Chronic Exertional Compartment Syndrome: A Review of Literature

Chronic exertional compartment syndrome (CECS) is a serious, yet underdiagnosed condition that can cause severe lower extremity pain in running athletes. CECS is a transient increase in compartment pressure leading to severe pain, paresthesia, and vascular compromise. Understanding the detailed anatomy is paramount to proper diagnosis and treatment. Diagnosis is made with measuring compartments pressures before and after exercise at certain time intervals. When properly diagnosed and treated, CECS can be appropriately managed and patients can return to their previous level of activity.

Near-Infrared Spectroscopy (NIRS) versus Hyperspectral Imaging (HSI) to Detect Flap Failure in Reconstructive Surgery: A Systematic Review

Rapid identification of possible vascular compromise in free flap reconstruction to minimize time to reoperation improves achieving free flap salvage. Subjective clinical assessment, often complemented with handheld Doppler, is the golden standard for flap monitoring; but this lacks consistency and may be variable. Non-invasive optical methods such as near-infrared spectroscopy (NIRS) and hyperspectral imaging (HSI) could facilitate objective flap monitoring. A systematic review was conducted to compare NIRS with HSI in detecting vascular compromise in reconstructive flap surgery as compared to standard monitoring. A literature search was performed using PubMed and Embase scientific database in August 2021. Studies were selected by two independent reviewers. Sixteen NIRS and five HSI studies were included. In total, 3662 flap procedures were carried out in 1970 patients using NIRS. Simultaneously; 90 flaps were performed in 90 patients using HSI. HSI and NIRS flap survival were 92.5% (95% CI: 83.3–96.8) and 99.2% (95% CI: 97.8–99.7). Statistically significant differences were observed in flap survival (p = 0.02); flaps returned to OR (p = 0.04); salvage rate (p < 0.01) and partial flap loss rate (p < 0.01). However, no statistically significant difference was observed concerning flaps with vascular crisis (p = 0.39). NIRS and HSI have proven to be reliable; accurate and user-friendly monitoring methods. However, based on the currently available literature, no firm conclusions can be drawn concerning non-invasive monitoring technique superiority

A rare case: Penetrating craneoencefalic trauma by knife

Background: Cranioencephalic penetrating trauma (CPT) is caused by a sharp or short- pointed object that passes through the bone, dura mater, brain and other structures. Its incidence is unknown and few cases are described; penetrating injuries represent 0.4%, therefore there is no protocolized management. Case report: A 24-year-old male patient suffered penetrating trauma at left parietal region with a "knife"; he was sutured and sent home with analgesics. Five days after the trauma, he was admitted for headache, disorientation and decreased visual acuity. X-ray (XR) of Cranium evidencing a foreign body, therefore it is sent to a reference hospital. Evolution: The diagnosis is confirmed by a computerized tomography (CT) scan of the skull with 3-dimensional reconstruction (3D) plus CT angiography (angio CT), which shows "knife" in the left parietal region without vascular compromise. Neurosurgeons perform removal of the foreign body plus a dura mater plasty. Patient stay 12 days hospitalized with a favorable evolution and improvement of neurological symptomatology. Conclusion: CPT due to a knife is an emergency and there is no protocolized management. The removal of the foreign body must be done in a hospital for the risk of lesions of large vessels.

Atrazine-Induced Hepato-Renal Toxicity in Adult Male Xenopus laevis Frogs

Atrazine (ATZ) is an herbicide commonly detected in groundwater. Several studies have focused on its immunological and endocrine effects on adult Xenopus laevis species. However, we investigated the impact of atrazine on the renal and hepatic biochemistry and histomorphology in adult male frogs. Forty adult male frogs were allocated to four treatment groups (control, one ATZ (0.01 µg/L), two ATZ (200 µg/L) and three ATZ (500 µg/L), 10 animals per group, for 90 days. Alanine aminotransferase (ALT) and creatinine levels increased significantly (p < 0.05) in the 200 and 500 μg/L groups but malondialdehyde only in the 500 μg/L group (p < 0.05). Histopathological observations of derangement, hypertrophy, vascular congestion and dilation, infiltration of inflammatory cells incursion, apoptosis and hepatocytes cell death were observed with atrazine exposure, mostly in the 500 μg/L group. Additionally, histochemical labelling of caspase-3 in the sinusoidal endothelium was observed in all the treated groups, indicating vascular compromise. Evaluation of renal histopathology revealed degradation and atrophy of the glomerulus, vacuolization, thick loop of Henle tubule epithelial cells devolution and dilation of the tubular lumen. Furthermore, expression of caspase-3 indicates glomerular and tubular apoptosis in atrazine-exposed animals. These findings infer that environmentally relevant atrazine doses (low or high) could induce hepatotoxicity and nephrotoxicity in adult male Xenopus laevis frogs and potentially related aquatic organisms.

Ogden Type I to III tibial tubercle fractures in skeletally immature patients: is routine anterior compartment fasciotomy of the leg indicated?

Purpose Determine the frequency of compartment syndrome of the leg after displaced, operatively treated modified Ogden I to III tibial tubercle fractures (TTFxs), evaluate the preoperative assessment and use of advanced imaging, and need for prophylactic fasciotomies. Methods Retrospective analysis of operatively treated, displaced modified Ogden I to III TTFxs, at our level 1 paediatric trauma centre between 2007 and 2019. Modified Ogden Type IV and V fracture patterns were excluded. Fracture patterns were determined by plain radiographs. Results There were 49 modified Ogden I to III TTFxs in 48 patients. None had signs nor symptoms of vascular compromise, compartment syndromes or impending compartment syndromes preoperatively. In all, 13 of the 49 fractures underwent anterior compartment fasciotomy at surgery; eight of the 13 had traumatic fascial disruptions, which were extended surgically. All incisions were primarily closed. There were no instances of postoperative compartment syndromes, growth arrest, leg-length discrepancy or recurvatum deformity postoperatively. All patients achieved radiographic union and achieved full range of movement. Conclusion The potentially devastating complications of compartment syndrome or vascular compromise following TTFx did not occur in this consecutive series of patients over 12 years. The presence of an intact posterior proximal tibial physis and posterior metaphyseal cortex (Modified Ogden TTFx Type I to III) may mitigate the occurrence of vascular injury and compartment syndrome. Plain radiographs appear appropriate as the primary method of imaging TTFxs, with use of advanced imaging as the clinical scenario dictates. Routine, prophylactic fasciotomies do not appear necessary in Ogden I to III TTFxs, but should be performed for signs and symptoms of compartment syndrome. Level of evidence Level IV

Hear, hear for ultrasound

Ultrasound technology is finally being used outside of the hospital setting. The simple, non-invasive and radiation-free imaging modality is now a reality in the medical aesthetic clinic. Ultrasound has been recognised as a suitable investigation in aesthetic complications since 2008 and recommended in practice since 2013. Technological advances have enabled professionals to deliver imaging in any environment. In treatment planning, delivery and aftercare, patient outcomes can be optimised. Ultrasound imaging allows reliable dermal filler identification, vascular mapping, management of vascular compromise and nodules, real-time rheology and measurement in relation to treatment outcomes. The challenges that remain relate to underpinning availability and enthusiasm with education and support. At the time of writing, there are no such mechanisms or educational programmes.

Successful umbilicus salvage following concurrent infraumbilical single-port myomectomy and free transverse rectus abdominis myocutaneous flap elevation: a case report

Performing a concurrent gynecologic operation and mastectomy with immediate breast reconstruction using a free transverse rectus abdominis myocutaneous flap may increase the risk of complications such as umbilical necrosis due to vascular compromise. Imaging studies such as preoperative computed tomography angiography and intraoperative indocyanine green testing can provide information regarding the umbilical blood supply, facilitating decision-making for pedicle selection. Therefore, in situations where a coordinated operation is unavoidable, a thorough preoperative and intraoperative evaluation of the umbilical blood supply is recommended to avoid complications.

836 DIEP Flap Monitoring Adherence

Aim The popularity of Deep Epigastric Perforator (DIEP) free flaps for breast reconstruction after mastectomies have increased due to their natural aesthetic results and reliability. Free flaps require strict post-operative monitoring by nursing staff during the early post-operative period where they should notify the surgeons to anticipate vascular compromise in order to salvage the flap. To ensure success the DIEP guidelines were introduced to Morriston Hospital, Swansea. This was a first cycle closed loop re-audit. Method Interventions from initial audit were implemented in 2018. Retrospective analysis of patient notes over an 8-month period (August 2019- March 2020) and compared with DIEP checklist. Clinical notes, nursing cartex and flap observations and medication charts were reviewed. Results 100% had bear huggers, antiemetics (87% in 2018), correct thromboprophylaxis (75% in 2018) and laxatives (37% in 2018). 100% had senior reviews daily post op (75% in 2018). 100% had flap observations performed as guidelines immediately post op. Conclusions This was a successful re-audit showing significant improvements in adherence rates amongst the surgical and nursing staff in the plastic surgery department. Implementation of the DIEP operation note template may help maintain such adherence amongst staff.

554 An Unusual Case of a “Hernia Within a Hernia” Resulting in Small Bowel Obstruction and Strangulation

59-year-old female presented with symptoms of small bowel obstruction. She had a history of previous open right hemi-colectomy. She also had a previous complex strangulated ventral hernia which had required laparotomy and repair. Following this the patient had recurrence of the ventral hernia. Examination demonstrated a non-tender irreducible recurrent ventral hernia in a patient with a high BMI (&gt; 40). CT reported a midline hernia containing dilated small bowel loops. Additionally, there was a separate narrower hernia arising from the original larger hernia containing a strangulated loop of small bowel. Emergency laparotomy was performed. At operation there was a large hernia containing a smaller secondary hernial defect. Within this secondary defect, there was a loop of jejunum with a constriction band. which was released. There was no vascular compromise to the bowel and no need for resection. The hernial sac was excised and the abdominal wall repaired. Post-operative recovery was uneventful. Discussion The patient had a known, recurrent wide necked ventral hernia. However, this was the first presentation of the new, smaller hernia. This case is unusual in that it demonstrates a multi-locular “hernia within a hernia”. Although multi-locular hernias have been previously described, there is a paucity of literature on these. Conclusions This “hernia within a hernia” is an uncommon surgical finding for which there is limited literature. Clearly without urgent surgical intervention there would be an increase in morbidity and mortality.