Pathogenic Aspects of Inherited Platelet Disorders

Inherited platelet disorders (IPDs) constitute a large heterogeneous group of rare bleeding disorders. These are classified into: (1) quantitative defects, (2) qualitative disorders, or (3) altered platelet production rate disorders or increased platelet turnover. Classically, IPD diagnostic is based on clinical phenotype characterization, comprehensive laboratory analyses (platelet function analysis), and, in former times, candidate gene sequencing. Today, molecular genetic analysis is performed using next-generation sequencing, mostly by targeting enrichment of a gene panel or by whole-exome sequencing. Still, the biochemical and molecular genetic characterization of patients with congenital thrombocytopathias/thrombocytopenia is essential, since postoperative or posttraumatic bleeding often occurs due to undiagnosed platelet defects. Depending upon the kind of surgery or trauma, this bleeding may be life-threatening, e.g., after tonsillectomy or in brain surgery. Undiagnosed platelet defects may lead to additional surgery, hysterectomy, pulmonary bleeding, and even resuscitation. In addition, these increased bleeding symptoms can lead to wound healing problems. Only specialized laboratories can perform the special platelet function analyses (aggregometry, flow cytometry, or immunofluorescent microscopy of the platelets); therefore, many IPDs are still undetected.

O32 TREATMENT OF FASCIAL DEHISCENCE IS IMPROVED BY MESH REINFORCEMENT

Aim In 2014 fascial dehiscence (FD) was treated with re-suturing the fascia as the only measure in half of the cases at our institution, with discouraging re-rupture and incisional hernia (IH) rates. A changing path away from fascia closure (FC) by re-suturing solely towards reinforcement of the closed fascia is now evaluated. Material and Methods Retrospective chart review of consecutive patients operated for FD 2016-2020. Available CT scans were scrutinized for IH. Results 58 patients (14 women) with a mean age of 71 years and a mean BMI of 27.3 were treated with: FC by re-suturing as the only measure (n = 1, 1.7%); FC preceded by a reinforced tension line (RTL) suture (n = 9, 15.5%); FC and on-lay mesh reinforcement (n = 23, 39.7%); retromuscular mesh closure (n = 10, 17.2%); open abdomen treatment with retromuscular mesh reconstruction (n = 1, 1.7%); and, open abdomen treatment with vacuum assisted wound closure and permanent on-lay mesh-mediated fascial traction (VAWCPOM) (n = 14, 24.1%). One patient in the RTL-group suffered a re-rupture (1.7%). The in-hospital mortality was 5%. Wound healing problems were seen in 29 (51.9%) patients. IH was evaluable in 49 patients with a total incidence of 22.4% at mean follow-up of 21 months. The hernia incidence for mesh reinforced or reconstructed patients was 17.5% compared to 44.4% in re-sutured or RTL patients. Conclusions FD treatment with mesh reinforced FC prevented re-rupture and resulted in a lower rate of IH. Additional standardization and refining the mesh techniques may further improve results.

The Internal Negative Pressure Wound Control System: A Paradigm Shift for Promoting Deep Space Healing in Complex Surgically Created Wounds

This article introduces a new technology to minimize seroma and promote more predictable healing in surgically created deep space wounds. Its novel design internalizes the delivery of a continuously generated high negative pressure (-125 mmHg) throughout the surgically created space using multi-branching Manifolds. In a small prospective cohort case study of 24 patients undergoing full abdominoplasty, all patients had placement of this device which was removed 7 days postoperatively. Results at 30 days revealed no evidence of wound healing problems, no clinical seroma and no device malfunction. The internalization of a constant negative pressure wound therapy (NPWT) provided by this system has the potential to significantly reduce clinical seroma, and to produce more consistent apposition of interfaces in deep tissue spaces in complex wounds seen in plastic surgery and other surgical disciplines.

The use of ‘blocking’ screws for the ‘closed’ reduction of difficult proximal and distal femoral fractures

Most meta-diaphyseal femoral fractures that are treated with intramedullary nailing can be reduced satisfactorily by skeletal traction without ‘opening’ the fracture site and therefore, complications such as nonunion, infection and wound healing problems are reduced. In cases where adequate fracture reduction cannot be achieved by skeletal traction, ‘reduction aids’ have been used during the operative procedure in order to avoid the exposure of the fracture site. The ‘blocking’ screw, as a reduction tool, was proposed initially for the ‘difficult’ metaphyseal fractures of the tibia. Subsequently, surgeons have tried to implement the ‘blocking’ screw technique in ‘difficult’ distal femoral fractures. This article presents the ‘blocking’ screw technique as an adjunctive process in the management of fractures of the proximal and distal femur which are found to be non-reducible by skeletal traction alone. The minimal invasiveness of the technique contributes greatly to the preservation of both the soft tissue integrity and the fracture haematoma and thus reduces the major complications that can occur by exposing the fracture site. Cite this article: EFORT Open Rev 2021;6:451-458. DOI: 10.1302/2058-5241.6.210024

Neglected Locked Patellar Dislocation in an Adult Female: Report of a Rare Case

Introduction: Dislocation of patella is a very common injury which usually reduces spontaneously or can be reduced easily using gentle manipulation. Irreducible patellar dislocations are rare and usually result due to either rotation of patella along the horizontal or vertical axis or due to bony impaction. Neglected locked patellar dislocations are extremely rare injuries presenting additional challenges. Case Report: We are reporting a case of a 24-year female who presented to us 4 months after suffering a knee injury for which she received native treatment initially. On presentation, patient was able to walk with a limp and some discomfort but was unable to squat or sit cross-legged. Clinical examination revealed a patellar dislocation which was irreducible. On open reduction, the patella was found to be locked in the lateral gutter with rotation along its vertical axis and with an osteochondral fracture of its medial margin. There were a lot of fibrotic adhesions which required extensive release, following which the patella could be derotated and reduced into the trochlear groove. The medial retinaculum was repaired using transosseous sutures. Postoperatively, the patient developed wound edge necrosis which was managed with debridement and secondary suturing. At 1-year follow-up patient had almost full knee range of motion without any signs of patellar pain or instability and was able to squat and sit cross-legged. Conclusion: Unlike acute irreducible patellar dislocations which can be managed easily with open reduction, a neglected dislocation necessitates wider surgical exposure and a lot of soft tissue releases, which may jeopardize vascularity of the soft tissues leading to wound healing problems. Release of all adhesions while taking care to prevent further chondral injury, adequate lateral retinacular release, derotation of patella to relocate it into trochlear groove, and meticulous medial retinacular repair is essential for a successful outcome. Keywords

Complications and mortality associated with olecranon fractures in the elderly: a retrospective cohort comparison from a large level one trauma centre

Background Olecranon fractures in the elderly have an increasing incidence. This retrospective study aims to identify the complications and survivorship of these patients. Methods All patients >70 years old treated for an olecranon fracture at our institution were identified between 2007 and 2019. Loss of reduction and/or metalwork loosening was recorded. Also noted were wound healing problems, deep/superficial infections, and any subsequent treatment including return to surgery and/or removal of metalwork. Results From a total of 177 cases, 28 presented with concomitant fractures (16%), half of which were hip fractures. The largest treatment group underwent tension band wiring ( n = 82, 46%, mean age 80.8 yrs). Twenty-one of these suffered failure of fixation (26%), all requiring return to surgery. The second largest treatment group underwent plating ( n = 50 28%, mean age 80.1 yrs). Four of these suffered failure of fixation (8%), all requiring return to surgery. Forty-four patients were treated non-operatively (25%, mean age 83.8 yrs). Two patients suffered other complications (4.5%). Overall 1 year survivorship was 0.82. Discussion Olecranon fractures in the elderly have higher than expected 1 year mortality rates. Operative management results in high complication rates, often requiring return to surgery for metalwork problems. Significant consideration of treatment options is required in this cohort.

Metastasierender Morbus Crohn vielleicht häufiger als bisher angenommen

<b>Background:</b> Metastatic Crohn’s disease (CD) is a rare manifestation of CD. It involves inflammatory skin lesions with histopathological findings (granulomas) similar to CD, without connection to the gastrointestinal tract. Hyperbaric oxygen therapy (HBO) has been suggested as a possible treatment option. <b>Objective:</b> This study aimed to identify and treat a consecutive series of patients with biopsy-proven metastatic CD and monitor wound healing using prospectively acquired outcomes. <b>Methods:</b> Pathology results of all patients with ongoing perineal wound-healing problems after proctectomy between 2005 and 2018 at the Amsterdam University Medical Centre were assessed for metastatic CD. Patients with a biopsy-proven diagnosis of perineal metastatic CD were offered HBO (40 daily sessions of 100% oxygen at 2.4 atmosphere absolute). Wound healing was monitored using photographs and standardised questionnaires (the Inflammatory Bowel Disease Questionnaire, EuroQol Visual Analogue Scale and the Female Sexual Function Index) at baseline and 1 and 3 months after HBO. <b>Results:</b> Out of 13 patients in the cohort with persisting perineal wounds after proctectomy, six (46%) had biopsy results consistent with metastatic CD. Of these, three accepted treatment with HBO. All three patients were female. One patient had complete healing of her perineal wound; another patient showed initial improvement but had a flare of luminal and perineal disease at the 3-month follow-up. The third patient showed improvement solely in the questionnaires, with higher scores on all three questionnaires. <b>Conclusion:</b> A high rate of metastatic CD was found in patients with ongoing wound-healing problems after proctectomy, implying that the disease might not be as rare in these selected patients as previously thought. HBO might be beneficial in the treatment of metastatic CD.

Severe Lactational Mastitis With Complicated Wound Infection Caused by Streptococcus pyogenes

Introduction Puerperal mastitis, a complication occurring during the breastfeeding period, is often caused by Staphylococcus aureus. Here we report on severe streptococcal mastitis in a lactating breast, with subsequent invasive disease and wound healing problems. Main issue The 41-year-old woman (G2, P2) presented at 2 weeks postpartum to our hospital with painful swelling and reddening of the left breast, in addition to fever and malaise, and complained about a nipple fissure on the left breast. Previously, her 4-year-old son was treated for an acute otitis media and her husband experienced flu-like symptoms. Management Due to the severity of the symptoms, Clindamycin antibiotic treatment was initiated intravenously. Streptococcus pyogenes was isolated in the milk. This strain is commonly known to cause infections of the upper respiratory tract, skin, and soft tissue, but rarely mastitis. Furthermore, the participant developed invasive disease with abscess formation and skin erosion with a milk fistula. Special dressing was applied to promote wound healing. The participant continued breastfeeding well into the child’s 2nd year of life. Conclusion This rare form of complicated mastitis with invasive disease caused by Streptococcus pyogenes called for an interdisciplinary approach. We want to draw attention to other pathogens causing mastitis and to alert health care workers to promote hygiene in lactating women to prevent transmission.

Minimally Invasive Versus Open Akin Osteotomy: A Comparative Study

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Minimally invasive techniques of Akin osteotomy grow in popularity in order to minimize wound healing problems. To date it is recommended to keep the lateral corticalis intact during first phalanx osteotomy. The lack of direct visual control makes this a challenging goal in minimally invasive surgery. This retrospective study investigates whether or not the perforation of the lateral corticalis causes clinical or radiological negative effects. The quality of fixation with crossed K-wires and double threaded screws is compared. Methods: 184 patients (210 feet) with symptomatic mild to severe hallux valgus deformity and pathological interphalangeal angle (IPA) of at least 10° underwent surgery combined with Akin osteotomy. 124 minimally invasive Akin osteotomies were fixed with two crossing K-wires and compared to 86 Akin osteotomies in open technique with double threaded screw fixation. After 6 and 12 weeks IPA and bony consolidation were assessed. Results: Preoperative interphalangeal angles were mean 13.4° (+- 3.6°) (minimally invasive group (MI)), or 13.3° (+- 3.5°) (open surgery group (OS)) degrees (p>0.05).Perforation of the lateral corticalis occurred in 12 (13.9%) (OS), or 64 (51.6%) cases (MI), respectively.12 weeks after surgery the mean IPA was 4.1° (+- 1.4°) (MI), or 4.8° (+- 1.2°) in the open surgery group (OS) (p > 0.05).Bony consolidation was noticed after 6 weeks (OS, double threaded screw) or 12 weeks (MI, crossing K-wires).Three deep infections occurred in the OS group after Lapidus arthrodesis and two deep infections were registered in the MI group after MICA. All patients required revision with removal of implants. Pseudarthrosis did not occur in any group. Conclusion: Perforation of the lateral corticalis did not cause negative effects on bone healing or IPA. Minimally invasive Akin osteotomy provides equivalent correction of IPA compared to open surgery with a slightly prolonged radiological bony consolidation. The fixation technique had no influence on IPA correction.

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomies are often required in correction of hindfoot deformities. The traditional open techniques as lateral or oblique incision are occasionally associated with wound healing problems and neurovascular injury. Methods: In a prospective study 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. 58 patients were operated using an open incision technique and 64 patients with 66 feet using a percutaneous technique. Clinical and radiological assessments were performed preoperatively, six weeks and one year postoperatively. Results: The AOFAS score and VAS improved in both groups postoperatively. The difference was not significant. The results of the radiological measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in both groups. The comparison of both groups showed a significant lesser risk for wound healing problems in percutaneous group (B). The hospitalisation time was significantly shorter in the percutaneous group. Conclusion: Due to the excellent results with the percutaneous calcaneal osteotomy the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy at our clinic.