Predicting Union, Osteomyelitis, and Amputation Outcomes of Gustilo IIIC Open Tibial Fractures: A Retrospective Study.

OBJECTIVE: Open tibial fractures are frequently encountered in high-energy traumas and can result in significant complications such as nonunion, osteomyelitis, and even amputation. Among open tibial fractures, Gustilo type IIIC cases are particularly challenging due to the concomitant occurrence of neurovascular injuries and soft tissue defects. This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures. METHODS: Patients who presented at our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, and the timing, number, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. We performed univariate analyses including chi-squared test, Fischer's exact test, analysis of variance, and Kruskal-Wallis test based on the normality of the data and multivariate analyses including Cox proportional hazards model and logistic regression analyses. RESULTS: Fifty-eight patients were enrolled and grouped by fracture healing time; eight had timely union (13.8%); 27 had late union (46.6%); eight had delayed union (13.8%); three had nonunion (5.2%); and 12 underwent amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with injury severity score (ISS) ≥ 16 points, and increased bone defect length. Additionally, a bone gap >50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within 2 years was stratified based on this score. CONCLUSION: IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation.

Neurectomy of the Nerve of Henle Associated with Periarterial Sympathectomy for Management of Intractable Raynaud's Phenomenon.

BACKGROUND: In periarterial sympathectomy for intractable Raynaud's phenomenon, the extent of adventitiectomy as well as postoperative outcomes and hand perfusion assessment tools remain debatable. We evaluated the outcome of neurectomy of the nerve of Henle combined with ulnar tunnel release and periarterial adventitiectomy in the treatment of refractory Raynaud's phenomenon using objective measurements and patient-reported outcomes. METHODS: Nineteen patients with 20 affected hands were prospectively enrolled and underwent the proposed procedures from 2015 to 2021. Relevant data, including Michigan Hand Outcomes Questionnaire and 36-Item Short Form health questionnaire scores, were documented for analysis during a 3-year follow-up. RESULTS: The average ingress value of the three measured fingers (index, long, and ring) on indocyanine green angiography increased after surgery (p=0.02). The median number of ulcers decreased (p<0.001) and the median digital skin temperature increased (p<0.001). Questionnaire scores showed improvement in physical aspects, such as overall hand function (p≤0.001), activities of daily living (p=0.001), work performance (p=0.02), pain (p<0.001), physical function (p=0.053), and general health (p=0.048), as well as mental aspects, such as patient satisfaction (p<0.001) and mental health (p=0.001). The average indocyanine green ingress value of the three measured fingers significantly correlated with the patient-reported outcomes, including overall hand function (r=0.46, p=0.04), work performance (r=0.68, p=0.001), physical function (r=0.51, p=0.02), and patient satisfaction (r=0.35, p=0.03). CONCLUSIONS: The proposed surgical procedures provided satisfactory outcomes, both subjectively and objectively, over a follow-up period of up to 3 years. Indocyanine green angiography may provide rapid and quantitative measurements for perioperative hand perfusion assessment.

Aligned core-shell fibrous nerve wrap containing Bletilla striata polysaccharide improves functional outcomes of peripheral nerve repair.

Peripheral nerve injuries are commonly encountered in extremity traumas. Their motor and sensory recovery following microsurgical repair is limited by slow regeneration speed (<1 mm/d) and subsequent muscle atrophy, which are consequently correlated with the activity of local Schwann cells and efficacy of axon outgrowth. To promote post-surgical nerve regeneration, we synthesized a nerve wrap consisting of an aligned polycaprolactone (PCL) fiber shell with a Bletilla striata polysaccharide (BSP) core (APB). Cell experiments demonstrated that the APB nerve wrap markedly promoted neurite outgrowth and Schwann cell migration and proliferation. Animal experiments applying a rat sciatic nerve repair model indicated that the APB nerve wrap restored conduction efficacy of the repaired nerve and the compound action potential as well as contraction force of the related leg muscles. Histology of the downstream nerves disclosed significantly higher fascicle diameter and myelin thickness with the APB nerve wrap compared to those without BSP. Thus, the BSP-loaded nerve wrap is potentially beneficial for the functional recovery after peripheral nerve repair and offers sustained targeted release of a natural polysaccharide with good bioactivity.

Comparison of the clinical outcomes between vascularized bone graft and the Masquelet technique for the reconstruction of Gustilo type III open tibial fractures.

BACKGROUND: Gustilo type III tibial fractures commonly involve extensive soft tissue and bony defects, requiring complex reconstructive operations. Although several methods have been proposed, no research has elucidated the efficacies and differences between vascular bone graft (VBG) and the Masquelet technique (MT) to date. We aimed to evaluate and compare the clinical effectiveness of VBG and the MT for the reconstruction of Gustilo type III tibial fractures. METHODS: This retrospective cohort study enrolled patients who underwent reconstruction for Gustilo type III tibial fractures using VBG or the MT in a single center from January 2000 to December 2020. The patients' demographics, injury characteristics, and surgical interventions were documented for analysis. The clinical outcomes including union status, time to union, postoperative infections, and the causes of union failure were compared between the two groups. RESULTS: We enrolled 44 patients: 27 patients underwent VBG, and 17 underwent MT. The average union time was 20.5 ± 15.4 and 15.1 ± 9.0 months in the VBG and MT groups, respectively (p = 0.232). The postoperative deep infection rates were 70.4% and 47.1% in the VBG and MT groups (p = 0.122), respectively. Though not statistically significant, the VBG group had a shorter union time than did the MT group when the bone defect length was > 60 mm (21.0 ± 17.0 versus 23.8 ± 9.4 months, p = 0.729), while the MT group had a shorter union time than did the VBG group when the bone defect was length < 60 mm (17.2 ± 5.6 versus 10.7 ± 4.7 months, p = 0.067). CONCLUSIONS: VBG and MT are both promising reconstruction methods for Gustilo type III tibial fractures. VBG appears to have more potential in reconstructing larger bone defects, while MT may play an important role in smaller bone defects, severe surgical site infections, and osteomyelitis. Therefore, flexible treatment strategies are required for good outcomes in Gustilo type III open tibial fractures.