Peripheral Trauma Research Articles

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006\u20132019: a population-based study

BackgroundUnderstanding trends in limb amputation (LA) can provide insight into the prevention and optimization of health care delivery. We examine the influence of primary (first report) and subsequent (multiple reports) limb amputation on the overall (all reports) rate of limb amputation in Saskatchewan considering amputation level.MethodsHospital discharged data associated with LA from 2006 to 2019 and population estimates in Saskatchewan were used. LA cases were grouped based on overall, primary, and subsequent LA and further divided by level into major (through/above the ankle/wrist) and minor (below the ankle/wrist). Incidence rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial were used to analyze the trends. In addition, the top three amputation predisposing factors (APF) were described by LA groups.ResultsThe rate of overall LA and primary LA remained stable (AAPC − 0.9 [95% CI − 3.9 to 2.3]) and (AAPC −1.9 [95% CI −4.2 to 0.4]) respectively, while the rate of subsequent LA increased 3.2% (AAPC 3.2 [95% CI 3.1 to 9.9]) over the 14-year study period. The rate of overall major LA declined 4.6% (AAPC − 4.6 [95% CI −7.3 to −1.7]) and was largely driven by the 5.9% decline in the rate of primary major LA (AAPC − 5.9 [95% CI − 11.3 to –0.2]). Subsequent major LA remained stable over the study period (AAPC −0.4 [95% CI − 6.8 to 6.5]). In contrast, the overall rate of minor LA increased 2.0% (AAPC 2.0 [95% CI 1.0 to 2.9]) over the study period which was largely driven by a 9.6% increase in the rate of subsequent minor LA (AAPC 9.6 [95% CI 4.9 to 14.4]). Primary minor LA rates remained stable over the study period (AAPC 0.6 [95% CI − 0.2 to 1.5]). The study cohorts were 1.3-fold greater risk of minor LA than major LA. Diabetes mellitus (DM) was the leading APF representing 72.8% of the cohort followed by peripheral vascular disease (PVD) and trauma with 17.1 and 10.1% respectively. Most (86.7%) of subsequent LA were performed on people with DM.ConclusionsOverall LA rates remained stable over the study period with declining rates of major LA countered by rising rates of minor LA. Minor LA exceeded major LA with the largest rate increase identified in subsequent minor LA. Diabetes was the greatest APF for all LA groups. This rising rate of more frequent and repeated minor LA may reflect changing intervention strategies implemented to maintain limb function. The importance of long-term surveillance to understand rates of major and minor LA considering primary and subsequent intervention is an important step to evaluate and initiate prevention and limb loss management programs.

In Situ Prevascularization Strategy with Three-Dimensional Porous Conduits for Neural Tissue Engineering.

Neovascularization is crucial for peripheral nerve regeneration and long-term functional restoration. Previous studies have emphasized strategies that enhance axonal repair over vascularization. Here, we describe the development and application of an in situ prevascularization strategy that uses 3D porous nerve guidance conduits (NGCs) to achieve angiogenesis-mediated neural regeneration. The optimal porosity of the NGC is a critical feature for achieving neovascularization and nerve growth patency. Hollow silk fibroin/poly(l-lactic acid-co-ε-caprolactone) NGCs with 3D sponge-like walls were fabricated using electrospinning and freeze-drying. In vitro results showed that 3D porous NGC favored cell biocompatibility had neuroregeneration potential and, most importantly, had angiogenic activity. Results from our mechanistic studies suggest that activation of HIF-1α signaling might be associated with this process. We also tested in situ prevascularized 3D porous NGCs in vivo by transplanting them into a 10 mm rat sciatic nerve defect model with the aim of regenerating the severed nerve. The prevascularized 3D porous NGCs greatly enhanced intraneural angiogenesis, resulting in demonstrable neurogenesis. Eight weeks after transplantation, the performance of the prevascularized 3D NGCs was similar to that of traditional autografts in terms of improved anatomical structure, morphology, and neural function. In conclusion, combining a reasonably fabricated 3D-pore conduit structure with in situ prevascularization promoted functional nerve regeneration, suggesting an alternative strategy for achieving functional recovery after peripheral nerve trauma.

The Utility of Dynamic Movement Orthoses in the Management of Complex Regional Pain Syndrome-A Case Series.

Complex regional pain syndrome (CRPS) is a relatively rare, but debilitating condition that may occur after limb or peripheral nerve trauma. Typical symptoms of CRPS include swelling, allodynia, hyperalgesia, and skin temperature changes. Although a variety of pharmacological and non-pharmacological approaches are commonly used in caring for individuals with CRPS, they are frequently ineffective and often associated with side effects and/or additional risks. Previously, elastomeric orthotic garments have been shown to decrease neuropathic pain, reduce edema, and increase proprioception, but no previous reports have described their use in treating CRPS. Accordingly, this case series describes our experiences using a Lycra-based, custom-fabricated Dynamic Movement Orthosis (DMO) as a novel treatment to reduce the symptoms of CRPS and promote function. Four patients were included in this case series, all of whom had very different causes for their CRPS, including a combat-related gunshot injury resulting in multiple foot fractures with a partial nerve injury, a post-metatarsophalangeal fusion, an L5 radiculopathy, and a case of post-lower leg fasciotomies. These four patients all reported subjective improvement in their pain, function, and exercise tolerance in association with their DMO use. All patients demonstrated reduced use of analgesic medications. The pre- and post-DMO lower extremity functional scale showed clinically significant improvement in the two patients for which it was obtained.

Biochemical functionalization of graphene oxide for directing stem cell differentiation

The regeneration of peripheral nerve tissue is crucial in the treatment of peripheral nerve trauma. In recent years, there has been increased focus on biomaterial scaffolds which can deliver stem cells, direct differentiation to the desired lineage and guide tissue regeneration at the site of injury. Here, we report on a graphene oxide (GO) scaffold which has been chemically functionalised to direct the differentiation of adipose-derived mesenchymal stem cells towards the neuroglial lineage and maintain the viability of differentiated cells. A comparison is made between substrates of GO, reduced GO and a peptide (IKVAV) functionalised GO in comparison to standard tissue culture glass. Our results show that the graphene substrates are highly biocompatible, and the IKVAV functionalised substrates are more effective in directing stem cell differentiation towards neuroglial phenotypes compared to glass and other graphene substrates. Furthermore, GO-IKVAV substrates showed increased neuronal attachment and neurons grown on GO-IKVAV sprouted longer neurites. These results suggest that graphene can be rationally functionalised to direct stem-cell differentiation and that functionalised GO could provide a viable scaffold in regenerative therapies of peripheral nerve injuries and disorders.

Can lithium enhance the extent of axon regeneration and neurological recovery following peripheral nerve trauma?

The clinical “gold standard” technique for attempting to restore function to nerves with a gap is to bridge the gap with sensory autografts. However, autografts induce good to excellent recovery only across short nerve gaps, in young patients, and when repairs are performed a short time post nerve trauma. Even under the best of conditions, < 50% of patients recover good recovery. Although many alternative techniques have been tested, none is as effective as autografts. Therefore, alternative techniques are required that increase the percentage of patients who recover function and the extent of their recovery. This paper examines the actions of lithium, and how it appears to trigger all the cellular and molecular events required to promote axon regeneration, and how both in animal models and clinically, lithium administration enhances both the extent of axon regeneration and neurological recovery. The paper proposes more extensive clinical testing of lithium for its ability and reliability to increase the extent of axon regeneration and functional recovery.

Sudden Onset, Fixed Dystonia and Acute Peripheral Trauma as Diagnostic Clues for Functional Dystonia.

ABSTRACTBackgroundThe differentiation of functional dystonia from idiopathic dystonia may be clinically challenging.ObjectiveTo identify clinical features suggestive of functional dystonia to guide physicians to distinguish functional dystonia from idiopathic dystonia.MethodsPatient data were extracted from the Italian Registry of Functional Motor Disorders and the Italian Registry of Adult Dystonia. Patients with functional and idiopathic dystonia were followed up at the same clinical sites, and they were similar in age and sex.ResultsWe identified 113 patients with functional dystonia and 125 with idiopathic dystonia. Sudden onset of dystonia, evidence of fixed dystonia, and acute peripheral trauma before dystonia onset were more frequent in the functional dystonia group. No study variable alone achieved satisfactory sensitivity and specificity, whereas a combination of variables yielded 85% sensitivity and 98% specificity. A diagnostic algorithm was developed to reduce the risk of misclassifying functional dystonia.ConclusionOur findings extend the current diagnostic approach to functional dystonia by showing that clinical information about symptom onset, fixed dystonia, and history of peripheral trauma may provide key clues in the diagnosis of functional dystonia.

The Biomechanics of Diabetic Foot Amputation

According to the International Diabetes Federation, approximately 463 million adults live with diabetes mellitus (DM), a number projected to increase to 700 million by 2045; a diabetic foot ulcer (DFU) will occur in about 15% of that population. Multiple factors contribute to the development of those wounds including diabetic peripheral neuropathy, biomechanical imbalances, trauma, and peripheral vascular disease. In addition, 85% of all lower limb amputations in patients with diabetes are preceded by a DFU resulting in significant biomechanical challenges for these patients, many of who never become ambulatory again. Prior to surgical intervention, patients come with inherited and acquired biomechanical imbalances or weaknesses such as equinus, severe pronation/supination, mid and forefoot deformities, and muscle weakness unrelated to their other diseases. Surgeons may not take these into consideration when making decisions about amputation level. Choosing the wrong level of amputation in an attempt to "preserve the foot" often sets up the patient to future failure and multiple amputations until a final resolution of the problem. The purpose of this review is to discuss specific biomechanical and quality of life issues associated with lower extremity amputations and identify the most functional levels for lower extremity amputation in compromised patients with a DFU. By reviewing recent data on these amputations, the authors hope to help surgeons choose the appropriate level for intervention and highlight areas of weakness in the literature requiring further investigation.

Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report

BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.

Inactivation of vimentin in satellite glial cells affects dorsal root ganglion intermediate filament expression and neuronal axon growth in vitro

Peripheral nerve trauma and regeneration are complex events, and little is known concerning how occurrences in the distal stump affect the cell body's response to injury. Intermediate filament (IF) proteins underpin cellular architecture and take part in nerve cell proliferation, differentiation and axon regeneration, but their role in these processes is not yet fully understood. The present study aimed to investigate the regulation and interrelationship of major neural IFs in adult dorsal root ganglion (DRG) neurons and satellite glial cells (SGCs) following sciatic nerve injury. We demonstrated that the expression of neural IFs in DRG neurons and SGCs after axotomy depends on vimentin activity. In intact DRGs, synemin M and peripherin proteins are detected in small neurons while neurofilament L (NFL) and synemin L characterize large neurons. Both neuronal populations are surrounded by vimentin positive- and glial fibrillary acidic protein (GFAP)-negative SGCs. In response to axotomy, synemin M and peripherin were upregulated in large wild-type DRG neurons and, to a lesser extent, in vim−/− and synm−/− DRG neurons, suggesting the role for these IFs in axon regeneration. However, an increase in the number of NFL-positive small neurons was observed in vim−/− mice, accompanied by a decrease of peripherin-positive small neurons. These findings suggest that vimentin is required for injury-induced neuronal IF remodeling. We further show that vimentin is also indispensable for nerve injury-induced GFAP upregulation in perineuronal SGCs and that inactivation of vimentin and synemin appears to accelerate the rate of DRG neurite regeneration at early stages in vitro.

Operative Management and Outcomes of Peripheral Vascular Trauma in Pediatric and Adolescent Population

Introduction: Unique characteristics of vascular injuries in children such as pronounced vascular spasm and lack of tissue support over small, thin-walled vessel make vascular repair challenging. This retrospective study was done to evaluate the management and outcome of pediatric and adolescent peripheral vascular trauma. Methodology: Fifteen patients with peripheral vascular trauma who met the inclusion criteria during the study period (August 2019-July 2020) were included. Data were analyzed retrospectively. Results: Majority, 12(80%) of patients suffered blunt trauma. Primary repair in 13(86.66%) patients was the most common surgical technique employed. All the patients had associated long bone fracture dealt with internal fixation. Four (26.66%) cases had median nerve injury which was amenable to direct repair. Associated venous injury in 5 (33.33%) was also repaired. No mortality, re-operations, or amputation was noted. Conclusion: Excellent limb salvage rate was achieved. Initial revascularization without delay should be the norm. Associated neurological involvement determines postoperative functional outcome. Clinical evaluation with Doppler assessment saves time and crucial in vascular injuries prone to spasm.

Quantitative assessment of intraneural vascular alterations in peripheral nerve trauma using high-resolution neurosonography: technical note

High-resolution neurosonography (HRNS) has become a major imaging modality in assessment of peripheral nerve trauma in the recent years. However, the vascular changes of traumatic lesions have not been quantitatively assessed in HRNS. Here, we describe the vascular-ratio, a novel HRNS-based quantitative parameter for the assessment of intraneural vascular alterations in patients with nerve lesions. N = 9 patients suffering from peripheral nerve trauma were examined clinically, electrophysiologically and with HRNS (SonoSite Exporte, Fuji). Image analyses using Fiji included determination of the established fascicular ratio (FR), the cross-section ratio (CSR), and as an extension, the calculation of a vascular ratio (VR) of the healthy versus damaged nerve and a muscle perfusion ratio (MPR) in comparison to a healthy control group. The mean VR in the healthy part of the affected nerve (14.14%) differed significantly (p < 0.0001) from the damaged part (VR of 43.26%). This coincides with significant differences in the FR and CSR calculated for the damaged part versus the healthy part and the controls. In comparison, there was no difference between VRs determined for the healthy part of the affected nerve and the healthy controls (14.14% / 17.72%). However, the MPR of denervated muscles was significantly decreased compared to the non-affected contralateral controls. VR and MPR serve as additional tools in assessing peripheral nerve trauma. Image analysis and calculation are feasible. Combined with the more morphologic FR and CSR, the VR and MPR provide a more detailed insight into alterations accompanying nerve trauma.

Perifeer zenuwletsel en het effect van vitamines op het herstelproces

Peripheral nerve injury and the effect of vitamins on the recovery process Although peripheral nerve injuries are usually not life-threatening, they can have a significant impact on the patient’s quality of life and daily functioning, with typical symptoms such as complete paralysis or severe neuropathic pain. The peripheral nervous system is capable of some regeneration and recovery, allowing conservative treatment in mild to moderate nerve damage. For severe peripheral nerve injuries surgical reconstruction remains the golden standard. However, despite the extensive knowledge of the pathophysiology of peripheral nerve trauma, a full functional recovery after a severe peripheral nerve injury is rare with the current therapeutic options. Success depends on a variety of factors: location and severity of the injury, age and physical condition of the patient, therapeutical approach, … Therefore, it is important to search for the best possible means to achieve maximal functional recovery. This article first discusses the current knowledge about the pathophysiology of peripheral nerve trauma, highlighting the most important factors that influence the recovery process. Subsequently, it will render a review of the influence of vitamins A/B/C/D/E/K on this recovery process: vit B and D seem to enhance the regeneration process of nerves and the functional recovery of the end organ, while vit C and E show an important antinociceptive effect.

Real-time visualisation of peripheral nerve trauma during subepineural injection in pig brachial plexus using micro-ultrasound

BackgroundNerve damage is consistently demonstrated after subepineural injection in animal studies, but not after purposeful injection in patients participating in clinical studies. There is a need to better visualise nerves in order to understand the structural changes that occur during subepineural injection. MethodsWe scanned the brachial plexuses of three anaesthetised pigs using micro-ultrasound imaging (55–22 MHz probe), inserted 21 gauge block needles into the radial, median, and axillary nerves, and injected two 0.5 ml boluses of saline into nerves at a rate of 12 ml min−1. Our objectives were to measure the area and diameter of nerves and fascicles, and to describe changes in nerve anatomy, comparing our findings with histology. ResultsImages were acquired at 42 sites across 18 nerves in three pigs and compared dimensions (geometric ratio; 95% confidence interval; P value). As expected, the nerve cross-sectional area was greater in the proximal brachial plexus compared with the mid-plexus (2.10; 1.07–4.11; P<0.001) and the distal plexus (2.64; 1.42–4.87; P<0.001). Nerve area expanded after 0.5 ml injection (2.13; 1.48–3.08; P<0.001). Using microultrasound, subepineural injection was characterised by nerve and fascicle rotation, uniform, or localised swelling and epineural rupture. Micro-ultrasound revealed a unique pattern suggestive of subperineural injection after a median nerve injection, and good face validity with histology. Histology showed epineural trauma and inflammation to the perineurium. ConclusionWe accurately identified fascicles and real-time structural changes to peripheral nerves using micro-ultrasound. This is the first study to visualise in vivo and in real-time the motion of nerves and fascicles in response to anaesthetic needle insertion and fluid injection.

HYPOCHLOROUS ION BASED DRESSING: THROWBACK TO THE SURGEONS’ CHOICE

1.1 BACKGROUND : As per Robbin's pathology(Robbins &amp; Cotran Pathologic Basis of Disease - 10th Edition, n.d.) "an ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing out of inamed necrotic tissue." In an era of modern-day fast track surgery and premier practices of medicine, management of wound remains an archaic, almost omnipresent challenge to a health care provider mediating the need for solutions. The hunt for an optimum dressing agent has been everlasting, one of which is our point of discussion in this study. The addition of Chlorine(Cl2) to Water(H2O) gives rise to Hypochlorous ion, a weak acid that has been used traditionally as disinfectant, sterilizer and beaches. These properties can be utilised for wound disinfection and swifter wound healing. 1.2 AIMS AND OBJECTIVES: Ÿ To study the efcacy of Hypochlorous ion-based dressing over traditional normal saline based dressing . Ÿ To study the effects factoring in various associated comorbidities in patients such as Diabetes Mellitus, Peripheral Vascular Disease, Trauma and Pressure Ulcer. 1.3 METHODOLOGY: A comparative study was conducted in a tertiary care facility in India that included 101 patients who were distributed randomly utilizing computerised algorithms into study and control group. The control group received daily normal saline dressing whereas the study group underwent daily hypochlorous ion-based dressing. The subjects were analysed after 4 weeks and evaluated for decrease in wound surface area and improvement of wound quality and tabulated for analysis. 1.4 CONCLUSION: Hypochlorous ion based daily dressing shows signicant reduction in wound surface area as well as signicantly better and faster improvement in the quality of wound in patients of Traumatic, Diabetic and Pressure Ulcer whereas the results in patients suffering from Peripheral Vascular Disease were equivocal.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses.

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient’s life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

Fully Implantable Plantar Cutaneous Augmentation System for Rats Using Closed-loop Electrical Nerve Stimulation.

Plantar cutaneous feedback plays an important role in stable and efficient gait, by modulating the activity of ankle dorsi- and plantar-flexor muscles. However, central and peripheral nervous system trauma often decrease plantar cutaneous feedback and/or interneuronal excitability in processing the plantar cutaneous feedback. In this study, we tested a fully implantable neural recording and stimulation system augmenting plantar cutaneous feedback. Electromyograms were recorded from the medial gastrocnemius muscle for stance phase detection, while biphasic stimulation pulses were applied to the distal-tibial nerve during the stance phase to augment plantar cutaneous feedback. A Bluetooth low energy and a Qi-standard inductive link were adopted for wireless communication and wireless charging, respectively. To test the operation of the system, one intact rat walked on a treadmill with the electrical system implanted into its back. Leg kinematics were recorded to identify the stance phase. Stimulation was applied, with a 250-ms onset delay from stance onset and 200-ms duration, resulting in the onset at 47.58±2.82% of stance phase and the offset at 83.49±4.26% of stance phase (Mean±SEM). The conduction velocity of the compound action potential (31.2 m/s and 41.6 m/s at 1·T and 2·T, respectively) suggests that the evoked action potential was characteristic of an afferent volley for cutaneous feedback. We also demonstrated successful wireless charging and system reset functions. The experimental results suggest that the presented implantable system can be a valuable neural interface tool to investigate the effect of plantar cutaneous augmentation on gait in a rat model.

Use of Flaps in Orthopedics in a Peripheral Trauma Center in Nepal without Plastic Surgery Services

Background: Soft tissue cover after surgical debridement, skeletal stabilization is an integral part of optimal management of high-velocity orthopedic injuries and orthopedic infections which is preferably done in collaboration with plastic surgeons. In our peripheral hospital, since plastic surgery service is not available, it has been our practice as orthopedic surgeons to be involved in the comprehensive surgical care of such patients including flap cover of the resulting soft-tissue defect. We reviewed the results of our flaps from June 2013 to May 2015 which were exclusively done by orthopedic surgeons. Materials and Methods: All patients from June 2013 to May 2015 with an open fracture or orthopedic infections who underwent flap cover of any kind in both the upper and lower limbs were retrospectively reviewed. Results: We had thirty-eight flaps in 36 patients. Two were lost to follow-up. There were eight (22.22%) upper limb flaps and 28 (77.77%) lower limb flaps. Average follow-up was 3 months (6 weeks–12 months). The average age was 35 years (17 years–65 years). Ten (27.7%) of the patients had flap done for infection and the rest 26 (72.2%) for an open fracture. The dimension of the flap ranged from 1 cm × 1 cm to 15 cm × 16 cm. Thirty-one out of thirty-six (83.33%) of the flaps healed primarily. Six (16.66%) patients had minor complications. There was no total flap loss. Conclusion: Comprehensive care of soft-tissue defects by orthopedic surgeons themselves seem to be a viable option with good outcome and acceptable complications in orthopedic trauma and infections when plastic surgery service in not available.

Posttraumatic functional movement disorders and litigation.

The concept of functional movement disorders has evolved considerably over the past few decades. More specifically, the views on the relation with psychological stressors or personality disorders have substantially changed, emphasizing a shift from the previously dominant dualistic scheme. This evolution is reflected in adaptations to diagnostic criteria and management approaches. Functional movement disorders which arise in a close temporal relationship with a peripheral trauma are specifically challenging with respect to diagnosis and treatment, but similar considerations seem to apply. The relationship of functional disorders with trauma appears to be much closer than is often thought. Clinical and pathophysiological research has identified shared factors underlying functional posttraumatic as well as primary movement disorders. These evolving insights impact on discussions in terms of litigation for compensation after trauma. The literature is reviewed and the consequences for argumentation in litigation are outlined, including ethical and legal considerations. Finally, we formulate a number of recommendations.

Silk Fibroin: An Ancient Material for Repairing the Injured Nervous System.

Silk refers to a family of natural fibers spun by several species of invertebrates such as spiders and silkworms. In particular, silkworm silk, the silk spun by Bombyx mori larvae, has been primarily used in the textile industry and in clinical settings as a main component of sutures for tissue repairing and wound ligation. The biocompatibility, remarkable mechanical performance, controllable degradation, and the possibility of producing silk-based materials in several formats, have laid the basic principles that have triggered and extended the use of this material in regenerative medicine. The field of neural soft tissue engineering is not an exception, as it has taken advantage of the properties of silk to promote neuronal growth and nerve guidance. In addition, silk has notable intrinsic properties and the by-products derived from its degradation show anti-inflammatory and antioxidant properties. Finally, this material can be employed for the controlled release of factors and drugs, as well as for the encapsulation and implantation of exogenous stem and progenitor cells with therapeutic capacity. In this article, we review the state of the art on manufacturing methodologies and properties of fiber-based and non-fiber-based formats, as well as the application of silk-based biomaterials to neuroprotect and regenerate the damaged nervous system. We review previous studies that strategically have used silk to enhance therapeutics dealing with highly prevalent central and peripheral disorders such as stroke, Alzheimer’s disease, Parkinson’s disease, and peripheral trauma. Finally, we discuss previous research focused on the modification of this biomaterial, through biofunctionalization techniques and/or the creation of novel composite formulations, that aim to transform silk, beyond its natural performance, into more efficient silk-based-polymers towards the clinical arena of neuroprotection and regeneration in nervous system diseases.

Life and Limb: Current Concepts in Endovascular Treatment of Extremity Trauma

Traumatic injury is the leading cause of death worldwide in younger patient populations and extremity trauma with associated vascular injury accounts for many trauma-related deaths. Iatrogenic injury is also a common cause of extremity vascular trauma and the incidence of iatrogenic injury will likely increase as endovascular techniques continue to become more ubiquitous. For many vascular injuries involving the extremities, surgical repair is viewed as the standard of care. Historically, endovascular techniques did not play a role in the treatment of these vascular injuries, rather they were utilized only as part of the diagnostic assessment; however, there is an increasing trend toward endovascular management of extremity vascular trauma. No validated, widely implemented algorithm to select patients for endovascular intervention exists. Transcatheter techniques, however, play an important role in the management of these patients. For arterial injuries, embolization can be used to rapidly achieve hemostasis if the vessel can be sacrificed. More advanced endovascular techniques such as stent-graft placement may be best employed in the context of isolated, proximal extremity injuries, although there is increasing literature supporting the use of advanced techniques for more distal arterial injuries. The management of peripheral venous trauma remains controversial; however, there is growing data describing successful endovascular management of some peripheral venous injuries. The purpose of this article is to review extremity vascular trauma, concepts of injury triage, endovascular techniques, and intraprocedural considerations.