Trochanteric Area Research Articles

The Treatment of Intertrochanteric Fractures of the Femur with Endovis Nail

BACKGROUND The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly persons with osteoporosis. The imperative goals of treatment are early mobilization by means of stable fixation using as minimally invasive a procedure as possible. Nowadays, there is an increasing interest in intramedullary nailing, especially for unstable intertrochanteric fractures. The aim of the present paper is to assess the efficacy of closed intramedullary osteosynthesis with the Endovis® proximal femoral nail in the treatment of peritrochanteric fractures to solve the problems associated with the use of intramedullary fixation devices. MATERIAL AND METHODS The authors describe their experience with 87 stable and unstable proximal extra-capsular femoral fractures treated with the Endovis femoral nail from July 2007 to March 2009. The results were evaluated clinically, functionally and radiographically during the 1st, 3th, 6th and 12th months post-op. Pre-injury activity and functional levels were recorded using the modified Harris hip score and V.A.S. score. RESULTS Postoperative radiographs showed a near-anatomical fracture reduction in 85% of patients. Three were the cases of cut-out, one case of valgus and two cases of shortening of the operated leg (<1 cm). The Harris Hip Score increased between the thirtieth and ninetieth postoperative day, accompanied by a significant decrease in pain symptoms and functional limitation. CONCLUSION 1. The application of an intramedullary nail provides primary stability of the fracture. 2. The Endovis nail constitutes a powerful synthesis for stable and unstable fractures of the trochanteric region, in which is difficult to reconstruct appropriate continuity between the medial and posterior cortical layers. 3.The good mechanical stability of the nail allows rapid mobilization and early functional recovery. 4. The presence of an additional anti-rotational screw and the free sliding mechanism of the lag screw may increase rotational stability of cervico-cephalic fragments and decrease overload on the femoral head.

Finite element model of a novel short stemmed total hip arthroplasty implant developed from cross sectional CT scans

Numerous short stemmed total hip arthroplasty (THA) implants have been introduced over the last decades. It is questionable if little differences between the implant designs affect stress shielding and bone remodeling. The finite element analysis allows an evaluation of the design rationale of the implant without negative side effects for the patient.OBJECTIVE: We investigated a relatively new short stemmed implant designed from clustered CT datasets of proximal femurs. How does the implant affect femoral bone remodeling? Can we see a positive effect on bone remodeling from the CT based design? We used a Finite Element Model that was validated by a prospective dual-energy-x-ray-absorptiometry study to calculate apparent bone density.RESULTS: Apparent bone density (ABD) decreased by 2.3% in the entire femur. Bone mass loss was pronounced in the proximal calcar region. Little ABD increase was seen in the lateral aspect of the cortical ring, in the minor trochanter area and at the lateral aspect of the stem. ABD reduction occurs in the proximal regions of the femur. The overall bone mass loss was little after THA with the investigated implant. The specific design seems to have no major effect on stress shielding or load distribution.

Skin preparation before hip replacement in emergency setting versus elective scheduled arthroplasty: Bacteriological comparative analysis

Hip arthroplasty needs to be performed in an emergency setting after intracapsular femur neck fracture, whereas pain makes preoperative skin preparation of the limb difficult and it may therefore be incomplete. To date no study has analyzed the patient's skin bacteriological status in these surgical conditions. The skin's bacterial flora is quantitatively and qualitatively different in the trauma context compared to an elective scheduled arthroplasty for chronic hip disease. Two groups of patients, undergoing hip arthroplasty and having the same preparation at the time of surgery but different skin preparation procedures the day before and the day of surgery, were prospectively compared: 30 patients operated on in an emergency setting for fracture (group A) had no skin preparation and 32 patients operated on in scheduled surgery (group B). Group A had no skin disinfection before going into surgery, whereas group B followed a predefined protocol the day before surgery. Skin samples were taken on gelose at three different stages of skin preparation at the time of surgery (before and after detersive cleaning, and at the end of the surgery) and on two sites (inguinal and greater trochanter). The bacteriological analysis took place after 48 hours of incubation. Before detersive cleaning, group A had 3.6 times more bacteria than group B in the trochanter region and 2.7 times more in the inguinal area. After detersive cleaning, the contamination rate in the trochanter area was similar in both groups (group A: 10%; group B: 12.5%), but different in the inguinal region (group A: 33%; group B: 3%; P=0.002). At the end of the surgery, no difference was identified. Coagulase-negative Staphylococcus and Bacillus cereus accounted for 44% and 37%, respectively, of the bacteria isolated. In addition, the frequency of pathogenic non-saprotrophic bacteria was higher in group A (38%) compared to group B (6%). At a mean follow-up of 9.7 months (range: 8-11 months), no infection of the surgical site was identified. The dermal flora is more abundant and different when the patient is managed in an emergency context. Although effective in the trochanter area, cutaneous detersive cleaning in the operating room is insufficient in the inguinal area and the frequency of pathogenic bacteria warrants identical rigor in preoperative preparation in all situations. III. Prospective case - control study.

Biomechanical Evaluation of Interlocking Lag Screw Design in Intramedullary Nailing of Unstable Pertrochanteric Fractures

Intramedullary nails with special lag screw designs may provide improved mechanical performance and alleviate clinical problems. We hypothesize that the proximal design of trochanteric nails affects mechanical performance. Ten pairs of human cadaveric femora were implanted with 2 different short intramedullary nails without (Gamma3) and with an interlocking lag screw (Intertan). An unstable, multifragmentary, pertrochanteric fracture was created. Bones were tested in a cyclic testing protocol with increasing loads until failure simulating 1 leg stance. Stiffness, failure load, cycles to failure, and fracture gap movements were measured. Initially stiffness of the interlocking lag screw nail was almost 40% larger (P = 0.005) compared with the noninterlocking nail. During the test, the difference in stiffness gradually decreased. Failure load (13%, P = 0.02) and cycles to failure (18%, P = 0.02) were larger for the interlocking nail construct. Rotation and varus collapse of the head were initially up to 84% lower (P = 0.013) for the interlocking technique. During the test, the rate of rotational instability gradually increased for both techniques. The interlocking lag screw design reduced movement of the femoral head and relative movement between fracture fragments. Beyond that the trapezoidal nail design of the Intertan reduced toggling within the trochanteric area and prolonged survival. Although this study showed a decrease in the retention of stability over time, failure did not occur until the equivalent of 2-3 months of reduced physical activity in which healing may have occurred under normal clinical conditions.

High Frequency of Adverse Local Tissue Reactions in Asymptomatic Patients With Metal-on-Metal THA

The key to successful management of patients with metal-on-metal (MOM) THAs is to diagnose adverse local tissue reactions (ALTRs) early. ALTRs have been described in asymptomatic patients with resurfacing arthroplasties. Whether this concerning finding applies to modular MOM THAs is unknown. We (1) determined the prevalence of ALTRs in asymptomatic patients with modular MOM THAs, (2) described any differences in the appearance of these lesions between symptomatic and asymptomatic patients, and (3) analyzed potential predictive factors for any associations with ALTR prevalence. We evaluated 114 patients with modular MOM THAs who had MRI with metal artifact reduction sequence software and metal ion laboratory results at a mean of 57 months postoperatively. There were 83 asymptomatic and 31 symptomatic patients. We defined ALTRs as abnormal fluid collections, solid or semisolid pseudotumors, or muscle or bone damage. Ion levels, lesion size, and cup abduction angles were analyzed. Twenty-six (31%) asymptomatic patients had ALTR lesions, all of which were in the greater trochanteric area. Most lesions in symptomatic patients also were in that location, but there was more diversity of location in this group. The cup position among patients with ALTRs was generally good; the average abduction angle for the asymptomatic patients with ALTRs was 40°. In 24 (92%) and 22 (85%) of 26 asymptomatic patients with ALTRs, respectively, chromium and cobalt levels were below the 7-ppb threshold. A 31% incidence of periarticular fluid collections in asymptomatic patients with modular MOM THAs is alarming and calls into question any algorithmic approach dependent on symptomatology. The presence of pain was insufficient to identify patients at risk for ALTRs. To determine whether routine cross-sectional imaging of all asymptomatic patients with MOM implants is necessary will require a larger study cohort, longer followup, and clearer understanding of the natural history of periarticular lesions in these patients.

Milk consumption throughout life and bone mineral content and density in elderly men and women

Association between bone mineral density and bone mineral content in old age and milk consumption in adolescence, midlife, and old age was assessed. The association was strongest for milk consumption in midlife: those drinking milk daily or more often had higher bone mineral density and content in old age than those drinking milk seldom or never. The role of lifelong milk consumption for bone mineral density (BMD) and bone mineral content (BMC) in old age is not clear. Here we assess the association between hip BMD and BMC in old age and milk consumption in adolescence, midlife, and current old age. Participants of the Age, Gene/Environment Susceptibility-Reykjavik Study, aged 66-96 years (N = 4,797), reported retrospective milk intake during adolescence and midlife as well as in current old age, using a validated food frequency questionnaire. BMC of femoral neck and trochanteric area was measured by volumetric quantitative computed tomography and BMD obtained. Association was assessed using linear regression models. Differences in BMC, bone volume, and BMD in relation to milk intake were portrayed as gender-specific Z-scores. Men consuming milk ≥ once/day during midlife had 0.21 higher Z-scores for BMD and 0.18 for BMC in femoral neck (95 % confidence interval 0.05-0.39 and 0.01-0.35, respectively) compared with < once/week. Results were comparable for trochanter. For women the results were similar, with slightly lower differences according to midlife milk consumption. For current and adolescent milk consumption, differences in Z-scores were smaller and only reached statistical significance in the case of BMD for current consumption in men, while this association was less pronounced for BMC. Our data suggest that regular milk consumption throughout life, from adolescence to old age, is associated with higher BMC and BMD in old age, with no differences seen in bone volume. The strongest associations are seen for midlife milk consumption in both genders.

The absence of a metal-on-metal bearing does not preclude the formation of a destructive pseudotumor in the hip—a case report

The absence of a metal-on-metal bearing does not preclude the formation of a destructive pseudotumor in the hip—a case report

Treatment of osteonecrosis of the femoral head by using the greater trochanteric bone flap with double vascular pedicles

The use of the bone flap transfer has been reported to be successful in treatment of patients with early to medium stage (Ficat and Arlet stage I-III) osteonecrosis of the femoral head (ONFH). We examined the vascular anatomy and blood supply of the greater trochanter area and evaluated the feasibility of revascularization of the femoral head by using the bone flap pedicled with transverse and gluteus medius branches of the lateral circumflex femoral artery. Based on the anatomy study, from January 2002 to May 2004, 32 ONFH patients were treated with the greater trochanteric bone flap pedicled with double blood vessels. Fifteen femoral heads were Ficat and Arlet stage II and 17 were stage III. The mean follow-up was 99.5 months. Two of the 32 patients required a total hip replacement due to severe hip pain after surgery. The overall Harris hip score improved from a mean of 55.2 points to 85 points. Our data suggest the procedure is relatively easy to perform, less donor-site morbidity and useful for young patients with stages II to III disease with or without mild collapse of the femoral head.

English

Introduction Proximal lateral thigh pain is a common musculoskeletal complaint. Tenderness at the femoral greater trochanteric area is often diagnosed as trochanteric bursitis. This term is probably a misnomer because of evident non-inflammatory pathologies, particularly of the abductor tendons of the hip and is currently referred as the greater trochanteric pain syndrome. Although the clinical presentation seems straightforward it is important to differentiate this extra-articular source from an intraarticular or a lower back source of pain. Non-traumatic acute pain does not require the use of imaging modalities. Imaging of the lower spine and pelvis should be ordered in cases of prolonged pain or uncertain diagnosis. Non-operative treatment that involves modifying activities, physiotherapy, analgesics, steroid injections and shock wave therapy is usually helpful. Nevertheless, despite the above treatments about one-third of the patients suffer from chronic pain and disability. These patients may be candidates for operative intervention such as local decompression, bursectomy and suture of torn tendons. The aim of this review was to discuss trochanteric bursitis of the hip. Conclusion The differential diagnosis for greater trochanteric pain syndrome includes pathologies around the hip and lower back. Usually non-operative treatment that includes modified activity, physiotherapy, local injections and shock wave therapy is helpful. Introduction Greater trochanteric pain syndrome (GTPS) is a common clinical diagnosis. Typically, the pain is at the lateral side of the hip around the greater trochanter (GT) region, mostly in middleaged women and disturbs the activities of daily living. The pathophysiology is not completely understood. One of the earliest descriptions was published by Partridge1 in 1948 and was often termed the ‘great mimicker’ because of its similarities to other pathologies. The more familiar term ‘trochanteric bursitis’ that implies an inflammatory process is probably inaccurate. Recent histological2, radiological3 and surgical4 investigations showed tendinopathy and tears of the gluteal tendons around the GT with no significant inflammation of the bursae. Currently, the more acceptable term is GTPS5,6. This article reviews the anatomy, aetiology, diagnosis and updated treatment modalities of GTPS. Discussion Anatomy The gluteus medius, gluteus minimus and tensor fascia lata muscles are the main abductors of the hip joint and stabilise the femoral head inside the acetabulum during motion and weight bearing7. The pain in GTPS is related to various pathologies in these tendons with secondary involvement of the surrounding bursae. There are some similarities in function and malfunction between the hip abductors and the rotator cuff tendons of the shoulder8. The abductor muscles originate from the posterior aspect of the iliac bone and insert into the femoral GT. Specifically, the gluteus medius inserts into the superolateral aspect and the gluteus minimus into the anterior aspect of the GT. Bursa is a small fluid-filled sac that reduces friction between bone and soft tissue. Four bursae were described around the GT and deep to the gluteal muscles (Figure 1) while two are consistently found in most people9: the subgluteus medius bursa (between the gluteus medius and the GT) and the subgluteus maximus bursa (between the gluteus medius and gluteus maximus, lateral to the GT). The latter is the largest and often accused in causing the pain of ‘trochanteric bursitis’. There are other minor bursae that decrease the friction between gluteal muscles, tensor fascia lata and iliotibial band (ITB). The subgluteus minimus bursa is small and located superior and anterior to the GT while, the gluteofemoral bursa is inferior to the GT, adherent to the ITB at the insertion site of the gluteus maximus. Aetiology The aetiology of GTPS is variable. Direct injury to the proximal thigh or repeated irritation of the gluteal muscles and ITB against the GT can trigger symptoms. Limb length differences whether static or temporary (i.e. running on uneven surfaces) create mechanical imbalance that may influence the abductor muscles. Although sometimes there is no obvious cause, many related factors were found to be correlated with GTPS such as age, female sex, overweight, gait disturbances and lower back pain10. Schapira et al.11 found that GTPS was correlated with arthritis of the lower back or lower limbs in 91.6% of the cases. *Corresponding author Email: barak_haviv69@hotmail.com Arthroscopy and Sports Injuries Unit, Hasharon Hospital, Rabin Medical Center, Petach-Tikva,

Supra-valvular aortic stenosis in a patient with homozygous familial hypercholesterolaemia

An 18-year-old female was referred for a cardiac murmur before surgical excision of large subcutaneous swellings over bi-lateral trochanteric areas ( Panel A ). On evaluation they were found to be tendon-xanthomas, that also involved the gluteal-folds, finger web-spaces ( Panel B ), and tendons of the foot. Corneal arcus was also noted ( Panel C ). Her total cholesterol of 696 mg% and low-density lipoprotein (LDL) cholesterol of 648 mg% were consistent with familial …

Assessing complexity of skin blood flow oscillations in response to locally applied heating and pressure in rats: Implications for pressure ulcer risk

The objective of this study was to investigate the effects of local heating on the complexity of skin blood flow oscillations (BFO) under prolonged surface pressure in rats. Eleven Sprague-Dawley rats were studied: 7 rats underwent surface pressure with local heating (△t=10°C) and 4 rats underwent pressure without heating. A pressure of 700 mmHg was applied to the right trochanter area of rats for 3 h. Skin blood flow was measured using laser Doppler flowmetry. The loading period was divided into nonoverlapping 30 min epochs. For each epoch, multifractal detrended fluctuation analysis (MDFA) was utilized to compute DFA coefficients and complexity of endothelial related metabolic, neurogenic, and myogenic frequencies of BFO. The results showed that under surface pressure, local heating led to a significant decrease in DFA coefficients of myogenic frequency during the initial epoch of loading period, a sustained decrease in complexity of myogenic frequency, and a significantly higher degree of complexity of metabolic frequency during the later phase of loading period. Surrogate tests showed that the reduction in complexity of myogenic frequency was associated with a loss of nonlinearity whereas increased complexity of metabolic frequency was associated with enhanced nonlinearity. Our results indicate that increased metabolic activity and decreased myogenic response due to local heating manifest themselves not only in magnitudes of metabolic and myogenic frequencies but also in their structural complexity. This study demonstrates the feasibility of using complexity analysis of BFO to monitor the ischemic status of weight-bearing skin and risk of pressure ulcers.

Trabecular Homogeneity Index Derived From Plain Radiograph to Evaluate Bone Quality

Radiographic texture analysis has been developed lately to improve the assessment of bone architecture as a determinant of bone quality. We validate here an algorithm for the evaluation of trabecular homogeneity index (HI) in the proximal femur from hip radiographs, with a focus on the impact of the principal compressive system of the trabecular bone, and evaluate its correlation with femoral strength, bone mineral density (BMD), and volumetric trabecular structure parameters. A semiautomatic custom-made algorithm was applied to calculate the HI in the femoral neck and trochanteric areas from radiographs of 178 femoral bone specimens (mean age 79.3 ± 10.4 years). Corresponding neck region was selected in CT scans to calculate volumetric parameters of trabecular structure. The site-specific BMDs were assessed from dual-energy X-ray absorptiometry (DXA), and the femoral strength was experimentally tested in side-impact configuration. Regression analysis was performed between the HI and biomechanical femoral strength, BMD, and volumetric parameters. The correlation between HI and failure load was R(2) = 0.50; this result was improved to R(2) = 0.58 for cervical fractures alone. The discrimination of bones with high risk of fractures (load <3000 N) was similar for HI and BMD (AUC = 0.87). Regression analysis between the HIs versus site-specific BMDs yielded R(2) = 0.66 in neck area, R(2) = 0.60 in trochanteric area, and an overall of R(2) = 0.66 for the total hip. Neck HI and BMD correlated significantly with volumetric structure parameters. We present here a method to assess HI that can explain 50% of an experimental failure load and determines bones with high fracture risk with similar accuracy as BMD. The HI also had good correlation with DXA and computed tomography-derived data.

Patterns of Changes in Femoral Bone Mineral Density Up To Five Years After Hip Resurfacing

This is a prospective study of 26 patients (29 hips) on the patterns of change in the Bone Mineral Density (BMD) in various zones of the femoral neck and proximal femur five years after hip resurfacing. We have found that BMD continues to positively change up to five years after hip resurfacing. This was observed primarily in the trochanteric and superior neck regions. In both these regions BMD had decreased by up to 10% at six-weeks and three-months after surgery and then had recovered to preoperative level by one year. A regression analysis to assess the influence of age, gender, BMI, preoperative BMD, component size and orientation revealed that the best predictor of change in BMD at five years in the trochanteric area was acetabular component inclination.

Lipolysis using a new 1540-nm diode laser: A retrospective analysis of 230 consecutive procedures

Background: Although traditional liposuction still remains the most required body sculpting procedure, laser lipolysis systems are becoming increasingly popular. The feasibility and efficacy of a new 1540-nm diode laser for suction-assisted laser lipolysis were evaluated. Methods: Two hundred-thirty patients underwent a new 1540-nm diode laser lipolysis. Outcomes were determined by case notes, clinical review of side effects, and a questionnaire through which patient satisfaction was assessed. Macroscopic and histologic effects on subcutaneous fat and collagen deposition were evaluated. Moreover thermal effects were studied through thermography. Results: The treated regions were abdomen in 56 cases, thighs in 54, trochanteric area in 27, flanks in 17, neck in 14, arms in 12, breast in 11, hips in 7, knees in 3; 29 cases were revisions of previous lipoplasties. No adverse effect as scarring, infection, burns, hypopigmentation, bruising, or swelling was observed. The required effects of laser lipolysis such as contour reshaping and skin tightening were achieved in almost all patients with high levels of satisfaction after treatment. Conclusion: Our investigation highlighted the safety and efficacy of the new 1540-nm diode laser assisted liposuction device for removal of small volumes of fat deposits associated with concurrent subdermal tissue contraction, tolerance and quick recovery time.

Trochanteric area pain, the result of a quartet of bursal inflammation

Bursitis is quite responsive to therapeutic intervention, once the afflicted area is accurately identified. This is especially notable for some hip complaints. Patients' use of the term "hip" can relate to anything from the low back to groin to lateral thigh pain. Trochanteric area surface localization of "hip" pain may afford an opportunity for immediate cure. Effectiveness of therapeutic intervention is predicated upon injection of not one or two, but all four peri-trochanteric bursa with a depot (minimally water-soluble) corticosteroid. The term trochanteric bursitis suggests that the inflammation is more focal than what is clinically observed. While easier to express, perhaps it is time to refer to inflammation in this area, naming all four affected bursae.

Simulation Study on Mechanisms of Hip Fractures in Backward Falls

Past researches that evaluated hip fracture risk had focused on sideways falls, while backward falls were also reported to cause as many hip fractures as the sideways falls do. To understand the mechanism of hip fracture during a backward fall, we conducted fall simulations using a “Multi-body and Finite-element Coupled Human Model”. This model was effective and efficient in simulating both the kinematic behavior of the whole body and the stress distribution around the femoral neck simultaneously and in evaluating hip fracture risk resulting from the fall. In the simulations, the lateral area of the greater trochanter contacted the floor in the sideways fall, and the proximal top of the greater trochanter contacted the floor in the backward fall with the upper body tilted laterally. In the backward fall, the impact velocity and the contact force with the floor were low. However, as the geometrical relationship among the femur, hip joint, and pelvis made the contact force work more efficiently, the shearing force and the torsional moment in the femoral neck were large and the maximum values of each stress were the same or higher as compared to that of the sideways fall. Besides, the pubic rami are likely to break and thereby prevent a femoral neck fracture in the sideways fall, but not while in the backward fall. This result shows that the risk of a hip fracture in the backward fall is the same or even higher than that in the sideways fall.

Salvage of a recurrent trochanteric pressure sore with coxofemoral osteoarthritis using a superficial inferior epigastric artery propeller flap

Sir, The recurrence of pressure sores remains a problem in paraplegic patients. More than 35 % of operated patients will have a recurrence [1–3]. Recurrent ulcers can occur after fasciocutaneous flaps and also musculocutaneous flaps. Then, flaps must be parsimoniously used for covering pressure sores. The superficial inferior epigastric artery (SIEA) flap is well known as a free flap, especially for breast reconstruction. We report the interest of the SIEA propeller flap for covering a recurrent trochanteric pressure sore in a paraplegic patient. Mr. D. is a 52-year-old male, having a T3 paraplegia, secondary to a spinal cord injury 29 years ago. In less than 25 years, he experienced pressure sores in sacral, trochanteric, and ischiatic areas. On the right trochanteric region, he was successively treated by a tensor fascia lata myocutaneous flap, a vastus lateralis muscle flap, and a groin flap for two recurrences in 20 years. Recently, he developed another trochanteric pressure sore, associated with an osteoarthritis of the right coxofemoral joint (Fig. 1). The patient complained about hyperthermia and a limitation of the hip mobility (10° in flexion, 0° in adduction, and 0° in abduction), making the chest to bed transfers more difficult. A multidetector-row computed tomography was made to confirm the osteoarthritis and evaluate the cutaneous perforators of the abdominal region. No reliable perforators was found from the deep inferior epigastric artery, but the caliber (2.6 mm) and the course (130 mm) of the SIEA were appropriate to raise a skin flap. The larger direct perforator of the SIEA had a 1.2-mm caliber, a 41-mm length, and the ascendant directionality adequate for a large skin flap. The surgery started by a large excision of the infected soft tissues around the ulcer. A femoral head–neck resection was performed. After a large cleaning and freshening of the acetabulum, the origin of the SIEA was dissected. The dominant direct perforator was found and included in the flap. A skin paddle measuring 15 × 20 cm was raised. The flap was rotated up to 100° for covering the trochanteric defect, as a propeller flap [4] (Fig. 2). The donor site was primarily closed. The operative time was 3 h, including the femoral head–neck resection, flap raising, and coverage of the coxofemoral defect. The patient was completely healed 2 weeks postoperatively. No recurrence or postoperative infection occurred during a follow-up of 24 months (Fig. 3). At 1 month, the patient recovered a mobility of 65° (45–110°) in flexion, 20° (0–20°) in adduction, and 40° (0–40°) in abduction. The chest to bed transfers and the dressing were significantly improved postoperatively. Fig. 1 Preoperative view of the trochanteric pressure sore. A central suppurative fistula is surrounded with inflammatory skin lesions. This trochanteric ulcer is associated with an osteoarthritis of the right coxofemoral joint Fig. 2 Intraoperative view of the superficial inferior epigastric artery propeller flap. The superficial inferior epigastric artery (yellow arrow) is dissected at the lower part of the abdomen. The proximal dominant perforator and the superficial inferior epigastric ... Fig. 3 Postoperative view of the trochanteric reconstruction. The trochanteric area is completely healed without infection 24 months postoperatively. No recurrence has occurred 24 months after the surgery. A few visible longitudinal scar can ... Pressure sores reconstructive surgery in paraplegics is known for a high risk of recurrence. Musculocutaneous flaps have been mainly used for their thickness and blood supply in this indication. However, the results of this complex case confirm that there is no statistical difference in ulcer recurrence between myocutaneous flaps and fasciocutaneous flaps [5]. Reeducation and prevention of skin hyperpressure seem to be more important than a muscle transfer. This case also reports the interest of the SIEA flap when classical flaps are not available for local reconstructions, and when no reliable perforators (>0.5 mm) are present for a deep inferior epigastric perforator flap. The SIEA flap can be safely rotated around its pedicle, as a propeller flap, without venous congestion or flap necrosis. It is a versatile flap for the coverage of large and infected trochanteric pressure sore.

Local cooling reduces skin ischemia under surface pressure in rats: an assessment by wavelet analysis of laser Doppler blood flow oscillations

The objectives of this study were to investigate the effects of local cooling on skin blood flow response to prolonged surface pressure and to identify associated physiological controls mediating these responses using the wavelet analysis of blood flow oscillations in rats. Twelve Sprague–Dawley rats were randomly assigned to three protocols, including pressure with local cooling (Δt = −10 °C), pressure with local heating (Δt = 10 °C) and pressure without temperature changes. Pressure of 700 mmHg was applied to the right trochanter area of rats for 3 h. Skin blood flow was measured using laser Doppler flowmetry. The 3 h loading period was divided into non-overlapping 30 min epochs for the analysis of the changes of skin blood flow oscillations using wavelet spectral analysis. The wavelet amplitudes and powers of three frequencies (metabolic, neurogenic and myogenic) of skin blood flow oscillations were calculated. The results showed that after an initial loading period of 30 min, skin blood flow continually decreased under the conditions of pressure with heating and of pressure without temperature changes, but maintained stable under the condition of pressure with cooling. Wavelet analysis revealed that stable skin blood flow under pressure with cooling was attributed to changes in the metabolic and myogenic frequencies. This study demonstrates that local cooling may be useful for reducing ischemia of weight-bearing soft tissues that prevents pressure ulcers.

Use of Lipofilling for the Treatment of Severe Burn Outcomes

Sir:FigureBurn outcomes still represent a problem because of aesthetic and functional concerns and also because of concern regarding the patient's social and psychological life. Lipofilling can be used in the treatment of the resulting scars, providing a sensitive improvement in the quality of the skin.1,2 Adipose tissue is a reserve of mesenchymal stem cells that can divide indefinitely, producing various cellular lines. It could be the physiologic means of replacing cells lost in atrophied scar tissues and ameliorating the mechanical and biological properties of the skin.3,4 From November of 2009 to December of 2010, 18 patients with postburn hypertrophic scars and keloids underwent surgery in the Plastic and Reconstructive Surgery Clinic at the Second University of Naples. They had previously undergone a mean of 5.5 (range, three to eight) restorative operations before fat grafting. The follow-up period was 15 months. Results were evaluated at the end of the follow-up period by the operating surgeons, by the patients themselves, and by an independent medical observer. The evaluations were obtained by means of a questionnaire (Table 1). Postoperative satisfaction was rated on a scale of 0 to 10. Clinical results were documented by preoperative and postoperative digital photographs.Table 1: Questionnaire Used to Determine the General Satisfaction of the PatientsGeneral anesthesia was used to avoid patient discomfort and the potential influence of local anesthetic on tissues. By means of 3-mm incisions, the abdominal or the trochanteric area was infiltrated with 0.9% sodium chloride cooled to 4°C, and fat was removed through a 20-ml syringe connected by a Luer-Lok attached to a cannula with a 3-ml exit hole, creating a small negative pressure inside the syringe. An adipose tissue sample (average, 40 cc per session) was obtained and then centrifuged once at 1300 rpm for 5 minutes.5 After centrifugation, the adipocyte cell fraction was isolated and transferred into syringes equipped with attached Luer-Lok of 2 ml with 17- to 18-gauge cannulas. The injection of the purified fat was achieved in multiple directions at the dermal-hypodermal junction of the scar areas. This procedure was performed three times for each patient, with a 3-month interval between sessions. A punch biopsy from the scar tissues was performed in each patient before and 9 months after the first surgical intervention, before the last operation. At 1-year follow-up, all of the patients noted an improvement of their clinical condition. The general satisfaction score of the patients, surgeons, and external observer was 7.5. Histologic findings showed new collagen deposition, neoangiogenesis, and dermal hyperplasia in the context of new tissue, demonstrating tissue regeneration. Clinically, a better texture, softness, thickness, color, and elasticity of the treated skin were observed, as was a reduction of the scar retraction (Figs. 1 and 2). The reported cases provide preliminary evidence that autologous fat grafting can greatly improve the aesthetic and functional outcomes in burned patients.Fig. 1: Patient with severe facial burn outcomes derived from the explosion of a hydrochloric acid tank.Fig. 2: Same patient as shown in Figure 1, 15 months after the first operation. Note the improvement in the skin softness and elasticity.The procedure can be adopted for most patients because fat is always available. Autologous fat grafting can complete and improve the results of the standard surgical approach used in burned patients. The procedure is safe and easy, with minimal morbidity, if performed by expert surgeons. Sergio Brongo, M.D., Ph.D. Giovanni Francesco Nicoletti, M.D., Ph.D. Simone La Padula, M.D. Carmine Michele Mele, M.D. Francesco D'Andrea, M.D., Ph.D. A.O.U. Second University of Naples, Naples, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

Bone and joint tuberculosis

Bone and joint tuberculosis has increased in the past two decades in relation with AIDS epidemics. A literature review of bone and joint tuberculosis, focusing on Pott's disease. Bone and joint TB comprises a group of serious infectious diseases whose incidence has increased in the past two decades, especially in underdeveloped countries, in part due to the AIDS epidemic. Tuberculous spinal infections should be suspected in patients with an insidious, progressive history of back pain and in individuals from an endemic area, especially when the thoracic vertebrae are affected and a pattern of bone destruction with relative disc preservation and paravertebral and epidural soft tissue masses are observed. Atypical tuberculous osteoarticular manifestations involving the extraspinal skeleton, a prosthetic joint, or the trochanteric area, and nontuberculous mycobacterial infections should be considered in favorable epidemiological contexts. Surgery combined with prolonged specific antituberculous chemotherapy is mainly indicated in patients with neurological manifestations or deformities, and provides satisfactory results in most cases. Spinal tuberculosis is still a relative common extra spinal manifestation of spinal tuberculosis that requires a high degree of suspicion in order to avoid neurological complications and need of surgery.