot dorsum injuries were the most common EHL tendon disruptions observed. We have seen that the reason for this is foot injuries remaining in the projection of the saw due to incorrect positioning of the foot. Protective gear and shoes must be used as precautions. More preventive measures could be taken while using chainsaws and similar tools, as they may cause serious injuries. Requirements for the use and sale of this tool should be introduced, and training should be given as it can be easily purchased by the public., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Gemci et al.)

We report the case of a 41-year-old man with a Morel-Lavallée lesion (MLL) that developed an infection. The patient was initially treated with intravenous antibiotics, but the infection persisted. He was then treated with outpatient cleansing and retention sutures, which resulted in successful wound healing. This case report demonstrates the efficacy of outpatient cleansing and retention sutures for the treatment of MLL infection. This treatment modality is less expensive than inpatient treatment, and it allows the patient to return to their normal activities sooner., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Miura et al.)

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]

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]

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]

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]

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]

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]

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.

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]