Unusual case of a free anterolateral thigh flap partial necrosis in a COVID-19 positive young male following extremity reconstruction / 中华创伤杂志(英文版)

Free flap procedure provides an overall success rate of 97%, which decreases to 85% in hypercoagulable states. COVID-19, as a pro-thrombotic disorder, therefore seems detrimental to free flap survival. We encountered a case of unique pattern of free flap partial failure in a young male who underwent extremity reconstruction. The patient was diagnosed as COVID-19 positive on the 3rd day post-reconstruction. The flap survived well for the first 7 days post-operatively, but gradually the skin got necrosed and the subcutaneous fat layer was preserved when debriding. To our knowledge, this is the only case in which the skin of the free flap of a COVID-19 positive patient was necrosed almost entirely subsequently, while the subcutaneous fat was relatively preserved.

Sowa-Rigpa (Amchi/Buddhist Medicine): A Review

Sowa-rigpa is known as Amchi or Buddhist medicine or Tibetan system of medicine which is primarily based on Buddhist philosophy. It is the fact that basic concepts of Sowa-Rigpa and Ayurveda are almost same and it seems that there is inter-relation among these two traditional systems of Indian Medicine. The description of Tridosha, Panchamahabhuta, seven Dhatus, three Malas, week wise embryological development are same. In Sowa-Rigpa, it has been mentioned that we all are sick due to ignorance as according to Buddhist philosophy, Ignorance is the cause of sufferings. The relation between ignorance and suffering as per the Sowa-Rigpa may be the unique concept which may show the path for human-beings to eradicate all human sufferings i.e., ultimately to walk on the path of Nirvana which is the goal of Buddhist philosophy and Moksha according to Ayurveda.

Prevalence and determinants of sarcopenia in Indian patients with chronic kidney disease stage 3 & 4

Objectives@#There is limited literature on the prevalence and determinants of sarcopenia in the Indian predialysis chronic kidney disease (CKD) population. The current study attempts to characterize sarcopenia in CKD stages 3 & 4 using 3-compartment model dual-energy X-ray absorptiometry (DXA). @*Methods@#This is secondary data from a randomized trial on bicarbonate supplementation for preserving muscle mass. A 3-compartment DXA was done to assess body composition in 188 subjects aged 18 to 65, with stable kidney function. Sarcopenia was defined by Asian Working Group criteria - appendicular skeletal mass index < 5.4 kg/m2 in women and < 7 kg/m2 in men. @*Results@#Sarcopenia was present in 69.1% (n = 130). There was no difference in the prevalence of sarcopenia in CKD stage 3 (n = 62; 72.1%) vs CKD stage 4 (n = 68, 66.7%); P = 0.434. A lower body mass index (BMI) (OR 1.69; 95% CI 1.43, 2.01) and lower bicarbonate levels (OR 1.22; 95% CI 1.02, 1.47), and age (OR 0.95; 95% CI 0.91, 0.98) was independently associated with the muscle mass. A BMI cut-off of 18 failed to identify sarcopenia in 78.4% (n = 102) subjects (Kappa statistic 0.396). The receiver operating characteristic curve for mid-arm muscle circumference for identifying sarcopenia was 0.651 (95% CI 0.561, 0.740). @*Conclusions@#Sarcopenia is highly prevalent in CKD 3 and 4. Sarcopenic individuals are older, with a low BMI and lower bicarbonate levels. The anthropometric parameters and biochemical parameters did not help identify sarcopenia in the predialysis population.

The Evaluation Of Pulp Score (PEPTIC Ulcer Perforation Score) As A Predictor Of Mortality Following Peptic Ulcer Perforation.

Introduction: Mortality and morbidity following perforated peptic ulcer (PPU) remains high, and mortality proportions of 25–30% have been reported in population–based studies.The aim of this study was to evaluate the efficacy of PULP SCORE in predicting 30 day mortality. Patients and methods: A series of 52 patients were enrolled in the study.Patients who underwent surgical treatment for perforated peptic ulcer were allotted points according to the PULP scoring system and stratified into high and low risk groups. All the data was prospectively analyzed. Observations and results:46 patients were in low risk and 6 patients were in high risk category. 5 patients were deceased in high risk group but none in low risk group. The PULP SCORE had a sensitivity of 83.33% and specificity of 97.83% in predicting mortality. In the ROC curve the AUC was 91.8%. 4 variables out of 8 variables in the score were found to be most important in predicting mortality. They were : 1. Treatment delay >24 hrs, 2. Shock on admission, 3. High ASA score, 4. Age >65 years. Conclusion:The prognostic predictors included in the PULP score can be readily identified prior to surgery, easy to use and feasible in emergency. The PULP score can assist in accurate and early identification of high–risk patients, and thus assist in risk stratification and triage of patients.

Cement Augmentation of Dynamic Hip Screw to Prevent Screw Cut Out in Osteoporotic Patients with Intertrochanteric Fractures: A Case Series / 대한고관절학회지

PURPOSE: The purpose of this study is to describe a method of inserting cement in the femoral head before fixation with dynamic hip screw to prevent screw cut out due to osteoporosis and to evaluate its clinical outcome in these patients. MATERIALS AND METHODS: In this prospective study, 30 patients aged 60 years and older with intertrochanteric fracture were included. Bone mineral density was measured. After reaming of the femoral head and neck with a triple reamer and polymethyl methacrylate, bone cement was introduced into the femoral head using a customized nozzle and a barrel fitted on a cement gun. A Richard screw was inserted and the plate was fixed over the femoral shaft. Patients were mobilized and clinical outcomes were rated using the Salvati and Wilson's scoring system. RESULTS: More patients included in this study were between 66 and 70 years old than any other age group. The most common fracture according to the Orthopaedic Trauma Association classification was type 31A2.2 (46.7%). The T-score was found to be −2.506±0.22 (mean±standard deviation); all patients were within the range of −2.0 to −2.8. The duration of radiological union was 13.67±1.77 weeks. Salvati and Wilson's scoring at 12 months of follow up was 30.96±4.97. The majority of patients were able to perform their normal routine activities; none experienced implant failure or screw cut out. CONCLUSION: Bone cement augmentation may effectively prevent osteoporosis-related hardware complications like screw cut out in elderly patients experiencing intertrochanteric fractures.

Thoracolumbar Vertebral Injuries with Neurological Deficit Treated with Posterior Decompression, Short Segment Pedicle Screw Fixation, and Interlaminar Fusion

STUDY DESIGN: Prospective clinical study. PURPOSE: The purpose of this study was to evaluate the effect of interlaminar fusion and short segment pedicle screw fixation on thoracolumbar vertebral injuries for preventing pain and post-traumatic kyphosis. OVERVIEW OF LITERATURE: The treatment of thoracolumbar injuries continues to be one of the most controversial areas in spine care. The main aim of surgical treatment is to decompress the spinal cord or nerve roots, realign the spine, and correct or prevent post-traumatic kyphosis. We evaluated the outcome of interlaminar fusion along with posterior decompression and short segment pedicle screw fixation in patients with thoracolumbar fractures with neurological deficit. METHODS: Twenty-two patients with traumatic thoracolumbar vertebral injuries and neurological deficit underwent short segment pedicle screw fixation above and below the fractured vertebrae, posterior decompression, and interlaminar fusion using a bone graft. RESULTS: All patients were followed up for 12 months postoperatively. The average operative time and blood loss was 142 minutes and 214 mL, respectively. Of the 22 patients, 14 recovered completely. Of the nine patients with American Spinal Injury Association (ASIA) grade A disease, two improved by 1 grade, whereas one each improved by grades 2, 3, and 4, and four did not recover. Radiologically, vertebral kyphosis angle improved from 20.91 preoperatively to 15.73 postoperatively, sagittal index improved from 24.77 to 18.73, the sagittal plane kyphosis angle improved from 17.45 to 11.41, regional angle kyphosis improved from 14.73 to 10.14, the superior inferior end plate angle from 16.14 to 13.00, and mean anterior body compression improved from 36.26 to 27.64 postoperatively. No implant failed and no patient had neurological deterioration. CONCLUSIONS: Short segment pedicle screw fixation with posterior decompression and interlaminar fusion provided considerable reduction in kyphosis, restored the vertebral height of patients with thoracolumbar vertebral injuries and neurological deficit, and prevented development of delayed kyphotic deformity.

Distal femoral physeal crush injury with metaphyseal comminution - A report of two cases and a new perspective to physeal injury / 中华创伤杂志(英文版)

The physis of a long bone may get 'sandwiched' and crushed between the metaphysis and the epiphysis if it is traumatically loaded along its long axis. Such a physeal injury may lead to complications like angular deformities and growth restrictions and hence, management of such injuries requires adequate planning and attentive execution. Two patients with distal femoral physeal crush injury were treated using a ring fixator such that one ring had the wires passing through the epiphysis and the other through the femoral shaft. On table image intensifier controlled distraction of the crushed physis was done to bring the height of the physis similar to that of the opposite limb. Patients were followed up for more than two years clinically and radiologically. There was no clinical or radiological angular deformity of the operated limbs. MRI scans showed intact physes with no physeal bar formation in either of the two patients. The distraction obtained by the ring fixator appears to have provided ample 'breathing space' to the compressed physis and that the growth potential may have been re-gained by the procedure. However, two years is a relatively short duration of follow-up and further follow-up of longer duration and in greater number of patients is needed to gauge the actual effectiveness of the technique used by us.

Demographic Trends of Patients with Compressive Myelopathy in a Developing Asian Country

STUDY DESIGN: Prospective case series. PURPOSE: To analyze the demographic picture of the patients suffering from compression myelopathy due to various spinal problems. Overview of Literature: There is a lack of literature depicting demographic picture of such patients with spinal injuries as most of the articles have shown the epidemiology of spinal cord injuries either managed conservatively or operatively. None have focused on the patients with compressive myelopathy requiring surgeries. METHODS: Patients with spinal pathologies with a neurological deficit due to compressive myelopathy requiring surgical decompression of dorsal and thoracolumbar region were studied. The different kinds of etiologies, the demographic profiles involved, the involvement of various regions of spine in each of the etiologies, sex distribution of different etiologies, association of age and sex with the occurrence of paraplegia, and association of thoracolumbar junction (TLJ) involvement by age and sex were studied. This study addressed the dorsal and TLJ till L2 vertebrae surgically treated by anterior transthoracic transpleural approach. RESULTS: With regard to gender, 75% of the females and 67.3% of the males were paraplegic but there was no relationship between gender and the occurrence of paraplegia (p >0.05). There was also no association between TLJ involvement and the age and sex of the patients (p >0.05). Seventy percent of the patients were paraplegic with a mean age of 38.90 years and 30% were paraparetic with a mean age of 43.43 years. Male to female ratio stood at 4.43:1. CONCLUSIONS: Traumatic spine in females is increasing. The occurrence of paraplegia and involvement of TLJ is not affected by the age and the sex of the patients. Deep epidemiological understanding of spinal pathologies can lead to a better appreciation of the potential impact of health care management strategies and health policies to prevent and minimize their consequences considering limited worldwide reports on the same.

A rare combination of fractures around the elbow: Bony variant of terrible triad / 中华创伤杂志(英文版)

Radial head and coronoid fractures without posterior dislocation of the elbow have not been recorded in the literature. There is no literature documenting the combined fractures of the radial head, capitellum and coronoid process together in the same elbow. This is a case report highlighting this combination of fractures in a 30 year old patient treated with open reduction and internal fixation of all three fractures. The patient was followed up for 28 months and had a good range of motion of the elbow without any instability. Thus such a triad with no ligamentous injuries could depict a bony variant of terrible triad and a mechanism for such an injury has also been explained.

Role of 3D FLAIR in demonstration of peripheral lesions of brainstem and cranial neuropathies.

Aim: We present a pictorial review of 3D FLAIR images depicting its importance in demonstrating the peripheral lesions of brainstem particularly in relation to attachment of cranial nerves and cranial neuropathies and particularly in context of patients with multiple sclerosis (MS). Discussion: T2 axials and routine 2D FLAIR have drawbacks in depicting the lesions on the peripheral aspects of brainstem. Such lesions are commonly found in MS. The revised McDonald’s criteria (2010) put equal emphasis on periventricular, juxtacortical, infratentorial and cord lesions. Detection of peripheral lesions thus play important role in fulfilling the criteria of dissemination in space and also provide anatomic correlate in several cranial nerve palsies. In clinically isolated syndromes, demonstration of lesions at the site of affected cranial nerves increase diagnostic confidence and exclude other potential disease processes. Ability to show signal changes at cranial nerve attachment can also potentially prevent a false attribution of symptoms to neurovascular compression. Conclusion: We propose that 3D FLAIR sequence is extremely useful in detecting abnormalities on the surface of brainstem and cranial nerve attachments and should be performed in all patients of MS and cranial nerve palsies.

A rare case of third ventricular epidermoid cyst as seen by newer MRI sequences.

Aim: We describe a 52 year old gentleman who had a third ventricular lesion, presumed to be epidermoid cyst, which is very rare. We also describe the appearances of this rare condition on newer MRI sequences. Presentation of Case: Third ventricle is a rare site of epidermoid cysts and difficult to visualise specially in routine MRI sequences. We used 3D FLAIR sequence as part of routine MRI protocol that was helpful in raising suspicion initially, aided by clinical presentation. Subsequent 3D T2 SPACE sequence confirmed the presence of abnormality. Discussion: The case highlights the importance of high resolution 3D FLAIR sequence as part of initial MRI protocol that is devoid of CSF flow artefacts and therefore helpful for small intraventricular lesions. Importance of 3D T2 SPACE is also highlighted which is another new MRI sequence. It has excellent spatial resolution without artefacts that is helpful in clearly delineating the presence of small lesions such as epidermoid cyst and its relationship with surrounding structures and increasing diagnostic certainty. Conclusion: We present a rare case of presumed third ventricular epidermoid cyst and potential role of newer MRI sequences in small intraventricular lesions.

Spontaneous enlargement then regression of a colloid cyst of the III ventricle.

Aim: We describe a case of a 22 year old pregnant female patient who was found to have a small colloid cyst that increased spontaneously, followed by spontaneous significant reduction in size. Presentation of Case: The patient’s colloid cyst was picked up incidentally in late pregnancy at 39 weeks. It showed spontaneous increase in size accompanied by deterioration of symptoms at 31 months post diagnosis and then showed significant spontaneous reduction in size at 38 months post diagnosis. Discussion and Conclusion: Spontaneous reduction of a colloid cyst of third ventricle is a very rarely described phenomenon. To our knowledge this is one of only 3 cases of spontaneous regression of an III ventricular colloid cyst. It may be reasonable to follow up cases, where there is a documented history of increase.

Sylvian fissure lipoma associated with middle cerebral artery aneurysm – Report of a rare case highlighting imaging pitfalls.

Aim: We describe a 60 year old lady who had a Sylvian fissure lipoma associated with an underlying middle cerebral artery saccular aneurysm which is a rare association and describe its imaging features. Presentation of Case: Due to its rarity and MRI appearances simulating blood products, this case offered an initial diagnostic dilemma to the reporting radiologists, when an incidental lesion like lipoma adjoining an aneurysm was initially misinterpreted as blood products. Discussion and Conclusion: This case highlights potential pitfalls in imaging interpretation even with a newer neuroimaging technique to accurately identify the nature of the lesion that can lead to misdiagnosis with the potential of inappropriate clinical management, at least in some cases.

Management of neglected cervical spine dislocation: a study of six cases / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To report a case series of six neglected cervical spine dislocations without neurological deficit, which were managed operatively.</p><p><b>METHODS</b>The study was conducted from August 2010 to December 2011 and cases were selected from the out-patient department of Postgraduate Institute of Medical Education and Research, India. The patients were in the age group of 30 to 50 years. All patients were operated via both anterior and posterior approaches.</p><p><b>RESULTS</b>During the immediate postoperative period, five (83.33%) patients had normal neurological status. One (16.67%) patient who had C5-C6 subluxation developed neurological deficit with sensory loss below C6 level and motor power of 2/5 in the lower limb and 3/5 in the upper limb below C6 level.</p><p><b>CONCLUSION</b>There is no role of skull traction in neglected distractive flexion injuries to cervical spine delayed for more than 3 weeks. Posterior followed by anterior approach saves much time. If both approaches are to be done in the same sitting, there is no need for instrumentation posteriorly. But if staged procedure is planed, posterior stabilization is recommended, as there is a risk of deterioration in neurological status.</p>

Post-traumatic dissecting aneurysms of bilateral cervical carotid arteries with delayed complications.

Carotid dissection is an uncommon complication of trauma. They can present with immediate or delayed complications. We describe the case of a young patient with bilateral carotid dissections and acute infarcts. Brief review of literature and treatment options are discussed.