Functional and oncological outcomes of patients with proximal humerus osteosarcoma managed by limb salvage

BACKGROUND

Osteosarcoma is the most common primary bone malignancy in skeletally immature patients. The proximal humerus is the third most common site of osteosarcoma. The literature shows a paucity of published data concerning the outcome of proximal humerus osteosarcoma managed by limb salvage. The purpose of this study was to answer the following questions: (1) do patients with proximal humerus osteosarcoma managed by limb salvage and neoadjuvant chemotherapy show good functional and oncological outcomes, and (2) are there any prognostic factors that are associated with better oncological and functional outcomes?

MATERIALS AND METHODS

The study was a retrospective case series study assessing the overall outcome of 34 patients with proximal humerus osteosarcoma. Eighteen patients were males (53%) while 16 were females. Biological reconstruction was done in 15 patients (44%), while nonbiological reconstruction was done in 19 patients. Resections were mainly intraarticular (82%). Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score, while oncological outcome was assessed based on local recurrence and development of chest metastasis. Comparisons between quantitative variables were done using the nonparametric Mann-Whitney test. To compare categorical data, the chi-square (χ2) test was performed. The exact test was used instead when the expected frequency was less than 5. Correlations between quantitative variables were examined using the Spearman correlation coefficient.

RESULTS

The mean MSTS score was 25.5 (range 23-29). A younger age was statistically correlated with a poorer MSTS score (P = 0.0016). Six patients out of 34 (17.6%) had local recurrence and four of them (67%) were treated by forequarter amputation. 41% of patients developed chest metastasis, and the majority of them were treated by chemotherapy (71%). In comparison with patients with osteosarcoma at other sites who were also managed in our institution, proximal humerus osteosarcoma patients showed higher incidence rates of local recurrence and chest metastasis along with lower 5-year patient and limb survivorships compared to distal femur, proximal tibia and proximal femur osteosarcoma patients.

CONCLUSION

Treatment of osteosarcoma of the proximal humerus by limb salvage and chemotherapy yields a good functional outcome. The method of reconstruction does not impact the resultant function. The 5-year survivorship of these patients is 65%. Younger patients have a better oncological outcome and an inferior functional outcome.

LEVEL OF EVIDENCE

Level IV therapeutic study.

Analysis Of Oklahoma Amputation Trends and Identification of Risk Factors to Target Areas For Limb Preservation Interventions

BACKGROUND

Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall healthcare performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set.

STUDY DESIGN

We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using ICD-9 and ICD-10 codes. Amputation rates were calculated per 1,000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups.

RESULTS

Over 5,000,000 discharges were identified from 2008-2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per thousand discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC: 6.0, 95% CI:4.7-7.3). Most amputations were minor (59.5%), and though minor increased at a faster rate compared to major (minor amputation APC: 8.1, 95% CI: 6.7-9.6 vs. major amputation APC: 3.1, 95% CI:1.5-4.7), major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (p=0.001) when compared within their respective category.

CONCLUSION

Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide healthcare problem. We also present imperative examples of amputation healthcare disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Popliteal-to-distal extreme bypass in endovascular era

OBJECTIVES

Chronic limb-threatening ischemia (CLTI) is characterized by rest pain and tissue loss, with an annual mortality rate of 20% and amputation rate of 40%, if not treated. Open bypass surgery is recommended in CLTI, depending on the availability of good quality venous material, outflow artery patency and surgical expertise. Aim of the study is to analyze primary patency, limb salvage and survival rate in patient undergoing popliteal-to-distal bypass.

METHODS

All consecutive patients who underwent popliteal-to-distal bypass surgery between January 2016 and December 2021 were enrolled in the study. Primary outcomes were primary patency, limb salvage and overall survival. Secondary outcomes included amputation-free survival and secondary patency.

RESULTS

Forty-nine patients were included during the study. Technical success was achieved in 100% of cases. Target outflow artery was in 27% (n. 13) of cases the anterior tibial artery in 27% (n. 13) dorsalis pedis, in 2% (n. 1) the peroneal artery, in 30% (n. 15) the retro-malleolar tibial artery, in 10% (n. 5) the medial plantar artery, in 4% (n. 2) the tarsal artery. Two-year primary patency was 85%±5. Secondary patency rates was 86%±3 at two years. The overall survival was 81% ±6 at 2 years, the amputation free survival was 70% ±9, and the limb salvage rate was 81% ±6.

CONCLUSION

Popliteal-to-distal bypass require high technical expertise to be performed. When a good autologous vein and adequate outflow artery are present, they can be feasible with good patency rates, and overall survival.

Factors Associated with Urgent Amputation Status and Its Impact on Mortality

OBJECTIVES

Thirty-day mortality is higher after urgent major lower extremity amputations compared to elective lower extremity amputations. This study aims to identify factors associated with urgent amputations and to examine their impact on perioperative outcomes and long-term mortality.

METHODS

Patients undergoing major lower limb amputation from 2013-2020 in the Vascular Quality Initiative (VQI) were included. Urgent amputation was defined as occurring within 72 hours of admission. Associations with sociodemographic characteristics, comorbidities, and outcomes including postoperative complication, inpatient death, and long-term survival were compared using univariable tests and multivariable logistic regression. Long-term survival between groups was compared using Kaplan-Meier analysis.

RESULTS

Of the 12,874 patients included, 4,850 (37.7%) had urgent and 8,024 (62.3%) had elective amputations. Nonwhite patients required urgent amputation more often than white patients (39.8% vs 37.9%, P=0.03). A higher proportion of Medicaid and self-pay patients presented urgently (Medicaid:13.0% vs 11.0%; self-pay: 3.4% vs 2.5%, P< 0.001). Patients requiring urgent amputation were less often taking aspirin (55.6% vs 60.1%, P<0.001) or statin (62.2% vs 67.2%, P<0.001), had fewer prior revascularization procedures (41.0% vs 48.8%, P<0.001), and were of higher ASA class 4-5 (50.9% vs 40.1%, P<0.001). Urgent amputations were more commonly for uncontrolled infection (48.1% vs 29.4%, P< 0.001) or acute limb ischemia (14.3% vs 6.2%, P<0.001). Post-operative complications were higher after urgent amputations (34.7% vs 16.6%, P<0.001), including need for return to operating room (23.8% vs 8.4%, P< 0.001) and need for higher revision (15.2% vs 4.5%, P<0.001). Inpatient mortality was higher after urgent amputation (8.9% vs 5.4%, P<0.001). Multivariable analysis revealed non-white race, self-pay, homelessness, current smoking, ASA class 4-5, and amputations for uncontrolled infection or acute limb ischemia were associated with urgent status, whereas living in a nursing home or prior revascularization were protective. Further, urgent amputation was associated with an increased odds of postoperative complication or death (OR 1.86 [1.69-2.04], P<0.001) as well as long-term mortality (OR: 1.24 [1.13-1.35], P<0.001). Kaplan-Meier analysis corroborated that elective status was associated with improvement of long-term survival.

CONCLUSIONS

Patients requiring urgent amputations are more often nonwhite, uninsured, and less frequently had prior revascularization procedures, revealing disparities in access to care. Urgency was associated with a higher post-operative complication rate, as well as increased long-term mortality. Efforts should be directed towards reducing these disparities to improve outcomes following amputation.

Pediatric Peripheral Vascular Trauma: Incidence and Outcomes

Peripheral vascular trauma (PVT) is rare in children, with an incidence estimated below 1%. We studied pediatric PVT and risk factors for major amputation by accessing the 2019 National Trauma Data Bank (NTDB). Demographics, injury type and location, trauma center capability, injury severity score (ISS), length of stay (LOS), and major amputation rates were evaluated. Statistical analysis included chi-square testing for categorical variables and t-tests for continuous variables. Of 130,554 pediatric trauma patients, 1196 (.9%) had 1460 upper extremity (UE) and lower extremity (LE) PVT. Patients were predominantly male (n = 933, 78%) with a mean age of 14 years. Most patients suffered penetrating injury (n = 744, 62.2%). The most common vessels injuries were radial (n = 198, 13.6%) and femoral (n = 196, 13.4%). Major amputation occurred in 2.6% of patients (n = 31). Patients who suffered blunt injury (OR, 3.3; 95% CI, 1.5-7.5; P = .004) and lower limb PVT (OR, 11.1; 95% CI, 3.3-37.9, P = .0001) had higher odds of amputation.

Limb Salvage Surgery for Ponatinib-Induced Bilateral Chronic Limb-Threatening Ischemia in a Patient with Chronic Myeloid Leukemia with T315I Mutation in BCR-ABL: A Case Report

A 72-year-old woman with chronic myeloid leukemia with T315I mutation in breakpoint cluster region-abelson (BCR-ABL) was treated with ponatinib. During the course of her treatment, chronic limb-threatening ischemia developed in both lower extremities, and the left lower extremity was amputated below the knee at a previous hospital. She was referred to our department for salvage of the right lower extremity. We performed a foot bypass and multidisciplinary treatment of the wound, and achieved epithelialization in about 1 month. The rate of vascular occlusive events with ponatinib has been reported to be high, and we believe that careful monitoring is important during use.

Outcomes of Endovascular and Open Surgical Therapy for Popliteal Artery Injury

OBJECTIVES

Popliteal arterial injury carries an appreciable risk of limb loss and, despite advances in stent and stent-graft technology, endovascular therapy for popliteal arterial trauma is infrequently used when compared with traditional open repair. Thus, this study aims to assess outcomes of endovascular management (EM) with open surgery (OS) as a historical reference.

METHODS

An electronic search was performed (from January 2010 until June 2023) using multiple databases. Initial records were screened against eligibility criteria. Next, the full-text manuscript of articles that passed the title and abstract assessment was reviewed for relevancy of data points. Data from articles passing the inclusion criteria was extracted and tabulated. Comparative analysis was completed by performing chi-square tests and two-sampled t-tests (Welch's).

RESULTS

The twenty-four selected studies described 864 patients (96 EM; 768 OS). In the endovascular group, patients underwent procedures primarily for blunt trauma using covered, self-expanding stents, resulting in universal technical success and patency. Patients had an average LOS 7.99 ± 7.5 days and follow-up time of 33.0 ± 7.0 months, with 21% undergoing fasciotomies, 6% undergoing amputation, and 4% having pseudoaneurysms. Patients in the open surgery group were evenly divided between blunt and penetrating trauma, chiefly undergoing vein graft interposition and exhibiting fasciotomy and amputation rates of 66% and 24%, respectively. Patients had an average LOS of 5.66 ± 4.6 days and a 96% survival rate at discharge.

CONCLUSIONS

The current evidence sheds light on the nature of treatment offered by endovascular management and open surgery treatment and suggests endovascular management is associated with several important positive outcomes. Although it is difficult to directly compare endovascular and open surgical techniques, the data with respect to open surgical management of popliteal artery trauma can still provide a powerful frame of reference for the outcomes of endovascular management to date. However, this claim is weak due to the little published data for endovascular management of popliteal trauma, publication bias accompanying the published studies, and general, selection bias. Additional prospective data is necessary to define patients who specifically benefit from endovascular repair.

From a Spark to a Flame: The Evolution of Diabetic Foot Disease in the Last Two Decades

Despite many improvements have been achieved, diabetic foot disease (DFD) remains a clinical, social, and economic burden. In the last years, DFD showed an evolution of its characteristics with an increase of the ischaemic/neuro-ischaemic foot in comparison to the pure neuropathic foot. Simultaneously, there was and increased incidence of concomitant cardiovascular co-morbidities, which influences the higher fragility of patients with DFS. Peripheral arterial disease (PAD) in subjects with diabetic foot seems to show a more aggressive pattern, being more distal and difficult to treat. Untreatable PAD remains the unmet need for clinicians and the main risk factor of major amputation in patients with diabetic foot ulcers. Authors aimed to describe the evolution of diabetic foot patients in the last two decades, describing also the current and future treatment which may improve outcomes in the next generations.

Comparison of Two Techniques for Proximal Margin Analysis of Toe Amputations: a Retrospective Review

Toe amputations are a common podiatric procedure for treatment of osteomyelitis. Whether or not the surgeon obtains a surgical cure, thus resolving the infection, can be difficult to assess. Obtaining a proximal bone margin can assist the treatment team in deciding the duration of postoperative antibiotics, need for re-operation, and postoperative care. The two senior surgeons use different methods to analyze proximal bone margins. The first surgeon obtains a microbiologic culture from the remaining bone, either at the proximal phalanx or metatarsal head, following the removal of the toe to be reviewed for osteomyelitis. Per the second surgeon's technique, the pathologist only analyzes the proximal aspect of the amputated toe for presence of osteomyelitis. Our goal is to analyze the re-operation and re-amputation rates between the techniques in which the proximal margin specimens are obtained. A retrospective chart review was performed on all isolated toe or partial toe amputations from March 2017- September 2022. There were 115 patients who met inclusion criteria. Re-operation and re-amputation rates were analyzed for positive and negative infection margins from intraoperative cultures. Our study found an overall 28% re-operation rate and 26% re-amputation rate for the negative margins group. In the positive proximal margin group, there was an overall 48% re-operation rate and 44% re-amputation rate. Our analysis did not find a statistically significant difference between the re-amputation rate in the negative margins group and the re-amputation rate in the positive margins group. In conclusion, our study found that a positive proximal margin for osteomyelitis exhibited a nearly double re-operation and re-amputation rate compared to patients with a negative margin, and that one margin analysis technique was not inferior to the other in regards to the need for additional surgeries. Level of Evidence: 3.

Application of Novosorb biodegradable temporising matrix in wounds of different aetiologies: a case series

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Calcaneal Bone Biopsy Inconsistency between Specimens Obtained From Trephine and Fine Needle Biopsy Techniques

Standardized methods for osteomyelitis (OM) diagnosis of the lower extremity have proven to be difficult. Preoperative probability of foot osteomyelitis necessitates a combination of clinical, laboratory, imaging evidence (i.e., X-ray, CT, MRI), and bone biopsy to guide diagnosis and treatment. In the recent past, the relative weight that clinicians give to these collections of data to advise potential surgical intervention has been challenged, particularly with histologic evaluation of bone biopsy-traditionally considered "gold standard" in OM diagnosis. This study seeks to further expand this dialogue by retrospectively comparing calcaneal bone biopsies performed by direct visualization trephine approach (performed by Surgeons) vs fine needle biopsy with fluoroscopy guidance (performed by Interventional Radiologists). Results obtained from 57 patients with suspected calcaneal osteomyelitis demonstrate that Trephine obtained samples are significantly more likely to produce histopathologic evidence of OM (p-value: .013), microbiologic evidence of OM (p-value: <.001) and have better histopathologic and microbiologic concordance (p-value: <.001) than calcaneal bone biopsies obtained from Fine Needle Biopsy with fluoroscopy guidance.

Revision surgery for periprosthetic fracture of distal femur after endoprosthetic replacement of knee joint following resection of osteosarcoma

Purpose

Periprosthetic fracture (PPF) is one of the severe complications in patients with osteosarcoma and carries the risk of limb loss. This study describes the characteristics, treatment strategies, and outcomes of this complication.

Methods

Patients were consecutively included who were treated at our institution between 2016 and 2020 with a PPF of distal femur. The treatment strategies included two types: 1) open reduction and internal fixation with plates and screws and 2) replacement with long-stem endoprosthesis and reinforcement with wire rope if necessary.

Results

A total of 11 patients (mean age 12.2 years (9-14)) were included, and the mean follow-up period was 36.5 (21-54) months. Most fractures were caused by direct or indirect trauma (n = 8), and others (n = 3) underwent PPF without obvious cause. The first type of treatment was performed on four patients, and the second type was performed on seven patients. The mean Musculoskeletal Tumor Society (MSTS) score was 20 (17-23). All patients recovered from the complication, and limb preservation could be achieved.

Conclusion

PPF is a big challenge for musculoskeletal oncologists, particularly in younger patients. Additionally, PPF poses a challenge for orthopedic surgeons, as limb preservation should be an important goal. Hence, internal fixation with plates and endoprosthetic replacement are optional treatment strategies based on fracture type and patient needs.

Treatment of clinically uninfected diabetic foot ulcers, with and without antibiotics

OBJECTIVE

Current guidelines do not recommend the use of antibiotics to treat clinically uninfected ulcers. However, physicians continue to prescribe antibiotics for clinically uninfected ulcers with the rationale 'better to be safe than sorry'. Yet, antibiotic resistance is increasing, side-effects are common and treatment costs are rising. Evidence is needed to identify whether antibiotic treatment for clinically uninfected ulcers can be justified or we should stop prescribing them. The aim of this study was to evaluate whether antibiotic treatment in cases of clinically uninfected ulcers improved ulcer healing compared to treatment without antibiotics.

METHOD

Consecutive patients treated in the outpatient clinic for clinically uninfected diabetic foot ulcer both in 2015 and in 2017 were retrospectively analysed. Primary outcome was ulcer healing at one year. Secondary outcomes were limb salvage, freedom from any amputation, amputation-free survival (AFS) and survival.

RESULTS

A total of 102 ulcers of 91 patients were included for final analyses. The non-antibiotics and antibiotics groups both consisted of 51 ulcers. Ulcer healing at one year was 77.3% in the non-antibiotics group and 74.7% in the antibiotics group (p=0.158). No difference was found for limb salvage (93.8% versus 95.9%, respectively; p=0.661), freedom from any amputation (85.6% versus 85.6%, respectively; p=1.000), AFS (85.4% versus 79.1%, respectively; p=0.460) or survival (89.6% versus 83.7%, respectively; p=0.426).

CONCLUSION

In this study, no benefits of antibiotic treatment over non-antibiotic treatment for clinically uninfected ulcers were identified. The findings of this study emphasise the recommendation of current guidelines to not treat clinically uninfected ulcer with antibiotics.

Complications and Outcome of Bone Sarcoma Patients with Limb Salvage using Liquid Nitrogen-treated Bone for Reconstruction

Introduction

The recommended treatment method for bone sarcoma is wide local excision and reconstruction to preserve limb function. Established methods of reconstruction are mega prosthesis or biological reconstruction. This study aimed to determine the complications and functional outcomes associated with limb salvage surgery using liquid nitrogen-treated bone.

Materials and Methods

We retrospectively observed the short-term outcome of limb salvage surgeries where liquid nitrogen bone was used for reconstruction. A total of 15 patients underwent reconstruction with liquid nitrogen auto graft from January 2018 to December 2020. We used the free freezing method of liquid nitrogen treatment after wide local excision of sarcoma. We observed short-term outcomes after liquid nitrogen-treated bone reconstruction in limb salvage surgery. Survival of the auto grafts was recorded using the Kaplan-Meier method with a 95% confidence interval.

Results

The mean follow-up was 19.83 ± 4.5 months. The mean musculoskeletal tumor society score was 62.4 ± 7.9%, while the average Toronto extremity score was 59.6 ± 5.7%. Three patients died during the study duration due to visceral metastasis. Skin necrosis and wound breakdown were major complications in 9 (60%) patients. Deep infection was observed in 4 (26.7%). Similarly, 4 (26.7%) patients had non-union at either the proximal or distal osteotomy site, while the average time of bone union in the rest of the patients was 6.3 ± 1.7 months. A total of 6 (40%) patients underwent reoperation after liquid nitrogen treatment, either due to infection or non-union at the osteotomy site. Recurrence was observed in 3 (20%) of patients.

Conclusion

We observed a high complication rate with liquid nitrogen-treated autograft reconstruction. Vascularized fibula with liquid nitrogen-treated autograft or endoprosthesis should be encouraged.

Effects of Pemafibrate on Reducing Oxidative Stress and Augmenting Angiogenesis in Ischemic Limb Tissue

OBJECTIVE

Oxidative damage is observed in the ischemic limbs of patients with arteriosclerosis obliterans. We investigated whether pemafibrate, a selective peroxisome proliferator-activated receptor alpha modulator, reduced oxidative stress in ischemic limbs and consequently rescued limb damage in model mice.

MATERIALS AND METHODS

We surgically induced hind-limb ischemia in mice and orally administered pemafibrate solution (P-05 group, 0.5 mg/kg/day; P-10 group, 1.0 mg/kg/day) or control solution (control group). Seven days after the surgery, differences in reactive oxygen species (ROS) contents, antioxidative enzyme and transcription factor expression, blood flow, and capillary density in ischemic limbs were assessed.

RESULTS

Tissue ROS levels were lower in the P-05 and P-10 groups compared with those in the control group. Although the tissue expression levels of nuclear factor-erythroid 2-related factor 2 increased in the P-10 group compared with that in the control group, no corresponding changes were observed in the tissue expression of four antioxidative enzymes. The limb salvage rates and capillary densities in ischemic limbs were higher in the P-05 and P-10 groups than that in the control group.

CONCLUSION

Pemafibrate treatment reduced oxidative stress and augmented angiogenesis in ischemic limbs, contributing to prevention of limb damage in mice.

An effective treatment for diabetic foot necrosis with traditional Chinese and Western medicine: a case report

Patients with diabetes who undergo a kidney transplant are at a great risk of undergoing amputations, usually associated with severe infection and necrosis. The treatment of severe diabetic foot necrosis is challenging in clinic, and the function of the limb is often hugely compromised. A 74-year-old male who had been diagnosed with severe post-renal transplant diabetic foot necrosis refused the option of below-knee amputation from previous surgeons, and requested to keep his left foot. The patient was treated with integrated traditional Chinese medicine (TCM) and Western medicine, with positive results. TCM therapeutic principles included 'clearing heat, removing toxicity, regulating Qi, resolving dampness, activating stagnant blood and nourishing yin as well as tonifying Qi and blood'. Treatment with Western medicine included wound debridement, internal fixation or joint fusion, and use of insulin, antibiotics and vasodilators. The patient was treated with a staged and diverse approach (i.e., a combination of TCM and Western medicine, surgical management and education for diabetic foot care), which ultimately helped the patient achieve limb salvage and regain normal function. A combination therapy of Western medicine and TCM may be a promising approach to heal diabetic foot ulcers.

Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease

Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.

30-Day Readmission Following Outpatient Transmetatarsal Amputation in the Geriatric Population: An ACS NSQIP Analysis

Whether secondary to deformity, traumatic injury, infection, neoplasm, or ischemic disease, the transmetatarsal amputation provides a functional means of limb preservation prior to major proximal amputation. With similar readmission rates following inpatient and outpatient surgery, prevention of an unnecessary admission among vulnerable patients, specifically geriatrics, proves beneficial. This investigation examines differences among geriatric patients admitted and not requiring readmission following outpatient transmetatarsal amputation. An ACS NSQIP database analysis following filtering for CPT 28805, specific for transmetatarsal amputations, was performed among geriatric patients. Patient demographic, medical history, operative characteristics, and social/functional determinants were compared between the no admission and readmission cohorts. The threshold for statistical significance was set at p ≤ .05. Overall, a 19% readmission rate was reported among geriatric patients who underwent an outpatient transmetatarsal amputation. No statistically significant difference among patient demographics, past medical history, or surgical presentation was found between cohorts. Geriatric patients that maintained some level of functional dependence were 3.41 times more likely to be readmitted than the nonreadmission cohort (p = .006). Among geriatric patients undergoing outpatient transmetatarsal amputation, function status should be taken into account prior to surgery. Greater consideration should also be given to patients who do not maintain independence during their activities of daily living. As the population continues to age, recognizing social circumstances associated with the geriatric population proves important in preventing readmission.

Lower limb preservation in pediatric trauma: a case study of Gustilo grade IIIC fracture in a 7-year-old

This case report describes the intricate aspects of managing pediatric lower limb trauma. A 7-year-old patient had a severe compound fracture and significant soft tissue damage in the left lower limb, classified as Gustilo Grade IIIC. This necessitated the use of scoring systems such as the Mangled Extremity Severity Score and limb salvage index to assess the likelihood of limb preservation. Despite these high amputation risk indicators, a multidisciplinary approach has led to limb salvage surgery with internal fixation. Detailed postoperative monitoring revealed progressive recovery culminating in restored sensation, bone healing, and functional recovery. The discussion emphasizes the difficulties in deciding between limb salvage and amputation, stressing the importance of tailored care and cautious scoring system interpretation in pediatric cases. This conclusion advocates the prioritization of limb salvage in children owing to their unique healing capabilities while highlighting the need for further research to refine treatment protocols for pediatric lower limb trauma.

Are current wound classifications valid for predicting prognosis in people treated for limb-threatening diabetic foot ulcers?

This study aims to investigate whether the current wound classifications were valid for the treatment prognosis of subjects treated for limb-threatening diabetic foot ulcers (LTDFU). A total of 1548 patients with LTDFU and infection were studied, with wounds recorded using the Wagner, Texas, PEDIS and WIfI classifications while major lower extremity amputations (LEAs) or in-hospital mortality incidences were defined as poor outcomes. Among them, 153 (9.9%) patients received major LEAs and 38 (2.5%) patients died. After adjustments, the Wagner classification and Texas stage as well as clinical factors such as comorbidity with major adverse cardiac events (MACE), being under dialysis and having serum levels of C-reactive protein (CRP) and albumin were independent factors for prognosis. For patients without dialysis, Wagner and Texas stage stood out independently for prognosis. For patients on dialysis, only levels of CRP (odds ratio [OR] = 2.2 in Wagner, OR = 2.0 in WIfI, OR = 2.2 in Texas, OR = 2.3 in PEDIS) and albumin (OR = 0.4 in four classifications) were valid predictors. The Wagner system and Texas stage were valid for predicting prognosis in treatment for LTDFUs, suggesting a role of vascular perfusion. MACE history, levels of CRP and albumin level should assist in prediction; more significantly, only levels of CRP and albumin appeared valid for those subjects undergoing dialysis.

Clinical exploration of the international society of limb salvage classification of endoprosthetic failure using Henderson in the application of 3D-printed pelvic tumor prostheses

Background

The use of 3D-printed pelvic prosthesis for postoperative reconstruction after pelvic tumor resection has become one of the primary reconstruction methods the incidence of complications related to postoperative prosthesis reconstruction is high. Drawing on the failure of the type of bone tumor reconstruction in Henderson,the occurrence of postoperative complications was explored to take advantage of the design improvement of the 3D-printed prosthesis of subsequent pelvic tumors.

Methods

The data for patients who underwent 3D-printed pelvic tumor prostheses in the Department of Bone and Soft Tissue Surgery at the Affiliated Cancer Hospital of Guangxi Medical University from January 2019 to October 2022 were collected and analyzed.

Results

The median follow-up time for all patients was 15.99 months (1.33-31.16 months). At the most recent follow-up,all patients were alive,with an average Musculoskeletal Tumor Society (MSTS) score of 21.46 (17 to 26 points). Local recurrence occurred in two cases (15.3%), metastasis in four cases (30.7%), and complications in 10 cases (76.9%). Early complications after surgery were primarily local wound fissure, deep tissue infection, and postoperative neuralgia. Later complications included loose dissolution of internal fixation, postoperative prosthetic dislocation, and postoperative gluteal middle muscle gait.

Conclusion

3D printing personalized design pelvic tumor prosthesis is an effective way to reconstruct, and designing pelvic 3D printed tumor prosthesis with the help of Henderson's bone tumor reconstruction failure concept may help bone tumor surgeons develop better pelvic tumor prosthesis.

Necrotizing Fasciitis and Diabetic Foot: Results of a Prompt Identification, Surgery and Antibiotic Therapy (P.I.S.A.) Protocol

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33-61.2%), 2 (7-12.9%) and 3 (14-25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths.

Clinical Implications of Diabetic Peripheral Neuropathy in Primary Infrapopliteal Angioplasty Approach for Neuro-Ischemic Foot Wounds

BACKGROUND

To assess the clinical effects of diabetic peripheral neuropathy (DPN) in patients with chronic limb-threatening ischemia (CLTI) treated by primary infrapopliteal angioplasty for neuro-ischemic Rutherford 5, foot wounds.

MATERIALS AND METHODS

Over a 10-year period (2009-2019), a series of 304 diabetic ischemic limbs adding or not evincible neuropathic affectation were treated by primary infrapopliteal angioplasty and their files were retrospectively reviewed. Mean length of treated arterial lesions was 6.1 cm (range 1-22 cm). Inferior limb vibration perception threshold diagnostic was performed for comparing and scoring detectable DPN in all studied diabetic patients (classed from 0 to 10 points). There were 19% limbs with normal (0-1 points) perception (group 1), 55% others with "mild" and "moderate" (2-6 points) neuropathic impairment (group 2), and 26% limbs showing "severe" (7-10 points) DPN (group 3).

RESULTS

Primary infrapopliteal angioplasty succeeded in 89% cases in group 1, in 82% in group 2, and in 68% of limbs in group 3. This latest group assembled the heaviest neuropathic affectation and arterial calcifications and proved the lowest clinical benefit at 36 months: 35% (95% confidence interval [CI]=22% to 48%) of primary patency, 36% (95% CI=22% to 50%) wound healing, and 54% (95% CI=39% to 69%) limb preservation rates. A comparison between groups 1 vs 3 and 2 vs 3 of primary patency (p=0.014 and p=0.043), tissue healing (p=0.049 and p=0.01), and limb salvage (p=0.006 and p=0.023) proved significant, yet without statistical weight for group 1 vs 2 (p>0.05). Overall survival was not significantly affected between groups (p=0.34).

CONCLUSION

The presence of severe DPN may jeopardize the results of infrapopliteal angioplasty in terms of patency, tissue cicatrization, and limb preservation, yet without significance on survival of these patients. When present, DPN requires appropriate stratification as specific indicator in CLTI treatment.

Consideration for Limb Salvage in Place of Amputation in Complex Tibial Fracture With Neurovascular Injury: A Case Report

High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV.

Staged Treatment of Posttraumatic Tibial Osteomyelitis with Rib Graft and Serratus Anterior Muscle Autografts-Case Report

Osteomyelitis of the tibia is a challenging condition, particularly when it occurs as a result of trauma. This abstract presents a case study detailing the successful staged treatment of posttraumatic tibial osteomyelitis utilizing a unique combination of rib graft and serratus anterior muscle. This medical abstract presents a case study of a 52-year-old male with a history of heavy smoking and obliterating arteriopathy of the lower limbs. The patient sustained a traumatic open fracture classified as Type IIIA Gustilo Anderson involving one-third of the distal right tibia diaphysis, with an associated right fibular malleolus fracture. The treatment approach comprised multiple stages, focusing on wound management, infection control, and limb salvage. The initial stage involved the application of an external fixation device in the emergency setting. Seven days later, an osteosynthesis procedure was performed using a Kuntscher nail and wire cerclage. However, complications emerged, with wound dehiscence and purulent secretion observed at 14 days postsurgery. Subsequently, secondary suturing was carried out at the 20-day mark. The second stage of the treatment involved implant removal, wide excisional debridement, pulse lavage, osteoclasia, and relaxation of the peroneal malleolus. A monoplane external fixation system was applied. As a part of postoperative care, aspiration therapy with a vacuum pump was administered, along with a 10-day course of vancomycin according to the antibiogram. Positive clinical signs of healing were noted, and sterile cultures confirmed the results. The third stage of the intervention focused on grafting the osteo-muscular defect, utilizing autografts from the rib and serratus anterior muscle. The external fixator was maintained in place during this phase. In the fourth and final stage, after an 8-week integration period of the musculocutaneous flap, the external fixator was removed, and internal fixation was accomplished with a blocked Less Invasive Stabilization System (LISS) plate inserted using the Minimally Invasive Plate Osteosynthesis (MIPO) technique. This case underscores the significance of a multistage approach in managing complex limb injuries, emphasizing the importance of timely intervention, infection control, and innovative techniques for limb salvage and restoration of function.

Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed.

OBJECTIVES

This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure.

DATA SOURCES

PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023.

METHODS

Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months.

RESULTS

A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively.

CONCLUSION

This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.

Spinal Neuromodulation for Peripheral Arterial Disease of Lower Extremities: A Ten-Year Retrospective Analysis

OBJECTIVE

This long-term retrospective study evaluated the survival and amputation outcome of subjects who received neuromodulation therapy for the management of peripheral arterial disease (PAD).

MATERIALS AND METHODS

The study reviews the health data of a single cohort of 51 patients who received spinal neuromodulation (spinal cord stimulation [SCS] or dorsal root ganglion stimulation [DRG-S]) for PAD from 2007 to 2022 in a single German center. Survival rate and major amputation rate were determined. Pain, quality of life, walking distance, and opioid usage were assessed before implantation (baseline), one, six, and 12 months (M) after implantation, and then annually (during a follow-up visit). Implant-related complications also were documented.

RESULTS

In total, 51 patients (37 men [mean age 68.9 ± 10.2 years], 14 women [mean age (68.7 ± 14.6 years]) underwent SCS (n = 49) or DRG-S (n = 2) implantation owing to persistent ischemic pain. The follow-up mean years ± SD is 4.04 ± 2.73. At baseline, patients were classified as Rutherford's category 3 (n = 23), category 4 (n = 15) or category 5 (n = 9). At 24 M, 42 of 47 patients did not require a major amputation after the implant. All the patients reported nearly complete pain relief from pain at rest. A total of 75% of patients were able to walk >200 m, and 87% of patients who used opioids at baseline were off this medication at 24 M. Overall, 93% of patients reported an improvement in their overall health assessment. These improved outcomes were sustained through years three to 10 for patients who have reported outcomes.

CONCLUSIONS

Our single-center data support the efficacy of spinal neuromodulation for improvements in limb salvage, pain relief, mobility, and quality of life. The data also show that neuromodulative therapy has a long-term therapeutic effect in patients with chronic limb pain with Rutherford category 3, 4, and 5 PAD.

Understanding Gangrene in the Context of Peripheral Vascular Disease: Prevalence, Etiology, and Considerations for Amputation-Level Determination

Gangrene is a grave complication of peripheral vascular disease (PVD), characterised by tissue necrosis due to inadequate blood supply. This review article comprehensively explores gangrene in PVD, encompassing its prevalence, aetiology, clinical presentation, diagnostic modalities, management strategies, prognosis, and future directions. Key factors influencing outcomes, including the timeliness of intervention and the choice between limb salvage and amputation, are identified. Moreover, this review underscores the importance of early detection and multidisciplinary care, emphasising the significance of patient-centred approaches. It also calls for increased awareness, continued research, and innovative solutions to improve the lives of individuals grappling with gangrene in the context of PVD.

Evaluation of endovascular treatment of chronic limb-threatening ischemia for patients in the PLAN gray zone

OBJECTIVE

To compare the results of endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients categorized under the gray and yellow zones of the patient risk, limb severity, and anatomic pattern (PLAN) concept over a 2-year follow-up period.

METHODS

Patients who underwent endovascular therapy for peripheral artery disease and presented with CLTI from February 2017 to February 2019 were retrospectively reviewed. The patients were grouped into yellow and gray zones based on the PLAN concept. Preoperative and postoperative walking distances, Rutherford classes, and postoperative target vessel patency rates were recorded and compared between the groups. Follow-up evaluations were performed at 1, 6, 12, and 24 months post-procedure.

RESULTS

Of the 387 patients evaluated, the yellow and gray groups comprised 88 patients each. The overall patency rates were similar between the groups (84 (95.45%) vs. 81 (92.05%), respectively). The occlusion-/stenosis-free survival times, amputation-free survival time, and mean survival time were not significantly different. However, the gray group had a significantly higher number of atherectomy interventions (74 vs. 59) and crosser devices used (62 vs. 42).

CONCLUSION

Endovascular therapy is an effective treatment option for patients in the gray zone of the PLAN color coding system.

Clinical Outcome in Patients With High-grade Soft-tissue Sarcoma Receiving Prosthetic Replacement After Tumor Resection of the Lower Extremities: Tokai Musculoskeletal Oncology Consortium Study

AIM

This multicenter retrospective study aimed to clarify the surgical and oncological outcomes of patients with high-grade soft tissue sarcoma (STS) who underwent prosthetic replacement reconstruction after lower extremity tumor resection.

PATIENTS AND METHODS

We retrospectively collected the data of 27 patients with high-grade STS. The mean follow-up duration after prosthetic replacement was 44.7 months.

RESULTS

The mean age at surgery was 63 years. The mean tumor size was 16 cm. For reconstruction, proximal femur replacement was performed in 15 patients, distal femur replacement in six, and total femur replacement in six. The major complications were infections in nine patients and aseptic loosening in four. Nine patients developed local recurrence. The cause of revision surgery was infection in five patients, aseptic loosening in three, and metal allergy in one. The 5-year prosthetic survival rate was 51.1%. At the final follow-up, amputation was performed in five patients. The 5-year limb salvage rate was 76.8%. The mean functional score of the 25 patients who could be assessed was 16.0 (53%). Of the 27 patients, five were excluded from the survival analysis because they underwent prosthetic replacement for local recurrence. The 5-year overall survival rate in the remaining 22 patients was 45.3%.

CONCLUSION

We identified a high rate of surgical complications and poor survival in patients with high-grade STS who underwent tumor resection and reconstruction using prosthetic replacement of the lower extremities, although limb salvage was achieved in 81.5% of the patients. Careful follow-up is needed for surgical complications and oncological events after surgery.

Amputation and limb salvage following endovascular and open surgery for the treatment of peripheral artery illnesses: A meta-analysis

A meta-analysis investigation was executed to measure the outcome of endovascular surgery (ES) and open surgery (OS) for the management of peripheral artery diseases (PADs) on amputation and limb salvage (LS). A comprehensive literature inspection till February 2023 was applied and 3451 interrelated investigations were reviewed. The 31 chosen investigations enclosed 19 948 individuals with PADs were in the chosen investigations' starting point, 8861 of them were utilising ES, and 11 087 were utilising OS. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of ES and OS for the management of PADs on amputation and LS by the dichotomous approaches and a fixed or random model. ES had significantly lower amputation (OR, 0.80; 95% CI, 0.68-0.93, P = 0.005) compared with those with OS in individuals with PADs. No significant difference was found between ES and OS in 30-day LS (OR, 0.95; 95% CI, 0.64-1.42, P = 0.81), 1-year LS (OR, 1.06; 95% CI, 0.81-1.39, P = 0.68), and 3-year LS (OR, 0.86; 95% CI, 0.61-1.19, P = 0.36) in individuals with PADs. ES had significantly lower amputation, 30-day LS, 1-year LS, and 3-year LS compared with those with OS in individuals with PADs. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Optimizing Traumatic Limb Salvage: Ectopic Implantation and Staged Rotationplasty

Rotationplasty, a limb-saving procedure involving a 180-degree ankle rotation to function as a knee joint, is now standard for treating distal femur osteosarcoma. However, challenges related to self-identification persist within the Asian population. This study presents a case involving the successful application of temporary ectopic implantation followed by staged rotationplasty after a severe traumatic amputation, resulting in a favorable outcome. Additionally, a systematic review is conducted to summarize the various difficulties and complications encountered in different studies. This approach improves the feasibility of rotationplasty in traumatic cases and enhances patient and family comprehension.

Hospital Readmission in Patients With Diabetic Foot Ulcers: Prevalence, Causes, and Outcomes

The aim of the current study was to evaluate the rate of readmission in patients affected by diabetes and foot ulcers (DFUs), and causes and outcomes of patients requiring a new hospitalization. The current study is a retrospective observational study including patients who have required hospitalization since January 2019 to September 2022 due to a DFU. Once patients were discharged, they were regularly followed as outpatients. Within 6 months of follow-up, the rate of hospital readmission for a diabetic foot problem was recorded. According to the readmission or not, patients were divided into 2 groups, readmitted and not readmitted patients, respectively. Hence, all patients were followed for 6 months more and outcomes of the 2 groups were analyzed and compared. Overall, 310 patients were included. The mean age was 68  ±  12 years, the majority of patients reported type 2 diabetes (>90%), and the mean diabetes duration was approximately 20 years. Sixty-eight (21.9%) patients were readmitted. The main reason for hospital readmission was the presence of critical limb ischemia (CLI) in the contralateral limb (6.1%), the recurrence of CLI in the previous treated limb (4.5%), and the onset of new infected DFU in the contralateral foot (4.5%). Readmitted patients reported lower rate of healing (51.5% vs 89.2%, P < .0001) and higher rate of major amputation (10.3% vs 4.5%, P  =  .2) in comparison to not readmitted patients. Critical limb ischemia resulted in the only independent predictor of hospital readmission. Hospital readmission is a frequent issue among patients with DFUs, and readmitted patients showed a lower chance of wound healing. Critical limb ischemia resulted in the main cause of new hospitalization.

Proximal femoral tumor resection followed by joint prosthesis replacement: a systematic review and meta-analysis

BACKGROUND

This study aimed to determine the prognostic outcome of hip joint replacement after resection of proximal femoral tumors by reviewing original studies.

METHODS

Two researchers independently searched PubMed, Embase, Cochrane Library, and Web of Science databases from inception to July 17, 2022. Then, the literature was screened by inclusion criteria. The basic information, primary outcomes, and secondary outcomes were extracted for weighted combined analysis. The quality of the included literature was evaluated using the Newcastle-Ottawa scale.

RESULTS

Twenty-four retrospective cohort studies comprising 2081 patients were included. The limb salvage rate was 98%. The survival rates at 1, 2, 3, 4, and 5 years were 80, 72, 65, 64, and 55% for patients with primary tumors and the rate at 1, 2, 3, 4, and 5 years were 44, 25, 17, 14, and 11% for patients with bone metastases, respectively.

CONCLUSION

As chemotherapy and radiotherapy treatment progressed, joint reconstruction after proximal femoral tumor resection improved patients' function and quality of life.

Effect of adjunctive prophylactic macrolides used at the caesarean section on endometritis and surgical site wound infection: A meta-analysis

A meta-analysis investigation was executed to measure the outcome of adjunctive prophylactic macrolides (APM) used at caesarean section (CS) on endometritis and surgical site wound infection (SSWI). A comprehensive literature inspection till February 2023 was applied and 1023 interrelated investigations were reviewed. The 10 chosen investigations enclosed 22 676 females with CS were in the chosen investigations' starting point, 14 034 of them were utilising APM, and 8642 were utilising control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of APM used at CS on endometritis and SSWI by the dichotomous approaches and a fixed or random model. Adjunctive prophylactic macrolides had significantly lower SSWI (OR, 0.43; 95% CI, 0.34-0.55, P < .001), and endometritis (OR, 0.34; 95% CI, 0.20-0.60, P = .005) compared with those with control in females with CS. Adjunctive prophylactic macrolides had significantly lower SSWI, and endometritis compared with those with control in females with CS. However, care must be exercised when dealing with its values because of the low number of nominated investigations for the meta-analysis.

3D-Printed Modular Endoprosthesis Reconstruction Following Total Calcanectomy in Calcaneal Malignancy

BACKGROUND

The use of 3D-printed endoprosthesis has been proposed as a viable limb-salvage procedure following total calcanectomy in patients with calcaneal malignancy. However, certain drawbacks persist concerning the prosthetic design. In this case series, we designed a modular endoprosthesis incorporating a novel drainage system, aiming to improve the functional outcomes and to promote wound healing.

METHODS

We retrospectively analyzed patients with calcaneal malignancy who underwent 3D-printed modular endoprosthesis reconstruction. Clinically, we evaluated functional outcomes using the 10-cm visual analog scale (VAS) score, the 1993 version of the Musculoskeletal Tumor Society (MSTS-93) score, and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Complications were also recorded.

RESULTS

Five male patients met the final inclusion criteria. The median age was 20 years (range 13-47 years). The median follow-up time was 28 months (range, 13-65 months). Median postoperative functional MSTS-93, VAS, and AOFAS scores were 27 points (range, 25-29), 0 points (range, 0-1), and 86 points (range, 83-93), respectively. Wound healing was observed in all patients, and there were no complications related to the endoprosthesis at the last follow-up.

CONCLUSION

The use of 3D-printed modular endoprosthesis was associated with satisfactory short-term outcomes in patients undergoing calcaneal reconstruction. The incorporation of a novel design featuring an integrated draining system has the potential to enhance wound healing and expedite functional recovery.

LEVEL OF EVIDENCE

Level IV, case series.

A novel Canadian multidisciplinary acute care pathway for people hospitalised with a diabetic foot ulcer

This manuscript describes the implementation and initial evaluation of a novel Canadian acute care pathway for people with a diabetic foot ulcer (DFU). A multidisciplinary team developed and implemented an acute care pathway for patients with a DFU who presented to the emergency department (ED) and required hospitalisation at a tertiary care hospital in Canada. Processes of care, length of stay (LOS), and hospitalisation costs were considered through retrospective cohort study of all DFU hospitalizations from pathway launch in December 2018 to December 2020. There were 82 DFU-related hospital admissions through the ED of which 55 required invasive intervention: 28 (34.1%) minor amputations, 16 (19.5%) abscess drainage and debridement, 6 (7.3%) lower extremity revascularisations, 5 (6.1%) major amputations. Mean hospital LOS was 8.8 ± 4.9 days. Mean hospitalisation cost was $20 569 (±14 143): $25 901 (±15 965) when surgical intervention was required and $9279 (±7106) when it was not. LOS and hospitalisation costs compared favourably to historical data. An acute care DFU pathway can support the efficient evaluation and management of patients hospitalised with a DFU. A dedicated multidisciplinary DFU care team is a valuable resource for hospitals in Canada.

Permanent Resection Arthroplasty of the Knee as Limb Salvage Following Recurrent Periprosthetic Infection Complicated with Osteomyelitis

Introduction

Permanent resection or excision arthroplasty of the knee involves the removal of any infected prosthetic material and thorough debridement, with no further reimplantation. The more common alternatives to permanent resection arthroplasty include knee arthrodesis or above-knee amputation (AKA).

Case Report

We describe two cases of complex periprosthetic infections of the knee associated with subsequent osteomyelitis, which were unsuitable for re-revision arthroplasty. Both patients chose to remain with an excision arthroplasty, rather than undergo arthrodesis or AKA, respectively, and were satisfied with their quality of life at long-term follow-up.

Conclusion

Although permanent resection arthroplasty of the knee is rarely performed, it remains a limb salvage option in certain cases where bone loss is limited, functional demands are low, and further surgery may present a significant risk.

The Opportunity for Impactful Integration of Vascular and Podiatric Care

BACKGROUND

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care.

METHODS

Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure.

RESULTS

From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed.

CONCLUSIONS

We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Limb Salvage and Survival in Chronic Limb-Threatening Ischemia: The Need for a Fast-Track Team-Based Approach

Chronic limb-threatening ischemia (CLTI) represents the end-stage form of peripheral arterial disease (PAD) and is associated with a very poor prognosis and high risk of limb loss and mortality. It can be considered very similar to a terminal cancer disease, reflecting a large impact on quality of life and healthcare costs. The aim of this study is to offer an overview of the relationship between CLTI, limb salvage, and mortality, with a focus on the need of a fast-track team-based management that is a driver to achieve better survival results. This review can be useful to improve management of this growing impact disease, and to promote the standardisation of care and communication between specialist and non-specialist healthcare professionals.

A Novel Orthoplastic Reconstruction of Relapsed Clubfoot With Total Ankle Arthroplasty

Congenital clubfoot is addressed in infancy and rarely persists into adulthood. Ankle arthroplasty is an increasingly popular surgical intervention for patients with ankle arthritis since it allows a natural ankle range of motion and completely replaces a degenerative hindfoot. Here, we describe the first successful total ankle arthroplasty (TAA) for a patient with previously treated congenital clubfoot that reverted later in life. To address the patient's poor soft-tissue integument and reduce the likelihood of post-surgical complications, a perioperative latissimus muscle-free flap was performed. This two-staged, novel orthoplastic intervention addressed our patient's ankle issues and appears to be a viable option for clubfoot patients.

Limb Salvage Surgery in a Voluminous Malignant Quadriceps Tumor

It is uncommon for soft tissue sarcomas to develop after adenocarcinoma of the rectum. In a treated rectal adenocarcinoma patient, we encountered a huge malignant quadriceps tumor as leiomyosarcoma and salvaged the limb. A 49-year-old male known case of treated moderately differentiated adenocarcinoma of the rectum presented in the Orthopedic Clinic with a new swelling in his left thigh. MRI of the left lower limb was obtained, and it demonstrated a large 15.8 x 13.2 x 30 cm well-defined mixed solid cystic lesion in the anterolateral aspect of the left mid-thigh without the involvement of adjacent bony cortex. Limb salvage surgery with wide local excision of the tumor was done. The patient was ambulated full weight from the very next day with a Musculoskeletal Tumor Society Score (MSTS) score of 20. Despite the massive size of the tumor, limb salvage was attempted successfully and achieved good functional status.

Prevalence of Peripheral Arterial Disease in Diabetic Foot Ulcer Patients and its Impact in Limb Salvage

Diabetic foot ulcer syndrome is a common complication of diabetes mellitus. Three main factors contribute to it: neuropathy, vasculopathy, and infection. This study was conducted to evaluate the prevalence of peripheral arterial disease (PAD) in diabetic foot ulcer patients and its impact on limb salvage as an outcome. This prospective cross-sectional study included 392 cases, who were divided according to the presence of PAD into 2 groups; patients with PAD were labeled as PAD +ve (172 cases) and those without PAD were labeled as PAD -ve (22 cases). All cases were clinically assessed, and routine laboratory examinations were ordered. Moreover, duplex ultrasound was done for suspected cases of having PAD by examination. Computed tomography angiography was ordered for patients who are in need of a revascularization procedure. Cases were managed by debridement and/or revascularization. After that, these cases were assessed clinically and radiologically for vascularity and infection and the possibility for amputation was evaluated. Infection was classified using Wagner Classification System, and revascularization was decided according to the TASC II system. The incidence of PAD in cases with diabetic foot ulcer syndrome was 43.87%. No difference was detected between the 2 groups regarding age and gender (P > .05). The prevalence of smoking, hemodialysis, ischemic heart disease (IHD), and hypertension was more significantly higher in cases with PAD (P < .05). Revascularization procedures were only performed in cases that had documented severe PAD or chronic limb-threatening ischemia in addition to foot ulcer and/or infection. With regard to limb salvage, it was more significantly performed in cases without PAD (82.3% vs 48.3% in PAD cases; P < .001). Male gender, smoking, ankle-brachial pressure index, hemodialysis, IHD, neuropathy, HbA1C, PAD, and high Wagner classification were predictors of limb amputation (P < .05). PAD is associated with worse outcomes in diabetic foot ulcer patients. Not only does it constitute a great number among diabetic foot ulcer patients, but it also has a negative impact on limb salvage.

Ten-year experience with use of cryopreserved allografts for redo infrapopliteal bypass

INTRODUCTION

The aim of this study is to report the early and late outcomes of cryopreserved saphenous vein (CSV) in redo infrainguinal bypass and to investigate possible predictors of primary patency loss.

METHODS

All patients who underwent a redo bypass for critical limb ischemia from January 2010 to December 2020 were reviewed. Early and late complications were analyzed and included. The endpoints of the study were all cause mortality, major limb amputation, and primary patency (PP).

RESULTS

Data were collected from 95 patients. Among the entire cohort, 16 (16.8%) patients received a cryopreserved vessel bypass with anastomosis in the popliteal artery and 79 (83.2%) patients had cryopreserved vessel bypasses with distal anastomosis in tibial vessels. Median duration of follow-up was 73 months; during this, period estimated survival at 5 years was 80.5 ± 4% (95% CI, 78.0-91.2) and estimates of freedom from limb amputation was 90.3 ± 3.2% (95% CI, 87.3-98.1). Overall, the estimated primary patency of the bypass was 43.7 ± 6.7% (95% CI, 30.2-51.4). On multivariable analysis, intraprocedural tibial vessel angioplasty (HR = 2.3, p = 0.01), distal anastomosis in tibial vessels (HR = 3.6, p = 0.36), and the use of a composite graft (HR = 2.4, p = 0.01) were independently associated with loss of PP.

CONCLUSIONS

The use of CSV in redo bypass is an effective strategy in salvaging threatened lower extremities and in preventing or delaying limb amputation. Our results confirm that further attempts at revascularization are generally appropriate, even in technically changing patients.

Clinical outcomes after vascular reconstruction using synthetic grafts for limb salvage in patients with lower extremity sarcoma: a single-center retrospective experience

Introduction

Limb-salvage surgery has become the mainstream approaches for the treatment of sarcoma in the lower extremity. In cases where the sarcoma infiltrates the primary vessel, concurrent resection of the vessels and vascular reconstruction are required to ensure sufficient resection and preservation of limb function. The objective of this study is to assess the clinical outcomes of patients who underwent vascular reconstruction utilizing synthetic grafts for limb salvage, specifically in terms of postoperative complications and limb functional status.

Methods

Between September 2016 and October 2021, 15 consecutive patients who underwent 15 arterial and 3 venous reconstruction procedures were included in this retrospective study. Incidence of postoperative morbidity, graft patency, rate of limb salvage, and overall survival of patients were analyzed.

Results

The median follow-up was 12.5 months (range, 4.5-72.0). Graft thrombosis occurred in 5 patients (33.3%) and graft occlusion occurred in 3 patients (20.0%). The median overall survival was 28.0 months with the estimated 2-year and 5-year overall survival of 57.8% and 43.4% respectively. The 1-year and 2-year estimated patency rates of arterial reconstructions were 82.3% and 62.1%, respectively. None of the included patients with limb amputation were observed as a consequence of severe vascular complications, while two patients underwent amputation due to the repeat recurrence, resulting in a limb salvage rate of 86.7%.

Conclusion

Our results show that the combination of vascular reconstruction and oncologic resection is a feasible option for preserving limbs in cases of musculoskeletal sarcoma with vessel involvement in the lower extremity. When vascular reconstruction surgery is performed, synthetic substitutes can be effectively used with low perioperative morbidity and an acceptable rate of limb salvage.

The effects of high quality team medicine on outcomes of chronic limb-threatening ischemia patients with infrapopliteal bypass

OBJECTIVES

A team approach for treatment of patients with CLTI is used worldwide. However, the quality of team medicine is a concern. The Global Vascular Guidelines provide recommendations for high quality team medicine, but there is limited knowledge of the significance of team quality in CLTI treatment. The objective of this study is to evaluate the effects of team quality on clinical outcomes after infrapopliteal bypass.

METHODS

A retrospective analysis was performed in 337 patients who underwent 414 infrapopliteal bypasses under a team medicine approach at a single center between 2009 and 2021. In 2017, team medicine was reorganized for improvement of quality. Comparisons were made between before (Group 1; 160 patients, 195 limbs) and after (Group 2; 177 patients, 219 limbs) reorganization. The primary endpoints were limb salvage and wound healing after infrapopliteal bypass.

RESULTS

The patients included 227 males (67%) and had a median age of 76 [68-83] years. Diabetes mellitus was present in 67% and end-stage renal disease with hemodialysis in 37%. The follow-up rate was 96% in a mean follow-up period of 31±30 months. The 3-year limb salvage rate was significantly lower in Group 1 (before reorganization) than in Group 2 (after reorganization) (84% vs 95%, p = .001). The wound healing rates in the whole cohort were 72% at 6 months and 85% at 12 months, with no significant differences between the groups. In multivariate analysis, the risk factors for major amputation were treatment before reorganization (HR 2.68; p = .017), hemodialysis (HR 2.27; p = .017), and non-ambulatory status (HR 2.63; p = .005).

CONCLUSIONS

A reorganized team approach with the goal of higher quality was independently associated with reduced major amputation for patients with CLTI treated with infrapopliteal bypass. This result indicates the importance of a high quality team approach for success of this treatment.

Impact of Optimal Medical Therapy on Reintervention and Survival Rates after Endovascular Infrapopliteal Revascularization

Within this single-center cohort study, we investigated the impact of optimal medical therapy on all-cause mortality, major amputation-free survival and clinically driven target lesion revascularization (CD TLR) in 552 patients with peripheral arterial disease (PAD) undergoing endovascular infrapopliteal revascularization. From the overall cohort, 145 patients were treated for intermittent claudication (IC) and 407 were treated for critical limb ischemia (CLI). Optimal medical therapy (OMT) was defined as the presence of at least one antiplatelet agent, statin and ACE inhibitor or AT-2 antagonist based on guideline recommendations. About half (55.5%) of all patients were prescribed OMT at discharge, with a higher proportion in claudicants (62.1%) versus CLI patients (53.2%). Over three years of follow-up, survival was significantly better in patients with IC (80.6 ± 3.8% vs. 59.9 ± 2.9%; p < 0.001). There was a signal towards better survival in those patients receiving OMT (log-rank p = 0.09). Similarly, amputation-free survival (AFS) was significantly better in patients with IC (p = 0.004) and also in patients receiving OMT (78.8 ± 3.6%) compared to that in those without OMT (71.5 ± 4.2%; p = 0.046). Freedom from CD TLR within three years was significantly better in the IC group (p = 0.002), but there were no statistically significant differences for CD TLR dependent on the presence of OMT (p = 0.79). In conclusion, there is still an important underuse of OMT in patients undergoing infrapopliteal interventions, which is even more pronounced in CLI despite a signal for its benefit regarding all-cause mortality and major amputation-free survival.

New insights in lower limb reconstruction strategies

High Energy Musculoskeletal Traumas (HEMTs) represent a relevant problem for healthcare systems, considering the high social costs, and both the high morbidity and mortality. The poor outcomes associated with HEMT are related to the high incidence of complications, including bone infection, fracture malunion and non-union. The treatment of each of these complications could be extremely difficult. Limb reconstruction often needs multiple procedures, rising some questions on the opportunity in perseverate to try to save the affected limb. In fact, theoretically, amputation may guarantee better function and lower complications. However, amputation is not free of complication, and a high long-term social cost has been reported. A comprehensive literature review was performed to suggest possible ways to optimize the limb preservation surgeries of HEMT's complications in order to ameliorate their management.

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are "spare parts" that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function.

Level of Evidence

5.

Percutaneous deep venous arterialization with balloon angioplasty salvaged a life-threatening critical limb in a hemodialysis patient after repeated pedal angioplasty failed: A case report

Chronic limb-threatening ischemia (CLTI) with severe below-the-ankle (BTA) lesions is often difficult to revascularize with endovascular treatment (EVT) and surgical treatment. We present a case of successful limb salvage using percutaneous deep venous arterialization (pDVA) in a patient with CLTI whose BTA lesion reconstruction failed. A 57-year-old man with diabetes mellitus and end-stage renal failure on maintenance hemodialysis was referred to our hospital because of gangrene in the second and third toes of his left foot. EVT was repeated for the anterior tibial artery, posterior tibial artery (PTA), dorsal foot artery, and plantar artery lesions; however, revascularization below the ankle was unsuccessful. As the infection had spread to the sole of the foot, below-the-knee amputation was indicated, but the patient refused. Therefore, we performed pDVA on the left PTA simultaneously with a Lisfranc amputation. An arteriovenous fistula was created at the ankle joint using a Venous Arterialization Simplified Technique and a guidewire was inserted into the plantar vein. Balloon dilatation from PTA to the plantar vein was performed to complete the pDVA. Although repeated EVT was required to maintain blood flow in the pDVA, skin grafting was performed 3 months after the pDVA, the wound completely healed, and he was discharged 6 months after the DVA. The pDVA can be an option for limb salvage in patients with no-option CLTI who are confronted by imminent amputation.