Ipsilateral Limb Research Articles

Retrograde tibiotalocalcaneal nailing for the treatment of acute ankle fractures in the elderly: a systematic review and meta-analysis.

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation. Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of TTC nailing for fragility ankle fractures. A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, and Web of Science, identifying 14 studies for inclusion. Studies including patients with a fragility ankle fracture, defined according to NICE guidelines as a low-energy fracture obtained following a fall from standing height or less, that were treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. This review was registered in PROSPERO (ID: CRD42021258893). A total of 312 ankle fractures were included. The mean age was 77.3 years old. In this study, 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection was 10% (95% CI: 0.06-0.16), deep infection 8% (95% CI: 0.06-0.11), implant failure 11% (95% CI: 0.07-0.15), malunion 11% (95% CI: 0.06-0.18), and all-cause mortality 27% (95% CI: 0.20-0.34). The pooled mean post-operative Olerud-Molander ankle score was 54.07 (95% CI: 48.98-59.16). Egger's test (P = 0.56) showed no significant publication bias. TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent post-operative rehabilitation protocols. Prospective randomised control trials with long follow-up times and large cohort sizes are needed to guide the use of TTC nailing for ankle fractures.

Type IIa Muscle Fibers Influence The Force-velocity Profile Of Healthy Adults During Maximal Cycling

During maximal cycling, vastii muscles contract during the extension phase of the pedaling cycle to generate a large portion of pedal forces. The contractile properties of the vastii muscles vary between individuals, depending on myosin heavy chain (MHC) composition. A positive association was reported between the cross-sectional area of type II muscle fibers in vastus lateralis (VL) and optimal cadence (Copt) during maximal cycling derived from power-cadence (P-C) relationships computed over the full pedal cycle. However, the contribution of vastii muscles to power produced over the full cycle may also vary across individuals due to potential differences in the relative contribution of the flexor and extensor muscles of the left and right lower limbs. PURPOSE: To investigate if MHC composition in VL influences variables derived from P-C relationships computed over the extension phase during maximal cycling. METHODS: Thirteen healthy adults (9 males, 4 females) performed a Force-Velocity test on a stationary cycle ergometer. We modelled individual P-C relationships using third order polynomial regressions to extract maximal power (Pmax), Copt and maximal cadence (C0) for the extension phase of the right leg only. From a muscle biopsy of the right vastus lateralis, we used electrophoresis to determine the MHC isoform composition (I, IIa and IIx). Pearson correlations were determined between % of each MHC type (I, IIa, IIx) and the variables derived from the P-C relationships (Pmax, Copt and C0). RESULTS: All individual P-C relationships were well fitted (r2 = 0.92 ± 0.01), allowing extraction of Pmax (11.9 ± 2.6 W/kg), Copt (130 ± 11 rpm) and C0 (235 ± 25 rpm). MHC isoform composition comprised 44 ± 10% type I, 47 ± 12% type IIa and 9 ± 5% IIx. Type I % MHC was negatively associated with Pmax (r = -0.553, p = 0.05) and Copt (r = -0.737, p < 0.05). Type IIa % MHC was positively associated with Pmax (r = 0.623, p < 0.05), Copt (r = 0.849, p < 0.001) and C0 (r = 0.805, p < 0.01). No significant associations were found between type IIx % MHC and Pmax, Copt or C0 (all P > 0.05). CONCLUSIONS: Healthy adults with higher type IIa % MHC in the VL muscle produced greater power at higher optimal cadences and reached higher maximal cadences during maximal cycling, when P-C relationships were computed over the extension phase of the ipsilateral limb.

Effect of leg dominance on ipsilateral and contralateral limb training adaptation in middle-aged women after unilateral sensorimotor and resistance exercise training

ABSTRACT The aim was to examine the directionality of global training effects in middle-aged women after unilateral training. Thirty-nine middle-aged female volunteers (59.4 ± 5.4 years) were randomly assigned to one of three groups: 1. Unilateral Dominant Lower Limb Training (UDLT); 2. Unilateral Non-Dominant Lower Limb Training (UNDLT) or 3. Control group. Outcome measures assessing isometric strength, static and dynamic balance were recorded at baseline, and 1 week after 12 weeks (post-test) of training or no-intervention. The net cross education adaptation changes of the contralateral quadriceps isometric maximum voluntary (MVC) force (F2,34 = 4.33; p = 0.022), Stork balance score (F2,34 = 4.26; p = 0.023) and the Star Excursion Balance test score (F2,34 = 11.80; p = 0.001) were asymmetrical in the UNDLT group and on average, exceeded the UDLT group. The results demonstrated asymmetrical cross education training adaptations with unilateral training of non-dominant leg (UNDLT) to contralateral homologous and heterologous muscles, with the exception of knee flexor MVC. The results of this study provide a novel exercise or rehabilitation strategy that can be employed when one of the limbs is affected.

Extra-anatomic temporary intravascular shunting to assist with replantation of an amputated hand with prolonged ischemic time.

Although temporary intravascular shunting has been reported to assist with hand revascularization and replantation after traumatic amputation, most reports have described using ipsilateral upper limb inflow. We present a case of a traumatic hand amputation in a patient who had presented with 4 to 5 hours of warm ischemic time. Because the replantation team believed that extra-anatomic revascularization would be necessary, we performed a novel type of temporary intravascular shunting by connecting two arterial sheaths placed in the ulnar and superficial femoral arteries. This permitted the hand to be successfully replanted away from the inflow source and resulted in a good long-term functional outcome.

Inflammation Modulating Activity of the Hydroethanol Stem Bark Extract of Bombax costatum in Murine Models

Bombax costatum (Bombacaceae) is traditionally used as a decoction of the leaves, stem, and root to treat headaches, fever, and oedema that may be associated with inflammatory conditions. Thus, the aim of this study was to evaluate the effect of 70%v/v ethanolic extract of the stem bark of Bombax costatum on acute and chronic inflammation. The effect of Bombax costatum extract (10, 50, 100 mg kg−1, p.o) was studied in prostaglandin E2-induced paw oedema in Sprague–Dawley rats (n = 5). Subsequently, the effect of the extract on clonidine and haloperidol-induced catalepsy was also investigated in ICR mice (n = 5). Finally, the ability of the extract to inhibit chronic inflammation was studied using a rat adjuvant-induced arthritis model. Pre-emptive and therapeutic administration of the extract at all doses significantly suppressed the formation of oedema following prostaglandin E2 administration. As a measure of indirect antihistaminic effect, treatment with the extract suppressed clonidine-induced catalepsy but not haloperidol-induced catalepsy. Moreover, Bombax costatum extract significantly inhibited joint inflammation and damage following injection of complete Freund's adjuvant. Treatment with the extract also inhibited the onset of polyarthritis; thus, suppressing the systemic spread of joint inflammation from ipsilateral limbs to contralateral limbs. In conclusion, the hydroethanol extract of the stem bark of Bombax costatum inhibits both acute and chronic inflammation.

P114. Cervical decompression surgery improves postural stability and gait velocity in patients with cervical spondylotic myelopathy

<h3>BACKGROUND CONTEXT</h3> Cervical spondylotic myelopathy (CSM) is a progressive degenerative condition that can lead to functional deficits and gait instability. Biomechanical changes to a patient's dynamic and postural stability after decompressive surgery are poorly understood. <h3>PURPOSE</h3> The aim of this study was to determine how spatiotemporal gait parameters, postural stability and dynamic stability change after decompressive surgery in patients with CSM. <h3>STUDY DESIGN/SETTING</h3> Prospective cohort study. <h3>PATIENT SAMPLE</h3> Patients aged 40 to 80 years old with Nurick grade 2 or 3 CSM spanning one to four levels undergoing decompressive surgery were prospectively enrolled in this study. Decompression surgery was defined as decompression with or without fusion of the cervical vertebra. Exclusion criteria included: patients who could not ambulate independently, had a history of surgery within 6 months of initial gait evaluation or gait altering lower extremity surgery. <h3>OUTCOME MEASURES</h3> A tilted ellipse area with bidirectional variance was used to assess postural stability metrics. Generated ground reaction forces (GRF) and variation in bidirectional center of pressure (CoP) motion were recorded and represented in an ellipse area around patient-generated CoP. Additionally, the analysis consisted of the examination of the following spatiotemporal gait parameters: stride length (distance over the ground between ipsilateral heel strikes), cadence (steps per minute), velocity (the speed of the patient's center of mass (CoM), step width (distance between two feet during period of double support), toe-off (percentage of the pre-swing portion of the gait cycle where ipsilateral limb leaves the ground and initializes single leg support) and double support (percentage of gait cycle spent with two feet on the ground). Dynamic stability of gait is inversely proportional to angular momentum regulation, where greater stability is shown by minimizing angular momentum excursion. Angular momentum was calculated using exported joint centers and joint angles, where each segment's angular momentum was computed as the sum of its local angular momentum and the angular momentum of the segment about the whole-body CoM, which was taken to be the sum of 15 body segments. <h3>METHODS</h3> A total of 47 subjects, including 23 Nurick grade 2 or 3 CSM patients and 24 controls, were included. Measurements were taken at baseline in both cohorts and then at 3- and 6-months following decompression in the CSM cohort. Standing balance trials were performed on a single force plate, and walking trials were conducted at a self-selected pace over a 15m runway and a series of five force plates. All trials were recorded with 3D motion analysis cameras, and gait modeling software was utilized. Repeated measures ANOVA was used to compare measurements at three timepoints, followed by paired t-tests. The significance value was set at P<0.05. <h3>RESULTS</h3> Patients with CSM had a significant increase in gait velocity postoperatively at 6 months (0.948 ± 0.248 m/s) compared to baseline (0.852 ± 0.257 m/s) (P = 0.008). CSM patients had a significant decrease in tilted ellipse area from baseline (979.8 ± 856.7 mm2) to 6 months (598.0 ± 391.1 mm2) (P = 0.018) postoperatively. There was no significant difference in angular momentum excursion between baseline and postoperative measurements. <h3>CONCLUSIONS</h3> Decompressive surgery in CSM patients was associated with significant improvement in gait velocity and postural stability. However, there was no significant change in dynamic stability throughout the study period. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

180 Retrograde Hindfoot Nailing for the Treatment of Acute Ankle Fractures in the Elderly - a Systematic Review and Meta-Analysis

Abstract Aim Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of hindfoot nailing for fragility ankle fractures. Method A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. Meta-regression analyses were performed to explore sources of heterogeneity, and publication bias was assessed using Egger's test. Results 312 ankle fractures were included. The mean age was 77.3 (32–101) years. 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06–0.16; I2=44%), 0.08 (95%CI:0.06–0.11, I2=0%), 0.11 (95%CI:0.07–0.15,I2=0%), 0.11 (95%CI:0.06–0.18; I2=51%), and 0.27 (95%CI:0.20–0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98–59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Egger's test (p=0.56) showed no significant publication bias. Conclusions TTC nailing is an adequate alternative option for fragility ankle fracture management. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures.

Deficits in Contralateral Limb Strength Can Overestimate Limb Symmetry Index After Anterior Cruciate Ligament Reconstruction

PurposeTo evaluate whether contralateral limb strength represents a dynamic, rather than static, data point after anterior cruciate ligament reconstruction (ACL-R).MethodsPatients who underwent isolated ACL-R at a single institution were identified. Patients completed an institutional Lower-Extremity Assessment Protocol (LEAP) testing protocol at 6 and 9 months postoperatively. Extension strength and flexion strength of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were compared between the 6- and 9-month testing outcomes. Subgroup analysis compared patients demonstrating less than or greater than 10% change in contralateral limb flexion and extension strength between 6 and 9 months postoperatively.ResultsA total of 144 subjects were included in this study. On average, contralateral limb flexion and extension strength increased 2-4% between 6 and 9 months postoperatively. However, the contralateral limb increased >10% from 6 to 9 months in extension and flexion strength in 35/144 (24.3%) and 55/144 (38.2%) of patients, respectively. The cohort with >10% change between 6 and 9 months had significantly weaker contralateral extension and flexion strength at 6 months compared to the cohort that demonstrated <10% change (extension: 2.00 vs 2.39; P < .001; flexion: 0.84 vs 1.08; P < .001), but similar ipsilateral limb performance. Therefore, the >10% change cohort had a significantly greater LSI at 6 months compared to the <10% change cohort (67.3% vs 59.4%; P = .006). No demographic or operative factors correlated with which patients demonstrated >10% flexion or extension strength changes of the contralateral limb.ConclusionA large percentage of patients demonstrate significant changes in their contralateral limb flexion and extension strength between 6 and 9 months postoperatively that result from an initial contralateral limb strength deficit. This may limit the utility of the contralateral limb as a control for comparison to the operative extremity during return to sport assessment.

EP-491 Retrograde Hindfoot Nailing for the Treatment of Acute Ankle Fractures in the Elderly - A Systematic Review and Meta-Analysis

Abstract Aim Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of hindfoot nailing for fragility ankle fractures. Methods A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. Meta-regression analyses were performed to explore sources of heterogeneity, and publication bias was assessed using Egger's test. Results 312 ankle fractures were included. The mean age was 77.3 (32–101) years. 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06–0.16; I2=44%), 0.08 (95%CI:0.06–0.11, I2=0%), 0.11 (95%CI:0.07–0.15, I2=0%), 0.11 (95%CI:0.06–0.18; I2=51%), and 0.27 (95%CI:0.20–0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98–59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Egger's test (p=0.56) showed no significant publication bias. Conclusion TTC nailing is an adequate alternative option for fragility ankle fracture management. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures.

Comparison of Motor Scores between OFF and ON States in Tremor-Dominant Parkinson's Disease after MRgFUS Treatment.

Objective: To compare the motor function improvements in ON and OFF states in tremor-dominant Parkinson’s disease (TDPD) patients within one year of follow-up after ablation of the unilateral ventral intermediate nucleus of the thalamus (Vim) by magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS). Methods: A total of nine consecutive patients confirmed with TDPD who underwent unilateral Vim ablation by MRgFUS between April 2019 and September 2019 were included. The Movement Disorder Society Unified Parkinson’s Disease Rating Scale part III (MDS-UPDRSIII) and Clinical Rating Scale for Tremor (CRST) were performed in the ON and OFF stages to distinguish the surgical effects from drug therapy effects. The adverse events and adjustment of drug doses were also recorded. Results: The preoperative MDS-UPDRSIII score in OFF and ON states was 55.0 (48.0, 65.5) and 26.0 (17.0, 27.0), while the CRST score was 46.0 (39.5, 53.5) and 20.0 (13.0, 23.5), respectively; the Levodopa equivalent dose was 600 (456, 600) mg/d. At 1 year after operation, the total MDS-UPDRSIII score and CRST score were 40.0 (30.0, 60.5) and 16.0 (10.0, 29.5) in the OFF state, and 21.0 (17.5, 27.0) and 2.0 (1.5, 7.0) in the ON state, respectively. Compared with the preoperative levels, follow-up at the two-time points (three months and one year after operation) showed the total MDS-UPDRSIII score, as well as MDS-UPDRSIII tremor, bradykinesia, and rigidity scores of contralateral limbs all significantly improved in OFF state. However, in the ON state, only the total MDS-UPDRSIII score and tremor score of contralateral limbs significantly improved. The total CRST score and the CRST (A + B) score of contralateral limbs significantly improved at three months and one year after the operation compared with before the operation in both ON and OFF states. The Levodopa equivalent dose at one and three months were not significantly different from the preoperative dose (p > 0.05). No serious adverse responses were observed. Conclusion: Treating TDPD with unilateral Vim ablation by MRgFUS could improve the symptoms of limb tremor and the other core symptoms, such as bradykinesia and rigidity, as well as some non-motor symptoms and the symptoms of ipsilateral limbs.

Poster 257: Deficits in Contralateral Limb Strength Can Overestimate Limb Symmetry Index after Anterior Cruciate Ligament Reconstruction

Objectives:Some literature suggests that strength deficits and functional impairment of the contralateral, uninjured leg exist following ACL injury. Given the emergence of these findings and the contralateral, uninjured limb frequently being used as a control for comparison to the operative extremity in return-to-play, limb symmetry assessments, the primary objective of this study was to evaluate whether the contralateral, un-injured limb represents a dynamic, rather than static, data point.Methods:144 patients undergoing ACL reconstruction at a single institution by six fellowship-trained surgeons between March 2013 and August 2018 were evaluated. Patients completed a standard institutional Lower-Extremity Assessment Protocol (LEAP) testing at six and nine months postoperatively for objective evaluation of ipsilateral and contralateral limb flexion and extension strength and functional performance. Retrospective chart review was performed to determine demographic and operative factors. Extension strength, flexion strength, limb symmetry index (LSI), and hop tests of ipsilateral and contralateral limbs were compared between the six- and nine-month LEAP testing outcomes. Further sub-analysis of cohorts demonstrating less than and greater than 10% difference in contralateral limb flexion and extension strength was performed. Binary logistic regression was utilized to evaluate demographic and operative risk factors for developing differences in contralateral limb strength.Results:On average, contralateral limb flexion and extension strength increased between 2-4% between six and nine months postoperatively. However, the contralateral limb demonstrated a difference of > 10% percent in extension strength in 24% of patients and in flexion strength in 38% of patients [Table 1; Table 2]. The cohort with >10% difference had significantly weaker contralateral extension and flexion strength at six months compared to the cohort that demonstrated < 10% difference (Extension: 2.00 vs. 2.39 N·m/kg, p < 0.001; Flexion: 0.84 vs. 1.08 N·m/kg, p < 0.001), but similar ipsilateral limb performance [Table 1; Table 2]. Therefore, the >10% difference cohort had a significantly greater LSI at six months compared to the < 10% difference cohort (67.3% vs. 59.4%, p = 0.006) [Table 1; Table 2]. At nine months postoperatively there was no difference in contralateral extension strength and LSI between cohorts. No demographic or operative risk factors were identified that correlated with which patients demonstrated deficits in contralateral limb strength.Conclusions:Although the contralateral, non-operative limb provides a relatively stable control value with which strength metrics of the ipsilateral, operative limb may be compared after ACL reconstruction, a significant percentage of patients will also demonstrate deficits in flexion and extension strength of the contralateral limb. This can result in an over-estimation of normality of limb symmetry comparisons. There were no identifiable demographic or operative risk factors to help identify which patients may demonstrate greater deficits with flexion and extension in the contralateral limb. Comparison of the operative extremity to a patient’s own pre-injury measures or that of a large, population-based, matched, un-injured, control group may be more ideal.Table 1.Contralateral Extension Performance.Table 2.Contralateral Flexion Performace.

Pallidal Activity Related to Posture and Movement during Reaching in the Cat.

We tested the hypothesis that the pallidum contributes to the control of both posture and movement. We recorded neuronal activity from the pallidum in a task in which male cats reached forward from a standing posture to depress a lever. In agreement with previous studies, we found that a majority of pallidal cells (91/116, 78%), including neurons in both the entopeduncular nucleus and the globus pallidus, showed significant modulation of their activity during reaching with the contralateral limb. Mostly different populations of cells were active during the transport (flexion) and lever press (extension) phase of the task. Most cells showed dynamic patterns of activity related to the movement. However, a modest proportion of modulated cells (18/91, 20%) showed properties consistent with a contribution to the control of anticipatory postural responses, whereas a further 10% showed activity consistent with a contribution to postural support during the movement. Although some cells that showed modified activity only during reaches with the contralateral forelimb, many cells (65/91, 71%) were also activated during reaches with the ipsilateral forelimb. This was particularly true for cells related to the lever press, many of which discharged similarly during reaches of either limb. This suggests a context-dependent control of movement and posture in which the same muscles are used for different functions during contralateral and ipsilateral reach. Comparison with the results from recordings made previously from the motor cortex and the pontomedullary reticular formation in the same task show more similarities with the former than the latter.SIGNIFICANCE STATEMENT Pathologic changes in basal ganglia function frequently lead to problems with postural stability and gait initiation. Here, we show that some neurons in one of the output regions of the basal ganglia, the pallidum, show discharge activity compatible with a contribution to postural control. At the same time, we note that such cells are a minority in this region with most cells being related to movement rather than posture. We also show that many neurons are active during movements of both the contralateral and ipsilateral limbs, sometimes with identical discharge patterns. We suggest that this indicates a context-dependent regulation of movement and posture in the pallidum.

The Incidence of Chronic Limb-Threatening Ischemia in the Midland Region of New Zealand over a 12-Year Period.

The epidemiology of severe PAD, as characterized by short-distance intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI), remains undefined in New Zealand (NZ). This was a retrospective observational cohort study of the Midland region in NZ, including all lower limb PAD-related surgical and percutaneous interventions between the 1st of January 2010 and the 31st of December 2021. Overall, 2541 patients were included. The mean annual incidence of short-distance IC was 15.8 per 100,000, and of CLTI was 36.2 per 100,000 population. The annual incidence of both conditions was greater in men. Women presented 3 years older with PAD (p < 0.001). Patients with short-distance IC had lower ipsilateral major limb amputation at 30 days compared to CLTI (IC 2, 0.3% vs. CLTI 298, 16.7%, p < 0.001). The 30-day mortality was greater in elderly patients (<65 years 2.7% vs. ≥65 years 4.4%, p = 0.049), but did not differ depending on sex (females 36, 3.7% vs. males 64, 4.1%, p = 0.787). Elderly age was associated with a worse survival for both short-distance IC and CLTI. There was a worse survival for females with CLTI. In conclusion, PAD imposes a significant burden in NZ, and further research is required in order to reduce this disparity.

Somato-somatic theory of referred pain elucidates observations of referred sensations during micropigmentation of nipple-areolar complex in a cohort study on patients undergoing pedicled latissimus dorsi flap breast reconstruction

Micropigmentation of the nipple-areolar complex is the final aesthetic step in autologous breast reconstruction. The mechanism of referred pain observed in patients during micropigmentation after a non-neurotonized pedicled latissimus dorsi flap breast reconstruction is poorly understood. Patients undergoing micropigmentation for nipple-areolar restoration at our breast unit were included in this study. Baseline sensitivity of both breasts was recorded using a questionnaire and non-invasive Semmes-Weinstein monofilament testing. Patients experiencing local and regional referred symptoms, while undergoing micropigmentation, were identified and their clinical data were collected and analysed. Three months postoperatively, the patients completed a questionnaire pertaining to their satisfaction and future analgesic preference. Thirty (17.8%) patients experienced referred sensations during micropigmentation. Their symptoms ranged from "ache" (6.7%), "discomfort" (13.3%) to "deep pain" (13.3%) and were either local and/or referred to ipsilateral axilla, upper limb and back. The majority were pleased with postoperative outcomes [shape (30, 100%), size (28, 93.3%), colour match (22, 73.3%)] and a small number were not satisfied with the shape (2, 6.7%,) position (1, 3.3%) and appearance of the tattoo (1, 3.3%). Micropigmentation is a safe procedure with good patient satisfaction and low rates of complications; however, patients may experience significant local or referred symptoms. This observation can be explained by the proposed "somato-somatic" theory of referred pain and ascertains the need for use of oral and/or local anaesthetic as well as improved counselling in these patients.

Hip fractures associated with concomitant upper limb fractures: a case series

&lt;p class="abstract"&gt;Elderly patients are at risk of fractures of distal radius, proximal humerus, spine and hip even due to trivial low energy falls. Hip injuries are commonly associated with concomitant ipsilateral upper limb injury because of a protective reflex of shielding their body from fall using their shoulder or outstretched hand. Here we presented a case series of 3 elderly patients who came to us with hip fractures and concomitant ipsilateral upper limb fractures. The injuries were adequately managed with splintage and operative procedures. Post-operatively mobilization was challenging. But patients were successfully mobilized with the help of relatives and physiotherapists. Concomitant hip fractures with associated ipsilateral upper limb fractures are quite common in elderly and difficult to treat. Post-operatively mobilization of patient and functional outcome is hampered. Proper counselling by operating surgeon, physiotherapy and postoperative rehabilitation with the help of relatives and assisting devices provides good outcome. In cases of hip trauma in old age, one should always thoroughly examine and screen for upper limb injuries. So that early appropriate treatment and mobilization can be done with good functional outcome.&lt;/p&gt;

Sex-Related Outcomes Following Drug Balloon Angioplasty in Patients from the BIOLUX P-III Registry: A Subgroup Analysis

PurposeTo evaluate the use of drug-coated balloons in a real-world patient population with peripheral arterial disease and analyse the impact of sex on mid-term outcomes following their utilisation.MethodsThe BIOLUX P-III is a prospective, international, multi-centre, registry of patients with infra-inguinal lesions treated using the Passeo-18 Lux, a drug-coated balloon. Our study is a 24-month subgroup analysis of these patients; primary endpoints were freedom from major adverse events and clinically driven target lesion re-vascularisation within 12 months post-intervention.ResultsOf the 877 patients in the registry, 561 (64.0%) were male and 316 (36.0%) were female. Chronic limb threatening ischaemia (Rutherford class ≥ 4) occurred in 35.7% of males and 40.6% of females. Rates of freedom from major adverse events and clinically driven target lesion re-vascularisation at 12 months were 87.3% (95% confidence interval [CI] 84.2–89.9) and 90.4% (95% CI 86.5–93.3), and 92.3% (95% CI 89.9–94.1) and 92.9% (95% CI 89.7–95.1) in males and females, respectively. All-cause mortality at 24 months was 12.0% (95% CI 9.4–15.3) in males and 11.9% (95% CI 8.6–16.5) in females. The major target limb amputation rate at 24 months was 9.1% (95% CI 6.9–11.9) in males and 4.0% (95% CI 2.3–7.0) in females.ConclusionTreatment with the Passeo-18 Lux DCB demonstrated high efficacy and low complication rates. Despite the greater proportion of chronic limb threatening ischaemia observed in females, males were at a greater risk of ipsilateral major limb amputation and major adverse events following drug-coated balloon utilisation.Clinical Trial RegistrationNCT02276313.Level of EvidenceLevel 4.

Intractable arteriovenous access-related pain relieved after a single, pain-free hemodialysis session under selective block of the sensory nerves in the upper limb: A psychosocial factorial case.

Intractable arteriovenous access (AVA)-related pain can not only lead to abandonment of a well-functioning AVA, but can also cause hemodialysis (HD) patients to be unwilling to accept, interrupt, or withdraw from HD. Such pain primarily derives from nociceptive and neuropathic factors caused by mechanical stimulation of needle cannulation; however, this might be related to psychosocial factors making it difficult for patients to accept their dependency on HD. Furthermore, the pain can be complicated by the interaction of biological and psychosocial factors, which hampers appropriate pain management and treatment. However, there have been few investigations pertaining to this matter. Herein, we describe the case of an HD patient who experienced chronic refractory AVA-related pain during a 32-month period of HD sessions, which occasionally caused treatment interruption. After clinical inquiry, physical evaluation, and ultrasonographic assessment of the blood circulation and cutaneous nerves in the ipsilateral upper limb to the radiocephalic arteriovenous fistula in the anatomical snuffbox, we diagnosed the patient with primarily psychosocially driven pain in consultation with an experienced pain clinician. A single, pain-free HD session under ultrasound-guided sensory nerve blocks in the upper limb markedly relieved her pain, followed by HD sessions with subtle but acceptable pain. This report provides insights into the mechanism underlying the vicious cycle of AVA-related pain, including the psychosocial aspects that might trigger such pain, as well as into the importance of treating such pain to improve the patient's quality of life, and underscores the need for cooperation of experts engaged in HD and pain management.

Ultra-Mini-Percutaneous Nephrolithotomy in Flank-Free Modified Supine Position vs Prone Position in Treatment of Pediatric Renal Pelvic and Lower Caliceal Stones.

Objectives: To report the safety and efficacy of ultra-mini-percutaneous nephrolithotomy (UMPCNL) in flank-free modified supine (FFMS) and prone positions in management of pediatric renal calculi. Patients and Methods: This prospective randomized study included 55 pediatric patients with symptomatic renal stones and suitable for UMPCNL. They were randomized into two groups. Group A included 28 patients who were treated by UMPCNL in FFMS position (with a pad below the ipsilateral shoulder and buttocks, putting ipsilateral upper limb over the chest, and crossing the extended ipsilateral lower limb over the flexed contralateral one) and Group B included 27 patients treated by UMPCNL in the prone position. In both groups dilatation was done to 13F sheath allowing the introduction of 6/7.5F semirigid ureteroscope and fragmentation of stones by Holmium: yttrium-aluminum-garnet laser with a 550-μm fiber laser lithotripter. Results: The operation time in FFMS position UMPCNL group was significantly shorter than prone position UMPCNL group (84.3 ± 9.87 vs 99.3 ± 8.75 minutes) with p = 0.022. There was no significant difference between both groups in terms of stone-free rate (89.3% vs 88.9%), overall complication rate (including transient fever; 21.4% vs 18.5%), postoperative pain (visual analog scale score; 3.4 ± 0.8 vs 3.3 ± 0.9), or hospital stay (3.53 ± 0.8 vs 4.1 ± 1.1 days). Conclusion: Both UMPCNL in FFMs and prone positions are feasible, safe, and effective in treatment of pediatric renal stones with relatively shorter operative time in FFMS position.

Endovasküler Yöntemlerle Tedavi Ettiğimiz Akut Alt Ekstremite Emboli Deneyimlerimiz

Objectives: The study aims to retrospectively evaluate the 1-year results of endovascular treatment with rheolytic thrombectomy(TR) or catheter-directed thrombolytic(CDT) infusion therapy in acute femoro-popliteal bypass graft occlusion.&#x0D; Methods: The patients who had a history of femoro-popliteal by-pass operation and during their follow-up diagnosed with ipsilateral acute limb ischemia between 2016 and 2018 were included. The total of 13 patients were included and they were divided into two groups according to their treatment methods (RT, n=8 vs CDT, n=5).&#x0D; Results: There was no statistically significant difference between the two groups in terms of demographic data and Rutherford embolism classification. Reolitic thrombectomy and catheter-directed thromolytic infusion primary patency values were 87.5% and 80% for 6 months, 75% and 60% for 12 months, respectively. Secondary patency values were found to be 100% in both groups for 6 months, and 87.5% and 80% for 12 months, respectively. There was no significant difference between the two groups in terms of primer and sekonder patency.&#x0D; Conclusion:Endovascular therapy can be preferred in the treatment of acute femoro-popliteal by-pass graft occlusion in selected patient groups due to its less invasiveness, early mobilization, and low mortality and morbidity rates compared to surgery,

A case report of surgical treatment of traumatic drop hand by quadruple tendons transfer.

IntroductionDrop hand is the case of inability to dorsiflexion of the hand and fingers according to radial nerve palsy (complete syndrome) or PIN (Posterior Interosseous Nerve) palsy (partial syndrome). Therefore, the patient loses part of the normal function of his/her hand causing life problems especially if it is the dominant hand. Tendon transfer is the main surgical treatment.Case reportWe present a case of a young male who sustained multiple traumatic war injuries especially in the left upper limb; open humerus fracture, open ulna fracture, open radius fracture with a clear drop hand syndrome. After quadruple tendons transfer, he got a very good result especially in thumb movements with good ROM (Range Of Motions) in the wrist.DiscussionSince it is difficult to restore full ROM and full muscular strength in the wrist and fingers of a drop hand with triple tendon transfer routinely, especially in the case of multiple injury to the upper extremity with the pronator teres being nonfunctional, we decided to perform quadruple tendon transfer depending on the tendons; FCR, PL, 3rdFDS, 4thFDS for stronger extension of the wrist, thumb, and other fingers.ConclusionOur aim here is to confirm that the drop hand does not have standard findings in all cases. It may be a challenge, and may have atypical findings especially in the case of ipsilateral multiple traumatic limb, which in turn may have weakness or restriction in some important movements, so, it is important to keep in mind alternatives of tendon transfer.