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Sadangi S, Saraiya H, Salunke AA, Bharwani N, Patel K, Pandya S, Warikoo V, Pandya S. The surgical management and oncologic outcomes of patients with fungating soft tissue sarcoma treated at a tertiary cancer centre and review of literature. J Orthop 2024; 53:94-100. [PMID: 38495576 PMCID: PMC10940886 DOI: 10.1016/j.jor.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/09/2024] [Indexed: 03/19/2024] Open
Abstract
Background Currently there is limited literature available on fungating soft tissue sarcoma and its effect of outcomes. In the current study we evaluated the surgical management and oncologic outcomes of patient with fungating soft tissue sarcoma. Materials and methods This was a retrospective observational study of patients with fungating sarcoma between January 2015 till January 2019 at a tertiary cancer care centre. A total of 59 patients were considered of which 16 had metastasis at presentation. The duration of symptoms prior to presentation averaged 10.2 months (median, 7.2months; range, 1-57 months). Median tumor length was 10 cm. Results 56% patients underwent amputation and 44% were treated with limb salvage. Following limb salvage surgery in10 cases primary closure of defect was performed and 6 cases required skin grafting for closure of defect. In 6 patients local flap was used for coverage of defect and 4 patients required free flap surgery. Two-year overall survival (OS) of the study cohort were 52.2% and 58% respectively. Two-year disease free survival (DFS) and OS in 43 non metastatic patients at presentation was seen in 58%(95% CI,38%-74%) and 66.5%(95% CI,42%-81%) respectively. The two-year disease OS in 16 patients with metastasis at presentation was 33.2 %. On univariate analysis, tumor size and metastatic at presentation had significant effect on survival. Conclusion Tumor size and metastatic at presentation has significant impact on survival in these patients. The oncologic outcomes including Disease free survival, overall survival and local recurrence rates similar amongst the two surgical modalities (amputation versus limb salvage). Amputation rates are more amongst fungating soft tissue sarcoma but limb salvage can be attempted whenever feasible keeping tumor free surgical margins under consideration.
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Affiliation(s)
- Sudam Sadangi
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
| | - Hemant Saraiya
- Department of Onco-Plastic Surgery, The Gujarat Cancer and Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Abhijeet Ashok Salunke
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
| | - Nandlal Bharwani
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
| | - Keval Patel
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
| | - Shivam Pandya
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
| | - Vikas Warikoo
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
| | - Shashank Pandya
- Department of Surgical Oncology, The Gujarat Cancer and Research Institute (GCRI) Ahmedabad, Gujarat, India
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Matthay ZA, Pace WA, Smith EJ, Gutierrez RD, Gasper WJ, Hiramoto JS, Reilly LM, Conte MS, Iannuzzi JC. Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits. J Vasc Surg 2024; 79:1447-1456.e2. [PMID: 38310981 DOI: 10.1016/j.jvs.2024.01.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Inadequate vein quality or prior harvest precludes use of autologous single segment greater saphenous vein (ssGSV) in many patients with chronic limb-threatening ischemia (CLTI). Predictors of patient outcome after infrainguinal bypass with alternative (non-ssGSV) conduits are not well-understood. We explored whether limb presentation, bypass target, and conduit type were associated with amputation-free survival (AFS) after infrainguinal bypass using alternative conduits. METHODS A single-center retrospective study (2013-2020) was conducted of 139 infrainguinal bypasses performed for CLTI with cryopreserved ssGSV (cryovein) (n = 71), polytetrafluoroethylene (PTFE) (n = 23), or arm/spliced vein grafts (n = 45). Characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, and outcomes were recorded. Multivariable Cox proportional hazards and classification and regression tree analysis modeled predictors of AFS. RESULTS Within 139 cases, the mean age was 71 years, 59% of patients were male, and 51% of cases were nonelective. More patients undergoing bypass with cryovein were WIfI stage 4 (41%) compared with PTFE (13%) or arm/spliced vein (27%) (P = .04). Across groups, AFS at 2 years was 78% for spliced/arm, 79% for PTFE, and 53% for cryovein (adjusted hazard ratio for cryovein, 2.5; P = .02). Among cases using cryovein, classification and regression tree analysis showed that WIfI stage 3 or 4, age >70 years, and prior failed bypass were predictive of the lowest AFS at 2 years of 36% vs AFS of 58% to 76% among subgroups with less than two of these factors. Although secondary patency at 2 years was worse in the cryovein group (26% vs 68% and 89% in arm/spliced and PTFE groups; P < .01), in patients with tissue loss there was no statistically significant difference in wound healing in the cryovein group (72%) compared with other bypass types (72% vs 87%, respectively; P = .12). CONCLUSIONS In patients with CLTI lacking suitable ssGSV, bypass with autogenous arm/spliced vein or PTFE has superior AFS compared with cryovein, although data were limited for PTFE conduits for distal targets. Despite poor patency with cryovein, wound healing is achieved in a majority of cases, although it should be used with caution in older patients with high WIfI stage and prior failed bypass, given the low rates of AFS.
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Affiliation(s)
- Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - William A Pace
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J Smith
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda M Reilly
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
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3
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Liu IH, El Khoury R, Hiramoto JS, Gasper WJ, Schneider PA, Vartanian SM, Conte MS. Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program. J Vasc Surg 2024; 79:1438-1446.e2. [PMID: 38401777 DOI: 10.1016/j.jvs.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. METHODS This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). RESULTS Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. CONCLUSIONS In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.
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Affiliation(s)
- Iris H Liu
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Rym El Khoury
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Jade S Hiramoto
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Warren J Gasper
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Peter A Schneider
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Shant M Vartanian
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Michael S Conte
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA.
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Thomas B, Hackenberg RK, Krasniqi D, Eisa A, Böcker A, Gazyakan E, Bigdeli AK, Kneser U, Harhaus-Wähner L. [Modern concepts of interdisciplinary extremity reconstruction in open fractures]. Unfallchirurgie (Heidelb) 2024:10.1007/s00113-024-01437-x. [PMID: 38739196 DOI: 10.1007/s00113-024-01437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/14/2024]
Abstract
The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland.
| | - Roslind K Hackenberg
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Demir Krasniqi
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amr Eisa
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Arne Böcker
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Emre Gazyakan
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amir K Bigdeli
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Ulrich Kneser
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Leila Harhaus-Wähner
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
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5
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Limam K, Lucena T, Courtot L, Marot V, Cavaignac E. Distal femoral megaprosthesis fracture treated by RescueSleeve MEGASYSTEM-C. Orthop Traumatol Surg Res 2024; 110:103822. [PMID: 38266671 DOI: 10.1016/j.otsr.2024.103822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/04/2023] [Accepted: 12/19/2023] [Indexed: 01/26/2024]
Abstract
Escalating revision surgery after megaprosthesis knee replacement sometimes raises the question of "limb salvage". Here we present a salvage technique for megaprosthesis fracture at the junction between the stem and the metaphyseal component. In this young active patient, the short residual proximal femur was not loose and was difficult to extract without prosthetic escalation. The technique described here conserved the well-fixed primary stem and used a custom-made RescueSleeve MEGASYSTEM-C connection sleeve (Link, Hamburg, Germany) plus spacer and a standard epiphyseal implant. This semi-conservative procedure avoided femorotomy or larger morbid segmental femoral resection. It conserved maximal bone stock and achieved rapid functional recovery. To our knowledge, this is the first reported case of this technique using a custom-made connecting part to manage megaprosthesis fracture. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Kenza Limam
- Clinique universitaire du sport, CHU Purpan, hôpital Pierre-Paul-Riquet, place du Dr Baylac, 31059 Toulouse, France
| | - Thibaut Lucena
- Clinique universitaire du sport, CHU Purpan, hôpital Pierre-Paul-Riquet, place du Dr Baylac, 31059 Toulouse, France
| | - Louis Courtot
- Clinique universitaire du sport, CHU Purpan, hôpital Pierre-Paul-Riquet, place du Dr Baylac, 31059 Toulouse, France
| | - Vincent Marot
- Hospital Nostra Senyora de Meritxell, 17, Baixos, AD700 Escaldes-Engordany, Andorra
| | - Etienne Cavaignac
- Clinique universitaire du sport, CHU Purpan, hôpital Pierre-Paul-Riquet, place du Dr Baylac, 31059 Toulouse, France.
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Brennan C, Khan U. Ortho-plastic approaches to fracture related infection (FRI). J Orthop 2024; 51:39-45. [PMID: 38299063 PMCID: PMC10825925 DOI: 10.1016/j.jor.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/08/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024] Open
Abstract
When a plastic surgery opinion is sought to support orthopaedic colleagues, invaluable contributions to decision-making in fracture-related infection (FRI) can be made. We summarise the plastic surgeon's perspective on the most pertinent questions which are relevant when assessing infections as a sequelae of fractures: 1.) How to define the soft tissues involved. 2.) Local & free tissue cover: options & outcomes. 3.) What to do when flaps fail. 4.) When simple dressings are an option.
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Affiliation(s)
- Christie Brennan
- Plastic and Reconstructive Surgery Department, North Bristol NHS Trust, Southmead Hospital, Southmead Road, BS10 5NB, UK
| | - Umraz Khan
- Plastic and Reconstructive Surgery Department, North Bristol NHS Trust, Southmead Hospital, Southmead Road, BS10 5NB, UK
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7
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Fernando-Canavan L, Abraham P, Devlin N, Tran-Duy A. Health-related quality of life in patients with extremity bone sarcoma after surgical treatment: a systematic review. Qual Life Res 2024; 33:1157-1174. [PMID: 38079025 DOI: 10.1007/s11136-023-03554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 04/26/2024]
Abstract
PURPOSE We conducted a systematic review of studies reporting on measurement of health-related quality of life (HRQoL), with a special focus on the use of the preference-weighted instruments, in patients with extremity bone sarcoma treated with limb-salvage surgery or amputation. METHODS We searched MedLine, Embase, Cochrane Library and Web of Science for English-language studies reporting on HRQoL of patients with bone sarcoma from inception to 28 August 2023. All records found were independently reviewed by two reviewers. We used the Newcastle-Ottawa Scale (NOS) and the CONSORT 2010 checklist to assess the quality of the cohort and randomised studies, respectively. RESULTS The search identified 1225 records, of which 16 studies were included for data extraction. Only one study used a preference-weighted instrument for measuring HRQoL in a small sample of patients (n = 28). Ten studies used the generic SF-36 questionnaire, but no preference-weighted HRQoL based on SF-6D was derived from the SF-36 scores. Most studies comparing HRQoL between amputation and limb-salvage surgery reported no significant differences. Twelve cohort studies scored six or more out of nine points based on the NOS. The only randomised study scored 54% on the CONSORT 2010 checklist. CONCLUSIONS The approaches used to measure HRQoL were inconsistent and outcome scores varied substantially. Only one study used preference-weighted instruments for HRQoL measurement. Future research into the surgical treatment of extremity bone sarcoma should consider the use of preference-weighted instruments to measure HRQoL, which will therefore enable economic evaluation for the growing orthopaedic armamentarium of novel surgical interventions. REGISTRATION This systematic review was registered with the PROSPERO International prospective register of systematic reviews (CRD42021282380).
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Affiliation(s)
- Liam Fernando-Canavan
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Patrick Abraham
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Nancy Devlin
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - An Tran-Duy
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
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Rai V, Munazzam SW, Wazir NU, Javaid I. Revolutionizing bone tumor management: cutting-edge breakthroughs in limb-saving treatments. Eur J Orthop Surg Traumatol 2024; 34:1741-1748. [PMID: 38461457 DOI: 10.1007/s00590-024-03876-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/12/2024]
Abstract
Limb salvage surgery has revolutionized the approach to bone tumors in orthopedic oncology, steering away from historical amputations toward preserving limb function and enhancing patient quality of life. This transformative shift underscores the delicate balance between tumor eradication and optimal postoperative function. Primary and metastatic bone tumors present challenges in early detection, differentiation between benign and malignant tumors, preservation of function, and the risk of local recurrence. Conventional methods, including surgery, radiation therapy, chemotherapy, and targeted therapies, have evolved with a heightened focus on personalized medicine. A groundbreaking development in limb salvage surgery is the advent of 3D-printed patient-specific implants, which significantly enhance anatomical precision, stability, and fixation. These implants reduce soft tissue disruption and the associated risks, fostering improved osseointegration and correction of deformities for a more natural and functional postoperative outcome. Biological and molecular research has reshaped the understanding of bone tumors, guiding surgical interventions with advancements such as genomic profiling, targeted intraoperative imaging, precision targeting of molecular pathways, and immunotherapy tailored to individual tumor characteristics. In the realm of imaging technologies, MRI, CT scans, and intraoperative navigation systems have redefined preoperative planning, minimizing collateral damage and optimizing outcomes through accurate resections. Postoperative rehabilitation plays a crucial role in restoring function and improving the quality of life. Emphasizing early mobilization, effective pain management, and a multidisciplinary approach, rehabilitation addresses the physical, psychological, and social aspects of recovery. Looking ahead, future developments may encompass advanced biomaterials, smart implants, AI algorithms, robotics, and regenerative medicine. Challenges lie in standardization, cost-effectiveness, accessibility, long-term outcome assessment, mental health support, and fostering global collaboration. As research progresses, limb salvage surgery emerges not just as a preservation tool but as a transformative approach, restoring functionality, resilience, and hope in the recovery journey. This review summarizes the recent advances in limb salvage therapy for bone tumors over the past decade.
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Affiliation(s)
- Vikramaditya Rai
- Department of Orthopedics, Dr. Rajendra Prasad Government Medical College and Hospital, Himachal Pradesh, Tanda at Kangra, India.
| | | | | | - Irum Javaid
- Khyber Medical College, Hayatabad, Peshawar, Pakistan
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9
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Meloni M, Giurato L, Monge L, Miranda C, Scatena A, Ragghianti B, Silverii GA, Vermigli C, De Cassai A, Volpe A, Tramonta R, Medea G, Bordieri C, Falcone M, Stefanon L, Bernetti A, Cappella C, Gargiulo M, Lorenzoni V, Scevola G, Stabile E, Da Ros R, Murdolo G, Bianchini E, Gaggia F, Gauna C, Romeo F, Apicella M, Mantuano M, Monami M, Uccioli L. Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome. Acta Diabetol 2024; 61:543-553. [PMID: 38461443 DOI: 10.1007/s00592-024-02246-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024]
Abstract
The treatment of patients with diabetic foot ulcers (DFUs) is extremely complex, requiring a comprehensive approach that involves a variety of different healthcare professionals. Several studies have shown that a multidisciplinary team (MDT) approach is useful to achieve good clinical outcomes, reducing major and minor amputation and increasing the chance of healing. Despite this, the multidisciplinary approach is not always a recognized treatment strategy. The aim of this meta-analysis was to assess the effects of an MDT approach on major adverse limb events, healing, time-to-heal, all-cause mortality, and other clinical outcomes in patients with active DFUs. The present meta-analysis was performed for the purpose of developing Italian guidelines for the treatment of diabetic foot with the support of the Italian Society of Diabetology (Società Italiana di Diabetologia, SID) and the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD). The study was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. All randomized clinical trials and observational studies, with a duration of at least 26 weeks, which compared the MDT approach with any other organizational strategy in the management of patients with DFUs were considered. Animal studies were excluded. A search of Medline and Embase databases was performed up until the May 1st, 2023. Patients managed by an MDT were reported to have better outcomes in terms of healing, minor and major amputation, and survival in comparison with those managed using other approaches. No data were found on quality of life, returning-to-walking, and emergency admission. Authors concluded that the MDT may be effective in improving outcomes in patients with DFUs.
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Affiliation(s)
- Marco Meloni
- Department of Systems of Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
| | - Laura Giurato
- Department of Endocrinology and Diabetology, CTO Hospital, 00145, Rome, Italy
| | - Luca Monge
- AMD-Italian Association of Clinical Diabetologists, Milan, Italy
| | | | | | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy
| | | | - Cristiana Vermigli
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | | | | | | | - Gerardo Medea
- SIMG- Italian Society of General Medicine, Florence, Italy
| | | | - Marco Falcone
- Cisanello Hospital and University of Pisa, Pisa, Italy
| | | | | | - Cristina Cappella
- Associazione Di Volontariato Piede Diabetico Umbria ODV, Perugia, Italy
| | - Mauro Gargiulo
- University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | | | | | - Roberto Da Ros
- Azienda Sanitaria Universitaria Giuliana Isontina, Monfalcone, Italy
| | - Giuseppe Murdolo
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | - Eleonora Bianchini
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | - Francesco Gaggia
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | | | | | | | | | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy
| | - Luigi Uccioli
- Department of Systems of Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
- Department of Endocrinology and Diabetology, CTO Hospital, 00145, Rome, Italy
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10
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Öztürk R. Indication and surgical approach for reconstruction with endoprosthesis in bone-associated soft tissue sarcomas: Appropriate case management is vital. World J Clin Cases 2024; 12:2004-2008. [PMID: 38680267 PMCID: PMC11045499 DOI: 10.12998/wjcc.v12.i12.2004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas (STS) have unique features in terms of indication, surgical approach and follow-up, in terms of the management of these cases. Some STS are associated with bone and major neurovascular structures. Bone-associated STS are generally relatively large and relatively deep-seated. Additionally, the tendency for metastasis is high. In some cases, the decision about which structures to resect is difficult. These cases are often accompanied by poor oncological and surgical outcomes. Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field. The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery. Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.
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Affiliation(s)
- Recep Öztürk
- Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen 45143, Germany
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11
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Farhat T, Moussally K, Nahouli H, Hamad SA, Qaraya KA, Abdul-Sater Z, El Sheikh WG, Jawad N, Al Sedawi K, Obaid M, AbuKhoussa H, Nyaruhirira I, Tamim H, Hettiaratchy S, Bull AMJ, Abu-Sittah G. The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip. Confl Health 2024; 18:35. [PMID: 38658929 PMCID: PMC11040898 DOI: 10.1186/s13031-024-00596-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context. METHODS A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation. RESULTS The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union. CONCLUSIONS This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.
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Affiliation(s)
- Theresa Farhat
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Krystel Moussally
- Médecins Sans Frontières, Lebanon Branch Office, Middle East Medical Unit, Beirut, Lebanon
| | - Hasan Nahouli
- Division of Orthopedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Shahd Abu Hamad
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Khulood Abul Qaraya
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Zahi Abdul-Sater
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Walaa G El Sheikh
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Jawad
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon
| | - Khouloud Al Sedawi
- Operational Centre Brussels, Gaza mission, Médecins Sans Frontières, Gaza, Palestine
| | - Mohammed Obaid
- Operational Centre Brussels, Gaza mission, Médecins Sans Frontières, Gaza, Palestine
| | - Hafez AbuKhoussa
- Operational Centre Brussels, Gaza mission, Médecins Sans Frontières, Gaza, Palestine
| | - Innocent Nyaruhirira
- Operational Centre Brussels, Medical Department, Médecins Sans Frontières, Brussels, Belgium
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Shehan Hettiaratchy
- Centre for Blast Injury Studies, Imperial College London, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Imperial College London, London, UK
| | - Ghassan Abu-Sittah
- Global Health Institute, American University of Beirut, Gefinor Center Block D, 3rd floor, P.O. Box 11-0236, Riad El Solh, Beirut, 1107-2020, Lebanon.
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12
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Yoneda H, Takeda S, Saeki M, Iwatsuki K, Yamamoto M, Tatebe M, Hirata H. Utility of severity scoring systems for mangled upper limb salvage: A systematic review and meta-analysis. Injury 2024; 55:111447. [PMID: 38417237 DOI: 10.1016/j.injury.2024.111447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/18/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The purpose of scoring systems is to aid in the decision-making process of whether to salvage or amputate mangled extremities, but their efficacy for upper limbs is uncertain. In this study, we examined the predictive potential of scoring systems for upper limb salvage. METHODS Two investigators undertook a systematic search of 3 leading databases for English or Japanese literature from 1985, when the first scoring system to evaluate mangled extremities was proposed, until January 2022. To be eligible, studies must have had upper extremity limb salvage or amputation as an outcome, and identified the scoring system used and treatment outcome in individual cases. RESULTS Ten studies (N = 338) of the Mangled Extremity Scoring System (MESS) were ultimately included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95 % CI = 0.69-0.99) and 0.81 (0.65-0.91), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.95 (0.93-0.97). A subgroup analysis showed lower specificity in isolated vascular injuries. Scoring systems other than MESS were ineligible for the quantitative synthesis because none were examined in an adequate number of publications. CONCLUSION The pooled sensitivity and specificity for MESS were comparable to those reported for the lower extremities. The specificity suggests that limb salvage was achieved in at least 20 % of the patients whose MESS was above the threshold beyond which amputation is indicated. Given the likelihood of upper extremity functional limitations following amputation and the drawbacks of prostheses, we conclude that current scoring systems poorly predict salvageability of a mangled upper extremity and should not be used to justify amputation.
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Affiliation(s)
- Hidemasa Yoneda
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan.
| | - Shinsuke Takeda
- Orthopedic surgery of Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Masaomi Saeki
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Katsuyuki Iwatsuki
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Michiro Yamamoto
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Masahiro Tatebe
- Othopedic surgery of Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Hitoshi Hirata
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
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13
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Farrelly E, Tarapore R, Lindsey S, Wieland MD. Management of the Mangled Extremity. Surg Clin North Am 2024; 104:385-404. [PMID: 38453309 DOI: 10.1016/j.suc.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Mangled extremities represent one of the most challenging injuries. They indicate the need for a comprehensive trauma assessment to rule out coexisting injuries. Treatment options include amputation and attempts at limb salvage. Although both have been associated with chronic disability, new surgical techniques and evolving rehabilitation options offer hope for the future.
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Affiliation(s)
- Erin Farrelly
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA.
| | - Rae Tarapore
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Sierra Lindsey
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Mark D Wieland
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
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14
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Dagi AF, LaValley MN, Diaddigo SE, Wu JK, Bogue JT. Trends in orthoplastic operative exposure for plastic surgery residents in the United States. J Plast Reconstr Aesthet Surg 2024; 90:224-226. [PMID: 38387419 DOI: 10.1016/j.bjps.2024.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Recent trials have demonstrated clinical benefits to a combined orthoplastic approach for complex reconstructive surgery of the hand, upper and lower extremity. PURPOSE We sought to assess recent trends in exposure to orthoplastic-type procedures among plastic surgery residents training in the United States. METHODS Independent plastic surgery residents' case logs were extracted from the Accreditation Council for Graduate Medical Education (2011-2022). Select reconstructive procedure were taken as proxies for orthoplastic-type cases and analyzed by descriptive statistical analysis. RESULTS The average number of orthoplastic-type cases completed per resident per year increased from 168.2 to 189.2 (12.5% increase) between 2011-2022. The greatest increase was in exposure to peripheral nerve injury repair of the hand and upper extremity (22.6 to 39.1, 73% increase). As a proportion of total procedures during the study period, orthoplastic-type procedures remained relatively unchanged (range 9.5-10.4%). CONCLUSIONS Our findings suggest that plastic surgery residents may be increasingly well-prepared to contribute to orthoplastic care during and following their training. The steady proportion of cases that orthoplastic-type procedures represented over the study period suggests the increase in relevant orthoplastic case volume may be incidental and secondary to an overall rise among all procedures. Given evidence of the benefits of an orthoplastic approach, we recommend consideration of explicit benchmarks for orthoplastic training among plastic surgery residents.
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Affiliation(s)
- Alexander F Dagi
- Division of Plastic and Reconstructive Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Myles N LaValley
- Division of Plastic and Reconstructive Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Sarah E Diaddigo
- Division of Plastic and Reconstructive Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - June K Wu
- Division of Plastic and Reconstructive Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Jarrod T Bogue
- Division of Plastic and Reconstructive Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.
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15
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Messeder SJ, López-Peña G, Pepper C, Saratzis A. Biomimetic Stents for Infrainguinal Peripheral Arterial Disease: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2024; 67:468-479. [PMID: 37931680 DOI: 10.1016/j.ejvs.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/30/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Biomimetic stents are peripheral infrainguinal self expanding stents that mimic the anatomy of the vasculature and artery movement. They are indicated for use in infrainguinal arteries. This research aimed to synthesise all current evidence on the use of biomimetic stents as adjuncts for endovascular treatment of infrainguinal peripheral arterial disease (PAD), helping to guide clinical decision making. DATA SOURCES MEDLINE, Embase, CINAHL and Cochrane databases. REVIEW METHODS Random effects meta-analysis following PRISMA guidelines (PROSPERO registration CRD42022385256). Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist, and certainty assessment through the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Endpoints included primary patency, target lesion revascularisation, stent fracture, secondary patency, and Death at one year. RESULTS In total, 37 studies were included in the meta-analysis (33 cohort studies, two case series, and two randomised controlled trials [RCTs]), representing 4 480 participants. Of these, 34 studies included data on the Supera (81.5% of participants) and three studies reported data on the BioMimics 3D (18.5% of participants) stents. The pooled primary patency rate of 33 studies at one year follow up was 81.4% (95% confidence interval [CI] 78.7 - 83.9%), and the pooled target lesion revascularisation rate of 18 studies at one year was 12.2% (95% CI 9.6 - 15.0%). The certainty of evidence outcome rating as qualified by GRADE was very low for both. Only one study reported a positive stent fracture rate at one year follow up of 0.4% with a certainty of evidence outcome of low. CONCLUSION Using biomimetic stents for infrainguinal PAD may be associated with acceptable one year primary patency and target lesion revascularisation rates, with a near negligible one year stent fracture rate. Their use should be considered in those presenting with infrainguinal PAD undergoing endovascular revascularisation. A RCT is necessary to determine their clinical and cost effectiveness.
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Affiliation(s)
- Sarah Jane Messeder
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK; British Heart Foundation, Clinical Research Training Fellow, Leicester, UK.
| | - Gabriel López-Peña
- Leicester Vascular Institute, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | - Coral Pepper
- Library and Information Services, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
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16
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Harrington CJ, Dearden ME, McGlone P, Potter BK, Tintle SM, Souza JM. The Scope and Distribution of Upper Extremity Nerve Injuries Associated With Combat-Related Extremity Limb Salvage. J Hand Surg Am 2024:S0363-5023(23)00500-2. [PMID: 38219089 DOI: 10.1016/j.jhsa.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE Chronic pain and functional limitations secondary to nerve injuries are a major barrier to optimal recovery for patients following high-energy extremity trauma. Given the associated skeletal and soft tissue management challenges in the polytraumatized patient, concomitant nerve injuries may be overlooked or managed in delayed fashion. Whereas previous literature has reported rates of peripheral nerve injuries at <10% in the setting of high-energy extremity trauma, in our experience, the incidence of these injuries has been much higher. Thus, we sought to define the incidence, pain sequelae, and functional outcomes following upper extremity peripheral nerve injuries in the combat-related limb salvage population. METHODS We performed a retrospective review of all patients who underwent limb salvage procedures to include flap coverage for combat-related upper extremity trauma at a single institution between January 2011 and January 2020. We collected data on patient demographics; perioperative complications; location of nerve injuries; surgical interventions; chronic pain; and subjective, patient-reported functional limitations. RESULTS A total of 45 patients underwent flap procedures on 49 upper extremities following combat-related trauma. All patients were male with a median age of 27 years, and 96% (n = 47) of injuries were sustained from a blast mechanism. Thirty-three of the 49 extremities (67%) sustained associated nerve injuries. The most commonly injured nerve was the ulnar (51%), followed by median (30%) and radial/posterior interosseous (19%). Of the 33 extremities with nerve injuries, 18 (55%) underwent surgical intervention. Nerve repair/reconstruction was the most common procedure (67%), followed by targeted muscle reinnervation (TMR, 17%). Chronic pain and functional limitation were common following nerve injury. CONCLUSIONS Upper extremity peripheral nerve injury is common following high-energy combat-related trauma with high rates of chronic pain and functional limitations. Surgeons performing limb salvage procedures to include flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Colin J Harrington
- Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD.
| | - Marissa E Dearden
- Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD
| | - Patrick McGlone
- Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD
| | - Benjamin K Potter
- Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD
| | - Scott M Tintle
- Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD
| | - Jason M Souza
- Department of Plastic and Reconstructive Surgery & Orthopaedic Surgery, Ohio State University, Columbus, OH
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17
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Ormaechevarria A, Vega de Céniga M, Blanco J, Yáñez L, Fernández J, Estallo L. Critical Limb Ischaemia in Octogenarians: Treatment Outcomes Compared With Younger Patients. EJVES Vasc Forum 2024; 61:36-42. [PMID: 38312331 PMCID: PMC10837062 DOI: 10.1016/j.ejvsvf.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/29/2023] [Accepted: 12/28/2023] [Indexed: 02/06/2024] Open
Abstract
Objective A growing proportion of patients with chronic limb threatening ischaemia (CLTI) are elderly, the most challenging for management decisions. The aim was to study the patient profile and outcome of CLTI in octogenarian patients, comparing them with younger patients. Methods Retrospective cohort of consecutive patients hospitalised for CLTI with infrainguinal disease in a Spanish centre (2013-2020). Data on age, comorbidity, anatomical characteristics, and treatment were gathered. Patients were stratified according to age (<80 and ≥80 years). The primary outcomes were overall survival and limb salvage (LS), analysed using Kaplan-Meier and Cox regression. Results : A total of 512 patients were enrolled: 305 were <80 years old with mean age 69.7 ± standard deviation (SD) 8.2 years, and 207 were ≥80 years old with mean age 85.3 ± SD 3.6 years. Smoking and diabetes mellitus were more frequent in younger patients (78.0% vs. 45.4%, p < .001; 68.5% vs. 59.5%, p = .037 respectively). Older patients had a higher prevalence of heart and kidney disease (70.5% vs. 57.0%, p = .002; 39.6% vs. 24.3%, p < .001, respectively). The arterial disease was femoropopliteal or tibial in 68.9% and 31.1% in patients <80 years and 58.9% and 41.1% in patients ≥80 years (p = .021). In younger patients, conservative treatment was indicated in 18.0%, endovascular treatment (ET) in 41.6%, and open or hybrid surgery (OS) in 40.3%; in patients ≥80 years these were 36.9%, 37.4%, and 25.7%, respectively (p <. 001). Mean follow up was 23.3 ± SD 17.4 months. One and two year overall survival was 85.4% and 73.0% in younger patients and 64.1% and 51.3% in patients ≥80 years (p < .001). LS was 83.7% and 79% at the same times in younger patients and 75.3% and 72.1% in older ones (p = .045). In younger patients ET led to worse LS than OS (p = .005) but not in older patients (p = .29). Conclusion Patients ≥80 years with CLTI have higher comorbidity and lower life expectancy and receive conservative treatment more frequently than younger patients. ET and OS are associated with similar survival and LS in these older patients.
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Affiliation(s)
- Amaia Ormaechevarria
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - Melina Vega de Céniga
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - June Blanco
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - Laura Yáñez
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - June Fernández
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - Luis Estallo
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
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McCann LJ, Dickinson JD. Considerations in Charcot Reconstruction. Clin Podiatr Med Surg 2024; 41:141-151. [PMID: 37951671 DOI: 10.1016/j.cpm.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Charcot deformity is a challenging condition often leading to foot and ankle deformity that subsequently causes decreased function, ulceration, infection, and limb loss. There are various treatment measures to take into consideration when managing these patients. Treatment approaches range from conservative casting to surgical reconstruction. The authors believe that when faced with deformity, aggressive reconstruction to maintain a plantigrade foot and prevent loss of function is critical. Because of the nature of the Charcot condition, timing and fixation are often debated. This article discusses the authors' approach to Charcot reconstruction in a large integrated health care system.
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Affiliation(s)
- Luke J McCann
- Kaiser South San Francisco Medical Center, 1200 El Camino Real, South San Francisco, CA 94108, USA.
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19
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Marchese RM, Al-Humadi S, Ruland C, Komatsu DE, Khan F. Elbow sarcoma resection and triceps reconstruction with Achilles allograft: an overview, case report, and technique guide. JSES Int 2024; 8:217-221. [PMID: 38312285 PMCID: PMC10837695 DOI: 10.1016/j.jseint.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Affiliation(s)
- Richard M Marchese
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Samer Al-Humadi
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Christopher Ruland
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - David E Komatsu
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Fazel Khan
- Department of Orthopaedics and Rehabilitation, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
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20
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Geiger EJ, Jensen AR, Singh AS, Nelson SD, Bernthal NM. Use of neoadjuvant pexidartinib with limb salvage surgery for diffuse tenosynovial giant cell tumor: A case report. J Orthop Sci 2024; 29:458-462. [PMID: 36402606 DOI: 10.1016/j.jos.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/24/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Erik J Geiger
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Andrew R Jensen
- Department of Orthopaedic Surgery, University of California-Los Angeles, Santa Monica, CA, USA
| | - Arun S Singh
- Department of Medicine, Division of Hematology-Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Scott D Nelson
- Departments of Pathology and Orthopaedic Surgery, University of California-Los Angeles, Santa Monica, CA, USA
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery, University of California-Los Angeles, Santa Monica, CA, USA
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21
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Liebetrau D, Teßarek J, Elger F, Zerwes S, Peters V, Scheurig-Münkler C, Hyhlik-Dürr A. Revascularization with BYCROSS atherectomy device- protocol of a prospective multicenter observational study. CVIR Endovasc 2023; 6:61. [PMID: 38051417 DOI: 10.1186/s42155-023-00404-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/14/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The BYCROSS™ device is a novel device intended for use in atherectomy of the peripheral arterial disease (PAD). With the BYCROSS™ atherectomy system, also prolonged calcifying lesions can be treated in a minimally invasive manner, which was previously reserved for bypass surgery. The aim of this study is to collect additional clinical data on safety and performance of the BYCROSS™ from patients undergoing revascularization of severely stenotic or occluded peripheral arterial vessels with the BYCROSS™. METHODS AND DESIGN This is an investigator-initiated national prospective multicenter observational study in patients with PAD. Sixty patients (20 per center) with PAD with stenosis higher than 80% or complete occlusion (de novo or recurrent stenosis) of vessels below the aortic bifurcation (min 3 mm vessel diameter) will be recruited. Three vascular surgery centers are participating in the study. The primary efficacy endpoint is procedural success, defined as passage of the occlusion through the BYCROSS device, and safety outcomes, explicated as freedom from device-related serious adverse events (SADEs). Secondary endpoints include primary and secondary patency rates, change in Rutherford classification, and freedom from amputation at 3 and 12 months. DISCUSSION The BYCROSS atherectomy system may be a novel device for the minimally invasive treatment of prolonged calcified lesions previously reserved for bypass surgery. This national prospective multicenter observational study could represent another step in demonstrating the efficancy and safety of this device for treatment of PAD. TRIAL REGISTRATION #DRKS00029947 (who.int). PROTOCOL APPROVAL ID: #22-0047(Ethics Committee at Ludwig-Maximilians-University Munich).
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Affiliation(s)
- Dominik Liebetrau
- Vascular Surgery, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Joerg Teßarek
- Vascular Surgery, Bonifatius Hospital Lingen, Wilhelmstraße 13, 49808, Lingen (Ems), Germany
| | - Florian Elger
- Thoracic and Vascular Surgery, Medical Faculty, University Medical Center Goettingen, Robert-Koch-Straße, 4037075, Goettingen, Germany
| | - Sebastian Zerwes
- Vascular Surgery, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Viktoria Peters
- Vascular Surgery, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Christian Scheurig-Münkler
- Department of Diagnostic and Interventional Radiology, University Hospital of Augsburg, Augsburg, Germany
| | - Alexander Hyhlik-Dürr
- Vascular Surgery, Medical Faculty, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
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Raj M, Arnav A, Pal AK, Mondal S. Global Research Trends in Limb Salvage Surgery for Osteosarcoma: Findings from a Bibliometric and Visualized Analysis over 15 Years. Indian J Orthop 2023; 57:1927-1948. [PMID: 38009167 PMCID: PMC10673777 DOI: 10.1007/s43465-023-01005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 09/21/2023] [Indexed: 11/28/2023]
Abstract
Background Limb salvage surgery in osteosarcoma requires a multidisciplinary team of experts, due to which research interest has remained limited globally. This article analyzes research trends over 15 years from 2007 to 2022. Materials and Methods Publications on limb salvage surgery in osteosarcoma were retrieved using the Web of Science. Bibliometric analysis of the publication metadata was done using R software. VOS viewer software was used to analyze the bibliographic coupling, co-citation, co-authorship, and co-occurrence to report the current trends in global research on limb salvage surgery in osteosarcoma. Results A total of 693 articles were retrieved. On applying the inclusion and exclusion criteria, a publication metadata of 276 articles was analyzed using the methodology mentioned. Annual scientific production on the subject has shown a steady rising trend globally. China has the highest number of publications on the topic; however, the USA has the highest citations globally. The Journal "Clinical Orthopedics and Related Research" remains the pioneer in the topic with the highest number of publications and H index among all journals. Most of the research interest is generated in the developed countries of the USA, Europe, and China. Keyword analysis suggested 4 clusters of surgical reconstruction, Survival, Chemotherapy, and general management related. Newer keywords such as biological reconstructions, allograft, metastases, cell, and chemotherapy suggest future research topics in the field. Conclusion Research interest in limb salvage surgery in osteosarcoma continues to grow with the introduction of concepts such as biological reconstructions and allografts. However, for more inclusive research on the topic, research interest must also be encouraged in underdeveloped and developing countries.
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Affiliation(s)
- Manish Raj
- Department of Orthopaedics, All India Institute of Medical Sciences, Deoghar, India
| | - Amiy Arnav
- Department of Surgical Oncology, All India Institute of Medical Sciences, Deoghar, India
| | - Arup Kumar Pal
- Department of Computer Science and Engineering, Indian Institute of Technology (ISM), Dhanbad, India
| | - Shukla Mondal
- Department of Computer Science and Engineering, Indian Institute of Technology (ISM), Dhanbad, India
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23
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Deviandri R, Rifardi D, Pratama K, Harahap DR, Alpharian GT. Successful megaprosthesis in a nearly amputated lower extremity after crush injury: A case report and literature review. Trauma Case Rep 2023; 48:100942. [PMID: 37846227 PMCID: PMC10577054 DOI: 10.1016/j.tcr.2023.100942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/18/2023] Open
Abstract
Crush injury is one of the most challenging decisions for a surgeon to decide whether to proceed with an amputation or salvage a limb. We presented a 24-year-old man who complained of having suffered a crushed thigh 12 h before admission to the hospital. The patient was driving a truck and hit the iron bridge barrier, which penetrated his left thigh. The patient's left foot was cold, pallid, and pulseless, with a MESS score of 11. The femur x-ray showed a displaced fracture of the left femur associated with a 15 cm bone defect. The patient was diagnosed with a crush injury on the left femur with vascular compromise. We performed a proximal femoral megaprosthesis for a crush injury on the lower extremity, After the sixth year's follow-up, it shows a good outcome and increased quality of life for this patient. In addition, there was an improvement in the Harris Hip Score and EQ5D score. Megaprosthesis used to treat a crush injury revealed good functional outcomes despite the MESS score of 11. A multi-professional approach to the patient is essential for decision-making regarding limb salvage rather than the use of a score.
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Affiliation(s)
- Romy Deviandri
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Physiology, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia
- Department of Surgery, Division of Orthopedics, Faculty of Medicine, Universitas Riau, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - Dhandia Rifardi
- Department of Surgery, Division of Orthopedics, Faculty of Medicine, Universitas Riau, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - Kevin Pratama
- Department of Surgery, Division of Orthopedics, Faculty of Medicine, Universitas Riau, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - Dedi Rahmad Harahap
- Department of Surgery, Division of Orthopedics, Faculty of Medicine, Universitas Riau, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - Gibran Tristan Alpharian
- Department of Orthopedics, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
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Stauss R, Graulich T, Omar Pacha T, Omar M. [Limb-sparing resection of axillary soft tissue sarcomas]. Oper Orthop Traumatol 2023; 35:377-389. [PMID: 37462680 DOI: 10.1007/s00064-023-00824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/09/2023] [Accepted: 06/09/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE For patients with soft tissue sarcoma, surgical resection is a key element of curative therapy. Surgery is performed as a wide resection with microscopically negative margins (R0 resection) and as limb-sparing procedure whenever possible to preserve maximum function. INDICATIONS Soft tissue sarcoma, metastases. CONTRAINDICATIONS Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care. SURGICAL TECHNIQUE Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus. POSTOPERATIVE MANAGEMENT Shoulder abduction brace for 6 weeks, passive mobilization for 6-12 weeks followed by active mobilization. Compression sleeve. Oncological follow-up. RESULTS Between 2017 and 2022, wide resection was performed in 6 consecutive cases including 4 primary soft tissue sarcomas and 2 metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5 months (3-60 months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.
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Affiliation(s)
- Ricarda Stauss
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
- Klinik für Unfallchirurgie, Sarkom-Zentrum, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Tilman Graulich
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Tarek Omar Pacha
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Mohamed Omar
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
- Klinik für Unfallchirurgie, Sarkom-Zentrum, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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25
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Kumar GR, Krishnan CK, Muralidharan K, Sundersingh S, Murugesan K, Raja A. Limb Salvage Surgery in a Rare Case of Recurrent Parosteal Osteosarcoma with Vascular Graft Thrombosis. Vasc Specialist Int 2023; 39:33. [PMID: 37927145 PMCID: PMC10626314 DOI: 10.5758/vsi.230058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
Recurrent parosteal sarcomas with vascular involvement are rare and present unique challenges in their diagnosis and management. We report the case of a 21-year-old woman with parosteal osteosarcoma of the left distal femur, encasing the popliteal vessels. En bloc transarticular resection of the distal femur and popliteal vessels was performed, followed by reconstruction using a modular prosthesis and a saphenous vein autograft for both the artery and vein. On the 1st postoperative day, the patient developed an arterial thrombus requiring reintervention with a jump polytetrafluoroethylene (PTFE) graft. Histopathology confirmed parosteal osteosarcoma. After a disease-free survival of 41 months, the patient experienced local recurrence involving the PTFE graft, leading to graft compression, erosion, and subsequent thrombosis. Despite these complications, limb salvage was possible due to adequate collateral blood supply. This case highlights the feasibility of limb salvage surgery in select cases of parosteal osteosarcoma with vascular involvement.
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Affiliation(s)
- Gaurav Ravi Kumar
- Department of Surgical Oncology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
| | - Chandra Kumar Krishnan
- Department of Surgical Oncology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
| | - Krishna Muralidharan
- Department of Vascular Surgery, Tamil Nadu Government Multi-Superspeciality Hospital, Omandurar Estate, Chennai, Tamil Nadu, India
| | - Shirley Sundersingh
- Departments of Onco-Pathology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
| | | | - Anand Raja
- Department of Surgical Oncology, Cancer Institute (W.I.A), Adyar, Chennai, Tamil Nadu, India
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Bhat S, Chia B, Barry IP, Panayi AC, Orgill DP. Free Tissue Transfer in Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 66:670-677. [PMID: 37500000 DOI: 10.1016/j.ejvs.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/10/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Free tissue transfer is a powerful reconstructive method for patients with substantial diabetic foot ulcers. This study aimed to perform an updated systematic review and meta-analysis investigating the flap characteristics, concurrent revascularisation rates, complications, and outcomes associated with free tissue transfer in diabetic foot ulcers. METHODS Two reviewers performed a systematic review of various databases since their inception, with no language restriction. Only data for free tissue transfer in non-traumatic diabetic foot ulcer patients were extracted from included studies where a heterogeneous population was studied. Outcome data were pooled using random effects meta-analysis for binomial data. RESULTS Of 632 studies identified, 67 studies encompassing 1 846 patients and 1 871 free flaps were included. A median of 18 patients [IQR 9, 37] per study, with a median age of 58.5 years [56, 63], were followed up for a median of 15 months [7, 25]. Most studies had serious risk of bias (n = 47 studies, 70%); sixteen (24%) had moderate risk of bias; and four (6%) had low risk of bias. The proportion of patients who underwent revascularisation was 75% (95% CI 60 - 87%; n = 36 studies) with a median time of 8 days between procedures. The pooled complete flap survival, major amputation, and ambulation rates were 88% (85 - 92%, n = 49 studies), 10% (7 - 14%, n = 50 studies), and 87% (80 - 92%, n = 36 studies), respectively. Death at individual study follow up was 6% (3 - 10%, n = 26 studies). The overall certainty of evidence was very low. CONCLUSION Free tissue transfer may be a useful treatment modality for recalcitrant diabetic foot ulcers in selected patients. Future studies should investigate long term functional outcomes and aim to develop patient selection algorithms to select the most suitable candidates for this procedure.
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Affiliation(s)
- Saiuj Bhat
- Department of Plastic and Reconstructive Surgery, Royal Perth Hospital, Perth, Australia; School of Medicine, The University of Western Australia, Crawley, Australia.
| | - Benjamin Chia
- Department of Plastic and Reconstructive Surgery, Royal Perth Hospital, Perth, Australia
| | - Ian P Barry
- Department of Plastic and Reconstructive Surgery, Royal Perth Hospital, Perth, Australia
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis P Orgill
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Özel M, Altintaş M, Tatliparmak AC, Yilmaz S, Ak R. The role of Mangled Extremity Severity Score in amputation triage in a transport health facility with catastrophic earthquake admissions. Injury 2023; 54:111003. [PMID: 37652779 DOI: 10.1016/j.injury.2023.111003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND The purpose of this study is to assess the diagnostic utility of the Mangled Extremity Severity Score (MESS) in the prediction of amputation after a major earthquake, and its utility in disaster triage. METHODS Study results were presented from a tertiary hospital in Diyarbakır, which was affected by the earthquake but served as a transport hub for other cities in the region affected by the earthquake. MESS was calculated and its diagnostic value is analyzed in predicting amputations. MESS scores were divided into low risk, intermediate risk, and high risk groups by the researchers based on their diagnostic value analysis. RESULTS 79 patients were included in the study. Based on the outcome of amputation or salvage, patients were divided into two groups. 24.1% (n = 19) of the patients had amputations. Both gender and mean age did not differ statistically significantly between the groups (p > 0.05). Compared with the salvage group, the amputation group had a significantly longer prehospital stay and higher rate of vascular injury and higher median MESS (p = 0.007, p < 0.001, p < 0.001; respectively). Based on MESS scores, amputation outcomes were predicted with an accuracy of 0.889 (95% CI 0.798-0.949). Those with a MESS score below 9 were considered low risk (sensitivity = 100%) whereas those with a MESS score above 12 were considered high risk (specificity = 98.33%). CONCLUSION In transport centers, MESS may be useful for surgical triage of earthquake-induced limb crush injuries.
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Affiliation(s)
- Mehmet Özel
- MD. Department of Emergency Medicine, Diyarbakır Gazi Yasargil Training and Research Hospital, University of Health Sciences, Diyarbakır, Turkey
| | - Mustafa Altintaş
- MD. Department of Orthopedic Surgery, Diyarbakır Gazi Yasargil Training and Research Hospital, University of Health Sciences, Diyarbakır, Turkey
| | | | - Sarper Yilmaz
- Department Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Rohat Ak
- Department Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, University of Health Sciences, İstanbul, Turkey.
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Ebeid WA, Badr IT, Mesregah MK, Hasan BZ. Outcomes of management of primary benign aggressive or malignant bone tumors around the elbow by limb-salvage surgery. J Exp Orthop 2023; 10:105. [PMID: 37870629 PMCID: PMC10593692 DOI: 10.1186/s40634-023-00675-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023] Open
Abstract
PURPOSE Bone tumors around the elbow are rare, with frequently delayed diagnosis. The current study aimed to assess the functional and oncological outcomes of limb salvage surgery for primary benign aggressive or malignant bone tumors around the elbow. METHODS We conducted a retrospective review of patients with primary aggressive benign and malignant bone tumors around the elbow treated with limb salvage surgery between 1995 and 2020 at a single musculoskeletal oncology center. The minimum follow-up period was 24 months. Functional results were assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the last follow-up visit. Local recurrence, chest metastasis, and complications were recorded. RESULTS This study included 30 patients, 19 males and 11 females, with a mean age of 25.4 ± 14.2 years. The tumor location was the distal humerus (n = 21), proximal radius (n = 5), and proximal ulna (n = 4). Reconstruction was done by elbow fusion using fibular graft (n = 10), mobile endoprosthesis (n = 9), excision arthroplasty (n = 7), and extracorporeal freezing and reimplantation (n = 4). The mean follow-up period was 36.2 ± 21.3 months. The median follow-up MSTS score was 27 [Interquartile range (IQR): 26-30]. Skeletally immature patients had a significantly higher MSTS score. The rate of postoperative complications was 26.7%. CONCLUSION Limb salvage surgery with different reconstructive options for benign aggressive and malignant bone tumors around the elbow can achieve good functional and oncological outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Walid Atef Ebeid
- Department of Orthopaedic Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ismail Tawfeek Badr
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt
| | - Mohamed Kamal Mesregah
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
| | - Bahaa Zakarya Hasan
- Department of Orthopaedic Surgery, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt
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Pomatto S, Faggioli G, Pini R, Ficarelli I, Pini A, Angherà C, Rocchi C, Caputo S, Vacirca A, Ruotolo C, Gargiulo M. Limb salvage and survival after urgent surgical treatment of popliteal artery aneurysm. World J Emerg Surg 2023; 18:49. [PMID: 37838652 PMCID: PMC10576300 DOI: 10.1186/s13017-023-00514-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/21/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Popliteal artery aneurysms (PAAs) need urgent treatment in case of acute thrombosis, distal embolization, or rupture. Few data are available in the literature about the treatment results in these scenarios. The aim of the present study was to evaluate an 11-year multicenter experience in the urgent treatment of PAAs. METHODS All symptomatic PAAs surgically treated in two vascular centers between 2010 and 2021 were retrospectively analyzed. In the postoperative period periodical clinical and Duplex-Ultrasound evaluation were performed. The evaluated endpoint was the outcome of urgent PAAs treatment according to their clinical presentation. Statistical analysis was performed by Kaplan-Meier log-rank evaluation and multivariable Cox regression tests. RESULTS Sixty-six PAAs needed an urgent repair. Twelve (18%) patients had a PAA rupture and 54 (82%) had an acute limb ischemia (ALI) due to either distal embolization or acute thrombosis. Patients with ALI underwent bypass surgery in 51 (95%) cases, which was associated with preoperative thrombolysis in 18 (31%) cases. A primary major amputation was performed in 3 (5%) cases. The mean follow-up was 52 ± 21 months with an overall 5-year limb salvage of 83 ± 6%. Limb salvage was influenced only by the number of patent tibial arteries (pTA) [5-years limb salvage 0%, 86 ± 10%, 92 ± 8% and 100% in case of 0, 1, 2 or 3 pTA, respectively (P = .001)]. An independent association of number of pTA and limb loss was found [hazard ratio (HR): 0.14 (95% confidence interval (CI) 0.03-0.6), P = .001]. Overall 5-year survival was 71 ± 7%. Ruptured PAAs were associated with lower 5-year survival compared with the ALI group (48 ± 2% vs. 79 ± 7%, P = .001). The number of pTA (33 ± 20%, 65 ± 10%, 84 ± 10% and 80 ± 10% for 0, 1, 2 and 3 pTA, respectively, P = .001) and the thrombolysis (94 ± 6% vs. 62 ± 10%, P = .03) were associated with higher survival in patients with ALI. There was an independent association of number of pTA and long-term survival [HR 0.15 (95% CI 0.03-0.8), P = .03]. CONCLUSIONS PAA rupture is the cause of urgent PAA treatment in almost one fifth of cases, and it is associated with lower long-term survival. ALI can benefit from thrombolysis, and long-term limb salvage and survival are associated with the number of pTA.
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Affiliation(s)
- Sara Pomatto
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Ilaria Ficarelli
- Division of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131, Naples, Italy
| | - Alessia Pini
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Cecilia Angherà
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Cristina Rocchi
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Stefania Caputo
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Carlo Ruotolo
- Division of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131, Naples, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
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Herold J, Notov D, Reeps C, Schaser KD, Kamin K, Mäder M, Kleber C. Limb salvage in traumatic hemipelvectomy: case series with surgical management and review of the literature. Arch Orthop Trauma Surg 2023; 143:6177-6192. [PMID: 37314526 PMCID: PMC10491572 DOI: 10.1007/s00402-023-04913-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/19/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Traumatic hemipelvectomies are rare and serious injuries. The surgical management was described in several case studies, with primary amputation often performed to save the patient's life. METHODS We report of two survivors with complete traumatic hemipelvectomy resulting in ischemia and paralyzed lower extremity. Due to modern emergency medicine and reconstructive surgery, limb salvage could be attained. Long-term outcome with quality of life was assessed one year after the initial accident. RESULTS AND CONCLUSIONS The patients were able to mobilize themselves and live an independent life. The extremities remained without function and sensation. Urinary continence and sexual function were present and the colostomy could be relocated in both patients. Both patients support limb salvage, even having difficulties and follow-up treatments. Concomitant cases are required to consolidate the findings. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J Herold
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - D Notov
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - C Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - K D Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - K Kamin
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - M Mäder
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - C Kleber
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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Lavía KF, Izquierdo Ó, Boccolini HS, Hernández R, Pérez G, Andrés M, Panadero M. Treatment of a case of septic tibial nonunion by the Capanna technique. Trauma Case Rep 2023; 47:100912. [PMID: 37637455 PMCID: PMC10458955 DOI: 10.1016/j.tcr.2023.100912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 08/29/2023] Open
Abstract
This report presents the case of a 25-year-old male with an infected tibial diaphyseal nonunion caused by a bone transport procedure carried out to treat an open fracture the patient had sustained 10 years before referral to our hospital. After an initial radical debridement, a bone defect was created, which was subsequently obliterated by placement of an antibiotic-impregnated cement spacer and Stimulan beads and covered by an anterolateral thigh flap. As the patient refused to wear an external fixator and his osseous biology was not amenable to a Masquelet procedure, a decision was made to apply the Capanna technique as soon as the infection healed. The second debridement resulted in a 12-cm-long bone defect that was filled with a tibial allograft and a vascularized fibular graft. At six months, the patient had regained full knee function and was able to bear his full weight, without pain or the need of support equipment. At one year, the bone had healed completely, the infection had subsided and the patient was able to resume his everyday activities. Although the Capanna technique was initially developed to reinforce reconstructions at risk of fracture or nonunion as a result of chemotherapy, its use in post-traumatic cases has been shown to be successful in a selected group of patents. Our study demonstrated that increasing the stability of a reconstruction with an allograft can accelerate the time to heal, and that using a vascularized fibular graft can enhance incorporation of the whole construct. It can be concluded that the Capanna technique is a valid treatment option for managing infected segmental bone defects in selected patients.
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Giusti JCG, Rossi FH, Cury MVM, Godoy MR, Palomo AT, Sacilotto R, Brochado Neto FC, Izukawa NM. Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia. J Vasc Surg 2023; 78:1021-1029.e3. [PMID: 37343730 DOI: 10.1016/j.jvs.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.
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Affiliation(s)
- Júlio César Gomes Giusti
- Department of Vascular and Endovascular Surgery, Hospital Municipal Dr. Carmino Caricchio - HMCC, São Paulo, São Paulo, Brazil.
| | - Fabio Henrique Rossi
- Department of Vascular and Endovascular Surgery, Instituto Dante Pazzanese de Cardiologia - IDPC, São Paulo, São Paulo, Brazil
| | - Marcus Vinicius Martins Cury
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Marcos Roberto Godoy
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Amanda Thurler Palomo
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Roberto Sacilotto
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Francisco Cardoso Brochado Neto
- Department of Vascular and Endovascular Surgery, Hospital Municipal Dr. Carmino Caricchio - HMCC, São Paulo, São Paulo, Brazil; Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Nilo Mitsuru Izukawa
- Department of Vascular and Endovascular Surgery, Instituto Dante Pazzanese de Cardiologia - IDPC, São Paulo, São Paulo, Brazil
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Plotnikovs K, Kamenska J, Movcans J, Pasters V, Solomin L, Plaudis H. Artificial Deformity Creation as a Method for Limb Salvage for Patients with Massive Tibial and Soft Tissue Defects: A Report of 26 Cases. Strategies Trauma Limb Reconstr 2023; 18:133-139. [PMID: 38404570 PMCID: PMC10891353 DOI: 10.5005/jp-journals-10080-1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/07/2023] [Indexed: 02/27/2024] Open
Abstract
Soft tissue and bone defects that occur consequence of high-energy trauma are serious and challenging problems. The aim of this retrospective cohort study is to show that the artificial deformity creation (ADCr) method allows the closure of soft-tissue defects, avoids amputation, and can facilitate the reconstruction of bone defects and restore limb length. Patients and methods Twenty-six adult patients (age range 20-81 years) with soft tissue defects of the lower limb were treated at the Riga East University Hospital from 2018 to 2021. All patients were treated using the ADCr method which is the technique of establishing an interim deformity for resolving tissue loss. The lower extremity functional scale (LEFS) and application of methods of ilizarov (ASAMI) criteria were used for the evaluation of bone healing and lower extremity function. Results Complete union was achieved in all cases. The functional evaluation showed that most patients could achieve excellent and good results and return to activities of daily living. The functional result was poor in one case of a multi-fragmentary distal tibial articular fracture for which an ankle fusion was performed. Final union in this case was achieved with some residual deformity. Conclusion The method of ADCr is an effective surgical technique in cases of severe tibial injuries with concomitant loss of bone and soft tissues. This method could be used in cases when either a plastic or microsurgeon is not available or for instances when closing the defect with a flap is either impossible or contraindicated. Excellent and good functional results are possible without severe complications. How to cite this article Plotnikovs K, Kamenska J, Movcans J, et al. Artificial Deformity Creation as a Method for Limb Salvage for Patients with Massive Tibial and Soft Tissue Defects: A Report of 26 Cases. Strategies Trauma Limb Reconstr 2023;18(3):133-139.
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Affiliation(s)
- Konstantins Plotnikovs
- Department of Traumatology and Orthopaedics, Riga East Clinical University Hospital, Riga, Latvia
| | - Jekaterina Kamenska
- Department of Traumatology and Orthopaedics, Riga East Clinical University Hospital, Riga, Latvia
| | - Jevgenijs Movcans
- Department of Traumatology and Orthopaedics, Riga East Clinical University Hospital, Latvia
| | - Vitalijs Pasters
- Department of Traumatology and Orthopaedics, Riga East Clinical University Hospital, Latvia
| | - Leonid Solomin
- Department of Orthopedics, Vreden National Medical Research Center of Traumatology and Orthopedics, St. Petersburg, Russia
| | - Haralds Plaudis
- Department of General Surgery, Riga Stradins University, Riga, Latvia
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Kuroki MT, Parikh UM, Chandra V. How I do it: Pedal access and pedal loop revascularization for patients with chronic limb-threatening ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101236. [PMID: 37496650 PMCID: PMC10366544 DOI: 10.1016/j.jvscit.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
An increasing proportion of patients with chronic limb-threatening ischemia are older and have multiple comorbidities, including diabetes and renal failure. For those who are not candidates for a surgical bypass, this set of patients presents a challenge to vascular surgeons and interventionalists owing to the complex below-the-knee and increasingly below-the-ankle disease pattern that can fail traditional approaches for endovascular intervention. Two techniques, the retrograde pedal access and the pedal-plantar loop technique, can be useful in these settings and in skilled hands can be used safely, with a high technical success rate. In patients with chronic limb-threatening ischemia who are not candidates for a single-segment saphenous vein bypass, the retrograde pedal access technique can be used not only in the setting of failed antegrade treatment, but also primarily when faced with a difficult groin or as an adjunct during a planned antegrade-retrograde intervention. The pedal plantar loop technique allows for retrograde access to tibial vessels without retrograde vessel puncture and additionally offers the ability to treat the pedal-plantar arch, which may have added benefit in wound healing. We describe the tips and tricks for these two techniques used in our limb salvage practice.
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Affiliation(s)
| | | | - Venita Chandra
- Correspondence: Venita Chandra, MD, Clinical Professor of Surgery, Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Rd, Ste CJ350H, Palo Alto, CA 94304
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Godoy-Santos AL, Pires EA, Fonseca FC, de Cesar-Netto C, Auch EC, Rammelt S. Staged reconstruction of the hallux for infected non-union using bulk autograft and a customized implant: Case report. Foot (Edinb) 2023; 56:102031. [PMID: 37075520 DOI: 10.1016/j.foot.2023.102031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 07/05/2021] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
This case report illustrates the outcome of a deep infection following internal fixation of a fracture of the big toe. Hallux amputation could be avoided through staged salvage procedure. This paper can assist readers on how to effectively and safely recognize and treat this type of injury.
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Affiliation(s)
- Alexandre Leme Godoy-Santos
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Lab Prof Manlio Mario Marco Napoli, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Eduardo Araujo Pires
- Lab Prof Manlio Mario Marco Napoli, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.
| | | | | | | | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
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Harutyunyan M, Hnath JC, Jacobson X, Le J, Shah MD, Kleene J, Darling RC. Trauma bypass performed by vascular surgeons demonstrate excellent long-term outcomes and limb preservation. J Vasc Surg 2023; 78:779-787. [PMID: 37330703 DOI: 10.1016/j.jvs.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Long-term outcomes in civilian trauma patients requiring upper or lower extremity revascularization is poorly studied secondary to limitations of certain large databases and the nature of the patients in this specific vascular subset. This study reports on the experience and outcomes of a Level 1 trauma center that serves both an urban and a large rural population over a 20-year period to identify bypass outcomes and surveillance protocols. METHODS Database of a single vascular group at an academic center was queried for trauma patients requiring upper or lower extremity revascularization between January 1, 2002, and June 30, 2022. Patient demographics, indications, operative details, operative mortality, 30-day nonoperative morbidity, revisions, subsequent major amputations, and follow-up data were analyzed. RESULTS A total of 223 revascularizations were performed, 161 (72%) lower and 62 (28%) upper extremities. One hundred sixty-seven patients (74.9%) were male, with a mean age of 39 years (range, 3-89 years). Comorbidities included hypertension (n = 34; 15.3%), diabetes (n = 6; 2.7%), and tobacco use (n = 40; 17.9%). Mean follow-up time was 23 months (range, 1-234 months), with 90 patients (40.4%) lost to follow-up. Mechanisms included blunt trauma (n = 106; 47.5%), penetrating trauma (n = 83; 37.2%), and operative trauma (n = 34; 15.3%). Bypass conduit was reversed vein (n= 171; 76.7%), prosthetic (n = 34; 15.2%), and orthograde vein (n = 11; 4.9%). Bypass inflow artery was superficial femoral (n = 66; 41.0%), above-knee popliteal (n = 28; 17.4%), and common femoral (n = 20; 12.4%) in the lower extremity, and brachial (n = 41; 66.1%), axillary (n = 10; 16.1%), and radial (n = 6; 9.7%) in the upper extremity. Lower extremity outflow artery was posterior tibial (n = 47; 29.2%), below-knee popliteal (n = 41; 25.5%), superficial femoral (n = 16; 9.9%), dorsalis pedis (n = 10; 6.2%), common femoral (n = 9; 5.6%), and above-knee popliteal (n = 10; 6.2%). Upper extremity outflow artery was brachial (n = 34; 54.8%), radial (n = 13; 21.0%), and ulnar (n = 13; 21.0%). Total operative mortality was nine patients (4.0%), all involving lower extremity revascularization. Thirty-day non-fatal complications included immediate bypass occlusion (n = 11; 4.9%), wound infection (n = 8; 3.6%), graft infection (n = 4; 1.8%), and lymphocele/seroma (n = 7; 3.1%). All major amputations (n = 13; 5.8%) were early and in the lower extremity bypass group. Late revisions in the lower and upper extremity groups were 14 (8.7%) and four (6.4%), respectively. CONCLUSIONS Revascularization for extremity trauma can be performed with excellent limb salvage rates and has demonstrated long-term durability with low limb loss and bypass revision rates. The poor compliance with long-term surveillance is concerning and may require adjustment in patient retention protocols; however, emergent returns for bypass failure are extremely low in our experience.
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Affiliation(s)
- Misak Harutyunyan
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Jeffrey C Hnath
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Xander Jacobson
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Jeremy Le
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Melissa D Shah
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Julia Kleene
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - R Clement Darling
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY.
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Hong AM, Sundaram A, Perianayagam G, Lo H, Lawless A, Zhou D, McDonough J, Thompson SR, Maclean F, Connolly EA, Coker D, Mar J, Lazarakis S, Johnston A. Surgery at specialised sarcoma centres improves patient outcomes - A systematic review by the Australia and New Zealand sarcoma association clinical practice guidelines working party. Eur J Surg Oncol 2023; 49:106951. [PMID: 37301636 DOI: 10.1016/j.ejso.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Optimal management of sarcoma requires multidisciplinary team input throughout the process of diagnosis, treatment and follow up. This systematic review aimed to evaluate the impact of surgery performed at specialised sarcoma centres on outcomes. METHODS A systematic review was conducted using the population, intervention, comparison and outcome (PICO) model. Medline, Embase, Cochrane Central databases were queried for publications that evaluated the local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival in patients undergoing surgery in a specialist sarcoma centre compared with non-specialist centre. Each study was screened by two independent reviewers for suitability. A qualitative synthesis of the results was performed. RESULTS Sixty-six studies were identified. The majority of studies were Level III-3 as assessed by the NHMRC Evidence Hierarchy, whilst just over half of the studies were of good quality. Definitive surgery performed at specialised sarcoma centres was associated with improved local control as defined by lower rate of local relapse, higher rate of negative surgical margins, improved local recurrence free survival and higher limb conservation rate. Available evidences show a favourable pattern of lower 30-day and 90-day mortality rates, and greater overall survival when surgery was performed in specialist sarcoma centres compared with non-specialised centres. CONCLUSIONS Evidences support better oncological outcomes when surgery is performed at specialised sarcoma centre. Patients with suspected sarcoma should be referred early to a specialised sarcoma centre for multidisciplinary management, which includes planned biopsy and definitive surgery.
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Affiliation(s)
- Angela M Hong
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia.
| | - Abay Sundaram
- Department of Orthopaedic Surgery, Sir Charles Gardiner Hospital, Nedlands, WA, 6009, Australia
| | - Ganaps Perianayagam
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Helen Lo
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia; Mid North Coast Cancer Institute, Port Macquarie, NSW, 2444, Australia
| | - Anna Lawless
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | - Deborah Zhou
- NHMRC Clinical Trials Centre, The University of Sydney, NSW, 2006, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | | | - Stephen R Thompson
- Faculty of Medicine, University of New South Wales, Randwick, NSW, 2131, Australia; Department of Radiation Oncology, Prince of Wales Hospital, Randwick, NSW, 2132, Australia
| | - Fiona Maclean
- Douglass Hanly Moir Pathology, North Ryde, NSW, 2113, Australia
| | - Elizabeth A Connolly
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | - David Coker
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Melanoma and Surgical Oncology, and Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Jasmine Mar
- Australia and New Zealand Sarcoma Association, Parkville, Victoria, 3010, Australia
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Parkville, Victoria, 3010, Australia
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Abstract
Management of acute limb ischemia is complex and time sensitive, and delays in diagnosis and treatment may lead to irreversible tissue damage. Current data challenge the commonly accepted 6-hour ischemic threshold for acute limb ischemia, although variations in practice remain. Patients with chronic peripheral artery disease may tolerate longer ischemia time due to presence of collateral circulation. Here the authors discuss the presentation, workup, management, and postoperative care of patients with acute limb ischemia, with a focus on how management is altered depending on the duration and degree of ischemia.
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Affiliation(s)
- Alexis L Lauria
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street - Halsted 668, Baltimore, MD 21287, USA.
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Sadek WMS, Ebeid WA, Ghoneimy AE, Ebeid E, Senna WGA. Functional and Oncological Outcome of Patients with Distal Femoral Osteosarcoma Managed by Limb Salvage Using Modular Endoprosthesis. Ann Surg Oncol 2023; 30:5150-5158. [PMID: 37273024 PMCID: PMC10319677 DOI: 10.1245/s10434-023-13679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/10/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND The aim of the study was to assess the functional and oncological outcomes of patients with distal femoral osteosarcoma managed by limb salvage using modular endoprosthesis as well as to assess related complications. PATIENTS AND METHODS A total of 82 patients were included in our study. Functional outcome was assessed using MSTS score and knee range of motion. Oncological outcome was assessed regarding local recurrence, chest metastasis, and patient survivorship. Complications were classified according to Henderson et al. RESULTS: The mean MSTS score was 26.21 (87.4%) (range 8-30 points) with 70.7% of patients having more than 90° of flexion. The incidence of local recurrence was 3.7% (3 patients), while the incidence of chest metastasis was 14.6% (12 patients). Aseptic loosening (type 2 failure) was the commonest complication (19.5%), followed by infection (15.9%). The 5- and 10-year survivorships of the limb were 98.8%, while the 5- and 10-year survivorships of the prosthesis were 67.7% and 52.4%, respectively. CONCLUSION This study showed that patients with osteosarcoma distal femur who are treated by chemotherapy and limb salvage have an excellent long-term prognosis in terms of patient as well as limb survivorship. The use of modular endoprosthesis in these patients offer an acceptable function, with two-thirds of the patients retaining their prosthesis after 5 years and more than half retaining them after 10 years.
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Affiliation(s)
| | - Walid Atef Ebeid
- Department of Orthopaedics and Traumatology, Cairo University, Cairo, Egypt
| | - Ahmed El Ghoneimy
- Department of Orthopaedics and Traumatology, Cairo University, Cairo, Egypt
| | - Emad Ebeid
- Department of Paediatric Oncology and Haematology, National Cancer Institute, Cairo University, Cairo, Egypt
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Liu G, Li L, Xu H, Kang B. Five-year outcomes after bypass graft versus Fogarty balloon catheter for the treatment of acute blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1989-1996. [PMID: 37039830 DOI: 10.1007/s00068-023-02268-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To evaluate long-term clinical outcomes after revascularization by bypass graft versus Fogarty balloon catheter in acute blunt popliteal artery injury and identify risk factors contributing to amputation. METHODS A retrospective review was conducted in patients treated for acute blunt PAI between 2011 and 2019. Inclusion criteria were patients who underwent bypass graft and Fogarty balloon catheter. The cumulative limb salvage rate was calculated by the Kaplan-Meier test and compared with Breslow-Wilcoxon test. Cox proportional hazard model was performed to estimate the potential risk factors for amputation. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off value for the potential risk factors. RESULTS The overall limb salvage rate was 60.4% (29/48), including 24 patients (66.7%) in bypass graft, and 5 patients (41.7%) in Fogarty balloon catheter with mean follow-up of 5 years (range, 2-10 years). Among amputees, 15 patients (15/19, 78.9%) received primary amputation due to vascular failure or severe soft tissue damage, and 4 received secondary amputation because of chronic bone infection or neurologic deficit. Kaplan-Meier curves showed patients who received Fogarty balloon catheter had significantly higher amputation rate than those received bypass graft, with a hazard ratio of 3.801 (95% CI: 1.162-12.43, p = 0.009). In addition, Cox proportional hazard model revealed that MESS was the only independent risk factor for patients developing amputation, and the optimal cut-off value of MESS was 8. CONCLUSION Five-year outcome demonstrated that Fogarty balloon catheter is not a safe procedure and has significantly higher amputation rate in severe blunt PAI. MESS is the only risk factor for amputation.
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Affiliation(s)
- Gang Liu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Lin Li
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Han Xu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Bin Kang
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China.
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Spoer DL, Huffman SS, Rogers AE, Berger LE, Foshag AC, Park RH, Marable JK, Lava CX, Cunningham MH, Evans KK. Examining the unmet needs of chronic wound patients with common mental disorders. J Plast Reconstr Aesthet Surg 2023; 82:176-185. [PMID: 37186973 DOI: 10.1016/j.bjps.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Common mental disorders (CMD) are highly morbid conditions not routinely screened for in chronic wound care. A comorbid psychiatric condition's influence on a patient with chronic wounds' quality of life (QoL) is unknown. This study investigates the implications of CMD on QoL in patients with chronic lower extremity (LE) wounds. METHODS This cross-sectional study surveyed patients with chronic LE wounds evaluated in our multidisciplinary clinic between June-July 2022. Surveys included validated physical and social QoL questionnaires, including the Lower Extremity Functional Scale (LEFS), Patient-Reported Outcomes Measurement Information System (PROMIS-3a) Scale v2.0, 12-Item Short-Form (SF-12), and a screening tool for common mental disorders, the Self-Reporting Questionnaire 20 (SRQ-20). Data regarding patient demographics, comorbidities, psychiatric diagnoses, and wound care history were retrospectively collected. RESULTS Of the 265 identified patients, 39 (14.7%) had documented psychiatric diagnoses, most often depression or anxiety. The diagnosed cohort had higher median SRQ-20 scores (6, IQR: 6 vs. 3, IQR: 5; P < 0.001) and a higher proportion of positive screens for CMD (30.8% vs. 15.5%; P = 0.020) than non-diagnosed patients. There were no differences in physical or social QoL in patients with and without a psychiatric diagnosis. However, individuals screening positively for CMD experienced significantly more pain (T-score 60.2 vs. 51.4, P = 0.0052) and reduced function (LEFS 26.0 vs. 41.0, P < 0.0000). CONCLUSION This study illustrates that patients with chronic LE wounds experience potentially meaningful psychologic distress. Further, symptoms of a CMD (SRQ-20 ≥8), rather than a previous diagnosis, may influence pain and functional outcomes. These findings emphasize the potential relevance of psychological distress in this population and reinforce the need for further investigation of actionable responses to this apparent need.
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Affiliation(s)
- Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States
| | - Ashley E Rogers
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, United States; Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Amanda C Foshag
- Georgetown University School of Medicine, Washington, DC, United States
| | - Ryan H Park
- Eastern Virginia Medical School, Norfolk, VA, United States
| | - Julian K Marable
- Georgetown University School of Medicine, Washington, DC, United States
| | - Christian X Lava
- Georgetown University School of Medicine, Washington, DC, United States
| | | | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States.
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Barnard L, Karimian S, Foster P, Shankar VK. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023; 18:87-93. [PMID: 37942434 PMCID: PMC10628618 DOI: 10.5005/jp-journals-10080-1588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 01/23/2023] [Indexed: 11/10/2023] Open
Abstract
Introduction Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications. Methods A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Results Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital. Conclusion Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications. How to cite this article Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.
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Affiliation(s)
- Liam Barnard
- Leeds School of Medicine, Worsley Building, University of Leeds, Woodhouse, Leeds, United Kingdom
| | - Sina Karimian
- Leeds School of Medicine, Worsley Building, University of Leeds, Woodhouse, Leeds, United Kingdom
| | - Patrick Foster
- Department of Trauma and Orthopaedics, Leeds Vascular Institute, Leeds General Infirmary, Leeds, United Kingdom
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Messeder SJ, Black I, Nickinson ATO, Houghton JSM, Perks J, Meffen A, Musto L, Dubkova S, Sayers RD, Davies RSM. The impact of the COVID-19 pandemic on a dedicated Vascular Emergency Clinic (VEC). Ann Vasc Surg 2023:S0890-5096(23)00190-5. [PMID: 37023916 PMCID: PMC10072978 DOI: 10.1016/j.avsg.2023.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES Vascular Emergency Clinics (VEC) improve patient outcomes in chronic limb-threatening ischaemia (CLTI). They provide a "one stop" open access policy, whereby "suspicion of CLTI" by a healthcare professional or patient leads to a direct review. We assessed the resilience of the outpatient VEC model to the first year of the coronavirus disease (COVID-19) pandemic. METHODS A retrospective review of a prospectively maintained database of all patients assessed in our VEC for lower limb pathologies between March 2020 and April 2021 was performed. This was cross referenced to national and loco-regional Governmental COVID-19 data. Individuals with CLTI were further analysed to determine PAD-QIF (Peripheral Arterial Disease - Quality Improvement Framework) compliance. RESULTS Seven hundred and ninety-one patients attended for 1084 assessments (Male n = 484, 61%; Age 72.5 ± SD 12.2 years; White British n = 645, 81.7%). In total, 322 patients were diagnosed with CLTI (40.7%). A total of 188 individuals (58.6%) underwent a first revascularisation strategy (Endovascular n=128, 39.8%; Hybrid n=41, 12.7%; Open surgery n=19; 5.9%; Conservative n=134; 41.6%). Major lower limb amputation rate was 10.9% (n=35) and mortality rate was 25.8% (n=83) at 12 months follow up. Median referral to assessment time was 3 days (IQR 1-5). For the non-admitted patient with CLTI, the median assessment to intervention was eight days (IQR 6-15) and median referral to intervention time of 11 days (11-18). CONCLUSIONS The VEC model has demonstrated strong resilience to the COVID-19 pandemic with rapid treatment timelines maintained for patients with CLTI.
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Affiliation(s)
- Sarah Jane Messeder
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
| | - Imelda Black
- NIHR Biomedical Research Unit, University Hospitals of Leicester NHS Trust
| | - Andrew T O Nickinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - John S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jemma Perks
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Anna Meffen
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Liam Musto
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Svetlana Dubkova
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Robert D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Robert S M Davies
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Tong X, He H, Zhang C, Liu Y, Zeng H, Qiu X, Liu Q. Use of LARS for soft tissue function reconstruction during tumor-type hemi-shoulder replacement achieves a good prognosis: a retrospective cohort study. World J Surg Oncol 2023; 21:123. [PMID: 37013566 PMCID: PMC10071767 DOI: 10.1186/s12957-023-03008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Shoulder soft tissue function reconstruction during tumor-type hemishoulder replacement is an important step to restore shoulder function. This study evaluates the functional prognosis and postoperative complications of ligament advanced reinforcement system (LARS)-assisted soft tissue functional reconstruction in tumor-type hemi-shoulder replacement. MATERIALS AND METHODS Twenty-two patients with an average age of 37.5 ± 17.8 years diagnosed with benign invasive tumors, primary malignant bone tumors, or bone metastases were enrolled in this study. The patient's medical records (history and surgical details), histological sections, imaging files, oncological prognosis, functional prognosis, and postoperative complications were collected. The upper limb function and shoulder joint function were evaluated using the Musculoskeletal Tumor Society (MSTS) system and American Shoulder and Elbow Surgeons (ASES) scoring criteria, respectively. RESULTS Twenty-two patients comprising 12 males and 10 females were enrolled. Overall, 9 patients had preoperative pathological fractures. The mean lesion length was 8.6 ± 3.0 cm. The local recurrence was observed in 3 cases, including 2 cases of osteosarcoma and 1 case of MGCT. A further 4 cases had pulmonary metastasis, including 2 cases with local tumor recurrence. The average postoperative MSTS score was 25.8 ± 1.7, and the score of postoperative ASES was 85.7 ± 6.0, both of which showed satisfactory functional recovery. Two cases experienced postoperative complications requiring surgical intervention, including one periprosthetic fracture and one giant cell granuloma. Prosthesis dislocation occurred in 1 case. None of the cases of periprosthetic infection or postoperative complications resulted in implant failure. CONCLUSIONS LARS-assisted soft tissue function reconstruction in benign and malignant proximal humerus tumors after a tumor-type hemi-shoulder replacement is an effective technical improvement, which can effectively repair the integrity of the joint capsule to restore joint stability, provide a medium for soft tissue attachment to rebuild the muscular dynamic system, and eliminate residual dead space around the prosthesis, effectively improving limb function and reduce postoperative infection complications.
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Affiliation(s)
- Xiaopeng Tong
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, 410008, People's Republic of China
| | - Hongbo He
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, 410008, People's Republic of China
| | - Can Zhang
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, 410008, People's Republic of China
| | - Yupeng Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, 410008, People's Republic of China
| | - Hao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China
| | - Xinzhu Qiu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China
| | - Qing Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87Th Xiangya Road, Changsha, 410008, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, 410008, People's Republic of China.
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Liu IH, El Khoury R, Wu B, Gasper WJ, Schneider PA, Hiramoto JS, Vartanian SM, Conte MS. Presenting limb severity is associated with long-term outcomes after infrainguinal revascularization for chronic limb-threatening ischemia. J Vasc Surg 2023; 77:1137-1146.e3. [PMID: 36584906 DOI: 10.1016/j.jvs.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The SVS Wound, Ischemia, foot Infection (WIfI) limb staging system was established to estimate risk of major amputation in chronic limb-threatening ischemia (CLTI) and better stratify outcomes comparisons. There is little data on treatment outcomes beyond 1 year based on presenting WIfI stage. METHODS This is a single-institution retrospective study of 413 patients who underwent infrainguinal revascularization for CLTI (2011-2021) with data available for WIfI staging. Patient characteristics and outcomes were gathered from the electronic medical record. Data were analyzed based on presenting WIfI stage and initial treatment received at our center. RESULTS Presenting WIfI stages were 1 to 2 (23%), 3 (27%), and 4 (50%). Index revascularization approach was endoluminal (59%), autogenous vein bypass (29%), or non-autogenous bypass (13%). Operative mortality within 30 days was 2.9% and was not associated with WIfI stage or revascularization approach. Median limb follow-up time was 502 days (interquartile range [IQR], 112-1256 days), and median survival follow-up time was 932 days (IQR, 343-1770 days). Major amputation or death occurred in 19% and 46% of patients at median times of 119 days (IQR, 28-314 days) and 739 days (IQR, 204-1475 days), respectively. WIfI stage was independently associated with major amputation (P = .001), as was initial revascularization approach (P = .01). In a Cox proportional hazards model, factors independently associated with major amputation were male sex (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.04-2.0; P = .03), diabetes (HR, 1.8; 95% CI, 1.3-2.5; P = .001), WIfI stage 4 (HR, 2.3; 95% CI, 1.5-3.5; P < .001), and non-autogenous bypass (HR, 2.9; 95% CI, 2.1-4.2; P < .001). In a Cox proportional hazards model for mortality, independently associated factors were age (HR, 1.04; 95% CI, 1.02-1.05; P < .001), end-stage renal disease (HR, 2.8; 95% CI, 1.9-4.0; P < .001), congestive heart failure (HR, 1.9; 95% CI, 1.4-2.5; P < .001), chronic obstructive pulmonary disease (HR, 1.5; 95% CI, 1.1-2.1; P = .02), and WIfI stage 4 (HR, 1.6; 95% CI, 1.04-2.2; P = .03). Among those presenting with WIfI stage 4 limbs, Kaplan-Meier estimated rates of freedom from major amputation or death at 2 years were 71% ± 3.7% and 68% ± 3.5%, respectively. In an inverse propensity weighted Cox proportional hazards model, non-white race (HR, 1.5; 95% CI, 1.01-2.2; P = .047), diabetes (HR, 2.0; 95% CI, 1.2-3.3; P = .008), Global Anatomic Staging System infrapopliteal grade (HR, 1.2; 95% CI, 1.05-1.3; P = .005), non-autogenous bypass (HR, 3.2; 95% CI, 1.9-5.3; P < .001), and endoluminal revascularization (HR, 2.6; 95% CI, 1.6-4.3; P < .001) were independently associated with major amputation in the WIfI stage 4 subgroup. CONCLUSIONS Presenting WIfI stage is strongly associated with long-term risks of major amputation and death following infrainguinal revascularization for CLTI and should be used to stratify outcomes comparisons. Effective revascularization is critical in WIfI stage 4 disease, and autogenous vein bypass provides durable long-term limb preservation.
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Affiliation(s)
- Iris H Liu
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Rym El Khoury
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Bian Wu
- Kaiser Permanente San Francisco, San Francisco, CA
| | - Warren J Gasper
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Peter A Schneider
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Jade S Hiramoto
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Shant M Vartanian
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Michael S Conte
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA.
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Gamieldien H, Ferreira N, Birkholtz FF, Hilton T, Campbell N, Laubscher M. Filling the gap: a series of 3D-printed titanium truss cages for the management of large, lower limb bone defects in a developing country setting. Eur J Orthop Surg Traumatol 2023; 33:497-505. [PMID: 36385681 DOI: 10.1007/s00590-022-03434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Large segmental long bone defects are notoriously difficult to manage. Treatment is resource-intensive due to the complexity, cost, and specialized skills required. Truss designs are known for their triangular shapes organized in web configurations. This allows for maximal mechanical strength, the least mass, and a lattice that can be filled with bone graft. Using a truss cage combined with contemporary internal fixation provides immediate stability for bone ingrowth and long-term potential union. The implant is designed using virtual 3D modelling of the patient's bone defect based on a CT scan. The truss cage can be used in a staged procedure combined with Masquelet's induced membrane technique. This study aims to review the outcomes of patient-specific, locally designed 3D titanium truss cages packed with cancellous autograft in treating segmental, long bone defects in the lower limb in a developing country setting. METHODS This retrospective series reviewed cases performed at various institutions between January 2019 and March 2022. Parameters assessed included patient demographics, size and location of the defect, time to clinical and radiological union and complications. RESULTS Nine cases were included for review, with a mean age of 36 years (range 19-52). Defects ranged from 60 to 205 mm, and eight cases were staged procedures. Eight cases used intramedullary reamings as bone graft. Contemporary intramedullary nails were used for fixation in all cases. No peri- or post-operative complications occurred. All cases progressed to functional union. CONCLUSION 3D-printed titanium truss cages combined with bone graft appear to be an effective treatment of large bone defects in the lower limb in a developing country setting in the short term. No complications were encountered, but longer follow-up is needed before definitive recommendations can be made. LEVEL OF EVIDENCE Level IV (retrospective case series).
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Affiliation(s)
- Hammaad Gamieldien
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Cape Town, 7925, South Africa.
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, 7505, South Africa
| | - Franz Friedrich Birkholtz
- Institute of Orthopaedics and Rheumatology, Stellenbosch University, Stellenbosch, South Africa
- Department of Orthopaedics, University of Pretoria, Pretoria, 0002, South Africa
| | - Thomas Hilton
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Cape Town, 7925, South Africa
| | - Neil Campbell
- LRS Implants - Unit C18, Prime Park, Mocke Rd, Diep River, Cape Town, 7700, South Africa
| | - Maritz Laubscher
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, H49 Old Main Building, Cape Town, 7925, South Africa
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Ciudad P, Escandón JM, Manrique OJ, Llanca L, Reynaga C, Mayer HF. Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19. Eur J Plast Surg 2023; 46:1-11. [PMID: 37363691 PMCID: PMC10020769 DOI: 10.1007/s00238-023-02052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/23/2023] [Indexed: 03/19/2023]
Abstract
Background Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19. Methods We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes. Results Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002). Conclusions In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Institute of Plastic, Reconstructive and Aesthetic Surgery, Ciruesthetic, Clinic, Lima, Peru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Lilyan Llanca
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - César Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Horacio F. Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), Buenos Aires, Argentina
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DiLosa K, Gibson K, Humphries MD. The use of telemedicine in peripheral artery disease and limb salvage. Semin Vasc Surg 2023; 36:122-128. [PMID: 36958893 PMCID: PMC10039282 DOI: 10.1053/j.semvascsurg.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
Chronic limb-threatening ischemia represents the morbid end stage of severe peripheral artery disease, with significant impact on patient quality of life. Early diagnosis of arterial insufficiency and referral for vascular intervention are essential for successful limb salvage. Disparate outcomes have been reported among patients residing in rural areas due to decreased access to care. Remote telemedicine outreach programs represent an opportunity to improve access to care in these rural communities. Establishment of a telehealth program requires identification of communities most in need of specialty care. After locating an ideal site, collaboration with local providers is necessary to develop a program that meets the specific needs of providers and patients. Surgeon guidance in development of screening and management algorithms ensures that patients obtain care reliably and with adjustments as needed to suit the referring provider, the patient, and the specialist. Telehealth evaluations can limit the financial burden associated with travel, while ensuring access to higher levels of care than are available in the patients' immediate area. Multiple barriers to telehealth exist. These include limited reimbursement, local provider resistance to new referral patterns, lack of in-person interaction and evaluation, and the inability to do a physical examination. Improved reimbursement models have made telehealth feasible, although care must be taken to ensure that practice patterns complement existing resources and are designed in a way that omits the need for in-person evaluation until the time of specialist intervention. Telemedicine is an underused tool in the arsenal of vascular surgeons. Targeted telehealth programs aid in increasing patient access to expert-level care, thereby improving health disparities that exist in rural populations.
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Affiliation(s)
- Kathryn DiLosa
- Department of Surgery, University of California Davis Health, University of California Davis Medical Center, 2335 Stockton Boulevard, NAOB 5001, Sacramento, CA, 95817
| | - Keenan Gibson
- Department of Surgery, University of California Davis Health, University of California Davis Medical Center, 2335 Stockton Boulevard, NAOB 5001, Sacramento, CA, 95817
| | - Misty D Humphries
- Department of Surgery, University of California Davis Health, University of California Davis Medical Center, 2335 Stockton Boulevard, NAOB 5001, Sacramento, CA, 95817.
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Döring K, Hegelmaier AV, Trost C, Krall C, Windhager R, Hobusch GM. Early postoperative gain in activity levels of lower extremity sarcoma survivors positively affects long-term physical activity and performance. Support Care Cancer 2023; 31:193. [PMID: 36856930 PMCID: PMC9977709 DOI: 10.1007/s00520-023-07644-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/13/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE Little is known about the effect of sports activity levels on health-related quality of life (HRQOL) in long-term survivors of lower-extremity sarcoma. METHODS Eighty-three long-term survivors of bone and soft tissue sarcoma of the lower extremities with a median follow-up of 14 (range: 5-35) years completed the University of California and Los Angeles (UCLA) activity scores before tumor resection, 1 year after surgery and at the latest follow-up, as well as a Short Form 36 (SF-36) health survey at the latest follow-up. Simple linear regression models as well as stepwise variable selection with Akaike information criterion (AIC) were undertaken. RESULTS The preoperative UCLA activity level (median: 9, range: 2-10) dropped to a median of 4 (range: 1-10) 1 year after surgery before increasing to a score of 6 (range: 2-10) 5 years after surgery. The long-term SF-36 physical health component summary score (PCS) was 49 (SD: 9), and the mental health component summary score (MCS) was 54 (SD: 7). A linear model with stepwise variable selection identified a negative correlation of PCS with age at surgery (estimate: -0.2; p = 0.02), UCLA score at the last follow-up (estimate: 1.4; p = 0.02) and UCLA score 1 year after surgery (estimate: 1.0; p = 0.02). CONCLUSION As not only the final activity levels but also the status immediately after surgery affect the PCS, higher early activity levels should be a goal of modern rehabilitation after sarcoma treatment. Further studies are needed to weigh the potential postoperative risks of higher sport activity levels against the benefits described in this study. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Kevin Döring
- Department of Orthopedics and Trauma Surgery, Comprehensive Cancer Canter Vienna, Medical University of Vienna, Waehringer Straße 18-20, 1090 Vienna, Austria
| | - Anna Vanessa Hegelmaier
- Department of Orthopedics and Trauma Surgery, Comprehensive Cancer Canter Vienna, Medical University of Vienna, Waehringer Straße 18-20, 1090 Vienna, Austria
| | - Carmen Trost
- Department of Orthopedics and Trauma Surgery, Comprehensive Cancer Canter Vienna, Medical University of Vienna, Waehringer Straße 18-20, 1090 Vienna, Austria
| | - Christoph Krall
- Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Comprehensive Cancer Canter Vienna, Medical University of Vienna, Waehringer Straße 18-20, 1090 Vienna, Austria
| | - Gerhard Martin Hobusch
- Department of Orthopedics and Trauma Surgery, Comprehensive Cancer Canter Vienna, Medical University of Vienna, Waehringer Straße 18-20, 1090 Vienna, Austria
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Eslami MH, Semaan DB. Increased Medicaid eligibility of Affordable Care Act: Evidence of improved outcomes for patients with peripheral artery disease. Semin Vasc Surg 2023; 36:58-63. [PMID: 36958898 DOI: 10.1053/j.semvascsurg.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023]
Abstract
Peripheral artery disease (PAD) is a debilitating disease that disproportionately affects people of low socioeconomic status and racial minority individuals. These groups also tend to have lower rates of revascularization and worse outcomes, including higher rates of major amputation. In 2010, the Affordable Care Act (ACA) was signed into law, providing better opportunities for health care access to millions of uninsured Americans, although the implementation of different components started at a later date. Political issues led to uneven adaptation by states of the different ACA components. In states that adopted Medicaid expansion under the ACA, similar to that under the Massachusetts Health Care Reform Law of 2006, patients of low socioeconomic status and racial minority patients gained better access to health care. This review article will examine the disparities that exist in peripheral artery disease outcomes, as well as the effects of the ACA and Medicaid expansion on revascularization, limb salvage, and major amputation rates.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular Surgery, UPMC, Heart and Vascular Institute, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213.
| | - Dana B Semaan
- Division of Vascular Surgery, UPMC, Heart and Vascular Institute, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213
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