Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary.
Recurrence of incisional hernia may be as high as 50 per cent. Abnormal collagen I/III ratios have been observed within scar tissue of patients with recurrent incisional hernias. We sought to determine whether collagen composition in primary, nonscarred tissue was similarly affected in these patients. In this prospective, case–control study, nonscarred, primary abdominal wall skin and fascia biopsies were obtained in 12 patients with a history of recurrent incisional hernias and 11 control subjects without any history of hernia while undergoing abdominal laparoscopic surgery. Tissue protein expression of collagen I and III was assessed by immunohistochemistry followed by densitometry analysis. The collagen I/III ratio in skin biopsies from the recurrent hernia group was significantly less compared with control subjects (0.88 ± 0.01 versus 0.98 ± 0.04, respectively, P < 0.05). Fascia biopsies from patients with recurrent hernias was not significantly decreased in collagen I/III ratio compared with control subjects (0.90 ± 0.04 versus 0.94 ± 0.03, respectively, P = 0.17). Decreased collagen I/III ratios within the skin of patients with recurrent hernias not involved with scar or healing tissue suggest an underlying collagen composition defect. Such a primary collagen defect, in addition to abnormal scar formation, likely plays a significant role in the pathogenesis of recurrent incisional hernias.
The defect of the femoral tunnel at the level of the physeal scar during transtibial and anteromedial portal (AMP) drilling for transphyseal anterior cruciate ligament reconstruction was compared. Five matched pairs of knees (n=10) were drilled, and computed tomography was used to evaluate tunnel position and size at the level of the physeal scar. Significant radiographic changes were observed, including tunnel defect area at the physeal scar: 0.44 cm (1.2%) in the transtibial group versus 0.99 cm (2.7%) in the AMP group (P=0.008). AMP drilling creates a larger and more lateral tunnel defect at the level of the physeal scar.
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