Omental Free-tissue Transfer for Coverage of Complex Upper Extremity and Hand Defects—The Forgotten Flap

Free omental tissue transfer is a versatile reconstructive option for trunk, head and neck, and extremity reconstruction. Its utility is due to the length and caliber of the vascular pedicle and the malleability and surface area of the flap. We report our experience with omental free flap coverage of complex upper-extremity defects. A retrospective analysis of eight omental free-tissue transfers in seven patients with complex upper-extremity defects between 1999 and 2008 was performed. Indications, operative technique, and outcome were evaluated. Patient age ranged from 12 to 59 years with five male and two female patients. Indications included tissue defects due to crush-degloving injuries, pitbull mauling, or necrotizing soft tissue infection. All patients had prior operations including: revascularization, debridement, tendon repair, skin grafts, and/or fixation of associated fractures. One patient sustained severe bilateral crush-degloving injuries requiring free omental hemiflap coverage of both hands. The mean defect size was 291 cm² with all patients achieving complete wound coverage. No flap loss or major complications were noted. Laparoscopic-assisted omental free flap harvest was performed in conjunction with the general surgery team in three cases. Mean follow-up was 2 years. The omental free flap is a valuable, often overlooked reconstructive option. The long vascular pedicle and large amount of pliable, well-vascularized tissue allow the flap to be aggressively contoured to meet the needs of complex three-dimensional defects. In addition, laparoscopic-assisted harvest may aid with flap dissection and may result in reduced donor-site morbidity.     

How Many Cultures Are Necessary to Identify Pathogens in the Management of Total Hip and Knee Arthroplasty Infections?

Background

Identification of the infecting organism is critical to the successful management of deep prosthetic joint infections about the hip and the knee. However, the number of culture specimens and which culture specimens are best to identify these organisms is unknown.

The Utility of the “NAFLD Fibrosis Score” in Morbidly Obese Subjects with NAFLD

Background To date, the noninvasive diagnostic tests for hepatic fibrosis in subjects with nonalcoholic fatty liver disease (NAFLD) have proven to be suboptimal. We evaluated the validity of a recently proposed “NAFLD fibrosis score” to identify liver fibrosis in morbidly obese individuals with elevated and normal alanine aminotransferase (ALT) levels. Methods Medical records of 401 patients that underwent a gastric bypass operation and intraoperative liver biopsy were analyzed. Three hundred thirty one patients with biopsy-proven NAFLD were included in the study (group A). These patients were divided into two ALT groups based on their levels according to the new proposed normal range: group B elevated level (ALT > 19 U/L in females and >30 U/L in males, n = 221) and group C normal ALT (n = 110). Diagnostic accuracy of the system was assessed for the presence/absence of any fibrosis, significant fibrosis (stage 2–4), and advanced fibrosis (stages 3 and 4) in all of the groups. Results The prevalence of advanced fibrosis in our cohort was about 14%. The low NAFLD fibrosis score demonstrated high accuracy for ruling out advanced fibrosis, with negative predictive value (NPV) of 98 and 99% in groups A and B, respectively. The NPV for significant fibrosis in groups A, B, and C was 87, 88, and 88%, respectively. The respective positive predictive value for the high NAFLD fibrosis score for the presence of any fibrosis was 88, 95, and 77% in groups A, B, and C. Conclusions The NAFLD fibrosis score may be a useful noninvasive approach for excluding significant and advanced fibrosis and in morbidly obese patients.     

The Disappearing Phalanx: A Case Report of a Vascular Tumor of the Toe

We report a unique case of an epithelioid hemangioma of the third middle phalanx in which the lesion replaced the phalanx, became symptomatic, and then required resection, bone grafting, and joint arthroplasty. To the best of our knowledge, this is the first report of an epithelioid hemangioma in the toe that was treated using this approach.     

CORR Insights®: Use of Compressive Osteointegration Endoprostheses for Massive Bone Loss From Tumor and Failed Arthroplasty: A Viable Option in the Upper Extremity

Clinical Orthopaedics and Related Research® -     

The Peroneus Quartus Muscle in a Locking Phenomenon of the Ankle: A Case Report

We present the case of a 64-year-old female who was referred to us with an unexplained clicking and locking phenomenon of the right ankle. The magnetic resonance imaging findings suggested a longitudinal tear of the peroneus brevis tendon. During tendoscopy, not only was a Raikin type B intrasheath tendon subluxation visible, but also a peroneus quartus muscle. The peroneus brevis tear was tubularized and the peroneus quartus muscle resected, which resolved the patient's complaints.     

Impact of Urinary Tract Infections in Kidney Transplant Recipients: A 4-Year Single-Center Experience

Background

Urinary tract infection (UTI) is the most frequent bacterial infection in kidney transplant recipients (KTRs), yet little is known about the impact of severe UTIs. We aimed to explore the burden of severe UTIs post renal transplant on both graft function and health care resources.

The Quality of Diagnostic Studies in Periprosthetic Joint Infections: Can We Do Better?

BackgroundThe diagnosis of periprosthetic joint infections (PJIs) continues to be a subject of extensive debate. This is in part due to the lack of a single “gold standard” test, and the marked heterogeneity in the design of studies evaluating the accuracy of different diagnostic modalities. The goal of this review is to critically analyze the evidence cited by the proceedings of the 2013 International Consensus Meeting (ICM) on PJI with regards to the diagnosis of PJI.MethodsReferences from the Proceedings of the ICM on PJI related to PJI minor criteria were retrieved and manually reviewed. A total of 25 studies were analyzed using a Validated Quality Assessment of Diagnostic Accuracy Studies tool.ResultsA large number of studies were determined to have a high risk of bias for flow and timing domains due to the large numbers of exclusions. Studies of synovial white blood cells count and polymorphonuclear neutrophils percentage suffered from threshold optimization and lack of internal validity. Furthermore, due to the lack of homogeneity across studies, index test and reference standard domains showed high risk of bias for white blood cell/polymorphonuclear neutrophil percentage and the utility histological analysis, respectively. Leukocyte esterase testing lacked standardization with regard to the strip reagent used, and the exclusion of bloody samples limited sample sizes.ConclusionThe 2013 ICM minor criteria were based on studies with a low quality of evidence. As the committee continues to adjust these guidelines, they should encourage future studies with sound clinical design, patient selection, and testing procedures.     

“One-Stop Hybrid Procedure” in the Treatment of Vascular Injury of Lower Extremity

As a new surgical technique, “one-stop hybrid procedure” is rarely applied in trauma patients. This paper aims to explore its role in vascular injury of the lower extremity. Vascular intervention combined with open surgery was performed to treat three cases of vessel injuries of the lower extremity in our hybrid operating room. One patient with stab injury to the left femoral vein was treated by temporary artery blocking after excluding arterial injury by angiography, followed by blocking surgery and debridement and repair of the injured vein. The other two patients with drug addiction history, who were found to have pricking injuries to the femoral artery combined with local infection, were successfully treated by endovascular techniques and open debridement. One-stop hybrid procedure in treating vascular injury patients could simplify the operation procedure, reduce operative risk, and achieve good curative effect.     

Involvement of Surgical Residents in the Management of Trauma Patients in the Emergency Room: Does the Presence of an Attending Physician Affect Outcomes?

Background  

Few studies have investigated whether the presence or absence of attending physicians (AP) in the emergency department (ED) during the management of trauma patients by residents.     

The Prognostic Value of the Neutrophil–Lymphocyte Ratio (NLR) in Acute Pancreatitis: Identification of an Optimal NLR

Introduction

The neutrophil–lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process. The aim of this study was to investigate the prognostic value of the NLR in acute pancreatitis (AP) and determine an optimal ratio for severity prediction.

Materials and Methods

NLRs were calculated on days 0, 1, and 2, and correlated with severity. Severity was defined using the Atlanta classification.

Results

One hundred forty-six consecutive patients managed were included, 22 with severe acute pancreatitis (SAP). NLR in SAP was significantly higher than in the favorable prognosis group on all 3 days (day 0, 15.5 vs. 10.5; day 1, 13.3 vs. 9.8; day 2, 10.8 vs. 7.6). The optimal cut-offs from ROC curves were 10.6 (day 0), 8.1 (day 1), and 4.8 (day 2) giving sensitivities of 63–90 %, specificities of 50–57 %, negative predictive value of 89.5–96.4 %, positive predictive values of 21.2–31.1 %, and accuracies of 57.7–60 %.

Conclusions

Elevation of the NLR during the first 48 h of admission is significantly associated with severe acute pancreatitis and is an independent negative prognostic indicator in AP.     

Histopathologic Type: An Independent Prognostic Factor in Primary Soft Tissue Sarcoma of the Extremity?

Background: We attempted to define the effect of tumor histotype on local recurrence, distant metastasis, and disease-specific survival in patients with surgically treated primary extremity sarcoma.Methods: A total of 951 patients with primary, localized soft tissue extremity sarcoma were followed up prospectively. Patient- and tumor-related variables, including histopathologic type, were used to identify independent prognostic factors for the study end points of local recurrence, distant recurrence, and disease-specific survival.Results: There were 137 local recurrences, and significant adverse prognostic factors for local recurrence were patient age >50 years, microscopically positive margins, and malignant peripheral nerve tumor. Adverse prognostic factors for distant recurrence (200 patients) were tumor size >5 cm, tumors beneath the investing fascia, high tumor grade, and leiomyosarcoma. Of the 199 patients who died of disease-related causes, patient age >50 years, tumors beneath the investing fascia, high tumor grade, microscopically positive margin, tumor size >5 cm, leiomyosarcoma, and malignant peripheral nerve tumor were adverse prognostic factors.Conclusions:These data suggest that differences in biological behavior may exist between sarcoma histotypes and deserve further study.Presented at the 53rd Annual Cancer Symposium of the Society of Surgical Oncology, New Orleans, Louisiana, March 2000.