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Kedar DJ, Suh HS, Park CJ, Hong JP. Soft Tissue Reconstruction After Revascularization. INT J LOW EXTR WOUND 2024; 23:27-32. [PMID: 37946321 DOI: 10.1177/15347346231210144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Diabetic foot ulcer represents the primary cause of hospital admissions, amputations, and mortality in diabetic patients. The development of diabetic foot ulcers is influenced by peripheral neuropathy, infection, and ischemia, with diabetes contributing to peripheral artery disease. Free tissue transfer combined with revascularisation of the lower extremity provides the potential opportunity for limb salvage in individuals with lower extremity defects due to critical limb ischemia and diabetic foot.
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Affiliation(s)
- Daniel J Kedar
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Hyun Suk Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Changsik John Park
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
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Christensen JM, Ahn L, Meulendijks MZ, Iskhakov D, Wong F, Winograd J, Valerio IL, Cetrulo CL, Helliwell LA, Eberlin KR. Technical Variables in Lower Extremity Free Flap Reconstruction. J Reconstr Microsurg 2024; 40:78-86. [PMID: 37040875 DOI: 10.1055/a-2071-3250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage. METHODS Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed. RESULTS In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032). CONCLUSION Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.
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Affiliation(s)
- Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Leah Ahn
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mara Z Meulendijks
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Iskhakov
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frankie Wong
- Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Winograd
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Curtis L Cetrulo
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Clegg DJ, Tasman JG, Whiteaker EN, Mazonas TW, Salomon BJ, Dupuy SD, Goldman MH, Roberson PN. Ambulatory Status before Diabetic Foot Ulcer Development as a Predictor of Amputation and 1-Year Outcomes: A Retrospective Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5383. [PMID: 37954216 PMCID: PMC10635617 DOI: 10.1097/gox.0000000000005383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/15/2023] [Indexed: 11/14/2023]
Abstract
Background Up to 25% of people with diabetes develop a diabetic foot ulcer (DFU) during their lifetime, which precedes approximately 85% of nontraumatic lower limb amputations. Diabetic limb salvage has been at the forefront of recent research, as major amputation is associated with 5-year mortality rates of 52%-80%. We sought to determine if ambulatory status before DFU diagnosis is predictive of amputations and outcomes within 1 year, as no studies have directly examined this relationship. Methods A retrospective review of patients diagnosed with DFUs from January 2011 to December 2021 was performed. Patients aged 18 years or more with type II diabetes were included. Ambulatory status was defined as the primary form of mobility reported by the patient before development of DFU, and was categorized as independent ambulation, ambulatory with assisting device (AWAD), or nonambulatory (NA). Statistical analyses included χ2, multinomial, and multivariable logistic regressions. Results After review, 506 patients were included. NA (OR = 5.10; P = 0.002) and AWAD status (OR = 2.77; P = 0.01) before DFU development were predictive of major (below or above-knee) amputation during hospitalization, emergency department visits within 30-days (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02), and mortality within one-year (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02). AWAD status was also associated with increased risk of hospital readmission (OR = 2.89; P < 0.001) within 30-days and any amputation (OR = 1.73; P = 0.01) within 1 year. Conclusions In patients with DFUs, NA and AWAD status were predictive of major amputation during hospitalization and are associated with poorer 1-year outcomes, including mortality. Ambulatory status assessment may be used to inform DFU treatment approaches.
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Affiliation(s)
- Devin J. Clegg
- From the Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
| | - Jordan G. Tasman
- Departments of Psychology and Surgery, University of Tennessee, Knoxville, Tenn
| | - Erica N. Whiteaker
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tenn
| | - Thomas W. Mazonas
- From the Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
| | - Brett J. Salomon
- From the Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
| | - Samuel D. Dupuy
- From the Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
| | - Mitchell H. Goldman
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn
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Limb salvage versus primary amputation in Gustilo-Anderson IIIB and IIIC tibial fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04804-2. [PMID: 36781435 DOI: 10.1007/s00402-023-04804-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/28/2023] [Indexed: 02/15/2023]
Abstract
INTRODUCTION The last systematic review on this topic was published in 2008. With advances in surgical techniques, patients with mangled extremities may now be potentially salvageable with comparable outcomes. This review aims to evaluate the outcomes of limb salvage compared to primary amputation in patients with severe open tibial fractures. MATERIALS AND METHODS A comprehensive search on PubMed, MEDLINE, Embase, Web of Science, Scopus, CENTRAL and CINAHL was performed from inception to 19 January 2022. The primary outcome was to evaluate clinical and functional outcomes. Secondary outcomes were to evaluate pain, patient preference, quality of life, and patient preferences. Methodological quality was evaluated using the MINORS criteria. Pooled estimates of relative risk (RR) and mean difference (MD) with 95% confidence interval (CI) were used as a summary statistic for dichotomous variables and continuous variables, respectively. RESULTS Sixteen studies with 645 patients met inclusion criteria. The methodological quality was moderate based on the MINORS score. The majority were male. Mean age was 36.3 years. There was no significant differences in the length of hospitalization (n = 8), return to work rates (n = 9), return to sport rates (n = 4) and quality of life scores (n = 4). Patients with primary amputation had a significantly lower risk of total complications (RR 0.21, 95% CI 0.08-0.53, p = 0.001) (n = 10), infections (RR 0.46, 95% CI 0.25-0.85, p = 0.01) (n = 9), and number of surgeries (MD - 4.17, 95% CI - 6.49 to - 1.85, p = 0.0004) (n = 6). Patients with primary amputation were able to ambulate significantly earlier (MD - 4.06, 95% CI - 7.65 to - 0.46, p = 0.03) (n = 3). Three studies found a significantly higher cost of hospitalization in limb salvage patients. Functional outcomes were similar in both groups. CONCLUSION While patients with primary amputation had better clinical outcomes in the short-term, functional outcomes were not significantly different in both groups. Despite the heterogenicity of the results in this review, surgeons need to contextualize the decision making for their patients and incorporate these findings. LEVEL OF EVIDENCE III. TRIAL REGISTRATION PROSPERO CRD42022303357.
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Yu H, Wang S, Song Q, You Y, Bao J, Yao M. Delayed femoral vein ligation reduces operative time and blood loss during hip disarticulation in patients with extremity tumors. Open Med (Wars) 2022; 17:1705-1711. [PMID: 36382056 PMCID: PMC9616051 DOI: 10.1515/med-2021-0372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/22/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022] Open
Abstract
This study aimed to evaluate the effects of delayed femoral vein ligation on the clinical outcomes of hip disarticulation. We retrospectively reviewed 20 patients with extremity tumors (10 bone tumors and 10 soft tissue sarcomas [STS]) who underwent hip disarticulation. Patients treated for hip disarticulation with synchronous femoral vein ligation (n = 10, regular surgery group) and hip disarticulation with delayed femoral vein ligation (n = 10, delayed ligation group), respectively, were enrolled in this study. The operative time and blood loss were used to evaluate the clinical outcomes. The delayed ligation group had significantly lower operative times than the regular surgery group (P < 0.05). Total, hidden, and intraoperative blood loss were all significantly lower in the delayed ligation group than in the regular surgery group (P < 0.05). However, there were no significant differences in postoperative blood loss. In conclusion, delayed femoral vein ligation could significantly reduce the operative time, hidden blood loss, and intraoperative blood loss in patients undergoing hip disarticulation.
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Affiliation(s)
- Hongwei Yu
- Department of Orthopaedics, The Tumor Hospital Affiliated to Harbin Medical University, Harbin, Heilongjiang, China
| | - ShuHuai Wang
- Department of Pathology, The Tumor Hospital Affiliated to Harbin Medical University,
Harbin, Heilongjiang, China
| | - Qi Song
- Department of Orthopaedics, The Hospital of Orthopaedics and Traumatology in Harbin,
Harbin, Heilongjiang, China
| | - Yan You
- Dermatology Department, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Junjie Bao
- Department of Orthopaedics, The Tumor Hospital Affiliated to Harbin Medical University, Harbin, Heilongjiang, China
| | - Meng Yao
- Department of Orthopaedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Nangang District, Harbin 150001, Heilongjiang, China
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Lumley ES, Kwon JG, Kushida-Conteras BH, Brown E, Viste J, Aulia I, Pak CJ, Suh HP, Hong JP. Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients. J Reconstr Microsurg 2021; 37:728-734. [PMID: 33792004 DOI: 10.1055/s-0041-1726394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. METHODS Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. RESULTS Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. CONCLUSION TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.
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Affiliation(s)
- Eleanor S Lumley
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Jin Geun Kwon
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | | | - Erin Brown
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Plastic Surgery, University of British Columbia, Canada
| | - Julian Viste
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Indri Aulia
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.,Department of Surgery, Plastic Reconstructive and Aesthetic Surgery Division, Universitas Indonesia, Jakarta, Indonesia
| | - Changsik John Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
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Kotsougiani-Fischer D, Fischer S, Warszawski J, Gruetzner PA, Reiter G, Hirche C, Kneser U. Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation. BMC Surg 2021; 21:168. [PMID: 33781250 PMCID: PMC8006355 DOI: 10.1186/s12893-021-01169-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation. Methods All patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients’ characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression. Results Fifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029). Conclusions MDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage. Trial registration: Retrospectively registered
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Affiliation(s)
- Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany.
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Paul A Gruetzner
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Gregor Reiter
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
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