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\nPlain-Language SummaryThis study examined the impact of 6 GHz (0.054 W/kg SAR) Radiofrequency-Electromagnetic Field (RF-EMF) on prenatal bone development. In this study, 20 female and 20 male Wistar Albino rats divided into four groups. The Control group received no treatment, while in Group-I, only male rats were exposed to RF-EMF, female rats had no exposure. Group-II, both male and female rats received RF-EMF treatment. While in Group-III, only female rats were exposed to RF-EMF, male rats had no exposure. The exposure lasted 4 hours per day for 6 weeks. The rats were then allowed to mate within the group. After pregnancy, pregnant rats (Group-II and III) were exposed 4 hours per day for 18 days. On the 18th day of gestation, fetuses were removed and their weight and various lengths were measured. The skeletal system development of fetuses was examined with double skeletal staining method and assessed ossification in the extremities. In the study, fetal weights, head-tail length, occipital-frontal and parietal-parietal lengths significantly increased in all exposure groups when compared to the control group (p < 0.001). Although occipital-frontal length was smallest in Group-I, Group-II and Group-III were more higher than the control group (p < 0.001). The bones of the anterior and posterior extremities showed significant increases in length, ossification zone length, and ossification percentage in all experimental groups compared to the control group (p < 0.001). Our study showed that rats exposed to 6 GHz (0.054 W/kg) RF-EMF during the prenatal period had significant increases in bone development.Radiofrequency Electromagnetic Field (RF-EMF) sources are one of the most widely used technology systems in daily life. This study examined the impact of 6 GHz RF-EMF on prenatal bone development.In this study, 20 female and 20 male Wistar Albino rats divided into four groups. The control group rats received no treatment, while in Group-I, only male rats, Group-II, both male and female rats, while in Group-III, only female rats were exposed to RF-EMF. The exposure lasted 4 hours/day for 6 weeks. The rats were then allowed to mate within the group. After pregnancy, pregnant rats (Group-II and III) were exposed 4 hours/day for 18 days. On the 18th day of gestation, fetuses were removed 10 fetuses each group were randomly selected in each group and their weight and various lengths were measured. The skeletal system development of fetuses was examined with double skeletal staining method. The ImageJ program was used assess ossification in the extremities.In the study, fetal weights, head-tail, occipital-frontal and parietal-parietal lengths significantly increased in all exposure groups when compared to the control group (p < 0.001). Although occipital-frontal length was smallest in Group-I, Group-II and Group-III were more higher than the control group (p < 0.001). The bones of the anterior and posterior extremities showed significant increases in length, ossification zone length, and ossification percentage in all experimental groups compared to the control group (p < 0.001). Our study showed that rats exposed to 6 GHz (0.054 W/kg) RF-EMF during the prenatal period had significant increases in bone development. [ABSTRACT FROM AUTHOR]

Extremity soft-tissue sarcomas are treated by wide surgical resection with normofractionated radiotherapy. Over the past 3 years, several phase II trials emerged on perioperative hypofractionated radiotherapy. We aimed to review the current practice in France and Luxembourg of hypofractionated radiotherapy as curative treatment for extremity soft-tissue sarcomas. We sent an electronic adaptive survey to sarcoma radiation oncologists at 28 centres in France and the Grand Duchy of Luxembourg belonging to the NETSARC network. The questionnaire was distributed via the NETSARC mailing list in December 2021 and January 2022. It consisted of four to nine questions with closed multiple choice, or open-ended (short or long) answers. Some questions assessed agreement with proposals for pre- or postoperative hypofractionated radiotherapy for extremity soft-tissue sarcomas. Of the 28 radiation oncologists surveyed, 11 (39.2 %) from nine centres responded. Of these, 55 % used hypofractionated radiotherapy, mainly for elderly and frail patients. The main reason why hypofractionated radiotherapy was not used was the lack of scientific evidence and therapeutic habits. Hypofractionated radiotherapy for extremity soft-tissue sarcomas remains to be investigated in high-powered studies but could be offered in the future for well-selected patients by a multidisciplinary board in a sarcoma referral centre. [ABSTRACT FROM AUTHOR]

Introduction/Aims: Neuromas come in different shapes and sizes; yet the correlation between neuroma morphology and symptomatology is unknown. Therefore, we aim to investigate macroscopic traits of excised human neuromas and assess the validity of a morphological classification system and its potential clinical implications. Methods: End‐neuroma specimens were collected from prospectively enrolled patients undergoing symptomatic neuroma surgery. Protocolized images of the specimens were obtained intraoperatively. Pain data (Numeric rating scale, 0–10) were prospectively collected during preoperative interview, patient demographic and comorbidity factors were collected from chart review. A morphological classification is proposed, and the inter‐rater reliability (IRR) was assessed. Distribution of neuroma morphology with patient factors, was described. Results: Forty‐five terminal neuroma specimens from 27 patients were included. Residual limb patients comprised 93% of the population, of which 2 were upper (8.0%) and 23 (92.0%) were lower extremity residual limb patients. The proposed morphological classification, consisting of three groups (bulbous, fusiform, atypical), demonstrated a strong IRR (Cohen's kappa = 0.8). Atypical neuromas demonstrated higher preoperative pain, compared with bulbous and fusiform. Atypical morphology was more prevalent in patients with diabetes and peripheral vascular disease. Discussion: A validated morphological classification of neuroma is introduced. These findings may assist surgeons and researchers with better understanding of symptomatic neuroma development and their clinical implications. The potential relationship of neuroma morphology with the vascular and metabolic microenvironment requires further investigation. [ABSTRACT FROM AUTHOR]

Inguinal skin flap necrosis (SFN) is a significant clinical problem associated with inguinal lymph node dissection (ILND). The aetiology of SFN is multifactorial, and its manifestations vary widely. Thermal damage caused by electrocautery during the elevation of the skin flap may contribute to this problem, which has not been studied previously. This prospective, observational study included patients undergoing ILND from January 2020 to July 2022. Based on the technique of raising the inguinal skin flaps, the patients were divided into two groups (cold knife or electrocautery). The remaining part of the procedure was the same. The inguinal wound was examined and photographed to assess the SFN. A total of 42 patients were included (21 in each group). Age, gender, body mass index (BMI), alcohol or tobacco consumption, immune compromised status, and serum albumin were comparable (p > 0.05). The average time required to elevate flaps was 13.14 vs. 11.47 min (p = 0.0231), and gauze soakage was 2.05 vs. 1.52 (p < 0.0001) with a cold knife compared to electrocautery. The incidence of SFN and surgical site infection (SSI) was significantly lower with the use of a cold knife [4.8% vs. 33.3% (p = 0.045) and 0% vs. 19% (p = 0.0378)]. Grade 3 necrosis was observed only with electrocautery use. Compared to conventional electrocautery, the cold knife technique lowers the incidence of SFN and SSI. Further research with a larger sample size and a standardized definition is needed to validate these results. [ABSTRACT FROM AUTHOR]

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.

Entities of low prevalence are evaluated as more extreme in their characteristics than those of high prevalence. We extended this idea to minorities, which by definition have fewer members than majorities, and found converging evidence for a minority extremity bias (MEB; N = 957). Participants associated the term 'minority' (rather than 'majority') with higher extremity (Study 1). Minorities were associated with higher extremity than majorities (Study 2). We added a manipulation of the minority size (Study 3, Part 1). Results indicated that the MEB is stronger for very small minorities than for small minorities. Participants assigned extreme behaviour more often to a minority than to a majority (Study 3, Part 2). We extended the MEB to more extreme ratings of minorities on evaluation scales (Study 4). Prevalence of group members correlated negatively with the extremity of group stereotyping (n = 118 groups; Study 5). Participants rated minorities on induced stereotypes more extreme than majorities (Study 6). We discuss the MEB in the context of alternative explanations such as the outgroup extremity effect. Taken together, this research demonstrates the MEB, which is a novel exploration in the realm of group evaluation that contributes to existing literature. [ABSTRACT FROM AUTHOR]

Background: Despite significant advances in patient treatment, infection remains a complication after surgery. The present study compared the incidence and severity of wound infection with two methods of washing the primary prep area with 70% alcohol and normal saline in patients who are candidates for orthopedic surgery in Kowsar Hospital of Sanandaj, Iran. Methods: This single-blinded randomized clinical trial was conducted on 190 candidates for upper limb orthopedic surgery aged 18 to 65. Patients were randomly assigned to two alcohol and normal saline groups based on the table of random numbers. The primary outcome of this clinical trial was the incidence and severity of wound infection after surgery, which was measured by the standard scale of the Asepsis index. The results were analyzed using SPSS version 23, and statistical values less than 0.05 were considered significant. Results: Patients’ hospitalization duration in the intervention group was (3.02±1.04 days) and in the control group (2.86±1.03 days) showed no significant statistical difference (p=0.297). The frequency of wound infection in the alcohol group was lower than in the normal saline group. this difference was statistically significant (p=0.023). Also, the severity of wound infection in the 70% alcohol group (Mean=5.12, SD=3.19) was lower than in the normal saline group (Mean=7.69, SD=4.12). This difference was statistically significant (p<0.001). Conclusion: The present clinical trial showed that the incidence and severity of wound infection after surgery were lower in the group washing the skin of the surgical area with alcohol compared to the group washing with normal saline. [ABSTRACT FROM AUTHOR]

The essay re-arranges elements of three online conversations between the authors in May-June 2022. Throughout these conversations the authors explored themes around the poetics of dissent, oppositional consciousness, dissidence, and poetry of witness, in relation to the process of coming-to-consciousness. The essay translates the resonant, non-linear dynamic of the conversations into writing, and arranges the content in six central sections: Stepping Out, Immersions and Accompaniments, Countering Acquiescence, Being Present, Extremity, and Dissidence. Each section is introduced first by a quote by Forché, then by a brief reflection and conceptualization by Gräbner, and a key term then introduces each train of thought. The themes emerge within a poetic, conceptual and political reflection on consciousness and conscience. [ABSTRACT FROM AUTHOR]

The surgical management of extremity bone and soft tissue sarcomas has evolved significantly over the last 50 years. The introduction and refinement of high-resolution cross-sectional imaging has allowed accurate assessment of anatomy and tumor extent, and in the current era more than 90% of patients can successfully undergo limb-salvage surgery. Advances in imaging have also revolutionized the clinician's ability to assess treatment response, detect metastatic disease, and perform intraoperative surgical navigation. This review summarizes the broad and essential role radiology plays in caring for sarcoma patients from diagnosis to post-treatment surveillance. Present evidence-based imaging paradigms are highlighted along with key future directions. [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. [ABSTRACT FROM AUTHOR]

Extremity vascular trauma in children can result in significant morbidity and mortality. Most published studies have focused on supracondylar humeral fracture related injuries, with little focus on other injuries. This scoping review describes the current state of knowledge on paediatric vascular injuries in the upper and lower limbs, excluding injuries related to supracondylar humeral fractures. MEDLINE, PubMed, Web of Science, and Cochrane databases were searched for relevant studies evaluating the epidemiology, diagnosis, management, and outcomes of upper and lower limb vascular trauma in those aged under 18 years. Studies related to supracondylar humeral fractures were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews was used. A total of 39 studies was included, all of which were retrospective, and 74% of which were based in North America or Europe. Extremity vascular trauma was reported to cause 0.6 – 4.4% of all paediatric trauma admissions, with penetrating mechanisms and upper limb injuries being the most common. Operative intervention was reported in 80 – 100% of children in the included studies. Primary repair was the most commonly reported operative intervention, followed by interposition graft and bypass graft. Synthetic graft use was less commonly reported (incidence range 0.5 – 33%). Lower limb fasciotomies and amputations were not commonly reported (incidence range 0 – 23% and 0 – 13%, respectively). The mortality rate appeared low, with 23 studies reporting no deaths (incidence range 0 – 4%). Complications were reported inconsistently, with no uniform outcome or follow up measures used. The incidence of extremity vascular trauma appears low in children, with penetrating mechanisms and upper extremity injuries appearing to dominate. Most studies are from high income countries, with probable selection bias towards those treated by operative intervention. Prospective studies are required focusing on patterns of injury, rates of operative and endovascular intervention, and long term outcomes. [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).

Three experiments tested how communicating attributes of initially liked or disliked groups might create more extreme attitudes. We gave non-neutral participants information about previously unknown groups and asked them to write social media posts describing the group to others. Participants who wrote social media posts to friends (Experiment 1, n = 332) or undecided strangers (Experiments 2 and 3, ns = 113 and 816) exaggerated and elaborated on initial information, subsequently reporting more extreme attitudes. These effects, mediated by extremity of associations to the target group, were interpreted as consistent with theory and research on going beyond the information given. (100 words) [ABSTRACT FROM AUTHOR]

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]

Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy. Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders. A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330). ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences. [ABSTRACT FROM AUTHOR]

Background The use of perforator flaps has become more popular with improvement of surgical technique, technology, as well as understanding of microvascular anatomy. The selection of well-perfused angiosomes is critical to the successful outcome of patients undergoing free tissue transfer. The number of perforators that are needed is dependent upon the surface area of the flap being harvested; however, there have been no studies to assess the optimal surface area supplied by each perforator. We hypothesized that the smaller the surface area supplied by each perforator correlated with fewer flap-related complications in the harvesting of the anterolateral thigh (ALT) flap. Methods All ALT flaps harvested from 2015 to 2021 at our institution were retrospectively reviewed. The surface area of the flap harvested was calculated as A = π ab , where a is the long radius and b is the short radius of the ellipse. The surface-perforator index (SPI) was calculated for each flap by dividing the surface area of the ALT flap by the number of perforators supplying the flap. Our primary outcomes were flap-related complications that included: partial flap loss, dehiscence, and venous congestion. Results A total of 106 patients were identified. Twenty-four patients (22.6%) developed perforator-related complications. An increasing SPI and SPI to body surface area were strongly associated with development of complications (adjusted odds ratio [95% confidence interval], adjusted p : 1.02 [1.01, 1.03], < 0.001and 1.23 [1.12, 1.42], p < 0.001). An SPI of greater than 150 cm 2 /perforator was associated with a higher probability of complications (p < 0.001). Conclusion Flap-related complications are significantly related to the number of perforators supplying the flap. The smaller the surface area supplied by a single perforator correlates with significantly fewer flap-related complications. SPI is a new index that may be used as a predictive tool to aid in identifying flaps that may be more prone to complications in free tissue transfer. [ABSTRACT FROM AUTHOR]

This study aimed to assess the feasibility of a skin marker–less patient setup using a surface-guided radiotherapy (SGRT) system for extremity radiotherapy. Twenty-five patients who underwent radiotherapy to the extremities were included in this retrospective study. The first group consisted of 10 patients and underwent a traditional setup procedure using skin marks and lasers. The second group comprised 15 patients and had a skin marker–less setup procedure that used an SGRT system only. To compare the two setup procedures for setup accuracy, the mean 3D vector shift magnitude was 0.9 mm for the traditional setup procedure and 0.5 mm for the skin marker–less setup procedure (p < 0.01). In addition, SGRT systems have been suggested to improve the accuracy and reproducibility of patient setups and consistently reduce interfractional setup errors. These results indicate that a skin marker–less patient setup procedure using an SGRT system is useful for extremity irradiation. [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.

Opinion statement: Neoadjuvant radiotherapy (RT) over 5–6 weeks with daily doses of 1.8–2.0 Gy to a total dose of 50–50.4 Gy is standard of care for localized high-grade soft tissue sarcomas (STS) of the extremities and trunk wall. One exception is myxoid liposarcomas where the phase II DOREMY trial applying a preoperative dose of 36 Gy in 2 Gy fractions (3–4 weeks treatment) has achieved excellent local control rates of 100% after a median follow-up of 25 months. Hypofractionated preoperative RT has been investigated in a number of phase II single-arm studies suggesting that daily doses of 2.75–8 Gy over 1–3 weeks can achieve similar oncological outcomes to conventional neoadjuvant RT. Prospective data with direct head-to-head comparison to conventional neoadjuvant RT investigating oncological outcomes and toxicity profiles is eagerly awaited. For the entire group of retroperitoneal sarcomas, RT is not the standard of care. The randomized multi-center STRASS trial did not find a benefit in abdominal recurrence-free survival by the addition of preoperative RT. However, for the largest histological subgroup of well-differentiated and grades I and II dedifferentiated liposarcomas, the STRASS trial and the post-hoc propensity-matched STREXIT analysis have identified a possible benefit in survival by preoperative RT. These patients deserve to be informed about the pros and cons of preoperative RT while the longer follow-up data from the STRASS trial is awaited. [ABSTRACT FROM AUTHOR]

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]

Background: Obtaining peripheral intravenous catheter (PIVC) access in children with severe neurological impairment (SNI) is often challenging and commonly associated with complications, including dislodgement, phlebitis and extravasation. In severe cases, extravasation injury may lead to tissue necrosis, ulceration and long‐term morbidity. The aim of this study was to determine the relative incidence of PIVC complications secondary to lower limb cannulation, compared to upper limb, in children with SNI. Methods: A single centre, retrospective, observational review was conducted. Patients with SNI, admitted at a tertiary paediatric centre over 6 months between July and December 2022, were included. Results: One‐hundred fifty‐five PIVC procedures were conducted in 110 children over the study period. Complications were more common in lower limb PIVCs (12/16, 75%) compared to upper limb (58/139, 42%), p = 0.01. Conclusion: Upper limb cannulation is preferred in children with SNI. [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]

According to contemporary diagnoses, democracy is foundering because of polarization. It is natural to think that if polarization is a problem, the remedy is to reconcile the conflicting sides. Yet reconciliation seems to involve the disturbing prescription that citizens should reconcile with radicals who have divested from democratic norms. That assumes, however, that polarization is symmetrical, whereby each side is equally responsible for it. But polarization need not depend on the assumption of such symmetry, such that depolarization may be possible without reconciliation. If so, polarization may be a problem not only between political alliances but within them. [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]

Purpose: This study aimed to analyse extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the French Forward Surgical Team deployed in Gao, Mali. Patients and methods: A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. Patients operated on for an extremity injury less than one month old were included. Results: During this period, 418 patients with a median age of 28 years [range 23–31 years] were included and totalized 525 extremity injuries. Among them, 190 (45.5%) sustained CRIs and 218 (54.5%) sustained NCRIs. Multiple upper extremity injuries and associated injuries were significantly more common in the CRIs group. The majority of NCRIs involved the hand. Debridement was the most common procedure in both groups. External fixation, primary amputation, debridement, delayed primary closure, vascular repair and fasciotomy were significantly predominant in the CRIs group. Internal fracture fixation and reduction under anaesthesia were statistically more frequent in the NCRIs group. The overall number of procedures and the overall number of surgical episodes were significantly higher in the CRIs group. Conclusion: CRIs were the most severe injuries and did not involve the upper and lower limbs separately. A sequential management was required with application of damage control orthopaedics followed by several procedures for reconstruction. NCRIs were predominant and mostly involved the hand among the French soldiers. This review supports the fact that any deployed orthopaedic surgeon should be trained in basic hand surgery and preferably have microsurgical skills. The management of local patients requires the execution of reconstructive surgery and therefore imposes the presence of adequate equipment. [ABSTRACT FROM AUTHOR]