Necessity of secondary Syme amputation of the foot after severely destroyed hindfoot injury due to suicidal jump from height in a psychiatric patient: Case presentation and brief review of literature

Abstract

Abbreviations: 3D CT : three-dimensional computed tomography; CREF: closed reduction and external fixation; DPNFCSAF: distally pedicled neurofasciocutaneous sural artery flap; O(C)RIF: open (closed) reduction and internal fixation. Case presentationA 44-year-old obese female (body mass index 37.2 kg/m 2 ) presented with open severely destroyed injuries of her both hindfoots after a suicidal jump from approximately 4 m height out of her private balcony. There was a longstanding history of a psychiatric disorder (schizophrenia) treated by psychopharmaca. The left foot showed an open Gustilo-Anderson II hindfoot injury at the lateral aspect of calcaneus, and three-dimensional computed tomography (3D CT) revealed a highly comminuted hindfoot fracture-dislocation injury involving the calcaneus, the subtalar joint, and the Chopart joint ( Figure 1A). The right foot showed an open Gustilo-Anderson IIIB hindfoot injury at the medial-plantar aspect of calcaneus, and 3D CT revealed a highly comminuted calacaneus fracture ( Figure 1B).Both injuries were initially treated by closed reduction and external fixation (CREF) accompanied with percutaneous pinning, negative-pressure vacuum assisted closure (VAC) therapy, and intravenous application of antibiotics (cefuroxime). Against our strict recommendations not to load her both legs, the patient mobilized herself with full-weight bearing and went away several times from our hospital and so nearly all pins of external and internal fixations were broken. As a consequence, the overall pins for external and internal fixation of both foots had to be removed 4 weeks after primary surgery, resulting in severe posttraumatic flat foot on both sites based on pronounced bony destruction and fragment dislocation and diastases of the calcaneus bones accompanied with re-dislocation in her left Chopart joint (Figures 2A and 3A). After intermittent negativepressure VAC therapy, a secondary wound closure of her left open II injury could be achieved without additional soft tissue coverage 3 weeks after injury. For closure of her right open IIIB injury, wound coverage with the use of a distally pedicled neurofasciocutaneous sural artery flap (DPNFCSAF) was performed 1 week after removal of the pins. For this purpose, the pedicle of the flap was primarily covered by a synthetic skin substitute (Epigard) at its 160° pivot point extending up distally to the flap, and secondarily covered by split-thickness skin grafts 1 week later that was associated with an uneventful wound healing (i.e. flap survival) ( Figures 2B-C).At the left foot, the further course after secondary wound closure of her open II injury without the need of coverage was complicated by development of severe osteomylitis of the hindfoot involving the distal tibia metaphysis presented with marked swelling of the overall foot and an infectious fistula at the lateral aspect of calcaneus (Staphylococcus aureus) ( Figures 3A-B). Hence, the Syme amputation was detected and performed by us that was associated with an uneventful course ( Fi...

Who introduced the "quadrangular-construct" modification of the Sauvé Kapandji procedure first? Case presentation and brief overview of literature with regard to general, specific and practicable aspects to primary trauma-related surgical treatment including possible salvage options at the distal radioulnar joint

“…cortico-cortical contact areas). The aim of creating corticocancellous contact areas by bony decorticalization is early cancellous bone ingrowth into the intramedullary space which has proven to be useful for ankle arthrodesis in the fibula-to-tibia/talus manner as well [65]. However, with both techniques there were no non-unions, no fractures of the fixation screws, and avascular bone graft resorption could not be observed as well in both studies.…”

“…Middle: Non-cemented UHR utilizing a metal head with standard offset that was primarily combined with another non-cemented TWA type for treatment of posttraumatic osteoarthritis accompanied with UPV based on a longstanding distal radius physeal arrest [95,97]. Using this TWA type, the non-cemented insertion is the mostly preferred and performed technique when the bone stock is sufficient as well, and cementation should also be done only when the bone stock is poor [65,114,115]. Right: Same patient as in Figure 10C, the Bowers procedure has been failed (painful convergence instability) and a conversion to a non-cemented UHR utilizing a metal head with extended (i.e.…”

“…USO is indicated for hereditary (Figures 4 and 5) and posttraumatic evident UPV, it can be performed in a diaphyseal or a metaphyseal manner (Figures 4, 5 and 11A), it can also be an option for primary forearm shortening in case of a highly comminuted distal forearm fracture to avoid posttraumatic UPV ( Figure 11A), and it is contraindicated when evident osteoarthritis in DRUJ is present [67,68]. When performing a diaphyseal USO, then the osteosynthesis plate Figure 10B) that led to an excellent functional outcome [65]. (B) Same patient, radiograph of her left wrist at time of injury demonstrating evident longitudinal DRUJ instability with widening of the radioulnar gap (yellow arrow) and UPV longer than 2 mm (transverse yellow pointed line) mimicing an Essex-Lopresti injury, but clinical assessment revealed a pre-existing longstanding posttraumatic UPV based on a distal forearm fracture in her childhood and followed by a longstanding distal radius physeal arrest.…”

“…subluxation in dorsal direction) ( Figures 1A-C, 6 and 7A-F). Figures 8A-B) [65]. Cementation was done because the bone stock was poor.…”

“…The first UHR with previously performed Darrach or Sauvé-Kapandji procedures utilizing a metal head which articulates with a metal cup proximal to the sigmoid notch was introduced in 1992 by Kapandji, and followed by Herbert and van Schoonhoven using an UHR with a ceramic head they started with its use in 1995 [93,94]. UHR can be performed as primary procedure as well as a salvage procedure after a failed (hemi-) resection procedure at the distal ulna with or without an additional TWA ( Figure 11D) [20,65,82,[95][96][97][98][99][100]. However, a recent systematic review revealed that UHR has produced acceptable results in small numbers of patients.…”