Treating surgical site infection following posterior instrumentation with free-style deepithelialized propeller flap: A case report.

Surgical site infection is a challenging situation for all types of surgeons. Extensive debridement with or without implant removal can create soft tissue defects. A well-vascularized, adequate soft tissue is needed to cover the wound and to fill the dead space for proper healing. Herein, we describe our approach to a large posterior trunk defect with dead space and our solution to manage an intraoperative complication using a free-style deepithelialized propeller flap.

Upper extremity arterial thromboembolism in a patient with severe COVID-19 pneumonia: A case report.

Although novel coronavirus-2019 (COVID-19) primarily affects the respiratory system, it can affect multiple organ systems, leading to serious complications, such as acute respiratory distress syndrome (ARDS) and multiple organ failure. Nearly 20 to 55% of patients with COVID-19 experience coagulation disorders that cause high mortality in line with the severity of the clinical picture. Thromboembolism can be observed in both venous and arterial systems. The vast majority of thromboembolic events are associated with the venous system and are often observed as pulmonary embolism. Arterial thromboembolisms often involve the arteries in the lower extremities, followed by those in the upper extremities. Herein, we report a rare case of COVID-19 pneumonia whose left arm was amputated at the forearm level after arterial thromboembolism in the left upper extremity. This case report is valuable, as it is the first reported case of upper extremity arterial thromboembolism in Turkey, as well as the only case in the literature in which the patient underwent four surgical interventions and is still alive.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment.

BACKGROUND: Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience. METHODS: We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients. RESULTS: Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay. CONCLUSION: To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

Sagittal patellar tilt and concomitant quadriceps hypotrophy after tibial nailing.

PURPOSE: The aim of the study was to analyse the patellofemoral alignment in the sagittal plane following tibial fracture surgery with intramedullary nailing and its relationship to parapatellar muscle status. METHODS: The patellofemoral MRI results of 27 patients (15 males and 12 females) treated with locked intramedullary nailing following tibia shaft fracture were reviewed. The mean age of the patients was 41.8 (±15) years. The patella-patellar tendon angle (P-PT) and the distance between the inferior patellar pole and the tibial tubercle (DP-TT) were evaluated for both the operated extremity and the contralateral normal side. MRI assessment of the infrapatellar fat pad, quadriceps, sartorius, gracilis, semi-membranosus muscles and biceps muscles was also carried out. The correlation between the changes in skeletal muscle mass, the volume of the infrapatellar fat pad and the alterations in the DP-TT distances and P-PT angles were analysed. RESULTS: The quadriceps muscle cross-sectional diameter had a mean of 157.2 mm(2) (115.6/319.5) in the operated extremity, and it was 193 mm(2) (77.6/282.2) in the non-operated normal side (p = 0.001). For the Gracilis muscle, the mean was 84.4 mm(2) (19.7/171) at the operated extremity and 75.7 mm(2) (26.9/238.2) on the normal side (p = 0.05). The cross-sectional areas of the semi-membranosus, sartorius and biceps muscles in the operated and non-operated extremity were not noticeably different (n.s). The P-PT angle was 153° (129.7/156.4) in the operated extremity and 145.7° (137.6/163.4) in the non-operated normal extremity (p < 0.05). While DP-TT distance was 11.4 mm (9.4/20.4) in the operated extremity, it was 14.1 mm (7.3/17.1) in the non-operated extremity (p = 0.001). The correlation analyses revealed that the quadriceps hypotrophy negatively correlated (r = -0.4, p = 0.02) with the P-PT angle but positively correlated with the increase in gracilis muscle volume (r = 0.4, p = 0.03). CONCLUSION: This study revealed that patellofemoral joint kinematics in the operated extremity was diminished in the sagittal plane correlating with the quadriceps muscle volume loss and gracilis muscle hypertrophy. The modalities focused on both preventing and treating the hypotrophy of the quadriceps muscle following the surgical treatment of tibial fracture, which may help to overcome this quite common pathology.