Limb Trauma Research Articles

P 85 Impaired pain processing on a brainstem level in patients with complex regional pain syndrome

Introduction: The complex regional pain syndrome (CRPS) is a chronic pain condition, which can follow limb trauma and is accompanied with sensorimotor dysfunction 1 . Current pathophysiological concepts assume local inflammatory processes that lead to peripheral and central sensitization of the nociceptive system 2 . Secondary maladaptive alterations of cortical sensorimotor excitability and disinhibition are well-established but little is known about the contribution of the brainstem. Preliminary evidence for altered brainstem excitability to trigeminal afferent stimulation was recently provided 3,4 . This study uses a more comprehensive assessment of the nociceptive blink reflex (NBR) to assess the interaction of brainstem excitability and habituation to painful stimuli. Methods : 14 CRPS patients (10 female, 53 ± 17.6 years) and 10 controls (HCs; 9 female, 52±18.3) received assessments of pain and the NBR (R2 component, 2 trials, 10 stimuli/trial, interstimulus interval 3-5s). The R2 area (R2a) and habituation (R2h; gradient of R2a against stimulus order) were measured for the stimulated/non-stimulated side (_s/_ns). Results : Pain levels were 5,0±1,5/10 at rest and 7,2±2,1/10 during movements. ANOVA revealed a significant group effect for patients vs. controls (F=4.0; p=0.015). Post hoc tests were corrected for multiple comparisons and showed exceeding excitability (R2a_s: t=2.42, p=0.048; R2a_ns: t=2.98, p= 0.028) and impaired habituation (R2h_s: t=2.45, p=0.044; R2h_ns t=2.60, p=0.036). No significant associations of both disease duration and pain levels with NBR measurements could be obtained. Discussion : We here provide first evidence of altered NBR excitability and habituation indicating altered pain processing on a brainstem level. These results complement previous findings by demonstrating disinhibition as a source of increased brainstem excitability to painful stimulation remote from the limb directly affected by CRPS 4 . Future investigations are needed for a better understanding of the brainstem and its role in the pathophysiology of CRPS. The potential of the NBR as clinical biomarker, as it has been demonstrated in other pain diseases, should also be clarified in further investigation 5 . Literature: 1 Veldman PH et al. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet 1993. 2 Eldufani J et al. A medical mystery of CRPS. Heliyon. 2020. 3 Thiele A, et al. Treatment with calcitonin gene-related peptide antibodies modifies brainstem excitability and habituation to nociceptive trigeminal stimulation in migraineurs. CEPHALALGIA. 2021. 4 Drummond P et al. The Source of Hemisensory Disturbances in CRPS, The Clinical Journal of Pain: 2021. 5 De Marinis M et al. Decreased habituation of the R2component of the blink reflex in migraine patients. Clinical neurophysiology. 2003.

Craniocerebral Gunshot Injuries in Chad: A Study of 44 Cases

Firearm head injuries cause great public health concern because of their severity. They are life-threatening due to intracranial lesions and sepsis risks. This prospective study evaluates the management of craniocerebral wounds in Chad. This is an observational study conducted over a period of 65 months with 44 patients with a ballistic craniocerebral wound (BCW), of which only 7.18% were assessed by neurosurgeons with gunshot wound. The mean age was 30.57 ± 13 years (range:2-60 years). The 21-30 age group was the most affected (31.8%). The sex ratio was 21. A total of 63.6% of cases involved military personnel. The average admission time was 24.95 ± 12 hours (range: 1-72 hours). Explosive device attacks represented 29.5% of cases, of which 53.3% occurred in civilian practice. Point-blank shooting was reported in 70.5% of cases. The entry hole of the projectile was frontal in 40.9%. Intracranial sequestration of the projectile was found in 56.8%. Association of upper limb trauma was found in 9.1% of cases. Brain scans were performed in 95.5% of cases. Surgical treatment was undertaken in 68.18% of cases. The recovery process was marked by brain abscess in 6.8% of cases. Seven deaths were recorded. This study shows that BCW is frequent and mainly affects young male individuals in Chad. Many of the cases were related to improvised explosive device attacks, especially in civilian practice (70.5%). The delay in diagnostic and therapeutic management favors the high rate of sequelae.

Autoantibodies from patients with complex regional pain syndrome induce pro-inflammatory effects and functional disturbances on endothelial cells in vitro.

Complex regional pain syndrome (CRPS) is an inadequate local response after a limb trauma, which leads to severe pain and autonomic and trophic changes of the affected limb. Autoantibodies directed against human β2 adrenergic and muscarinic M2 receptors (hβ2AR and hM2R) have been described in CRPS patients previously. We analyzed sera from CRPS patients for autoantibodies against hβ2AR, hM2R, and endothelial cells and investigated the functional effects of purified IgG, derived from 13 patients with CRPS, on endothelial cells. Eleven healthy controls, 7 radial fracture patients without CRPS, and 10 patients with peripheral arterial vascular disease served as control subjects. The CRPS-IgG, but not control IgG, bound to the surface of endothelial cells ( P < 0.001) and to hβ2AR and hM2R ( P < 0.05), the latter being reversed by adding β2AR and M2R antagonists. The CRPS-IgG led to an increased cytotoxicity and a reduced proliferation rate of endothelial cells, and by adding specific antagonists, the effect was neutralized. Regarding second messenger pathways, CRPS-IgG induced ERK1/2, p38, and STAT1 phosphorylation, whereas AKT phosphorylation was decreased at the protein level. In addition, increased expression of adhesion molecules (ICAM-1 and VCAM-1) on the mRNA level was induced by CRPS-IgG, thus inducing a pro-inflammatory condition of the endothelial cells. Our results show that patients with CRPS not only develop autoantibodies against hβ2AR and hM2R, but these antibodies also interfere with endothelial cells, inducing functional effects on these in vitro, and thus might contribute to the pathophysiology of CRPS.

Utility outcomes score assessment of living with below-knee amputation

Objectives: Lower limb trauma that involves severe soft-tissue injuries continues to pose treatment challenges when considering whether to perform an amputation or salvage the injured extremity. This study aimed to measure the perceived health burden of living with unilateral below-knee amputation (BKA). A secondary aim was to compare the health burden of living with BKA and single-eye blindness and/or double-eye blindness (SEB and DEB). Methods: A web-based survey was utilized to establish the effectiveness of outcome scores for three health states (unilateral BKA, SEB, and DEB) in a sample of 116 participants recruited from the general population. The outcome measures included the time trade-off (TTO), standard gamble (SG), and visual analog scale (VAS) tests. Results: The TTO, SG, and VAS scores for BKA were 0.75 ± 0.2, 0.78 ± 0.18, and 0.57 ± 0.16, respectively. These measures indicate that participants were willing to undergo a theoretical surgery that carries a 22% chance of mortality and trade 9 years of life to avoid a BKA. These were lower than the values of SEB VAS (P = 0.02) and TTO (P = 0.002) tests and the SG measure (0.8 ± 0.17, P = 0.09). Age, gender, race, income, and education were not statistically significant independent predictors of the utility scores for BKA. Conclusion: When faced with a BKA, individuals in our sample population would choose to undergo reconstructive surgery with a hypothetical 22% chance of mortality. They would be willing to sacrifice 9 years of their life for such a surgery to avoid a BKA. These data can be beneficial to understand better how patients perceive their disability and help in patients’ counseling.

Efficacy of pedicled anterolateral thigh flap for reconstruction of regional defects - a record analysis.

The anterolateral thigh (ALT) flap was described as the fasciocutaneous flap. It can be harvested as apedicled and/orfree flap. Majority of the free flaps are harvested as afasciocutaneous flap. Their use in head and neck reconstruction and limb trauma is well established. Apart from these advantages, this flap has various applications which are less utilized. ALT flap can be used as amyocutaneous flap along with vastus lateralis muscle. When muscle and fasciocutaneous flaps are required, both can be harvested as achimeric flap which can cover two different regions of the wound. Moreover, harvest of the pedicled flap procedure is less time-consuming than that of afree flap. Since it has along vascular pedicle, when used as pedicled flap, it can reach up to the gluteal region. To evaluate these less applied advantages of pedicled ALT flap, our study was undertaken. This study aimed to evaluate the efficiency of ALT flap in terms of the surface area of coverage, arc of rotation and the advantages of including vastus lateralis muscle as part of the flap. Aretrospective record analysis of all pedicled ALT flap reconstruction of trochanteric, upper thigh, gluteal and flank regions from 2016 to 2018 was undertaken; 7 patients with 8 defects were included. All the flaps healed successfully. There was no major necrosis of the flap and minor complications like wound gapping were found in three patients. The ALT-vastus lateralis flap dimensions can be very large and can be easily harvested in avery short time. Vastus lateralis muscle harvested can be used to fill the defect or can be used as chimera to cover the defect. The use of muscle over long standing infective pressure sores can sterilize the wound bed and help in preventing recurrence. The vascularity of this flap is robust and highly reliable. Even after amaximum arc of rotation (up to 170°) all the flaps survived without any major complications.

Traumatic Peripheral Nerve Injury in Mice.

Traumatic peripheral nerve injury (TPNI) is a common cause of morbidity following orthopedic trauma. Reproducible and precise methods of injuring nerve and denervating muscle have long been a goal in musculoskeletal research. Many traumatically injured limbs have nerve trauma that defines the long-term patient outcome. Over several years, precise methods of producing microsurgical nerve injuries have been developed, including crush, lacerations, and nerve-gap grafting, allowing for reproducible outcome assessments. Moreover, newer methods are created for calibrated crush injuries that offer clinically relevant correlations with outcomes used to assess human patients. The principles of minimal manipulation to ensure low variability in nerve injury allow for adding still more associated tissue injuries into these models. This includes direct muscle crush and other components of limb injury. Finally, atrophy assessment and precise analysis of behavioral outcomes make these methods a complete package for studying musculoskeletal trauma that realistically incorporates all the elements of human traumatic limb injury.

Correlation between miRNA-124, miRNA-544a, and TNF-α levels in acute spinal cord injury

Study designRetrospective.ObjectivesAcute spinal cord injury (ASCI) is caused by direct or indirect strikes from external forces on the spinal cord. Here, we investigated the correlation between the miR-124, miR-544a, and TNF-α levels in patients with ASCI, aiming to evaluate the potential usage of miR-124 and miR-544a in ASCI diagnosis.SettingUniversity/hospital.MethodsA total of 90 (58 male/32 female) ASIA patients and 15 (9 male/6 female) control patients (with acute limb trauma) were involved in the presented study. The ASIA patients were further subclustered based on the International Standards for the Neurological Classification of SCI (ISNCSCI) exam. 30 (18 male/12 female)cases were determined to have complete spinal cord injury (CSCI) and classified as ASIA grade A (Complete); 30 (20 male/10 female) cases were determined to have incomplete spinal cord injury (ISCI) and classified as ASIA grade B (sensory incomplete), C (motor incomplete), or D (motor incomplete); 30 (20 male/10 female) cases were determined to have normal neurological function (NNF) and classified as ASIA grade E (Normal). Plasma miR-124, miRNA-544a, and tumor necrosis factor-alpha (TNF-α) levels were measured from the blood samples collected 24 h, 48 h, and 72 h after trauma.ResultsThe levels of miR-124 and miR-544a in the CSCI and ISCI groups were significantly higher than those of the NNF and the control group 24 h after injury (P < 0.05). The increased levels gradually declined from 24 h to 72 h after injury. The area under the receiver operating characteristic curve (ROC) of miR-124, miR-544a and TNF-α 24 h after trauma in patients with acute spinal cord injury were 0.948 [95% CI (0.890, 1.000)], 0.815 [95% CI (0.638, 0.994)] and 0.770 [95% CI (0.641, 0.879)], respectively.ConclusionThe miRNA-124 and miRNA-544a levels increased significantly in ASCI patients compared with control patients 24 h after injury. These increased levels gradually reduced from 24 h to 72 h after injury. There is a strong positive correlation between miRNA-124, miRNA-544a, and acute spinal cord injury.SponsorshipThe present study was supported by a University-level project of Ningxia Medical University (Project Number: XY2017147).

Free fibula flap thumb salvage after a gunshot wound: Case report emphasizing the orthoplastic approach

High-energy hand trauma damaging bone and soft tissue often leads to amputation. Thumb loss leads to significant disability and decreased quality of life. A variety of options exist to preserve or restore thumb function, but many are not viable when significant bone and overlying soft tissue are lost. In this case report, we present a case of a 30-year-old warehouse worker who suffered a gunshot blast injury to the hand, destroying his metacarpophalangeal joint and overlying soft tissue. Initially this was repaired at an outside hospital with a nonvascularized bone graft and no definitive soft tissue coverage that subsequently became infected. Free fibula osteocutaneous flap reconstruction prevented amputation and restored form and function to the thumb. Implementing an orthoplastic approach resulted in thumb salvage and restoration of this patient's quality of life. • Gunshot wounds to the upper extremity often cause impairment and disability. • Reconstruction with a free fibula osteocutaneous flap to the thumb prevented amputation. • The orthoplastic approach is the preferred method for reconstruction following limb trauma.

Abstract No.: ABS1180: A randomised comparative evaluation of ultrasound guided classical vs parasacral parallel shift (PSPS) technique of sciatic nerve block combined with femoral nerve block as a sole anaesthetic modality for orthopaedic lower limb surgeries

Background and Aims:Sciatic nerve can be blocked in the gluteal region via anterior, posterior and a newly developed lateral/parasacral approach. Primary objective of the study was to compare success of sciatic nerve block using classical versus parasacral parallel shift approach (PSPS).Methods:This study was conducted in a tertiary medical college hospital from October 2020 to October 2021 after approval of Institutional Ethics Committee and written informed patient consent. Total 160 patients (80 in each group) aged 18-80 years with American Society of Anesthesiologists physical status I-III ,undergoing traumatic lower limb orthopaedic surgery were assessed for eligibility based on the inclusion and exclusion criteria. Ultrasonography was used for the blocks.Results:Successful block was administered in 98.61%(n=71) subjects via PSPS approach, compared to 90.27%(n=57) via classical approach(table1). Time between ultrasound localisation of nerve to drug administration was significantly higher with classical as compared to PSPS approach. Successful first needle pass was seen in 90.27%(n=65) of PSPS group compared to 45.54%(n=27) of classical group. Time to motor blockade was found to be 17.33+/-3.6 minutes with PSPS approach, significantly lower than classical (22+/-3.53 minutes) approach.Conclusion:Parasacral sciatic nerve block via PSPS approach is superior to classical approach in terms of time to administration of block, success of block, requirements of sedation intraoperatively, time to motor blockade and time to sensory blockadeTable 1Block performance characteristicsClassical groupPSPS groupPSuccessful blockn=65 (90.27%)n=71 (98.61%)0.029Successful first needle passn=32 (44%)n=65 (90.27%)0.000Time from ultrasound localisation to drug administration (min)9.51±2.163.28±1.190.000Time to motor blockade (min)21.94±3.1917.32±2.490.000Time to sensory blockade (min)20.00±2.7716.21±3.080.000

Analysis of the therapeutic effect of artificial leather embedding combined with fascial sleeve flap transplantation on chronic wounds of lower limbs with bone and plate exposure

BackgroundAfter severe trauma of lower limbs, bone, tendon or plate graft exposure is common. The traditional repair method is to use a variety of skin flap transplantation to cover the exposed part, but the wound often can not heal after operation, or the wound is cracked, ulcer, sinus, bone and steel plate are exposed again after wound healing. The reason for this result is that when the flap is covered, the space around the bone plate is not well closed, forming a dead cavity, blood and exudate accumulation, hematoma formation or infection, and finally the wound ruptures again. In addition, due to the swelling and contracture of the flap after operation, the suture tension between the flap and the receiving area becomes larger, the skin becomes thinner and broken, and then the wound is formed. In order to solve the above problems, we carried out the study of artificial true skin embedding combined with fascial sleeve flap transplantation in the treatment of chronic bone plate exposed wounds of lower limbs.MethodsIn this paper, 11 cases of chronic wounds with bone exposure and skin necrosis after steel plate implantation were selected. First stage is the wound bed preparation including primary wound expansion, removal of necrotic tissue and incision of sinus wall, removal of deep necrotic bone and fibrotic scarred skin on the outer wall of steel plate to normal tissue on the outer edge of the wound, removal of precipitated peptone and purulent fur in the hole, periphery and bone space of the steel plate, and removal of tendon tissue with basal necrosis and disintegration of the wound. After vacuum sealing drainage (VSD) 1–2 weeks, the peritraumatic basal granulation tissue grew well and there was no necrotic tissue in the wound. In the second stage, the exposed bone was covered with artificial dermis, the steel plate hole or the periphery and the basal space were filled, and the exposed steel plate was completely embedded, and then the fascia sleeve flap was transplanted to cover the wound. The sural neurovascular flap was performed in nine cases and the lateral superior malleolar artery perforator flap in two case.ResultsThe flap survived well in all 11 cases. During the follow-up of 6 months to the removal of the plate, there was no case of rupture, exposure and sinus formation.ConclusionsArtificial dermal covering combined with fascial sleeve flap transplantation can effectively avoid wound dehiscence or sinus formation caused by foreign body retention, infection and flap contracture. It has good effect in repairing chronic wounds with bone plate exposure after severe trauma of lower limbs.

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.

Major traumatic amputations and replantations of the upper extremity in Germany – National quality reports 2014–2018

The treatment of traumatic major upper limb amputation is complex and of great urgency. Loss of time often represents a majorrestriction for replantation. Thus, logistical and infrastructural developments, such as the expansion of specialised hand trauma centres, are crucial for optimizing delivery of care. Surveillance represents the fundament for a proper, demand-adapted implementation of such therapeutical improvements. However, a comprehensive database for surveillance of these injuries does currently not exist in Germany or Europe.In this study quality reports of German hospitals from 2014 to 2018 were screened retrospectively for traumatic major upper extremity amputations and replantations. A total of 329 amputations and 87 replantations were recorded, accounting for an overall replantation rate (RR) of 26%. Most of the injuries affected the level of the wrist and forearm. Treatment of these injuries experienced an increasing centralisation to medical teaching facilities, which accounted for higher RRs compared with non-teaching facilities. The cumulatively most populous federal states handled most of the amputation injures in this five-year study period.Ratio calculations on the basis of population counts, however, revealed great discrepancies to these results, with Hamburg, Rhineland-Palatinate and Saarland accounting for the highest per capita incidences. In 2018 Germany was provided with 46 specialised hand trauma and replantation centres, which performed 45% of the replantations in that year, revealing a RR of 17%, compared to an overall RR of 14% in that year. Nevertheless, there might be potential for improvement in the geographical distribution of these specialised centres.The provision of highly specialised therapy in highly specialised centres for highly complex injuries is a future challenge in replantation surgery. This data is contributing to logistical improvements for a need-adapted expansion of these specialised hand trauma centres.The study demonstrates an approach of a standardised and comprehensive injury surveillance program based on national quality reports, while underlining the importance of such a national or rather European database for optimisations in medical care.Level of evidence IV.

Complications of limb trauma traditional treatment at the University Hospital Center Le Bon Samaritain in Walia (N'Djamena, Chad)

RésuméIntroductionLe traitement traditionnel des traumatismes des membres par des tradipraticiens est omniprésent dans les sociétés africaines au sud du Sahara. Ces pratiques sont source de nombreuses complications. Cette étude se propose de préciser le profil de ces complications et d’identifier les facteurs favorisant le recours à ces tradipraticiens.Matériel et méthodesÉtude descriptive et analytique sur 12 mois, du 1er février 2018 au 31 janvier 2019, concernant tous les patients ayant consulté dans le service de chirurgie du Centre hospitalier universitaire Le Bon Samaritain de N’Djamena (CHUBS) pour une complication de fracture ou de luxation au niveau d’un membre qui avait été prise en charge par un tradipraticien. Le recueil des données a été fait à l’aide d’un questionnaire préétabli avec un recul moyen de 14 mois.RésultatsSur 144 patients atteints de traumatismes des membres, 47 souffraient au moins d’une complication de fracture ou de luxation suite à un traitement traditionnel, soit 33 % des cas. Parmi eux, 32 ont été retenus pour l’étude. L’âge moyen était de 23 ± 3 ans (extrêmes de 10-61) et le sex-ratio de 2,6 en faveur des hommes. La provenance était majoritairement rurale. Les élèves/étudiants et les cultivateurs/éleveurs étaient les plus représentés. Les accidents de la circulation routière étaient les plus rencontrés (n = 20). L’influence de l’entourage (n = 14) a représenté le premier facteur conduisant au choix d’un traitement traditionnel. L’attelle en bois n’immobilisant pas les articulations proximales de la fracture, associée au bandage ischémiant à l’origine des gangrènes, a constitué le premier mode de contention (n = 15). Le délai moyen entre le traumatisme et le début du traitement traditionnel était de 8,5 heures. Le délai moyen entre le traitement traditionnel et la survenue des complications était de 106 jours (extrêmes de 1-302). L’œdème du membre, le cal vicieux, la gangrène et la pseudarthrose ont représenté les complications les plus fréquentes. La lésion initiale a été une fracture fermée dans la plupart des cas (n = 22) avec une prédominance des membres inférieurs (n = 22). La prise en charge hospitalière a été chirurgicale (n = 19) ou orthopédique (n = 13). L’évolution thérapeutique a été bonne, assez bonne ou mauvaise, respectivement dans 24, 2 et 6 cas.ConclusionLes complications des traitements traditionnels des lésions traumatiques des membres sont graves. Une formation des tradipraticiens sur la connaissance des notions élémentaires d’immobilisation et la reconnaissance des signes de gravité, leur collaboration avec les structures de santé ainsi qu’une gratuité des soins dans les services hospitaliers permettraient de réduire ce phénomène. Les médias et réseaux sociaux devraient permettre de toucher un large public.

Application of a Knowledge, Attitude, Belief, and Practice Model in Pain Management of Patients with Acute Traumatic Fractures and Alcohol Dependence.

Objective To evaluate the outcome of a knowledge, attitude, belief, and practice mode (KABP) in the pain management in patients with acute traumatic fractures complicated with alcohol dependence. Methods Twenty-nine alcohol-dependent male patients with acute traumatic fractures and who received surgical treatment between January 2019 and December 2020 were included in this retrospective case-control study. The age range was 30–65 years (average 50.03 ± 7.94). Fracture Type. Six cases of spinal burst fractures and 23 cases of limb trauma fractures. Ten patients were treated with routine nursing (control group), and 19 patients were treated with pain management in KABP mode (experimental group). The control group received traditional pain care, including the conventional numerical rating scale (NRS) pain score system, with focus on symptomatic treatment. On this basis, the experimental group managed pain using KABP, including cognitive behavioral intervention, optimization programs, modification of personal beliefs, and behavior patterns. NRS, self-rated anxiety/depression scale (SAS), and quality of life (SF-36) scale were applied at admission, 1 day before surgery, and 3 months after surgery. Results The perioperative NRS score of the KABP group was lower than that of the control group, and the postoperative anxiety levels improved. Discharge satisfaction was significantly higher than that in the control group (p < 0.05). There were behaviors promoting health in the experimental group, and five patients expressed abstinence behavior after discharge (p < 0.05). Conclusion Patients with alcohol dependence represents a unique set of cases for perioperative pain management. To ensure patient safety, individualized pain management through the application of KABP can significantly reduce postoperative pain and promote the generation of healthy behaviors in patients.

Histomorphometric Analysis of Femoral and Sciatic Nerve Regeneration in a Rat Hindlimb Allotransplantation Model

Peripheral nerve regeneration is essential for functional recovery after traumatic limb injury or limb transplantation. With the use of immunosuppression, it has the capacity to provide regeneration and function equal to that of an autograft. The purpose of this study was to determine whether there is any difference in regeneration and rejection response between peripheral femoral and sciatic nerve in rat hindlimb allotransplantation model. The hindlimbs of recipient Fischer 344 rats were amputated at the mid-thigh and the donor and recipient femurs were joined by an intramedullary rod. The femoral and sciatic nerves were repaired with 10-O nylon end-to-end suture followed by vessel, muscle, and skin closure. The control group received auto-transplantation and the experimental group received allo-transplantation from Sprague-Dawley donor rats. The recipients were treated with an immunosuppressive agent, FK506 (2 mg/kg), for the observation period. Both sciatic and femoral nerves were harvested 10 weeks after operation and histomorphometric analysis was conducted between these 2 nerves and control group. The sciatic nerve showed better regeneration, with significantly increased percentage nerve, fiber count, and density (P < .05), but demonstrated more immune cell proliferation relative to femoral nerve. The data showed that there are some differences in axonal regeneration capacity and immune response between large peripheral nerves.

The burden of post-traumatic amputations in a developing country – An epidemiological study from a level I trauma centre

BackgroundWith the rapidly growing population and expanding vehicle density on the roads, there has been an upsurge in road accidents in developing countries. Knowledge about the causes and patterns of trauma-related amputations helps in the formulation of strategies for limb savage, timely management, and effective rehabilitation. ObjectiveTo study the epidemiology, demographic profile, and outcomes of post-trauma amputations at a level I tertiary care centre in North India. MethodsRetrospective evaluation of the amputee data from 1st January 2018 to 31st December 2019, focusing on demographic details, injury mechanisms, surgical delays, hospital stay, and complications. ResultsA total of 17,445 trauma cases were seen in our trauma centre during the study period. Of these, 442 patients (2.5%) underwent major limb amputation. The hospital-based prevalence of traumatic limb amputation was 2.5%. The mean age of the amputees was 35.6years (range 1–75), and the majority were males (n = 369, 83.5%). The lower to upper limb involvement ratio was 3:1 (n = 338:105). A road traffic accident was the most common mode of injury (77.4%), followed by machine-cut injuries (16.1%). On-site traumatic amputation was seen in 23.1% (n = 102), while 43.5% had a mangled limb amputated in the hospital (mean MESS score 9.53). Overall, 27% of cases had a vascular injury after trauma, ultimately ending in limb amputation. The in-hospital mortality was 2% (n = 9/442). 43.7% of patients with a single limb amputation were discharged within 48 h. Extended hospital stay was noted in cases with associated fractures in the other limbs (28.5%), head or facial injury (9.9%), and with or without a combination of chest, abdomen, pelvic, or spine injury (7.2%). ConclusionA 2.5% incidence of post-trauma amputation reflects on the severity of injury related to road and industrial accidents which predominantly affect the lower limbs at the peak of productive work life. In the absence of national amputation registries, the results underscore the need to focus on road safety protocols, patient transfer methods, and the up-gradation of local hospitals.

Sinestre, deviance, or biology? An investigation of hand dominance in relation to tendon absence.

The present study aimed to examine the relationship between hand dominance and the presence or absence of the flexor digitorum superficialis (FDS) in the fifth digit to add to the current body of knowledge. We hypothesized that the absence of the FDS in the right small finger is more prevalent in left-handed individuals. This was a prospective study conducted from January 2020 to April 2021 and performed at the plastic surgery department of a university hospital. The sample consisted of volunteers with no history of upper limb trauma, surgery, or any other condition. The study included male and female individuals over 18 years old at a local Rhode Island university campus. The FDS tendons of the bilateral fifth fingers were evaluated through clinical testing by an independent examiner. A total of 236 hands from 118 volunteers were analyzed. Left-hand dominant participants composed of 5% of the population. For these participants, the prevalence of absence of the fifth finger FDS tendon in the right hand was significantly higher than that of right-hand dominant participants (71.4% vs. 28.8%). No significant difference between sex assigned at birth (male vs. female) was noted and the absence of the FDS in either hand, regardless of hand dominance. The results from the current study demonstrate that anatomy may contribute to one's preference for left-handedness. For children who have difficulty using their right hand, perhaps, an assessment of their FDS status may result in earlier acceptance of using their left hand.

Satisfaction of lower limb amputees with their prostheses and with the clinical services - a cross-sectional survey.

To evaluate the amputees' satisfaction with their prostheses and with the clinical services. The cross-sectional study was conducted at the Medical Rehabilitation Hospital, Madinah, Saudi Arabia, from August 2018 to November 2019, and comprised unilateral, traumatic lower limb amputees. Data was collected using the client satisfaction with the device, and the client satisfaction with service modules of the Orthotics and Prosthetics User's Survey instrument. Data was analysed using SPSS 23. Of the 220 subjects, 43(19.54%) were transfemoral amputees; 37(86%) males with a mean age of 51.9±12.7 years, and 6(14%) females with mean age 51.9±12.7 years. There were 168(76.36%) transtibial amputees; 146(87%) males with mean age 51.7±12.9 years, and 22(13%) females with mean age 54.1±12.7 years. Besides, there were 9(4.09%) female partial-foot amputees with a mean age of 36.0± 6.5 years. Overall, 165(75%) subjects were satisfied with the durability of their prostheses, and 213(97%) were satisfied with the service standard. Most of the participants were generally satisfied with their prostheses, and almost all of them were generally satisfied with the clinical services.

Analysis Of Concomitant And Isolated Venous Injury In Military Lower Extremity Trauma

OBJECTIVES The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. METHODS The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). RESULTS 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries-IVI) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). CONCLUSION Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes. The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries-IVI) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.

CLINICAL ANATOMY AND VARIATION OF PROFUNDA FEMORIS ARTERY- CASE SERIES

Background:The profundafemoris artery (PFA) or deep femoral artery is a large branch that arises posterolaterally from femoral artery (FA) distal to the inguinal ligament. Primary source for the blood supply of the head of the femur is the mainly by the deep branch of profundafemoris artery (Medial circumflex artery). In the indication and choice of profundaplasty, vascular reconstructive procedure, the knowledge of the anatomy of PF may be particularly important for the clinicians dealing with them. Objectives: The study aimed at study of origin and branching pattern of PF, b. Correlation with surgical aspect of PF. Material &amp; Methods: The present study was conducted in 10 formalin-fixed lower limbs from the Department of Anatomy, Shri AtalBihari Vajpayee Medical college&amp; RI, Bangalore&amp; Bangalore Medical college &amp; Research Institute. Dissection of PFA and its branches were carried out &amp; the following parameters were observed and photographed. Results: Origin of PF was posterolateral in 6cases , posterior in 3, &amp; lateral in 1 to FA. Origin of MCFA was from PFA in 9cases &amp; FA in 1. The mean distance of origin of MCFA was 1.8 cm (range 0.1-8.5 cm). Origin of LCFA was from PFA in 9 cases &amp; FA in 1. The mean distance of origin of LCFA was 2.3 cm (range 0.3-7 cm) Conclusion: Knowledge of PFA is very important for surgeons to prevent iatrogenic injury as well as during profundoplasty as it is sole artery to supply majority of thigh region. Knowledge of variations in profundafemoris and its branches helps surgeons during preoperative clinical evaluation for surgical and interventional revascularization of the ileo-femoral and femoro-popliteal segments, in open canulation of femoral artery for cardiopulmonary bypasss, in radiological interventions for A-V malformations, and in salvage operations for traumatic limb ischemia.