Good Functional Recovery Research Articles

1097A: THERAPEUTIC PLASMA EXCHANGE FOR THROMBOTIC MICROANGIOPATHY ASSOCIATED WITH PANCREATITIS IN A CHILD

Introduction: Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA). These features reflect the presence of an active microvascular endotheliopathy. TMA has been reported as a rare complication of acute pancreatitis in adults, with good outcomes after therapeutic plasma exchange (TPE). Sparse pediatric literature addresses the association of TMA and pancreatitis, or the merit of TPE for this indication. Description: A 13-year-old obese male with no previous medical history was admitted to the pediatric intensive care unit for management of acute pancreatitis and kidney injury after two days of abdominal pain, nausea, emesis, and decreased urine output. After fluid resuscitation, his initial labs revealed a lipase of 8520U/L, AST 153U/L, ALT 150U/L, Hgb 14g/dL, WBC 23,000/uL, Platelets 58,000/uL, INR 1.3, BUN 37mg/dL and Cr 4.06mg/dL. A non-contrast CT scan confirmed radiographic evidence of acute pancreatitis. He was afebrile, with stable hemodynamics and a reassuring neurological exam. His hemoglobin decreased to 10.8g/dL 24 hours after admission with subsequent workup suggestive of hemolysis (haptoglobin < 30mg/dL, LDH 4898U/L, schistocytes on peripheral blood smear). A diagnosis of MAHA with thrombocytopenia was established and TPE was initiated. Common underlying conditions associated with TMA such as disseminated intravascular coagulation, infection, drug-induced, autoimmune disorders and malignancy were addressed and ruled out. Complement levels (C3 and C4) were normal, direct/indirect Coombs were negative and ADAMTS13 activity was normal (>60%). The patient received three days of TPE with improvement in platelet counts to 102,000/uL and decrease in LDH to 486U/L after the third session. Renal replacement therapy (RRT) was required for nine days after TPE with good recovery of renal function. He was discharged on hospital day 19 with downtrending Cr 0.78mg/dL and lipase 53U/L. He was tolerating a regular diet without volume restriction prior to discharge. Discussion: Thrombocytopenia and MAHA should raise a suspicion for TMA in children presenting with acute pancreatitis. Acute renal failure requiring RRT is a frequent comorbidity. TPE with RRT may be effective and lifesaving in these patients.

738: CRITICAL CARE UTILIZATION AND OUTCOMES IN PEDIATRIC MODERATE TRAUMATIC BRAIN INJURY

Introduction: Patients with moderate traumatic brain injury (mTBI) have outcomes that range from good functional recovery to death. We compared neurocritical care utilization of patients with high Glasgow Coma Scale (GCS) mTBI (hmTBI, GCS 11-13) and low GCS mTBI (lmTBI, GCS 9-10), and functional outcomes of patients with mTBI and severe TBI (sTBI, GCS < 9) 3-months post injury. We hypothesize that patients with lmTBI have higher neurocritical care needs and worse outcomes than patients with hmTBI and similar to patients with sTBI. Methods: We performed a dual continent prospective observational study from June 2018 – April 2022 among children (age < 16 years) with mTBI and sTBI admitted to 33 pediatric intensive care units in the Pediatric Acute & Critical Care Medicine Asian Network (PACCMAN) and LARed: Red Colaborativa Pediatrica de Latinoamerica. We assessed functional outcomes using the Glasgow Outcome Scale – Extended Pediatric Revision (GOS-E Peds, scale 1-8, 1 = upper good recovery, 8 = death). Results: We analyzed 396 children with mTBI (24%) and sTBI (70%). In-hospital mortality was 0% and 12%, respectively. Compared with mTBI, the sTBI group was more likely to be mechanically ventilated in the first hour of ICU admission (76.9% vs 28.7%, p< 0.001), have a longer duration of mechanical ventilation (5.00, [interquartile range (IQR) 4.00, 8.50] vs 3.00 [IQR 1.5, 6.00] days, p 0.023), and longer duration of ICU stay (8.00 [IQR 4.00, 13.5] vs 4.00 [IQR 2.00, 7.00] days, p< 0.001). Patients with lmTBI (vs. hmTBI) were more likely to have intracranial pressure (30.3% vs. 3.1%) and intra-arterial blood pressure monitoring (51.5% vs. 27.9%) and a longer duration of ICU stay 5.00 [4.00, 9.74] vs 4.00 [2.00, 6.00]) days, (p < 0.05). At 3 months follow-up, GOS-E Peds scores were different in the 3 groups (hmTBI (1.00 [IQR 1.00, 3.00]), lm TBI (3.00 [IQR 2.00, 6.00]) and sTBI (5.00 [IQR 1.00, 6.25]), (p< 0.001). Conclusions: Patients with lmTBI have higher rates of neurocritical care utilization and worse functional outcomes than those with hmTBI but better than those with sTBI. Our findings highlight the importance of routinely considering multimodal neuromonitoring and ICP targeted treatments to improve outcomes in this population.

The clinical application of individualized three-dimensional printing guiding template for assisting scaphoid fracture fixation through dorsal approach

The purpose is to introduce a novel scaphoid screw placement surgery based on a novel three-dimensional (3D) printing guiding template through dorsal approach, and to evaluate the clinical feasibility and accuracy. The diagnose of scaphoid fracture was confirmed by Computed Tomography (CT) scanning, and subsequently the CT scanning data was input into a three-dimension imaging system(Hongsong software, China). An individualized 3D skin surface template with a guiding hole was printed. We put the template to the correct position on patient's wrist. Fluoroscopy was used to confirm the accurate position after drilling of Kirschner wire according to the prefabricated holes of template. Finally, the hollow screw was inserted through the wire. The operations were performed successfully without incision and complications. The operation time was below 20 minutes and the blood loss was below 1ml. The intraoperative fluoroscopy demonstrated good position of the screws. Postoperative imaging showed that the screws were considered to be placed perpendicularly to the fracture plane in the scaphoid. Three months after the operation, the patients acquired good recovery of the motor function of their hands. This present study suggested that the computer-assisted 3D printing guiding template is effective, reliable, and minimally invasive for the treatment of type B scaphoid fracture through dorsal approach.

Long-Term Outcomes of Patients with Stroke Predicted by Clinicians to have no Chance of Meaningful Recovery: A Japanese Cohort Study.

Little is known about the natural history of comatose patients with brain injury, as in many countries most of these patients die in the context of withdrawal of life-sustaining therapies (WLSTs). The accuracy of predicting recovery that is used to guide goals-of-care decisions is uncertain. We examined long-term outcomes of patients with ischemic or hemorrhagic stroke predicted by experienced clinicians to have no chance of meaningful recovery in Japan, where WLST in patients with isolated neurological disease is uncommon. We retrospectively reviewed the medical records of all patients admitted with acute ischemic stroke, intracerebral hemorrhage, or nontraumatic subarachnoid hemorrhage between January 2018 and December 2020 to a neurocritical care unit at Toda Medical Group Asaka Medical Center in Saitama, Japan. We screened for patients who were predicted by the attending physician on postinjury day 1-4 to have no chance of meaningful recovery. Primary outcome measures were disposition at hospital discharge and the ability to follow commands and functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), which was assessed 6months after injury. From 860 screened patients, we identified 40 patients (14 with acute ischemic stroke, 19 with intracerebral hemorrhage, and 7 with subarachnoid hemorrhage) who were predicted to have no chance of meaningful recovery. Median age was 77years (interquartile range 64-85), 53% (n = 21) were women, and 80% (n = 32) had no functional deficits prior to hospitalization. Six months after injury, 17 patients were dead, 14 lived in a long-term care hospital, 3 lived at home, 2 lived in a rehabilitation center, and 2 lived in a nursing home. Three patients reliably followed commands, two were in a vegetative state (GOS-E 2), four fully depended on others and required constant assistance (GOS-E 3), one could be left alone independently for 8h per day but remained dependent (GOS-E 4), and one was independent and able to return to work-like activities (GOS-E 5). In the absence of WLST, almost half of the patients predicted shortly after the injury to have no chance of meaningful recovery were dead 6months after the injury. A small minority of patients had good functional recovery, highlighting the need for more accurate neurological prognostication.

Phrenic nerve injury occurring from removal of a chest drain in a 26-year-old male

Chest tubes are a common procedure performed worldwide, especially in trauma. Complications arising can be from the result of insertion, incorrect position, or infection. Phrenic nerve injury has previously been a rare complication, found usually in neonates. We described the unusual and previously unreported case of a 26-year-old male who suffered a right phrenic nerve injury as a result of a misplaced chest tube, occurring not in insertion but during removal. The chest tube was placed initially emergently during a polytrauma for bilateral pneumothoraces. With removal, sudden tachypnea was noted with negative workups for pulmonary embolus or reaccumulation of pneumothorax. There was ongoing reduction of spirometry volumes and a persistently raised right hemidiaphragm, with suspicion for bronchial plugging and resorption atelectasis. Following respiratory review, the diagnosis was confirmed with chest wall fluoroscopy with a ‘Sniff test’. With good recovery of overall respiratory function, the patient was discharged with conservative management.

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.

Plasma exchange and COVID 19

Plasma exchange and COVID 19

Clinical analysis of accelerated rehabilitation surgery for Gustilo type IIIA/B open tibio fibular fracture.

To investigate the clinical efficacy of accelerated rehabilitation surgery for the treatment of Gustilo type IIIA/B open tibiofibular fracture with emergency stage I debridement, internal fracture fixation, bone grafting, coverage of the wound surface with a muscle flap combined with vacuum sealing drainage (VSD), and internal and lateral leg reduction. A retrospective analysis was performed on the clinical data of 15 patients with Gustilo type IIIA/B open tibiofibular fracture who were admitted to the Affiliated Zhongshan Hospital of Dalian University from January 2015 to December 2018. There were 12 males and 3 females. The patients ranged in age from 20 to 62years, with an average of 39.5years. After admission, the patients underwent stage I emergency debridement (including exploration and repair of nerves and tendons), open reduction and internal fixation of the tibia and fibula, iliac bone grafting, muscle flap and VSD coverage of the bone defect, complete tensioning of the calf inside and outside, tibia-sparing incision before healing, and stage II free skin grafting. Patients were followed up periodically to observe muscle flap survival, fracture healing time, length of hospitalization, wound healing time, delayed union, bone nonunion, osteomyelitis and other complications. At the last follow-up, the Johner-Wruhs criteria were used to evaluate the rate of good functional recovery from tibial shaft fracture, fracture healing quality was evaluated by the Merchant score, and limb function was evaluated by the LEFS. All 15 cases were followed up for 12-32months, with an average of 22.8months. All the fractures healed; the range of healing time was 14-30weeks (mean 18.5weeks). The length of hospitalization was 25.1 ± 7.6days, and wound healing took 12.2 ± 2.0days. None of the patients had complications such as osteomyelitis infection. When the Johner-Wruhs evaluation criteria for functional recovery from tibial shaft fracture were applied at the last follow-up, the outcomes were as follows: excellent in 13 cases, good in 1 case and fair in 1 case, for an excellent and good rate of 93.3%. When fracture healing was evaluated according to the Merchant scoring standard, the outcomes were as follows: excellent in 12 cases, good in 1 case, fair in 1 case, and poor in 1 case, for an excellent and good rate of 86.7%. The mean LEFS score of the affected limb at the last follow-up was 70 (59-80). For Gustilotype IIIA/B open tibiofibular fractures, emergency stage I debridement, internal fixation of the fracture, bone grafting, coverage of the wound with a muscle flap, complete tensioning of the calf inside and outside, and application of VSD can improve the repair of leg soft-tissue defects, shorten hospitalization time, promote fracture healing, and effectively reduce infection and complications related to bone exposure. More importantly, this treatment protocol provides effective wound repair, guarantees the recovery of limb function, significantly speeds up recovery, and improve patients' quality of life.

Post-intensive Care Unit COVID-19 Survivors: Functional Status and Respiratory Function Three Months After an Inpatient Rehabilitation Program.

Introduction and objectives Long-term coronavirus disease 2019 (COVID-19) sequelae have become an increasing concern, with persistent dyspnoea and fatigue being the most common and long-lasting symptoms reported.The aim of this study was to evaluate the functional status and respiratory function three months after discharge from an inpatient rehabilitation program. Materials and methods This was a prospective study including post-ICU COVID-19 survivors consecutively admitted to an inpatient and multimodal rehabilitation program in a rehabilitation center. Evaluation of functional status (brief balance evaluation systems test (brief-BESTEST), timed up and go (TUG) test, 1 min sit to stand test (1STST), 6 min walking test (6MWT)); respiratory muscle strength (maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP)); cough effectiveness (peak cough flow (PCF)); and fatigue (fatigue assessment scale (FAS)) were assessed at admission (T0), discharge (T1), and three months after discharge (T2). Results A total of 36 patients were included. Between T1 and T2, there was a significant improvement in MEP (84.47±20.89 vs 97.23±24.63 cmH2O, p<0.001), PCF (367.83±117.24 vs 441.33±132.90 L/min, p=0.003), functional capacity (1STST (19.90±6.37 vs 23.13±6.07, p=0.004), and 6MWT (459.25±153.70 vs 500.00±163.74 meters, p=0.003)). No differences were seen in MIP, brief-BESTEST, or TUG. Patients presented a higher median final FAS score at T2 compared to T1: 21.50±5 vs 18.60±2.65, p=0.002. Conclusions Post-ICU COVID-19 survivors admitted to an inpatient rehabilitation program maintained a good functional recovery at the three-month follow-up. Despite overall improvement, we found higher scores of FAS, suggesting worsefatigue levels.

Abstract 227: Acute Inpatient Rehabilitation And Social Determinants Of Health Are Associated With Functional Recovery Patterns At 12 Months Relative To Hospital Discharge From Cardiac Arrest.

Introduction: Cardiac arrest (CA) survivors have significant impairments and poor functional outcomes at hospital discharge. We assessed if discharge disposition to acute inpatient rehabilitation after CA-related hospitalization is associated with improved functional recovery at 12 months relative to alternative acute care hospital discharge dispositions. Methods: Adults with the return of spontaneous circulation after in-hospital or out-of-hospital CA between 2/1/2016- 1/31/2020 admitted to intensive care units in a single tertiary care center were enrolled in an observational, prospective cohort study. A series of logistic regressions were used to assess acute inpatient rehabilitation associations with good functional recovery patterns, defined as persistent Modified Rankin Score (mRS) 0-2, or absence of any worsening of mRS at 12 months relative to discharge mRS. The model included demographics, individual and structural-level Social Determinants of Health, and pertinent clinical characteristics. Results: Of 201 included patients (24% Hispanic and 19% Black; average age 56±16 years; 40% women), 63% (n=127) reported good functional recovery pattern. Patients who went to acute inpatient rehabilitation were significantly more likely to experience good recovery pattern (54.3% vs 37.8% with poor recovery pattern, p&lt;0.01). In a multivariable model, acute inpatient rehabilitation was significantly associated with a good recovery pattern when compared to other discharge dispositions (home with out-patient rehabilitation services (odds ratio (OR), 0.3; CI, 0.1-0.8; p = 0.02), and skilled nursing facility (OR, 0.2; CI, 0.1-0.6; p&lt;0.01). SDOH including minority race/ethnicity, poor insurance, premorbid unemployment, no carepartner or spouse, and patients with longer hospital length of stay had independent and significant associations with poor functional recovery patterns. Conclusions: Acute inpatient rehabilitation was associated with a good functional recovery pattern 12 months after hospital discharge from CA. Social determinants of health have an independent effect on the functional recovery patterns and should be systematically collected for future outcome-based studies.

Diagnostic and Treatment of Spinal Fracture and Luxation in Italian Wolves (Canis lupus italicus)

The medical records of 14 Italian wolves (Canis lupus italicus) with a vertebral fracture or luxation (SFL) between C1 and L7 treated at Ospedale Veterinario San Michele from 2017 and 2022 were reviewed. The most common cause of SFL was "road traffic accident". Neurological signs were graded from 0 to 6 using a modified Frankel scale. Spinal fractures occurred in C1-C5 in 1 case, in T3-L3 in 11 cases and in L4-L7 in 2 cases. Six wolves were euthanized without treatment because they presented paraplegia without deep pain perception (DPP). Two animals with motor function were treated conservatively, and later on one of them was euthanized because of neurological impairment. Six wolves were surgically treated. Seven wolves had good neurological recovery, and six of them were released into the wild. Our results suggest that wolves with DPP before surgery may have a good functional recovery.

Inferiorly based nasolabial flap for reconstruction of full-thickness medium-sized lower lip and commissural defects following ablative cancer surgery.

Information regarding the design and usage of inferiorly based nasolabial flap for lower lip and commissural defect reconstruction following ablative cancer surgery remains limited. This study aimed to provide our design and experiences for such reconstructive purpose. Patients with lower lip or oral commissural cancer who received curative surgery involving reconstruction with inferiorly based nasolabial flap were included. The demographic data and clinical outcomes of these patients were obtained by retrospective chart review. A total of eight patients were enrolled in this study. All patients received ablative surgery at the National Cheng Kung University Hospital during May 2019 to May 2021, with their surgical defects reconstructed with unilateral inferiorly based nasolabial flap successfully. Among the five patients with lower lip cancer, one had a limited area of necrosis at flap tip. Another patient had a small orocutaneous fistula that healed spontaneously. No trismus or oral incompetence was noted following recovery. For the three patients with commissural cancer, a second stage commisuroplasy was needed after primary reconstruction. One patient had limited wound dehiscence at mouth angle following surgery, resulting in mild oral incompetence. Although mild trismus was noted in these three commissural cancer patients, all patients resumed normal diet during follow-up. Inferiorly based nasolabial flap is an excellent local flap for lower lip reconstruction following cancer ablative surgery. It is also a viable option for reconstruction of oral commissural defects. Minimal donor side morbidity, good functional recovery, and esthetic outcomes can be achieved with meticulous flap design.

Safety of Recanalization Therapy in Acute Ischemic Stroke Patients on Direct Oral Anticoagulant Therapy: An Updated Systematic Review and Meta-Analysis.

This review provides an updated assessment of the safety of recanalization therapy for Acute Ischemic Stroke (AIS) patients receiving direct oral anticoagulants (DOAC) therapy. We checked the literature for published observational from 1st January 1950 to 31st March 2021. The rate of symptomatic intracerebral hemorrhage (sICH), arterial recanalization rate, good functional recovery, and mortality at 3 months were investigated, and data were expressed as Risk ratio (RR) with a 95% confidence interval (CI). Publication bias, sensitivity analysis, and meta-regression analyses were conducted utilizing STATA software. 17 articles [14 for endovascular therapy (EVT) and 3 intravenous thrombolysis for (IVT)] were finally included in the review. AIS patients with DOAC therapy showed a decreased rate of sICH (RR = 0.85, 95% CI = 0.72 to 1.00, P = 0.04), and lower probability of good functional recovery at three months (RR = 0.79, 95% CI = 0.73 to 0.85, P < 0.001) than patients without anticoagulation therapy post EVT. However, no significant differences in sICH rates in AIS patients with DOAC therapy after IVT (RR = 0.87, 95% CI = 0.48 to 1.58, P = 0.64) were observed. AIS patients not prescribed DOAC after EVT had a higher mortality risk (RR = 1.29, 95% CI = 1.15-1.44, P < 0.001). Patients with AIS on DOAC therapy were found to have a lower incidence of sICH following EVT. However, no evidence of an increased bleeding risk in patients previously treated with DOAC after IVT was observed. Therefore, more detailed studies with biological data to monitor compliance and details on the size and etiology/severity of the incident ischemic lesion is needed.

Tension band wiring in a rare case of isolated acromion fracture: a case report

&lt;p&gt;Fracture of the acromion process is an uncommon injury. The most common mechanism of injury is direct trauma to the acromion. Isolated acromion fractures are rare as usually they are associated with concomitant skeletal and soft tissue injuries of the shoulder. We present a case of a 45-year-old male with a type 3 fracture of acromion process with reduction of subacromial space. Patient was managed surgically and fracture was fixed using tension band wiring. Patient was followed up using UCLA, DASH and VAS scores and showed good radiological and functional outcomes. Minimally displaced fractures should be regularly followed up for displacement and sub-acromial space compromise. Although acromion fractures are usually treated conservatively, albeit a higher non-union rate, they should be treated surgically in the event of displacement or sub-acromial space reduction, in order to achieve good functional recovery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Retained Metallic Part of a Dislodged Knife in the Thoracic Spine with Paraparesis

The incidence of traumatic spinal cord injury is reported as 30-40 million per year. Among these, stab wounds to the spinal canal are usually rare. These injuries often lead to complete or incomplete neurological deficits. An appropriate management can ensure good functional recovery for approximately two-third of the patient. As these cases are uncommon, their treatment protocols are still controversial and under evaluation. Some literatures reveal various surgical approaches. Spinal canal injury with retained part of the causative agent (knife, bullet, glass etc.) or any other complication on the wound site demands immediate surgical exploration. Here we report on a patient with a retained metallic foreign body (tip of knife) in the thoracic region traversing the left pedicle of sixth thoracic vertebrae along with spinal canal with paraparesis and after neuro-surgical exploration and complete removal of the foreign body, patient shows gradual improvement of neuro-functional status. Proper wound care and long term close follow up was ensured during post operative period.

Plate Augmentation in Aseptic Femoral Shaft Nonunion after Intramedullary Nailing: A Literature Review.

Background: Femoral shaft fractures (FSFs) are a frequent injury in traumatology for which intramedullary nailing (IMN) is considered the gold standard treatment. Nonunion (NU) is one of the most frequent complications in FSF treated with IMN, with a percentage from 1.1% to 14%. Plate augmentation (PA), the addition of a compression plate and screws, with or without bone graft has been described as an effective option for the treatment of NU, improving the biomechanical conditions at the fracture site. The aim of this review was to analyze the literature relating to the use of PA in NU after IMN in FSFs to assess the efficacy of the technique. Methods: An electronic search on PubMed, Google Scholar, and Web of Science was conducted to search for all studies concerning PA of femoral shaft NUs after IMN. Results: Twenty-four studies were included in the review comprising a total of 502 patients with a mean age of 39.5 years. Of these, 200 hundred patients had atrophic pseudoarthrosis and 123 had hypertrophic pseudoarthrosis, while in 179, the type of pseudoarthrosis was not reported. The most frequently used plate for PA was the dynamic compression plate (DCP); in 87.1% of the cases, the authors added a bone graft to the plate fixation. In 98.0% of the patients, a complete bone union was achieved in a mean time of 5.8 ± 2.12 months. Conclusion: The patients treated with PA included in this review showed a good rate of consolidation in the femoral shaft NUs, with good functional recovery and a low incidence of complications.

3D-printed hemipelvic prosthesis combined with a dual mobility bearing in patients with primary malignant neoplasm involving the acetabulum: clinical outcomes and finite element analysis

BackgroundLimb salvage reconstruction for pelvic tumors, especially periacetabular tumors, is challenging. We combined the use of dual mobility bearing and 3D-printed hemipelvic prosthesis to improve function and reduce the probability of complications after hemi-pelvic resection in patients with primary acetabular malignancy. The purpose of this study was to evaluate the efficacy and safety of this combination.MethodsBetween October 2011 and May 2021, 11 patients with malignancies involving the acetabulum received hemipelvic replacement with a 3D-printed prosthesis and dual mobility bearing. Follow‐up of postoperative survival, complications, and Musculoskeletal Tumor Society 93 (MSTS-93) lower limb functional scores were carried out. A finite element model of the postoperative pelvis was developed and input into the finite element analysis software. The Von Mises equivalent stress formula was used to analyze the stress distribution of each part of the pelvis under one gait cycle and the stress distribution at different angles of the hip joint.ResultsBy the last follow-up, 9 of the 11 patients (81.8%) were still alive, and 2 patients had local tumor recurrence. The complications including 1 deep infection and 1 dislocation of the artificial joint. Excluding 1 amputation patient, the average score of the remaining 8 patients at the last follow-up was 21.4/30 (71.3%) on the MSTS-93. In the reconstructed pelvis, stress distributions were concentrated on the junction between hemipelvic prosthesis and screw and iliac bone on the resected side, and between femoral prosthesis stem and femoral bulb, while the stress of polyethylene lining was small. Before impact, the polyethylene lining will rotate at a small angle, about 3°. The inner stress of polyethylene liner is greater than the outer stress in all conditions. The polyethylene liner has no tendency to slide out.ConclusionPelvic tumor resection and reconstruction using 3D-printed hemipelvic prosthesis combined with dual mobility bearing was an effective treatment for pelvic tumors. Our patients achieved good early postoperative efficacy and functional recovery. The dual mobility bearing is beneficial to prevent dislocation, and the mechanical distribution and wear of the prosthesis are acceptable.

Kirschner wire combined with PEEK anchor for the treatment of WagstaffeⅡfracture

To explore clinical effect of Kirschner wire combined with PEEK anchor with thread to fix fibula bone block in WagstaffeⅡfracture. From January 2018 to December 2020, 29 patients with WagstaffeⅡfracture of ankle joint were treated with Kirschner wire fixation of avulsed fibular bone block, PEEK with thread anchor repair and reinforcement, and plaster external fixation, including 18 males and 11 females, aged from 27 to 69 years old with an average of (46.3±10.2) years old. All of them were unilateral operations, and the time from injury to operation ranged from 3 to 5 days with an average of(4.05±0.63) days. Clinical efficacy was evaluated by using American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot functional scoring system and visual analogue scaleat scoring system before and after operation at 6 months. All patients were followed up from 6 to 12 months with an average of (9.7±2.1) months. Two patients occurred pain of ankle joint during walking, which was relieved after strengthening rehabilitation exercise and anti-nflammatory and analgesic drug treatment. AOFAS score was incrased from(62.16±19.73) preoperativyly to(91.35±6.37) at 6 months after operation (t=5.51, P<0.01);15 patients got excellent results, 12 moderate and 2 good. VAS was decreased (5.91±1.57) preoperativly to (0.41±0.37) at 6 months after operation(t=10.54, P<0.01). Kirschner wire combined with PEEK anchor with thread to fix fibula bone block in WagstaffeⅡfracture strengthen repair of inferior tibiofibular syndesmosis ligament and anterior talofibular ligament, and effectively relieved ankle joint pain, obtain good function recovery, the avulsion fracture block was fixed securely, and receive good clinical effect.

Core techniques and adverse events in anterior cruciate ligament reconstruction using a new generation of artificial ligaments: the consensus of Chinese specialists based on a modified Delphi method (Part 2)

Anterior cruciate ligament (ACL) reconstruction using a new generation of artificial ligaments (NGAL) gained popularity in China owing to its good effectiveness and early functional recovery, but iatrogenic surgical failures and preconceived misconceptions have seriously affected its standardized clinical application. A specialist consensus is now developed to provide guidance and reference for orthopaedic sports medicine doctors when adopting or considering the NGAL for ACL reconstruction. The consensus on the core techniques and adverse events in ACL reconstruction using the NGAL was developed by a modified Delphi method, referring exclusively to the NGAL for ACL reconstruction approved by the National Medical Products Administration (NMPA). Consensus specialists were selected from the members of the Chinese Association of Orthopaedic Surgeons (CAOS) and the Chinese Society of Sports Medicine (CSSM). The drafting team summarized the draft consensus terms based on medical evidence and organized rounds of investigation: two rounds of online questionnaire investigation and the final round of face-to-face meeting. After discussion, revision, and voting, a consensus on the draft consensus term was reached when the agreement rate exceeded 85%. The consensus terms were categorized as "strong" (agreement rate: 95.0%-100%), "moderate" (agreement rate: 90.0%-94.9%), and "basic" (agreement rate: 85.0%-89.9%). Thirty-one specialists completed the questionnaire investigation. They all practiced in university teaching hospitals (Grade-A tertiary hospitals) from 16 provinces, autonomous regions, and municipalities in China. Among them, 28 were chief physicians and 3 were associate chief physicians; 22 were professors and 7 were associate professors; the average seniority in orthopedic sports medicine was 25.2 years (range, 12-40 years); the average seniority in performing ACL reconstruction procedures was 13.2 years (range, 7-23 years); in terms of the number of ACL reconstruction using the NGAL, 18 completed more than 100 cases, of which 6 had more than 300 cases; in terms of research, 28 had published more than 1 related paper in the past 5 years, of which 13 had published more than 3 related papers. Twenty-six specialists attended the face-to-face meeting and reached a consensus on 9 terms, including 8 strong terms and 1 moderate term. ACL reconstruction using the NGAL must deploy "isometric" or "near-isometric" reconstruction and should preserve the natural ACL remnants as much as possible. Bone tunnel positioning can be performed using intraoperative radiographic measurements or the lateral femoral intercondylar ridge as reference marks. Incorrect positioning of the bone tunnel is the main reason of surgical failure, and there is a lack of consensus on handling interference screws during revision. Bone tunnel enlargement exists after reconstruction but rarely causes related symptoms. Synovitis and infection are uncommon complications. The aging effect of polyethylene terephthalate fiber on the long-term clinical outcomes is unknown and deserves attention.

Variations of Extended Latissimus Dorsi Musculocutaneous Flap for Reconstruction of Large Wounds in the Extremity.

ObjectiveThe aim of the present study was to report a novel nomenclature system for extended latissimus dorsi musculocutaneous (LD) flaps. To evaluate the clinical application and surgical efficacy of the different extended LD flaps for large wounds in the extremities.MethodsFrom January 2004 to December 2018, 72 consecutive patients who received extended LD flaps were retrospectively analyzed. Patients' ages ranged from 2 to 68 years with 37 males and 35 females. All wounds were extensive in either the upper or lower limbs, while the skin defect area ranged from 18 cm × 10 cm to 37 cm × 21 cm. Forty‐one wounds were located in the calf, 18 in the foot and ankle, six in the shoulder and upper arm, four in the thigh, and three at the knee joint. Twenty‐eight patients had fractures, and six of these patients with segmental bone defects (ranging in size from 3 to 7 cm) required secondary orthopaedic procedures. Single‐ and double‐wing extended LD flaps were designed and harvested according to the shape of the wounds.ResultsThe flaps received consisted of 64 single‐wing and eight double‐wing extended LD flaps, and the mean flap harvest time was 56.2 min. The donor sites were closed primarily for all patients. Additional subcutaneous veins were anastomosed to the recipient's vessels in 14 patients. The venous crisis was noticed on the first postoperative day in four cases. Two flaps were salvaged after emergency re‐exploration, and another two patients' flaps were necrosed. In these two patients, lower limb amputation and extended LD flap on the other side were used, respectively, for the final treatment. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Six patients had segmental bone defects that required secondary orthopaedic procedures, two patients were repaired with vascularized iliac crest bone grafts, and another four patients were reconstructed by the Ilizarov technique. All the patients' bone defects achieved union and most patients achieved good functional recovery at the recipient site. The mean follow‐up was 15.7 months (range, 10–56 months). No significant donor site morbidities limiting patients' daily activities occurred during the follow‐up. Eight patients developed a donor site hypertrophic scar, three patients on the back, and five on the anterolateral thigh.ConclusionSingle‐ and double‐wing extended LD flaps are simple and reliable methods for large skin and soft tissue defects in the extremity, with good functional and aesthetic results.