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BackgroundDuring the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture.MethodsThe study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement.ResultsTwo patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01).ConclusionExtremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Algorithms of social media platforms are often criticized for recommending ideologically congenial and radical content to their users. Despite these concerns, evidence on such filter bubbles and rabbit holes of radicalization is inconclusive. We conduct an audit of the platform using 100,000 sock puppets that allow us to systematically and at scale isolate the influence of the algorithm in recommendations. We test 1) whether recommended videos are congenial with regard to users ideology, especially deeper in the watch trail and whether 2) recommendations deeper in the trail become progressively more extreme and come from problematic channels. We find that YouTubes algorithm recommends congenial content to its partisan users, although some moderate and cross-cutting exposure is possible and that congenial recommendations increase deeper in the trail for right-leaning users. We do not find meaningful increases in ideological extremity of recommendations deeper in the trail, yet we show that a growing proportion of recommendations comes from channels categorized as problematic (e.g., IDW, Alt-right, Conspiracy, and QAnon), with this increase being most pronounced among the very-right users. Although the proportion of these problematic recommendations is low (max of 2.5%), they are still encountered by over 36.1% of users and up to 40% in the case of very-right users.

Soft tissue sarcomas are defined as relatively rare, wide-ranging mesenchymal tumors that present several forms of aggressive behavior. In order to improve the therapeutic result and thus the patient's prognosis, reliable diagnostic and evaluation tools are needed, capable of establishing the evolutive pattern of each patient. Materials and Methods. An analytical observational study was conducted in the period 2016-2023 in the Orthopedics Department of the Bucharest University Emergency Hospital, on patients diagnosed with soft tissue sarcoma. Data such as sex, age, site, size, depth, histotype, grade and margin status, vessel or bone involvement, adenopathies, adjuvant therapy, clinical findings, etc., were analyzed. Diagnosis included immunohistochemistry after macroscopic pathological findings were carefully reviewed by a dedicated pathologist. A molecular study was performed to increase the accuracy of diagnosis, prognosis and clinical management of selected sarcomas. Results. In adult soft tissue sarcomas, histotype has been reported to be a significant predictor of overall survival. In terms of survival rate, vascular invasion appears to be a significant pathological factor for progression in extremity STS. Even though the local control of the disease has improved, the development of systemic metastases seems to be largely influenced by the biological characteristics of the tumor. Conclusions. Significant prognostic factors for the likelihood of a lower survival and death rate are tumor size, tumor depth, histology type, and vascular invasion. The results of the study support and complement the literature data, thus improving the understanding of the prognosis of soft tissue sarcomas.

Vascular leiomyomas are infrequent benign soft tissue neoplasms arising from vascular wall. These lesions are more frequent in females, predominantly seen in lower extremities presenting as slowly enlarging freely mobile palpable soft tissue lesions, often painful. The role of imaging in small peripheral soft tissue masses is often limited to preoperative mapping with a long list of potential differentials. We are presenting 2 case studies of palpable masses with similar pathology, soft tissue vascular leiomyomas where its MR features can be helpful in inclusion of this entity not only in differential diagnosis of enhancing small peripheral soft tissue masses but can suggest a diagnosis in appropriate clinical scenario.

Three-dimensional (3D) motion analysis (MA) techniques are progressively being used in biomechanics research and for clinical applications to assess the risk of injuries. A marker-based 3D MA protocol has been developed to measure the upper and lower extremity (UE and LE) joints' active and passive ranges of motion (AROM and PROM) in children. The joints that were included in this protocol are shoulder, elbow, wrist, hip, knee and ankle. The anatomical joint coordinate systems (JCS) have been defined for the upper and lower extremities to standardize reporting. A marker placement model was defined according to the International Society of Biomechanics (ISB) recommendations and used to develop the protocol. The proposed movements will be captured and analyzed using the Motion Analysis Corporations 3D MA system integrated with Cortex software. The movements adopted in this study have been selected from various sources to incorporate all joint rotations while ensuring the isolation of each joint motion during the movements. It is recommended that future studies utilize this protocol to draw a relationship between the joints' range of motion (ROM) and the adjacent segments characteristics, i.e., segment length, joint stiffness, etc. [ABSTRACT FROM AUTHOR]

Background: In melanoma, nodal status of major lymph node basins are commonly assessed; however, minor lymph node basins (epitrochlear and popliteal regions) are often overlooked. Significant variability in reported incidences of lymphatic drainage and metastasis to these areas exists. By systematically reviewing existing literature and examining studies specifically focusing on the distal extremity, we review the rates of drainage and metastasis to these lesser studied regions and assess the implications for routine clinical examination and care. Methods: A literature search was performed to identify studies evaluating outcomes of SLNB and clinical metastasis to minor node basins in distal extremity melanoma. PUBMED, EMBASE and COCRANE databases were searched. The primary outcome measure was the location of sentinel node at SLNB. The secondary outcome measures were the rates of micro and macro metastasis. Data synthesis was conducted using the Stuart—Ord method. Results: 259 articles were screened and 50 examined in detail. 10 studies were identified as suitable for synthesis of data, representing 7346 distal extremity melanomas. Pooled proportion of drainage to epitrochlear and popliteal nodes on SLNB were 0.14 and 0.09 and respectively. Rates of positive nodes at SLNB were equivalent to major lymph node basins. Conclusions: In any distal extremity, there is approximately a 1 in 10 chance of melanomas primarily draining to a minor nodal basin. In the upper extremity, this is higher at approximately 1 in 7. Risk of metastasis is equivalent to that of a major lymph node basins. We propose that clinical examination of minor nodal basins, in addition to performing SPECT-CT lymphoscintigraphy and inclusion of minor basins in ultrasongography, be employed to better detect micro and macrometastasis to these regions.

Background: Trauma is globally associated with significant mortality with developing countries bearing a disproportionately high burden. It represents a major epidemic of non – communicable disease. The aim of this study is to evaluate the incidence of various fracture and dislocation patterns in patients with extremity injuries and their 1- year mortality rate. Materials and Methods: An observational, prospective study was undertaken to analyse the incidence of fracture and dislocation patterns in patients coming to the Orthopaedics OPD and emergency medicine department in a tertiary hospital during a period of two years from 1st, October 2017 to 30th, September 2019. Overall, 1182 patients were enrolled for the study with a mean age of 43 yrs. Results: Age group 21 – 30 years was most common (17.1%) age to suffer injuries with a male preponderance (67.5%). The most common mode of injury was by road traffic accident (43%). 97.9% of the injuries had unilateral involvement with the lower extremity (57.2%) and the femur (21.2%) being most frequently fractured. Dislocations/fracture-dislocations constituted only 5.5% cases with shoulder dislocation being the most frequently involved joint. Plain radiographs were used in 96.9% cases for final diagnosis. Forty cases (3.4%) were found to not survive in the 1-year follow up after fracture. Conclusion: The present study shows that most of the causes of trauma are preventable. This study could assist in raising the profile of RTI as a public health problem which needs to be addressed as a preventable cause of mortality and morbidity, and planning appropriate interventions for this major challenge.

Abstract Background Oncologic surgical resection is the standard of care for extremity and truncal soft tissue sarcoma (STS), often accompanied by the addition of pre- or postoperative radiation therapy (RT). Preoperative RT may decrease the risk of joint stiffness and fibrosis at the cost of higher rates of wound complications. Hypofractionated, preoperative RT has been shown to provide acceptable outcomes in prospective trials. Proton beam therapy (PBT) provides the means to decrease dose to surrounding organs at risk, such as the skin, bone, soft tissues, and adjacent joint(s), and has not yet been studied in patients with extremity and truncal sarcoma. Methods Our study titled “PROspective phase II trial of preoperative hypofractionated protoN therapy for extremity and Truncal soft tissue sarcOma (PRONTO)” is a non-randomized, prospective phase II trial evaluating the safety and efficacy of preoperative, hypofractionated PBT for patients with STS of the extremity and trunk planned for surgical resection. Adult patients with Eastern Cooperative Group Performance Status ≤ 2 with resectable extremity and truncal STS will be included, with the aim to accrue 40 patients. Treatment will consist of 30 Gy radiobiological equivalent of PBT in 5 fractions delivered every other day, followed by surgical resection 2–12 weeks later. The primary outcome is rate of major wound complications as defined according to the National Cancer Institute of Canada Sarcoma2 (NCIC-SR2) Multicenter Trial. Secondary objectives include rate of late grade ≥ 2 toxicity, local recurrence-free survival and distant metastasis-free survival at 1- and 2-years, functional outcomes, quality of life, and pathologic response. Discussion PRONTO represents the first trial evaluating the use of hypofractionated PBT for STS. We aim to prove the safety and efficacy of this approach and to compare our results to historical outcomes established by previous trials. Given the low number of proton centers and limited availability, the short course of PBT may provide the opportunity to treat patients who would otherwise be limited when treating with daily RT over several weeks. We hope that this trial will lead to increased referral patterns, offer benefits towards patient convenience and clinic workflow efficiency, and provide evidence supporting the use of PBT in this setting. Trial registration: NCT05917301 (registered 23/6/2023).

Soft tissue sarcomas are defined as relatively rare, wide-ranging mesenchymal tumors that present several forms of aggressive behavior. In order to improve the therapeutic result and thus the patient's prognosis, reliable diagnostic and evaluation tools are needed, capable of establishing the evolutive pattern of each patient. Materials and Methods. An analytical observational study was conducted in the period 2016-2023 in the Orthopedics Department of the Bucharest University Emergency Hospital, on patients diagnosed with soft tissue sarcoma. Data such as sex, age, site, size, depth, histotype, grade and margin status, vessel or bone involvement, adenopathies, adjuvant therapy, clinical findings, etc., were analyzed. Diagnosis included immunohistochemistry after macroscopic pathological findings were carefully reviewed by a dedicated pathologist. A molecular study was performed to increase the accuracy of diagnosis, prognosis and clinical management of selected sarcomas. Results. In adult soft tissue sarcomas, histotype has been reported to be a significant predictor of overall survival. In terms of survival rate, vascular invasion appears to be a significant pathological factor for progression in extremity STS. Even though the local control of the disease has improved, the development of systemic metastases seems to be largely influenced by the biological characteristics of the tumor. Conclusions. Significant prognostic factors for the likelihood of a lower survival and death rate are tumor size, tumor depth, histology type, and vascular invasion. The results of the study support and complement the literature data, thus improving the understanding of the prognosis of soft tissue sarcomas. [ABSTRACT FROM AUTHOR]

Simple Summary: This study assessed the overall complications in 169 patients treated for extremity soft tissue sarcomas (ESTS) with a multimodal treatment involving radiotherapy and surgery. Risk factors for complications were identified, including postoperative, acute, and chronic radiotherapy-related complications, aiming to optimize treatment strategies to reduce morbidity. Multimodal treatment of ESTSs demonstrated excellent tolerance, with manageable side effects. Introduction: Soft tissue sarcomas of the extremities (ESTSs) pose significant challenges in treatment and management due to their diverse nature and potential complications. This study aimed to assess complications associated with multimodal treatments involving surgery and radiotherapy (RT) and to identify potential risk factors. Methods: We retrospectively analyzed nonmetastatic ESTS patients treated with surgery and pre- or post-operative RT between 2007 and 2020 in Strasbourg, France. Complications, including wound complications (WCs), lymphedema, acute and chronic RT-related complications, and fractures, were meticulously evaluated. Results: A total of 169 patients diagnosed with localized ESTSs were included, with a median age of 64 years (range 21–94 years). ESTSs primarily occurred proximally (74.6%) and in the lower limbs (71%). The median follow-up was 5.5 years. WCs occurred in 22.5% of patients, with proximal and lower extremity tumors being significant risk factors. Acute RT-related complications included radiodermatitis, with grade ≥ 2 occurring in 43.1% of patients, which was associated with superficial tumors. Three patients had an edema grade ≥ 2. Chronic complications included telangiectasias (21.7%) and fibrosis (38.7%), with higher rates associated with larger PTVs and higher RT doses, respectively. Fractures occurred in 5 patients, mainly in the tibia (40%). Conclusions: Multimodal treatment of ESTSs demonstrated excellent tolerance, with manageable side effects. Numerous risk factors have been highlighted, providing insights for optimizing treatment strategies and enhancing patient care in this rare disease. [ABSTRACT FROM AUTHOR]

Background: Oncologic surgical resection is the standard of care for extremity and truncal soft tissue sarcoma (STS), often accompanied by the addition of pre- or postoperative radiation therapy (RT). Preoperative RT may decrease the risk of joint stiffness and fibrosis at the cost of higher rates of wound complications. Hypofractionated, preoperative RT has been shown to provide acceptable outcomes in prospective trials. Proton beam therapy (PBT) provides the means to decrease dose to surrounding organs at risk, such as the skin, bone, soft tissues, and adjacent joint(s), and has not yet been studied in patients with extremity and truncal sarcoma. Methods: Our study titled "PROspective phase II trial of preoperative hypofractionated protoN therapy for extremity and Truncal soft tissue sarcOma (PRONTO)" is a non-randomized, prospective phase II trial evaluating the safety and efficacy of preoperative, hypofractionated PBT for patients with STS of the extremity and trunk planned for surgical resection. Adult patients with Eastern Cooperative Group Performance Status ≤ 2 with resectable extremity and truncal STS will be included, with the aim to accrue 40 patients. Treatment will consist of 30 Gy radiobiological equivalent of PBT in 5 fractions delivered every other day, followed by surgical resection 2–12 weeks later. The primary outcome is rate of major wound complications as defined according to the National Cancer Institute of Canada Sarcoma2 (NCIC-SR2) Multicenter Trial. Secondary objectives include rate of late grade ≥ 2 toxicity, local recurrence-free survival and distant metastasis-free survival at 1- and 2-years, functional outcomes, quality of life, and pathologic response. Discussion: PRONTO represents the first trial evaluating the use of hypofractionated PBT for STS. We aim to prove the safety and efficacy of this approach and to compare our results to historical outcomes established by previous trials. Given the low number of proton centers and limited availability, the short course of PBT may provide the opportunity to treat patients who would otherwise be limited when treating with daily RT over several weeks. We hope that this trial will lead to increased referral patterns, offer benefits towards patient convenience and clinic workflow efficiency, and provide evidence supporting the use of PBT in this setting. Trial registration: NCT05917301 (registered 23/6/2023). [ABSTRACT FROM AUTHOR]

Three-dimensional (3D) motion analysis (MA) techniques are progressively being used in biomechanics research and for clinical applications to assess the risk of injuries. A marker-based 3D MA protocol has been developed to measure the upper and lower extremity (UE and LE) joints’ active and passive ranges of motion (AROM and PROM) in children. The joints that were included in this protocol are shoulder, elbow, wrist, hip, knee and ankle. The anatomical joint coordinate systems (JCS) have been defined for the upper and lower extremities to standardize reporting. A marker placement model was defined according to the International Society of Biomechanics (ISB) recommendations and used to develop the protocol. The proposed movements will be captured and analyzed using the Motion Analysis Corporations 3D MA system integrated with Cortex software. The movements adopted in this study have been selected from various sources to incorporate all joint rotations while ensuring the isolation of each joint motion during the movements. It is recommended that future studies utilize this protocol to draw a relationship between the joints’ range of motion (ROM) and the adjacent segments characteristics, i.e., segment length, joint stiffness, etc.

Curettage is recommended for the treatment of Campanacci stages 1–2 giant cell tumor of bone (GCTB) in the extremities, pelvis, sacrum, and spine, without preoperative denosumab treatment. In the distal femur, bone chips and plate fixation are utilized to reduce damage to the subchondral bone and prevent pathological fracture, respectively. For local recurrence, re-curettage may be utilized when feasible. En bloc resection is an option for very aggressive Campanacci stage 3 GCTB in the extremities, pelvis, sacrum, and spine, combined with 1–3 doses of preoperative denosumab treatment. Denosumab monotherapy once every 3 months is currently the standard strategy for inoperable patients and those with metastatic GCTB. However, in case of tumor growth, a possible malignant transformation should be considered. Zoledronic acid appears to be as effective as denosumab; nevertheless, it is a more cost-effective option. Therefore, zoledronic acid may be an alternative treatment option, particularly in developing countries. Surgery is the mainstay treatment for malignant GCTB.

Abstract Background Early diagnosis of muscular tuberculosis (TB) without coexistent active skeletal involvement is often challenging because the disease is very rare and its clinical manifestation is nonspecific and misleading. To raise the awareness and emphasize early diagnosis of muscular TB, we present a case of multiple tuberculous muscle abscesses in a systemic lupus erythematosus (SLE) female, but without pulmonary tuberculosis (PTB), in order to increase awareness of and stress the need of early detection of muscular TB. Case presentation A 44-year-old woman with a 6-year history of SLE who had been treated with methylprednisolone for a long time complained of erythema on her trunk and extremities for five months, along with edema and myalgia for two months, and fever for one month. The patient was first misdiagnosed as SLE overlap dermatomyositis. However, an ultrasound-guided drainage of muscle abscesses revealed positive acid-fast staining combined with positive deoxyribonucleic acid fragment of Mycobacterium tuberculosis using metagenomic next-generation sequencing (mNGS). The patient was cured and released following standard anti-tuberculosis medication, local puncture drainage, and an intravitreal injection of streptomycin. Literature search found only 19 cases of tuberculous muscle abscesses occurring in the extremities reported from 1999 to 2023. Conclusions Extrapulmonary TB with predominantly muscle involvement is rare and with no specific clinical presentation. Muscular tuberculosis may be disdiagnosed for dermatomyositis due to the high muscle enzyme levels, delaying diagnosis and treatment. mNGS technology is helpful in the early and rapid diagnosis of muscular TB. On the basis of traditional anti-tuberculosis treatment, an ultrasound-guided percutaneous puncture drainage and intracavitary injection of streptomycin for the treatment of tuberculous muscle abscess is easy to operate, safe and effective, which is worthy of clinical popularization and application.

Aims: The aim of this study is to determine the predictors of overall survival (OS) and predictive factors of poor prognosis of conventional high-grade osteosarcoma of the limbs in a single-centre in South Africa. Methods: We performed a retrospective cross-sectional analysis to identify the prognostic factors that predict the OS of patients with histologically confirmed high-grade conventional osteosarcoma of the limbs over ten years. We employed the Cox proportional regression model and the Kaplan-Meier method for statistical analysis. Results: This study comprised 77 patients at a three-year minimum follow-up. The predictors of poor OS were: the median age of ≤ 19 years (hazard ratio (HR) 0.96; 95% confidence interval (CI) 0.92 to 0.99; p = 0.021); median duration of symptoms ≥ five months (HR 0.91; 95% CI 0.83 to 0.99; p < 0.037); metastasis at diagnosis (i.e. Enneking stage III) (HR 3.33; 95% CI 1.81 to 6.00; p < 0.001); increased alkaline phosphatase (HR 3.28; 95% CI 1.33 to 8.11; p < 0.010); palliative treatment (HR 7.27; 95% CI 2.69 to 19.70); p < 0.001); and amputation (HR 3.71; 95% CI 1.12 to 12.25; p < 0.032). In contrast, definitive surgery (HR 0.11; 95% CI 0.03 to 0.38; p < 0.001) and curative treatment (HR 0.18; 95% CI 0.10 to 0.33; p < 0.001) were a protective factor. The Kaplan-Meier median survival time was 24 months, with OS of 57.1% at the three years. The projected five-year event-free survival was 10.3% and OS of 29.8% (HR 0.76; 95% CI 0.52 to 1.12; p = 0.128). Conclusion: In this series of high-grade conventional osteosarcoma of the appendicular skeleton from South Africa, 58.4% (n = 45) had detectable metastases at presentation; hence, an impoverished OS of five years was 29.8%. Large-scale future research is needed to validate our results. Cite this article: Bone Jt Open 2024;5(3):210–217.

Abstract Background During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy—a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture. Methods The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement. Results Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01). Conclusion Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Background/Aims:Due to the prioritization of limb and life-saving efforts by medical teams, peripheral nerve injuries (PNIs) resulting from earthquakes are frequently overlooked or receive delayed treatment. Thus, we examined earthquake-related PNIs in terms of their descriptive characteristics and injury patterns Methods: The study was conducted retrospectively in a tertiary hospital after Kahramanmaraş Earthquakes. The study included victims under rubble admitted to the hospital and diagnosed with PNI according to their medical records between 06 February and 28 February 2023. Results: The study included 70 patients and a total of 98 limbs with PNIs, with a mean patient age of 22.31±14.91 years. 77.6% (n=76) of PNIs involved the lower limb (68 peroneal and 8 sciatic nerves) and 22.4% (n=22) of PNIs involved the upper limbs (14 radial nerves, 5 ulnar nerves, 2 median nerves, 1 brachial plexus). It was found that 45.9% of PNIs (n=45) occurred in the right and 54.1% (n=53) in the left extremities. The median time under the rubble of the patients was 15 hours (IQR 8.75 - 32 hours). Fasciotomy was treated in 54.1% (n=43) of the extremities with PNI. Fasciotomies were most commonly performed on the cruris (42.9%), foot (26.5%), and thigh (16.3%). Conclusion: This study found that PNIs occurred most frequently in the lower limbs, compared with the upper limbs, among earthquake victims with CLIs. Lower limb PNIs mainly occurred in the peroneal nerve, while upper limb PNIs mainly occurred in the radial nerve.

ObjectiveField tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications.MethodsTwenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use.ResultsTourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application.ConclusionField tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

Curettage is recommended for the treatment of Campanacci stages 1–2 giant cell tumor of bone (GCTB) in the extremities, pelvis, sacrum, and spine, without preoperative denosumab treatment. In the distal femur, bone chips and plate fixation are utilized to reduce damage to the subchondral bone and prevent pathological fracture, respectively. For local recurrence, re-curettage may be utilized when feasible. En bloc resection is an option for very aggressive Campanacci stage 3 GCTB in the extremities, pelvis, sacrum, and spine, combined with 1–3 doses of preoperative denosumab treatment. Denosumab monotherapy once every 3 months is currently the standard strategy for inoperable patients and those with metastatic GCTB. However, in case of tumor growth, a possible malignant transformation should be considered. Zoledronic acid appears to be as effective as denosumab; nevertheless, it is a more cost-effective option. Therefore, zoledronic acid may be an alternative treatment option, particularly in developing countries. Surgery is the mainstay treatment for malignant GCTB. [ABSTRACT FROM AUTHOR]

Background: Early diagnosis of muscular tuberculosis (TB) without coexistent active skeletal involvement is often challenging because the disease is very rare and its clinical manifestation is nonspecific and misleading. To raise the awareness and emphasize early diagnosis of muscular TB, we present a case of multiple tuberculous muscle abscesses in a systemic lupus erythematosus (SLE) female, but without pulmonary tuberculosis (PTB), in order to increase awareness of and stress the need of early detection of muscular TB. Case presentation: A 44-year-old woman with a 6-year history of SLE who had been treated with methylprednisolone for a long time complained of erythema on her trunk and extremities for five months, along with edema and myalgia for two months, and fever for one month. The patient was first misdiagnosed as SLE overlap dermatomyositis. However, an ultrasound-guided drainage of muscle abscesses revealed positive acid-fast staining combined with positive deoxyribonucleic acid fragment of Mycobacterium tuberculosis using metagenomic next-generation sequencing (mNGS). The patient was cured and released following standard anti-tuberculosis medication, local puncture drainage, and an intravitreal injection of streptomycin. Literature search found only 19 cases of tuberculous muscle abscesses occurring in the extremities reported from 1999 to 2023. Conclusions: Extrapulmonary TB with predominantly muscle involvement is rare and with no specific clinical presentation. Muscular tuberculosis may be disdiagnosed for dermatomyositis due to the high muscle enzyme levels, delaying diagnosis and treatment. mNGS technology is helpful in the early and rapid diagnosis of muscular TB. On the basis of traditional anti-tuberculosis treatment, an ultrasound-guided percutaneous puncture drainage and intracavitary injection of streptomycin for the treatment of tuberculous muscle abscess is easy to operate, safe and effective, which is worthy of clinical popularization and application. [ABSTRACT FROM AUTHOR]

Simple Summary: This study investigates health-related quality of life changes in patients with a soft-tissue sarcoma during the diagnostic and treatment trajectory, and the differences in health-related quality of life changes between adults and the elderly since they face different challenges due to different levels of physical, social or work-related activities. Examining data from the VALUE-PERSARC trial, 97 patients completed the HRQoL questionnaires at diagnosis, and 3, 6 and 12 months thereafter. Results show comparable patterns across all measures, i.e., lower baseline scores, and a decrease at 3 months followed by subsequent improvement, reaching similar levels as the general population at 12 months. However, patients seem to struggle with the mental aspect of well-being, independent of age. The results of this study suggest that it is important to address both physical and mental health in the care of patients with a soft-tissue sarcoma. Introduction: Changes in health-related quality of life (HRQoL) during the diagnostic and treatment trajectory of high-grade extremity soft-tissue sarcoma (eSTS) has rarely been investigated for adults (18–65 y) and the elderly (aged ≥65 y), despite a potential variation in challenges from diverse levels of physical, social, or work-related activities. This study assesses HRQoL from time of diagnosis to one year thereafter among adults and the elderly with eSTS. Methods: HRQoL of participants from the VALUE-PERSARC trial (n = 97) was assessed at diagnosis and 3, 6 and 12 months thereafter, utilizing the PROMIS Global Health (GH), PROMIS Physical Function (PF) and EQ-5D-5L. Results: Over time, similar patterns were observed in all HRQoL measures, i.e., lower HRQoL scores than the Dutch population at baseline (PROMIS-PF:46.8, PROMIS GH-Mental:47.3, GH-Physical:46.2, EQ-5D-5L:0.76, EQ-VAS:72.6), a decrease at 3 months, followed by an upward trend to reach similar scores as the general population at 12 months (PROMIS-PF:49.9, PROMIS GH-Physical:50.1, EQ-5D-5L:0.84, EQ-VAS:81.5), except for the PROMIS GH-Mental (47.5), where scores remained lower than the general population mean (T = 50). Except for the PROMIS-PF, no age-related differences were observed. Conclusions: On average, eSTS patients recover well physically from surgery, yet the mental component demonstrates no progression, irrespective of age. These results underscore the importance of comprehensive care addressing both physical and mental health. [ABSTRACT FROM AUTHOR]

Background: Forearm fractures are the most common paediatric fractures. While successful management in the preadolescent is often conservative, outcomes in adolescents have greatly improved with intramedullary Titanium Elastic Nail System (TENS) and rigid plate fixation. However, there have been no objective criteria for determining when TENS may be used in adolescents. This study aimed to compare the modified method of Sauvegrain et al. (2005) for skeletal age scoring against chronological age to predict treatment outcomes in adolescents with a forearm fracture treated by TENS and subsequently determine the skeletal age limits of TENS in adolescents. Patients and methods: This was a single-centre retrospective study of adolescents aged 10–16 years with an isolated, complete diaphyseal forearm fracture managed surgically from January 2014 to 2018. The modified Sauvegrain method provided skeletal age scoring via elbow radiographs. Functional outcomes were classified into good and poor groups by considering the treatment complication, range of motion and functional ability at the final review one year after intervention. Results: There were 128 TENS patients, comprising 15 females and 113 males. On average, males displayed older skeletal age than chronological age with a mean (SD) difference of 1.29 (1.03) years (p

James Joyce’s neologism “debths” (Finnegans Wake) that Susan Howe elects for the title of her 2017 volume of poetry points to at least three semantic coordinates of “obligation,” “trespass,” and “demise,” never—due to its implied transaction between the sound and the spelling—fully yielding to or being appropriated by any stable signification. In Debths, the end of life, writing, and, perhaps, literature are palpable, if overtly manifested, currents of poetic discourse. In my article, I advance the idea of recognizing this tripartite taxonomy as a variant of what Divya Victor calls “extremity.” Within this context, I demonstrate the emergence of a dialogic, intertextual, and appropriative subjectivity of the poet.

Background: Diffuse extremity vascular malformation as a source of severe lower limb pain in the setting of septic shock and pneumonia has not been described in the literature. Such a presentation would naturally arouse suspicion of necrotizing fasciitis. Case report: Our patient is a teenager with a history of extensive right lower limb vascular malformation with previous multiple sclerotherapies. He presented with septic shock secondary to right upper zone pneumoniae. There was also severe right leg pain which was initially diagnosed as necrotizing fasciitis. This was later found to be due to increase bloodflow through his vascular malformation. In this report, we share such a case discussing some distinctive features and mechanisms. Conclusion: Pain from increased flow and vasodilation is an important feature of extremity vascular malformations. This can be from exercise, trauma or even fever. This leads to engorgement of the blood vessel which then brings about pain, which is often a heavy, bursting-like feeling similar to that in chronic venous insufficiency.

This feasibility study aims to explore the use of three-dimensional virtual surgical planning to preoperatively determine the need for reconstructive surgery following resection of an extremity soft-tissue sarcoma. As flap reconstruction is performed more often in advanced disease, we hypothesized that tumor volume would be larger in the group of patients that had undergone flap reconstruction. All patients that were treated by surgical resection for an extremity soft-tissue sarcoma between 1 January 2016 and 1 October 2019 in the University Medical Center Groningen were included retrospectively. Three-dimensional models were created using the diagnostic magnetic resonance scan. Tumor volume was calculated for all patients. Three-dimensional tumor volume was 107.8 (349.1) mL in the group of patients that had undergone primary closure and 29.4 (47.4) mL in the group of patients in which a flap reconstruction was performed, p = 0.004. Three-dimensional tumor volume was 76.1 (295.3) mL in the group of patients with a complication following ESTS treatment, versus 57.0 (132.4) mL in patients with an uncomplicated course following ESTS treatment, p = 0.311. Patients who had undergone flap reconstruction had smaller tumor volumes compared to those in the group of patients treated by primary closure. Furthermore, a larger tumor volume did not result in complications for patients undergoing ESTS treatment. Therefore, tumor volume does not seem to influence the need for reconstruction. Despite the capability of three-dimensional virtual surgical planning to measure tumor volume, we do not recommend its utilization in the multidisciplinary extremity soft-tissue sarcoma treatment, considering the findings of the study. [ABSTRACT FROM AUTHOR]

Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities.

Abstract Background Validated self-reporting tools are required to evaluate the functional outcome and health-related quality of life (HRQOL) for those who had extremity bone sarcomas in their childhood or adolescence. Our study pursued cross-cultural adaptation and validation of the pediatric Toronto Extremity Salvage Score (pTESS) and Toronto Extremity Salvage Score (TESS) to assess the functional outcome for Egyptian children and adult survivors following surgeries of extremity bone sarcomas. In the modified versions of pTESS and TESS, mental domains were added to allow the evaluation of HRQOL using a specific instrument for childhood bone cancer. Methods The internal consistency and test–retest reliability of the studied forms were assessed with Cronbach’s alpha and Intra-class coefficients (ICC), respectively. For convergent validity, correlations between scores of the generic Pediatric Quality of Life Inventory (PedsQL 4.0) and pTESS /TESS scores were reported. Factor Analysis was feasible for pTESS-leg; due to the insufficient samples, only the average inter-item correlation coefficients were reported for the remaining versions. Results Out of 233 participants, 134 responded to pTESS-leg, 53 to TESS-leg, 36 to pTESS-arm, and only 10 to TESS-arm. All versions showed excellent internal consistency (Cronbach’s alpha >0.9), good test–retest reliability (ICC >0.8), moderate to strong correlations with PedsQL, and acceptable average inter-item correlation coefficients (≥0.3). Three factors were extracted for the pTESS-leg, in which all mental items were loaded on one separate factor with factor loadings exceeding 0.4. Active chemotherapy, less than one year from primary surgery, or tibial tumors were associated with significantly inferior pTESS/TESS scores in the lower extremity group. Conclusion The Egyptian pTESS and TESS are valid and reliable self-reporting tools for assessing the functional outcome following surgeries for extremity bone sarcomas. The modified pTESS and TESS versions, which include additional mental domains, enabled the assessment of the overall health status of our population. Future studies should include a larger sample size and evaluate the ability of pTESS/TESS to track progress over time.

Merkel cell carcinoma (MCC) has a tendency for lymphatic spread and locoregional recurrence, although there is little data examining the risk factors for patients with lymph node-positive extremity lesions. The purpose of the current study was to examine the outcomes and risk factors associated with nodal metastasis in extremity MCC. We retrospectively reviewed the medical record of 120 patients with extremity MCC evaluated at our institution between 1994 and 2021. The mean age of this cohort was 71 years; 33% of patients were female; and 98% were Caucasian. Seventy-eight (65%) patients presented with localized disease. Thirty-seven (31%) patients had stage III disease, and five (4%) patients had stage IV disease. Treatment of primary lesions consisted primarily of margin-negative excision and adjuvant radiotherapy. Nodal metastases were most treated with adjuvant radiation or completion lymph node dissection. Five-year disease-specific survival in our series was 88% for patients with localized disease, 89% for stage IIIa disease, 40% for stage IIIb disease and 42% for stage IV. Factors associated with worse survival included immunosuppression and macroscopic nodal disease. In conclusion, extremity MCC has a low rate of local recurrence when treated with margin-negative excision and adjuvant radiation. However, treatment of nodal metastases remains a challenge with high rates of recurrence and mortality, particularly for patients who are immunosuppressed or who have macroscopic nodal disease.

Background: The use of musculoskeletal ultrasound (US) among hand surgeons appears to be increasing. The purpose of this study was to determine the utilization patterns and attitudes regarding US among American Society for Surgery of the Hand (ASSH) members in 2020 as well as the changes in usage patterns since a previous survey in 2015. Methods: In 2020, an updated and expanded 27-question survey was distributed to 4852 members of the ASSH. Questions assessed respondent demographics, training, and practice patterns, and access, utilization, training, and opinions pertaining to US. Results: A total of 418 surveys (8.6%) were analyzed. Compared to 2015, there was an increase in the percentage of respondents using US for diagnostic purposes (51%-68%), as well as having personal access to US machines (43% to 58%). US use to assist in diagnosing carpal tunnel syndrome increased from 19% to 27%. The most common reason for using US was convenience and practice efficiency, while the most common reasons for not using US was no machine access. In 2020, 33% of respondents performed US-guided injections. Conclusions: Compared to 2015, the majority of responding upper extremity surgeons now have personal access to US machines. Utilization of diagnostic US appears to be increasing, and two-thirds of respondents believed that US use will continue to increase among upper extremity surgeons. [ABSTRACT FROM AUTHOR]

Background: Detecting bone marrow edema (BME) as a sign of acute fractures is challenging on conventional computed tomography (CT). This study evaluated the diagnostic performance of a three-material decomposition (TMD) approach for detecting traumatic BME of the extremities on spectral computed tomography (SCT). Methods: This retrospective diagnostic study included 81 bone compartments with and 80 without BME. A TMD application to visualize BME was developed in collaboration with Philips Healthcare. The following bone compartments were included: distal radius, proximal femur, proximal tibia, distal tibia and fibula, and long bone diaphysis. Two blinded radiologists reviewed each case independently in random order for the presence or absence of BME. Results: The interrater reliability was 0.84 (p < 0.001). The different bone compartments showed sensitivities of 86.7% to 93.8%, specificities of 84.2% to 94.1%, positive predictive values of 82.4% to 94.7%, negative predictive values of 87.5% to 93.3%, and area under the curve (AUC) values of 85.7% to 93.1%. The distal radius showed the highest sensitivity and the proximal femur showed the lowest sensitivity, while the proximal femur presented the highest specificity and the distal tibia presented the lowest specificity. Conclusions: Our TMD approach provides high diagnostic performance for detecting BME of the extremities. Therefore, this approach could be used routinely in the emergency setting. [ABSTRACT FROM AUTHOR]

Exercise training has the potential for inducing enhancements in peripheral circulation, which can play important preventive and therapeutic roles in peripheral circulatory diseases. However, the relevant published studies show conflicting and inconclusive results. Furthermore, useful or optimum ambient temperature for this purpose has not yet been established. Therefore, we investigated the acute responses in peripheral circulation from exposure of healthy subjects to treadmill exercise under different ambient temperatures; A total of 12 young adult volunteers (males 6, females 6) randomly underwent three sessions of treadmill exercise for 30 min under three different ambient temperatures (10°C, 20°C, and 30°C), at a predetermined exercise intensity. Before and after the intervention, leg skin blood flow (SBF) was measured by laser Speckle flowgraphy and hand skin temperature (ST), by digital thermometry; After the cessation of treadmill exercise, compared to the corresponding baseline values, a significant increase in SBF was observed under all ambient temperature conditions (P [ J Adv Biotechnol Exp Ther 2023; 6(1.000): 222-230]

Abstract Background War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities. Methods The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed. Results Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P 2-week hospital stay in 31% vs. 19%, P

Objective:International classification of functioning, disability and health (ICF) was prepared by the World Health Organization to create a standard language for the definition and measurement of health and health-related states. ICF classification collects disease and disability situation sunder 3 titles as organ/system structure sand functions, activity limitations (daily and social life activities). The guide prepared by the American Medical Association (AMA guideline-6th edition) has been prepared based on ICF terminology. AMA guideline calculates the disability rating according to the effects of the person’s daily and social life activities.Methods:It is aimed to compare the regulations used in our country (The Regulation on Determination of Working Powerand Loss of Profitability in Profession-SGK and the Regulation on Disability Assessment for Adults-disabled) with the AMA guideline over the calculated disability rates. The disability rates of 315 cases who developed extremity injuries as a result of traffic accidents between 2018 and 2019 were calculated according to 3 regulations. The cases were analyzed in terms of gender, age at the time of the incident, type of accident, time between the incident and admission, injury sites, the clinics for which consultation was requested, whether the operation was performed and the complications that occurred.Results:81.9% of the cases were male, the mean age was 31.14 years, when we look at the disability rate values, the highest disability rates is calculateda according to the SGK Regulations and the lowest disability rates calculated according to AMA guideline.Conclusion:It is seen that active life activities are not included in the calculation of disability ratio in there gulations used in our country. AMA guideline has been prepared in detail and clearly for extremity disability calculation and we think that it should be in routine practice to prevent loss of rights.

Background: Validated self-reporting tools are required to evaluate the functional outcome and health-related quality of life (HRQOL) for those who had extremity bone sarcomas in their childhood or adolescence. Our study pursued cross-cultural adaptation and validation of the pediatric Toronto Extremity Salvage Score (pTESS) and Toronto Extremity Salvage Score (TESS) to assess the functional outcome for Egyptian children and adult survivors following surgeries of extremity bone sarcomas. In the modified versions of pTESS and TESS, mental domains were added to allow the evaluation of HRQOL using a specific instrument for childhood bone cancer. Methods: The internal consistency and test–retest reliability of the studied forms were assessed with Cronbach's alpha and Intra-class coefficients (ICC), respectively. For convergent validity, correlations between scores of the generic Pediatric Quality of Life Inventory (PedsQL 4.0) and pTESS /TESS scores were reported. Factor Analysis was feasible for pTESS-leg; due to the insufficient samples, only the average inter-item correlation coefficients were reported for the remaining versions. Results: Out of 233 participants, 134 responded to pTESS-leg, 53 to TESS-leg, 36 to pTESS-arm, and only 10 to TESS-arm. All versions showed excellent internal consistency (Cronbach's alpha >0.9), good test–retest reliability (ICC >0.8), moderate to strong correlations with PedsQL, and acceptable average inter-item correlation coefficients (≥0.3). Three factors were extracted for the pTESS-leg, in which all mental items were loaded on one separate factor with factor loadings exceeding 0.4. Active chemotherapy, less than one year from primary surgery, or tibial tumors were associated with significantly inferior pTESS/TESS scores in the lower extremity group. Conclusion: The Egyptian pTESS and TESS are valid and reliable self-reporting tools for assessing the functional outcome following surgeries for extremity bone sarcomas. The modified pTESS and TESS versions, which include additional mental domains, enabled the assessment of the overall health status of our population. Future studies should include a larger sample size and evaluate the ability of pTESS/TESS to track progress over time. [ABSTRACT FROM AUTHOR]

Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities. [ABSTRACT FROM AUTHOR]

Merkel cell carcinoma (MCC) has a tendency for lymphatic spread and locoregional recurrence, although there is little data examining the risk factors for patients with lymph node-positive extremity lesions. The purpose of the current study was to examine the outcomes and risk factors associated with nodal metastasis in extremity MCC. We retrospectively reviewed the medical record of 120 patients with extremity MCC evaluated at our institution between 1994 and 2021. The mean age of this cohort was 71 years; 33% of patients were female; and 98% were Caucasian. Seventy-eight (65%) patients presented with localized disease. Thirty-seven (31%) patients had stage III disease, and five (4%) patients had stage IV disease. Treatment of primary lesions consisted primarily of margin-negative excision and adjuvant radiotherapy. Nodal metastases were most treated with adjuvant radiation or completion lymph node dissection. Five-year disease-specific survival in our series was 88% for patients with localized disease, 89% for stage IIIa disease, 40% for stage IIIb disease and 42% for stage IV. Factors associated with worse survival included immunosuppression and macroscopic nodal disease. In conclusion, extremity MCC has a low rate of local recurrence when treated with margin-negative excision and adjuvant radiation. However, treatment of nodal metastases remains a challenge with high rates of recurrence and mortality, particularly for patients who are immunosuppressed or who have macroscopic nodal disease. [ABSTRACT FROM AUTHOR]

The question of whether ability-related emotional intelligence (ability EI) predicts important life outcomes has attracted considerably more attention than the question of what ability EI consists of. In the present paper, the authors draw from the attitude and emotion literatures to suggest that the evaluation dimension of meaning is likely key in understanding how ability EI operates. Measures of ability EI predict the extent to which individuals can accurately evaluate words and measures of the latter type act as emotional intelligence measures. Extending this analysis, the paper reviews recent sources of data linking ability EI to attitudinal processes, such as those involved in attitude–behavior relationships and affective bipolarity. Individuals with high EI appear to experience their affect in more bipolar terms and they display evidence of greater decisiveness in their evaluations. Pursuing links of the present type will allow researchers to generate new predictions concerning the ability EI construct. [ABSTRACT FROM AUTHOR]

Objective The aim of the present study was to report a novel nomenclature system for extended latissimus dorsi musculocutaneous (LD) flaps. To evaluate the clinical application and surgical efficacy of the different extended LD flaps for large wounds in the extremities. Methods From January 2004 to December 2018, 72 consecutive patients who received extended LD flaps were retrospectively analyzed. Patients' ages ranged from 2 to 68 years with 37 males and 35 females. All wounds were extensive in either the upper or lower limbs, while the skin defect area ranged from 18 cm × 10 cm to 37 cm × 21 cm. Forty‐one wounds were located in the calf, 18 in the foot and ankle, six in the shoulder and upper arm, four in the thigh, and three at the knee joint. Twenty‐eight patients had fractures, and six of these patients with segmental bone defects (ranging in size from 3 to 7 cm) required secondary orthopaedic procedures. Single‐ and double‐wing extended LD flaps were designed and harvested according to the shape of the wounds. Results The flaps received consisted of 64 single‐wing and eight double‐wing extended LD flaps, and the mean flap harvest time was 56.2 min. The donor sites were closed primarily for all patients. Additional subcutaneous veins were anastomosed to the recipient's vessels in 14 patients. The venous crisis was noticed on the first postoperative day in four cases. Two flaps were salvaged after emergency re‐exploration, and another two patients' flaps were necrosed. In these two patients, lower limb amputation and extended LD flap on the other side were used, respectively, for the final treatment. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Six patients had segmental bone defects that required secondary orthopaedic procedures, two patients were repaired with vascularized iliac crest bone grafts, and another four patients were reconstructed by the Ilizarov technique. All the patients' bone defects achieved union and most patients achieved good functional recovery at the recipient site. The mean follow‐up was 15.7 months (range, 10–56 months). No significant donor site morbidities limiting patients' daily activities occurred during the follow‐up. Eight patients developed a donor site hypertrophic scar, three patients on the back, and five on the anterolateral thigh. Conclusion Single‐ and double‐wing extended LD flaps are simple and reliable methods for large skin and soft tissue defects in the extremity, with good functional and aesthetic results.

Background One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

This research article discusses feminine death in three short stories: The Little Match Girl (1906) by Hans Christian Andersen, Dead Men's Path (1972) by Chinua Achebe, and The Story of an Hour (1969) by Kate Chopin. It aims to reveal the existence of extremity and sacrifice in the death of a woman. This study used a qualitative-descriptive design to reveal and investigate the phenomena and forms, or modes, of women's deaths. The theory of feminine death from Elizabeth Bronfen (2017) is used to reveal the extremity and sacrifice of a woman, and the theory of philosophical death and female finitude from Linnell Secomb (1999) is used to reveal the mode and symbols of feminine death. Based on Spradley's theory and analysis, we argue that the three short stories all have extremity and sacrifice; in the short story by Hans Christian Andersen, there is a mode or form of death called "being-towards-death." Furthermore, in the work of Chinua Achebe, there is a mode of death called "the master-slave battle to the death." Lastly, Kate Chopin produced "dwelling-with-death". The three short stories can be found in extremity, sacrificing, and feminine modes of death. Thus, the identification can reveal the feminine death phenomenon in the short story.

The purpose of this study was to investigate fracture patterns due to pediatric firearm injuries. The data used was from the US Firearm Injury Surveillance Study 1993–2019. Over these 27 years, there were 19,033 children with fractures due to firearm activity with an average age of 12.2 years; 85.2% were boys and the firearm was a powder type in 64.7%. The finger was the most common fracture location, while the tibia/fibula was the most common location for those admitted to the hospital. Children ≤ 5 years of age sustained more skull/face fractures; most spine fractures occurred in the 11–15-year age group. The injury was self-inflicted in 65.2% of the non-powder and 30.6% of the powder group. The injury intent was an assault in 50.0% of the powder and 3.7% of the non-powder firearm group. Powder firearms accounted for the majority of the fractures in the ≤5 and 11–15 year-olds, non-powder firearms accounted for the majority of the fractures in the 6–10 year-olds. Injuries occurring at home decreased with increasing age; there was an increase in hospital admissions over time. In conclusion, our findings support the need for safe storage of firearms in the home away from children. This data will be helpful to assess any changes in prevalence or demographics with future firearm legislation or other prevention programs. The increasing acuity of firearm-associated injuries seen in this study is detrimental to the child, impacts familial wellbeing, and results in significant financial costs to society. [ABSTRACT FROM AUTHOR]

Background: Although an intensive care unit (ICU) admission is a risk factor for missed injury, there has been some disagreement on whether missed injuries in trauma ICU patients have a longer length of stay (LOS). With this in mind, these patients' frequency of missed injuries and related factors were investigated. Materials and methods: This was a prospective cohort study on multiple trauma injury patients in a tertiary referral trauma center's trauma intensive care unit (TICU) from March 2020 to March 2021. A tertiary survey was conducted in the TICU by attending physicians to find the types I and II missed injuries (any injury discovered after primary and secondary surveys during the hospital stay). A logistic regression model was designed for predictors of missed injuries in ICU-admitted multiple trauma patients. Results: Out of 290 study participants, 1,430 injuries were found, and of those injuries, 74 cases (25.5%) had missed injuries. In other words, there were 103 missed injuries, resulting in a missed injury detection rate of 7.2%. The most frequently missed injuries (43.4%) were concluded as extremities fractures. The regression model showed that the patients with missed injuries are prone to longer TICU LOS [odds ratio (OR) = 1.15; p = 0.033], and cases who underwent a computed tomography (CT) scan are less likely to have missed injuries (OR = 0.04; p < 0.001). The abbreviated injury scale (AIS) range was 1--3 in missed injuries. Conclusion: Our research underlines the importance of finding missed injuries and the necessity of CT scan to decrease them. In teaching centers, life-threatening injuries decrease with increasing visits and examination times. Although these missed injuries do not increase mortality, they cause longer TICU LOS and costs. [ABSTRACT FROM AUTHOR]

Individualized survival prognostic models for symptomatic patients with appendicular metastatic bone disease are key to guiding clinical decision-making for the orthopedic surgeon. Several prognostic models have been developed in recent years; however, most orthopedic surgeons have not incorporated these models into routine practice. This is possibly due to uncertainty concerning their accuracy and the lack of comparison publications and recommendations. Our aim was to conduct a review and quality assessment of these models. A computerized literature search in MEDLINE, EMBASE and PubMed up to February 2022 was done, using keywords: “Bone metastasis”, “survival”, “extremity” and “prognosis”. We evaluated each model’s performance, assessing the estimated discriminative power and calibration accuracy for the analyzed patients. We included 11 studies out of the 1779 citations initially retrieved. The 11 studies included seven different models for estimating survival. Among externally validated survival prediction scores, PATHFx 3.0, 2013-SPRING and potentially Optimodel were found to be the best models in terms of performance. Currently, it is still a challenge to recommend any of the models as the standard for predicting survival for these patients. However, some models show better performance status and other quality characteristics. We recommend future, large, multicenter, prospective studies to compare between PATHfx 3.0, SPRING 2013 and OptiModel using the same external validation dataset.

Abstract Background Sarcomas are a heterogeneous group of rare malignant tumors of mesenchymal origin in the musculoskeletal system. The main treatment is surgery often supplemented with pre-or postoperative radiotherapy. A retrospective study by Bedi et al. indicated that negative pressure wound therapy (NPWT) reduced the risk of postoperative wound complications in patients treated with preoperative radiation followed by surgical tumor removal of lower extremity soft tissue sarcomas (STS), and the use of NPWT was not associated with an increased risk of local recurrence. Previous studies have shown that NPWT can reduce postoperative complications. STS surgeries are a high-risk procedure concerning wound complications. Methods Non-blinded single-center randomized controlled trial comparing NPWT versus conventional wound dressing and postoperative wound complications after surgical removal of deep-seated high-malignant STS of the extremities or trunk wall Sample-size calculation: 154 STS patients (80% risk of avoiding type II error, 5% risk of type I error, and an 80% wound complication risk) Block randomization of 8 into: Group A: Conventional wound dressing Group B: NPWT (PREVENA PLUS™ Incision Management System) Inclusion criteria: Surgery for a deep-seated STS of an extremity or the trunk wall Exclusion criteria: Age

Background: War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities. Methods: The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed. Results: Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014). Conclusion: Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach. [ABSTRACT FROM AUTHOR]

James Joyce's neologism "debths" (Finnegans Wake) that Susan Howe elects for the title of her 2017 volume of poetry points to at least three semantic coordinates of "obligation," "trespass," and "demise," never--due to its implied transaction between the sound and the spelling--fully yielding to or being appropriated by any stable signification. In Debths, the end of life, writing, and, perhaps, literature are palpable, if overtly manifested, currents of poetic discourse. In my article, I advance the idea of recognizing this tripartite taxonomy as a variant of what Divya Victor calls "extremity." Within this context, I demonstrate the emergence of a dialogic, intertextual, and appropriative subjectivity of the poet. [ABSTRACT FROM AUTHOR]

In developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. Aim of this study was to assess limb survival and complications after delayed revascularization of extremity following major vascular injury. 20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented >8 h after vascular trauma were included in this study. All patients had road traffic accidents as the cause of extremity injury. These patients were operated by primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma. The commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 h. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses. Limb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications. [ABSTRACT FROM AUTHOR]

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