High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [
Orthopedics
. 2019; 42(5):260–266.]
Summary:
We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.
Background: MUTYH-associated polyposis is a rare disorder resulting from mutations involved in DNA mismatch repair. This results in an increased susceptibility to colonic adenomatosis and other cancers. Studies have examined the resulting frequency of extracolonic manifestations; however, these typically occur alone, concurrently, or temporally separate from an already diagnosed colorectal cancer in individuals with a biallelic mutation.Case: Reported here is a case of five distinct primary neoplasms presenting simultaneously in a patient monoallelic for an MYH mutation. These neoplasms included squamous cell carcinoma of the vulva, rectal adenocarcinoma, synchronous anal adenocarcinoma, papillary thyroid carcinoma, and ovarian serous psammocarcinoma.Throughout her course, she underwent multiple surgical procedures, neoadjuvant chemoradiation, with further adjuvant therapy, and treatment ongoing. Due to her unique presentation, she underwent genetic testing that demonstrated she was monoallelic for an MYH mutation.
Conclusion:The patient had a positive response to her treatment and surgical procedures with ongoing adjuvant therapy. She will continue to undergo further genetic testing, and testing for her children is being considered. This case demonstrates a unique presentation associated with a monoallelic MYH mutation that is not described in the current literature and warrants further investigation.
Background: MUTYH-associated polyposis (MAP) is a rare, and only recently described disorder resulting from mutations in genes encoding enzymes involved in DNA mismatch repair. These mutations result in an increased susceptibility to colonic adenomatosis as well as a variety of cancers. In current literature, studies have examined the frequencies of extracolonic manifestations of this disorder. However, these manifestations typically occur alone concurrently, or temporally separate from an already diagnosed colorectal cancer in individuals with a bi-allelic mutation. Case Presentation: 48-year-old female with five distinct primary neoplasms presenting simultaneously in a patient mono-allelic for an MYH mutation, and only a single gastrointestinal polyp. Family history included colon, rectal, and lung cancer. Her past medical history included obesity and type 2 diabetes mellitus and a large ventral hernia was noted on examination. She initially presented with a several-month history of an enlarging pruritic labial mass found to represent a high grade squamous intraepithelial neoplasm for which a radical right partial vulvectomy was performed. Final pathology demonstrated a stage IB squamous cell carcinoma. At follow-up, the patient complained of fecal incontinence. To evaluate this, upper and lower endoscopies were performed which demonstrated a large rectal mass representing adenocarcinoma characterized by a low probability of microsatellite instability and an anal mass representing a second adenocarcinoma. An asymptomatic thyroid mass was discovered with pathology demonstrating papillary thyroid carcinoma. During her en bloc surgical resections of previously mentioned malignancies, a left ovarian serous implant of psammocarcinoma was identified. Scattered foci of low-grade serous carcinoma (psammomatous carcinoma) were found within the ventral hernia sac tissue.Conclusions: The disparate and aggressive presentation of this case serves two purposes; to highlight the importance of a thorough workup in patients with oncologic presentations suspicious for genetic aberration, and to highlight how variable expressivity can lead to unpredictable presentations necessitating a broad differential diagnosis.
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