Mangled Limb Research Articles

Functional Chimeric Double-barrel Fibula and Reinnervated Peroneus Brevis Osteomyocutaneous Flap for One-stage Forearm Reconstruction.

Reconstructing a mangled limb is complex and requires expertise in both bone and soft-tissue reconstruction, particularly when there is significant muscle loss. Typically, multistage surgery is necessary, starting with soft-tissue coverage, followed by bone grafting and tendon transfers. Sometimes, microsurgical techniques such as vascularized bone grafts and free functional muscle transfers are necessary, especially when there is a bone defect of over 6 cm; the soft-tissue environment is infected, scarred, or poorly vascularized; or there are extensive musculotendinous injuries. We treated a 34-year-old man who had a crushed left forearm resulting in an 18 × 8 cm open wound, 5-cm radius and 7-cm ulna bone defects, loss of the extensor pollicis longus and brevis muscles, and extensive injuries to the other musculotendinous structures of the forearm. To accomplish a one-stage reconstruction, we used a chimeric fibula osteomyocutaneous flap that included a 20 × 10 cm skin flap, peroneus brevis muscle with its motor nerve, and two segments of fibula. The proximal and distal fibula segments were used for ulnar and radial bone reconstruction, respectively, preserving forearm supination and pronation. The peroneus brevis tendon was sutured to the extensor pollicis longus tendon, and its motor nerve was coaptated with the posterior interosseous nerve to restore thumb extension. The skin flap provided complete coverage of all exposed bone and tendon structures. At the 12-month follow-up, the patient regained full extension of the thumb, and there were no difficulties with forearm supination and pronation or with foot eversion and plantar flexion at the donor leg.

Revisiting the Mangled Extremity Severity Score (MESS) in Popliteal Artery Injury: A Single-Centre Experience in Vietnam.

Popliteal artery injury is a severe condition that can lead to limb loss. Early intervention is essential to achieve optimal outcomes, including limb salvage. The Mangled Extremity Severity Score (MESS) is a scoring system used to predict amputation rates for mangled limb injuries. The effectiveness of the MESS in predicting amputationin patients with traumaticpopliteal artery injury is unclear, particularly in settings with a high prevalence of motorcycle accidents. This retrospective study was conducted at a single center in Vietnam between January 2018 and June 2020. The study included 120 patients who underwent surgical treatment for popliteal artery injury. Data were collected from electronic medical records, radiology reports, and operative notes. Logistic regression model and the area under the curve (AUC) were used to evaluate the predictive value of the MESS. Patients with a MESS score of ≥8 had a higher rate of amputation compared to those with a MESS score of <8. However, the predictive value of the MESS was limited, with an AUC of 0.68. Higher skeletal/soft tissue injury score, limb ischemia score, and shock score were associated with a higher risk of amputation. The age score of the MESS was unexpectedly higher in the limb salvage group. The MESS score can be useful in predicting amputation rates in patients with popliteal artery injury, but its predictive value is limited. A team approach involving experienced surgeons is recommended for decision-making regarding amputation.

Assessment of Risk Factors Correlated with Outcomes of Traumatic Lower Extremity Soft Tissue Reconstruction.

The National Trauma Data Bank (2015-2018) was queried for lower extremity reconstructions. Univariable and multivariable analyses determined associations with inpatient outcomes. There were 4675 patients with lower extremity reconstructions: local flaps (77%), free flaps (19.2%), or both (3.8%). Flaps were most commonly local fasciocutaneous (55.1%). Major injuries in reconstructed extremities were fractures (56.2%), vascular injuries (11.8%), and mangled limbs (2.9%). Ipsilateral procedures prereconstruction included vascular interventions (6%), amputations (5.6%), and fasciotomies (4.3%). Postoperative surgical site infection and amputation occurred in 2% and 2.6%, respectively. Among survivors (99%), mean total length of stay (LOS) was 23.2 ± 21.1 days and 46.8% were discharged to rehab. On multivariable analysis, vascular interventions prereconstruction were associated with increased infection [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.05-3.79, P = 0.04], amputation (OR 4.38, 95% CI 2.56-7.47, P < 0.001), prolonged LOS (OR 1.59, 95% CI 1.14-2.22, P = 0.01), and discharge to rehab (OR 1.49, 95% CI 1.07-2.07, P = 0.02). Free flaps were associated with prolonged LOS (OR 2.08, 95% CI 1.74-2.49, P < 0.001). Prereconstruction vascular interventions were associated with higher incidences of adverse outcomes. Free flaps correlated with longer LOS, but otherwise similar outcomes. Investigating reasons for increased complication and healthcare utilization likelihood among these subgroups is warranted.

Amputation versus Reconstruction in Severe Lower Extremity Injury: A Systematic Review and Meta-Analysis.

Cases of severe lower limb injuries that previously were amenable only to amputation can now, in certain circumstances, be managed with reconstruction. The present systematic review and meta-analysis was designed to compare the results of amputation and reconstruction in severe lower extremity injuries. PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were comprehensively searched for studies comparing amputation and reconstruction for severe lower extremity injuries. The search terms used were the following: "amputation", "reconstruction", "salvage", "lower limb", "lower extremity", and "mangled limb", "mangled extremity", "mangled foot". Two investigators screened eligible studies, assessed the risk of bias and extracted the data from each study. Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). The I2 index was used to assess heterogeneity. Fifteen studies with 2,732 patients were included. Amputation is associated with lower rehospitalization rates, lower length of stay in the hospital, lower number of operations and additional surgery and fewer cases of infection and osteomyelitis. Limb reconstruction leads to faster return to work and lower rates of depression. The outcomes with respect to function and pain are variable among the studies. Statistically significance was achieved only with regards to rehospitalization and infection rates. This meta-analysis suggests that amputation yields better outcomes in variables during the early postoperative period, while reconstruction is associated with improved outcomes in certain long-term parameters. Severe lower limb injuries should be managed on their individual merit. The results of this study may be a useful tool to aid in the decision-making for the treating surgeon. High-quality Randomized Controlled Studies are still required to further our conclusions.

Clinical effectiveness of the Ganga Hospital Open Injury Severity Score for limb salvage versus amputation in patients with complex limb injuries : a systematic review and meta-analysis.

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations.Cite this article: Bone Joint J2023;105-B(1):21-28.

Foot fracture may predict poor patient reported functional outcomes in lower extremity reconstruction of the traumatically injured lower extremity: A case–control study

A paucity of evidence currently exists regarding factors affecting the success of lower extremity reconstruction at restoring a functional limb. We aim to determine the effect of foot fracture on outcome measures of ambulatory success after lower extremity salvage in a trauma population. A retrospective chart review was performed on 63 patients presenting to an urban level 1 trauma center between 01/2007 and 01/2015 who received soft tissue coverage of a lower extremity traumatic wound. Demographics, injury, and perioperative data were recorded. Patients were administered the Lower Extremity Functional Scale (LEFS) questionnaire via phone. The LEFS is out of 80 possible points. Ambulatory success is measured on a scale of 0 to 4 across 20 activities, with 0 indicating “extreme difficulty or inability to perform activity”, and 4 indicating “no difficulty”. Functional outcomes were compared using a two-tailed two-sample unequal variances t-test. This study represents data on the 63 unique patients treated with vascularized flaps whom we attempted to contact. A total of 21 patients completed the LEFS questionnaire, representing an overall response rate of 33%. Responders to the surveys included 4 (19%) patients with foot fractures and 17 (81%) without foot fractures. Average total LEFS scores were significantly lower in patients with foot fractures (23.8 ± 5.9) than in patients without (36.2 ± 19.2) foot fractures (p = 0.04). With respect to the SF36 functional scale, patients with foot fractures paradoxically reported significantly higher measures of physical functioning (81 ± 11) in comparison to those without a foot fracture (59 ± 25) at a p-value of 0.02, and role limitation due to physical health (98 ± 3) versus those with no foot fracture (74 ± 37) at a p-value of 0.02. Sustaining a foot fracture during severe traumatic injury that necessitates lower extremity reconstruction may result in significantly decreased ambulatory success scores. Fractures of the foot may predict poor patient reported functional outcomes following lower extremity reconstruction and should be considered as a factor in the pre-operative risk and benefit assessment when deciding whether to attempt reconstruction of the mangled limb. • In trauma patients with injuries necessitating lower extremity reconstruction, patients with foot fractures report worse physical function, particularly in actions related to ambulation. • Patients with foot fractures may have delayed time to attempted ambulation, full weight bearing, or physical therapy. • Fractures of the foot may predict poor patient reported functional outcomes following lower extremity reconstruction and should be considered as a factor in the pre-operative risk and benefit assessment when deciding whether to attempt reconstruction and salvage of the mangled limb.

Limb Salvage vs. Amputation: Factors Influencing the Decision-Making Process and Outcomes for Mangled Extremity Injuries

In the setting of acute severe limb injury, the clinical decision to either attempt limb salvage or to perform a primary amputation presents a significant challenge to the trauma team. The initial step in the management of a mangled limb is invariably resuscitation and stabilisation of the patient and an evaluation of the limb. However, the decision-making process on whether to amputate vs attempt limb salvage is dependent on a range of complex factors. This includes assessing the degree of injury to the components of the limb architecture, essential skeletal stability, soft tissues, vasculature, and neurological structures. Whether or not the patient would survive an attempt to limb salvage is of course not the only variable to be taken into account. The likely and expected outcomes of attempted salvage in each individual case must be considered and furthermore, what the acceptable side-effect profile including the risk of failure would be for each individual patient should be assessed against the importance, real or perceived, that limb function is maintained. Finally, the patient's choice should also be taken into account alongside their occupation and pre-morbid functional status. How the surgeon makes this life-changing, or life-threatening decision, is of great clinical significance, and there are myriad scoring systems published that purport to assist in this matter. However, the changing structures of the trauma system, expansion and advancement of skillsets and technology means an updated review is required to help weigh up the challenging decision of limb amputation vs salvage, which usually takes place in a time-pressured and highly emotional emergency setting. An evidence-based, standardised structure to assist in these calculations could support surgeons and improve outcomes for these patients.

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.

The majority of major amputations after resuscitative endovascular balloon occlusion of the aorta are associated with preadmission trauma

ObjectiveResuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and in-hospital mortality among patients undergoing REBOA for trauma. MethodsThe National Trauma Data Bank (2015-2017) was queried for patients presenting to trauma centers and treated with REBOA. We included REBOA performed on hospital day 1 in patients who survived 6 or more hours from presentation. Univariable and multivariable analyses evaluated associations with major amputation and in-hospital mortality. ResultsA total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years and the majority were male (73%) and White (56%). Most patients presented to level I trauma centers (72%) after blunt injuries (79%) with an average Injury Severity Score (ISS) of 31 ± 15, indicating major trauma. In 15 patients (5%), there were 18 major amputations—7 above knee and 11 below knee. A subgroup of 11 amputations were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity injuries of serious to severe Abbreviated Injury Scale severity. Comparing patients with amputations with those without amputations, there were no significant differences in patient demographics, comorbidities, or hospital characteristics. During hospitalization, patients requiring amputation more frequently received open peripheral vascular interventions (40% vs 10%; P = .002), underwent similar numbers of endovascular interventions (6.7% vs 4.7%; P = .5), and more often developed compartment syndrome (13% vs 2%; P = .04). Overall, there were 110 deaths (35%). The major amputation prevalence was similar between patients who died vs those who survived (3.6% vs 5.3%; P = .5). In multivariable analysis, prehospital cardiac arrest (odds ratio [OR], 8.47; 95% confidence interval [CI], 1.47-48.66; P = .02), penetrating vs blunt trauma (OR, 5.5; 95% CI, 1.05-28.82; P = .04), decreased Glasgow Coma Scale score (OR, 1.18; 95% CI, 1.05-1.32; P = .01), older age (OR, 1.06; 95% CI, 1.03-1.10; P < .001), and increased Injury Severity Score (OR, 1.05; 95% CI, 1.0-1.1; P = .03) were associated with higher mortality. ConclusionsThe majority of major amputations in patients undergoing REBOA were secondary to the initial traumatic mechanism. Injury type and severity, as well as initial hemodynamic derangements, are associated with mortality after REBOA. Despite concerns about prohibitive limb complications of REBOA, baseline injuries seem to be the primary cause of limb loss, but further prospective analysis is needed.

Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts.

The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage. Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments. All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3months after their final surgery. At 24months follow-up, 90% amputation free survival is still maintained. Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.

A Multistep Iter for Functional Reconstruction in Mangled Upper Limb: A Retrospective Analysis of Integrated Surgical and Medical Approach

Background and objectives: Complex limb wounds with multiple tissue involvement are commonly due to high energy trauma. Tissue damage is a dynamic entity and the exact extent of the injury is rarely instantly perceptible. Hence, reconstruction frequently involves a multi-stage procedure concluding with tissue replacement. Materials and Methods: A retrospective study was conducted between 2006 and 2018 and included 179 patients with contaminated multi-tissue injuries treated with hyperbaric oxygen therapy, negative pressure therapy, physiotherapy and drug treatment associated with multiple surgical time in a multistep approach, focusing on pain levels and wound closure rates. Results: Despite the long-term response to traumatic events, a combined approach of delayed surgical reconstructive time in mangled upper limb yielded satisfactory functional outcomes. Conclusions: The complex upper limb wound with deep tissue exposure may be treated with a multi-stage procedure alternatively to immediate reconstruction. The integrated technique enables the preservation of existing healthy tissue and concurrent radical debridement, reducing the risk of infection, as well as avoiding the loss of free flaps and dehiscence due to incorrect wound estimation.

Injury patterns in patients with QINGQI motorcycle rickshaw related road traffic accidents presenting at accident and emergency department of Mayo Hospital, Lahore.

Objectives: The objective of this study was to determine the patterns of the injuries in patients of Qingqi rickshaw related accidents. Study Design: Descriptive Cross-Sectional study. Setting: Accident and Emergency Department of Mayo Hospital, Lahore. Period: Six months from 1st of March, 2019 to 31st of August, 2019. Material &amp; Methods: Non-probability consecutive sampling technique was used and all tri-wheeler Qingqi related trauma patients fulfilling the inclusion and exclusion criteria were included. Frequency and percentages were calculated for patterns of injuries and presented as tables. Results: A total of 356 Qingqi rickshaw related injured patients presented in six months study period. There were 243 (68.3%) males and 113 (31.7%) females and a mean age of 32.5 +2.5 years. Soft tissues injuries like subcutaneous edema, abrasions and lacerations were noticed in 206 patients (57.9%). Most common region involved was lower limb in 98 (27.5%) cases followed by upper limb trauma in 65 (18.2%) cases. Ploy trauma was present in 58 (16.3%) and head and spinal injuries were noticed in 27 (7.6%) and13 (3.7%) cases, respectively. The turning over of the rickshaw due to different reasons (47.2%) and head on collision (38.4%) were the leading cause of serious injuries. None of the Qingqi rickshaw drivers (0%) were wearing helmet. A total of 46 (12.9%) cases were pedestrians. Three patients had to undergo amputation for mangled limb injuries. Conclusion: The common pattern of injuries related to Qingqi accidents include lower limb injuries followed by upper limb and poly trauma comprising of head injuries. Males in their younger age group are most commonly injured. These accidents can result in serious morbidity and even mortality. It is now time to consider measures for safety of three-wheelers to reduce such incidents.

The Majority of Major Amputations After Resuscitative Endovascular Balloon Occlusion of the Aorta Are Associated With Preadmission Trauma

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially lifesaving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and inpatient mortality in patients undergoing REBOA for major trauma. The National Trauma Data Bank (2015-2017) was queried for patients who presented to trauma centers and were treated with REBOA. We included REBOAs performed on hospital day 1 in patients who survived at least 6 hours from presentation. Univariable and multivariable analyses were performed to evaluate associations with major amputation and in-hospital mortality. A total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years, and the majority were men (73%) and white (56%). Most patients presented to level I trauma centers (72%) after blunt injuries (79%) with an average Injury Severity Score of 31 ± 15. In 15 patients (5%), there were 18 major amputations, 7 above knee (39%) and 11 below knee (61%). Eleven of the amputations (61%) were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity (LE) injuries of serious to severe Abbreviated Injury Scale. Comparison of patients with and without major amputations revealed no significant differences in patients’ demographics or chronic comorbidities or hospital characteristics. Patients undergoing major amputation were more likely to present with LE vascular injuries (33% vs 9%; P = .01) and LE Abbreviated Injury Scale severe vascular injuries (6.7% vs 1.3%; P = .01). They more frequently received open peripheral vascular interventions (40% vs 10%; P = .002) and developed compartment syndrome (13% vs 2%; P = .04) during hospitalization. There were 110 deaths (35%). On multivariable analysis, prehospital cardiac arrest (odds ratio [OR], 8.47; 95% confidence interval [CI], 1.47-48.66; P = .02), penetrating vs blunt trauma (OR, 5.5; 95% CI, 1.05-28.82; P = .04), increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), increased Injury Severity Score (OR, 1.05; 95% CI, 1-1.1; P = .03), and decreased total Glasgow Coma Scale score (OR, 0.85; 95% CI, 0.76-0.95; P = .005) were associated with increased mortality. The majority of major amputations in patients undergoing REBOA are trauma related from injuries sustained before admission. Injury type and severity as well as initial hemodynamic derangements are associated with mortality after REBOA. Despite concerns about limb complications of REBOAs, baseline injuries appear to be the primary cause of limb loss, but further prospective analysis is needed.

Crucifixion in Roman Antiquity: The State of the Field

Crucifixion in Roman AntiquityThe State of the Field Felicity Harley (bio) Chapman, David W. Ancient Jewish and Christian Perceptions of Crucifixion. Wissenschaftliche Untersuchungen zum Neuen Testament II/244. Tübingen: Mohr Siebeck, 2008; republished by Baker Publishing Group, 2010. Pp. xiii + 321. €29.00. Chapman, David W. and Eckhard J. Schnabel. The Trial and Crucifixion of Jesus. Wissenschaftliche Untersuchungen zum Neuen Testament 344. Tübingen: Mohr Siebeck, 2015. Pp. xxiv + 867. €39.00. Cook, John Granger. Crucifixion in the Mediterranean World. Wissenschaftliche Untersuchungen zum Neuen Testament 327. Tübingen: Mohr Siebeck, 2014 (a second enlarged edition scheduled to appear in 2019). Pp. xl + 549. €79.00. Samuelsson, Gunnar. Crucifixion in Antiquity: An Inquiry into the Background and Significance of the New Testament Terminology of Crucifixion. Wissenschaftliche Untersuchungen zum Neuen Testament II/310. Tübingen: Mohr Siebeck, 2011; rev. ed. 2013. Pp. xxxii + 364. €79.00. Late in January 41 c.e., a newly composed mime about the exploits of the notorious Roman bandit Laureolus was performed before the emperor Gaius and his guests in the Imperial Palace, on Rome's Palatine Hill.1 The performance was part of the ludi Palatini, a private festival held in honor [End Page 303] of the deified Augustus; the historian Josephus observed that at the mime's climax, the capture and crucifixion of the runaway slave turned robber, a great quantity of fake blood was shed across the stage.2 In the same city several decades later, before tens of thousands of spectators, blood remained central to the staging of the same mime but was no longer artificial. The poet Martial records that the dénouement was a live execution, a criminal being cast in the role of Laureolus and executed on stage, suspended not from a theater set but from a real cross (non falsa cruce), before being fatally mauled by a bear: Nuda Caledonio sic uiscera praebuit ursonon falsa pendens in cruce Laureolusuiuebant laceri membris stillantibus artusinque omni nusquam corpore corpus erat. Laureolus, hanging on no false cross,gave up his defenceless entrails to a Scottish bear.His mangled limbs were still alive, though the parts were dripping with blood, and in his whole body there actually was no body.3 In the modern imagination, crucifixion (from the Latin verb crucifigo, "to fasten to a cross") constitutes a highly specific method of execution: the fatal suspension of a living victim from a cross-shaped scaffold. This narrow definition is conveyed linguistically by the English word and its equivalents in a variety of modern languages, and visually by the remarkably stable iconography of Jesus's crucifixion that was formulated by the late sixth century and circulated widely. On this understanding of crucifixion, the death of Laureolus on "no false cross" is easy for us to visualize; and on this scaffold, the victim becomes an easy target for the bear, who claws away his flesh in an add-on torture that both hastens and colors the death. In fact Martial does not provide any specific information about the scaffold. He takes some delight in describing the bloody process [End Page 304] of disembowelment, lingering over the fact that despite being little more than a hanging carcass, severed nerves cause Laureolus's lacerated limbs to twitch, as though still alive.4 Yet nowhere does he describe the shape of the scaffold (crux), or the method used to affix Laureolus to it. A similar lack of interest in these details, which are fundamental to the modern definition of crucifixion, is betrayed in Josephus's account wherein Laureolus is simply described as crucified (σταυρωθέντα), as though the reader knew exactly what this entailed and so supplied the particulars from their imagination or memory. Yet what those particulars were is a moot point. In antiquity, there was no single word to designate "crucifixion" in the narrow way that term is used and understood in various modern languages today. Hence the recovery of ancient understandings of crucifixion is a complex process, more so than is customarily assumed, with the methods of doing so contested, as a recent body of literature has demonstrated. When searching for descriptions of or references to crucifixion in ancient sources it is...

Can we use creatine kinase muscle type as a potential marker for muscle viability in mangled extremities? A preliminary evaluation of its applicability and a literature review

Objectives: Increased expression of serum creatine kinase muscle type (CK-MM) in muscle overuse or injury has been documented in many situations. However, the expression of CK-MM and its correlation with the extent of traumatic damage to skeletal muscle tissue has not been explored. We studied the pattern of expression of CK-MM in substantially damaged muscle tissue and attempted to correlate its expression with the extent of muscle damage. Methods: At level 1 trauma center, 15 patients with mangled lower limb were prospectively evaluated. All patients underwent primary amputation (mangled extremity severity score ≥7) using specific criteria. Muscle tissue samples were obtained intraoperatively from 3 different zones (chosen arbitrarily based on clinical parameters of muscle viability, Zones A, B, and C) for all patients. Samples were evaluated by hematoxylin and eosin (H and E) staining and immunohistochemistry (IHC) staining with polyclonal CK-MM antibody. Results: H and E staining correlated with the clinical extent of muscle death in Zones A, B, and C; the percentage of viable muscle fibers was 6.7% in Zone A, 20% in Zone B, and 73% in Zone C. Least CK-MM expression was noted in muscle tissues on IHC in Zone A (most necrotic area) and most in Zone C (most viable area). The score developed by us corroborated with the extent of muscle damage and viability. Conclusion: IHC staining for CK-MM can be used as a definite biomarker of muscle integrity and can be used as an adjunct to clinical evaluation to help define limb viability as well as levels of amputation when that is required.

Diagnosis and Management of Polytraumatized Patients With Severe Extremity Trauma.

Multiply injured patients with severe extremity trauma are at risk of acute systemic complications and are at high risk of developing longer term orthopaedic complications including soft-tissue infection, osteomyelitis, posttraumatic osteoarthritis, and nonunion. It is becoming increasingly recognized that injury magnitude and response to injury have major jurisdiction pertaining to patient outcomes and complications. The complexities of injury and injury response that affect outcomes present opportunities to apply precision approaches to understand and quantify injury magnitude and injury response on a patient-specific basis. Here, we present novel approaches to measure injury magnitude by adopting methods that quantify both mechanical and ischemic tissue injury specific to each patient. We also present evolving computational approaches that have provided new insight into the complexities of inflammation and immunologic response to injury specific to each patient. These precision approaches are on the forefront of understanding how to stratify individualized injury and injury response in an effort to optimize titrated orthopaedic surgical interventions, which invariably involve most of the multiply injured patients. Finally, we present novel methods directed at mangled limbs with severe soft-tissue injury that comprise severely injured patients. Specifically, methods being developed to treat mangled limbs with volumetric muscle loss have the potential to improve limb outcomes and also mitigate uncompensated inflammation that occurs in these patients.

Damage Control Orthopedics in Mangled Limb and Open Fractures

Damage Control Orthopedics in Mangled Limb and Open Fractures

Validation of mangled extremity severity score in assessing the need for extremity amputation

INTRODUCTION: The decision to either salvage or amputate a mangled extremity poses great challenge to a surgeon.Different scoring systems were therefore developed to aid orthopaedic surgeons in this decision,eitherto contemplate amputation or proceed to salvage a mangled extremity. Of these scoring systems, the mangled extremity severity score (MESS) is mostly used.However,the high predictive accuracy reported by its developers has not been replicated by other authors. This study was carried out to validate the use of this scoring system in Nigeria and by extension, Africa.PATIENTS MATERIALS AND METHOD:The study was a hospital based prospective descriptive one which studied all patients with mangled extremities that were admitted into the Accident and Emergency room of the Lagos University Teaching Hospital (LUTH), Idi- Araba, from April 2014 to March 2015. Injured patients with mangled extremities were resuscitated and relevant investigations conducted. The MESS was calculated at presentation in the emergency room by two senior doctors in orthopaedic and trauma units (not lower than senior registrar cadres) independently and an average score calculated, rounded up to the nearest positive integer and documented.Type of treatment offered was based on the experience of the managing consultants. Patients' progresses were monitored and functional outcomes documented. All data generated during the study were analysed using Statistical Package for the Social Sciences (SPSS inc. Chicago, Illinois. version 21.0.Year of release - 2012).RESULTS: Twenty-nine mangled extremities in 27 patients were studied.The male: female ratio was 3.5:1.Age of patients ranged between 21-70 years with a mean age of 39.9 ±12.3years. Nineteen (65.5%) extremities were salvaged while 10(34.5%) were primarily amputated. Average MESS of all mangled limbs reviewed was 8.1+ 2.6 with scores that ranged from 3 to 13. The mean MESS for limb salvage was 7.0 +2.2while that for primary amputation was 10.1+2.0(P value- 0.01).MESS in this study had a sensitivity of 90%,specificity of 47.4%,positive predictive value of 47.4%, negative predictive value of 90%.AUROC in this study was 0.853.The cost of treatment, number of surgeries, and duration of hospital stay were higher in those with Salvaged limbs.The functional outcome for salvaged upper and lower extremities were better than for those whose limbs were amputated.Level of satisfaction was better in the limbs salvaged group than for those who had ablative surgery with statistical significance (P value- .000).CONCLUSION: This study validated the clinical utility of MESS in predicting the need for amputation in patients with mangled extremity injuries but it had a low predictive accuracy for extremities that would eventually enter the limb salvage pathway.Therefore,when contemplating limb salvage for a patient with mangled extremity,in addition to the result of the MESS score,the surgeons experience cannot be overemphasized.KEY WORDS: Open fracture,mangled limb,amputation,MESS score,classification

Hellish Falls: Faustus's Dismemberment, Phaeton's Limbs and Other Renaissance Aviation Disasters—Part II

ABSTRACTThe first part of this essay (published in a previous issue of English Studies) grounded Marlowe's Doctor Faustus in the grisly history of Renaissance aviation. This continuation instead situates Marlowe's tragedy alongside other “Icarian” plays in the Admiral's repertoire that likely featured vertical ascents followed by horrific falls. While Part I spotlighted the links between Faustus and the failed aviators Icarus, Lucifer and Simon Magus, Part II reveals how Faustus's death evokes the flight disasters and subsequent dismemberments of Bladud and Phaeton—both of whom apparently featured in lost plays at the Rose. In presenting Faustus's “mangled limbs” on stage, the Admiral's Men would likely have recycled “Faetones lymes”, listed in Henslowe's property inventory. Phaeton's death could thus have provided an important literary and theatrical antecedent for the staging of Faustus's “hellish fall”. Collectively, these two articles hold a candle to the repertorial practices of the Admiral's Men, while showing how Repertory Studies can illuminate new dimensions of familiar plays like Faustus.

Hellish Falls: Faustus's Dismemberment, Phaeton's Limbs and Other Renaissance Aviation Disasters—Part I

ABSTRACTWith its aerial voyages and ominous allusions to the failed aviators Icarus, Lucifer and Simon Magus, Doctor Faustus presents an uncanny commentary on the Renaissance dream of flight. This article uncovers Marlowe's infatuation with human flight as the ultimate act of physical, intellectual and spiritual trangression. So the grisly addition to the B-text, in which a group of scholars examine—like a forensics team at a crash site—the carnage of Faustus's “mangled limbs”, is more than a lurid flourish. Mangled limbs are splattered all over the annals of pre-modern aviation. While implicating the play in Renaissance aeronautics, this study of Faustus also has some eye-opening implications for theatre history. Faustus was penned at a time when on-stage ascents and descents became increasingly feasible, and Marlowe's Icarian muse may have spurred the Admiral's Men to interpolate more spectacular flying effects, taking advantage of the throne, pulleys and dragons recorded in Henslowe's Diary. The revisions to Faustus not only showcase the flight-simulation capabilities of the Admiral's playhouses but also associate Marlowe's conjuror with other presumptuous aeronauts in the company's repertoire. In particular, Part II of this essay (to be published in a forthcoming issue of English Studies) will argue that Faustus's “hellish fall” and dismemberment mirrors that of Phaeton, the titular protagonist of a lost play performed by the Admiral's Men in 1598. While reading the fall of these characters as a literal enactment of de casibus tragedy, Part II concludes that the increasingly sophisticated aerial stunts reflect a technological optimism about transhuman flight that undercuts the Chorus's warning not to “practice more than heavenly power permits”.