Amputation Flap Research Articles

Biopsies for Soft-Tissue Sarcoma of the Hand: Dangers, Hazards, and Outcomes.

Excisional biopsies for soft-tissue sarcoma (STS) of the hand are commonly done outside of sarcoma centers and can compromise incorporation of the biopsy site into standard limb salvage or amputation flaps. We sought to identify risk factors for these suboptimal biopsies. We analyzed prospective data on all patients (N = 109) who underwent definitive resection of primary STS of the hand between 1995 and 2019 at our institution. Biopsies were classified by type (excisional vs. incisional/needle), whether they were done before referral, and whether the incision could be incorporated into standard limb salvage or amputation flaps (ILS biopsies) or not (NILS biopsies). Analyses examined potential predictors of NILS biopsies and whether outcomes differed by biopsy type. Biopsies done before referral (N = 91) were more likely to be excisional (79% vs. 17%). Excisional biopsies were associated with smaller tumor size (median, 2.0 vs. 3.15 cm; P = 0.025) and longer time to first intervention (1.88 vs. 1.17 months; P = 0.001). Forty-eight percent of excisional and 29% of incisional biopsy sites required soft-tissue coverage at the time of definitive surgery ( P = 0.07). Biopsy type was not associated with Musculoskeletal Tumor Society score or need for amputation. Risk factors for NILS biopsies included larger tumor size, deep tumor, and excisional biopsy. High-risk areas for NILS biopsies included the carpal tunnel, volar wrist, first webspace, radial palm, and proximal thumb. NILS biopsies were associated with positive margins, need for soft-tissue coverage, and lower Musculoskeletal Tumor Society scores. This study informs referral guidelines for patients with STS of the hand. Patients with tumors that are deep, large, or in high-risk locations should be referred to a sarcoma center before biopsy. If that is not possible, incisional biopsy in line with standard resection incisions or radiology-guided core needle biopsy is preferable to excisional biopsy. Prognostic study. Level II.

Flap Capillary Blood Glucose Monitoring As a Predictor of Flap Survival in Below Knee Amputation Stump

Monitoring of flap blood glucose levels during and after surgery is important for determining flap salvage or loss. Decision to re operate and do revision amputation was solely based on clinical assessment and no objective measurement is available till date. The objective of this study is to validate flap capillary blood glucose monitoring serially as an indicator to predict flap survival in below knee amputation patients. The study was conducted at Coimbatore medical college hospital, general surgery department from march-2016 to june- 2016. 50 patients with peripheral arterial occlusive disease with established gangrene of lower limb requiring BK amputations were selected. Out of the 50 patients who underwent BK amputations 45 patients in whom the flap survived had flap glucose level more than 62mg/dl, in the first 24 hours. This simple and cheap technique can be used for routine monitoring of BK amputation flaps along with the routine clinical evaluation.

The SALSA spike: A novel technique using Kirschner wires to anchor tenuous midfoot and forefoot amputation flaps

Extensive tissue resection often mandates unique approaches to complete a functional reconstruction. While there are numerous options for selecting a donor site for a skin or soft tissue flap, available options for securing a local flap following midfoot amputation are quite limited. Adequate flap fixation is essential to maintain its viability, yet this may be challenging to achieve when there is a substantial residual post debridement requiring coverage and only limited remaining viable surrounding soft tissue available for anchoring. Over thinning the flap may compromise vital circulation to it from plantar (or other pertinent) artery perforators. In our experience, the adjunctive use of Kirschner wire(s) to support external soft-tissue fixation in conjunction with traditional methods has been successful in securing such tenuous fasciocutaneous flaps. To our knowledge, few alternative techniques have been described to fasten flaps in instances of compromised surrounding skin and soft tissue integrity in high-risk patients. This technique offers the surgeon a strong, inexpensive, and versatile solution for soft tissue anchoring. It allows for mechanical creep and ultimately stress relaxation at a potential wound closure site. This manuscript reviews several cases, each using this simple, novel approach to fixate an unsecured flap during the closure of an open amputation.

A 65‐year‐old man with longstanding seropositive rheumatoid arthritis and lower extremity ulceration

A 65‐year‐old man with longstanding seropositive rheumatoid arthritis and lower extremity ulceration

Magnetic resonance imaging appearances following hindquarter amputation for pelvic musculoskeletal malignancy

To describe our experience of the magnetic resonance imaging (MRI) appearances after hindquarter amputation, focusing on the normal pattern of time-related changes in signal intensity within the amputation flap and appearances of local disease recurrence. This was a retrospective review of the records of patients identified on our orthopaedic oncology database who had undergone hindquarter amputation at our centre. Examinations were divided into one group consisting of 'normal' postoperative findings and another group demonstrating local recurrence. 'Normal' postoperative findings were assessed for signal intensity, morphology and presence of the 'muscle texture sign' within the amputation flap. Examinations were grouped according to time from surgery. Examinations demonstrating local recurrence were assessed for site, signal intensity, morphology and axial dimensions of recurrent tumour. Comparison was made to pre-operative imaging. Thirty-five patients with postoperative MR images were identified. Seventy-seven examinations were reviewed (range 1-18 per patient). The 'normal group' comprised 18 patients (seven female, 11 male, mean age 44 years, range 16-75 years), with 47 examinations reviewed. The 'muscle texture sign' was preserved in all examinations in this group. Up to 6 months after surgery, 100% (10) of examinations showed hyperintense T2- and short-tau inversion recovery (STIR-weighted) signals within the muscle flap, indicating oedema. Only after 4 years was the muscle flap signal isointense in all cases (13). Up to 6 months after surgery, 50% (5 of 10) of examinations demonstrated flap swelling, but after 1 year, 100% (28) showed atrophy. Twenty percent (2 of 10) of examinations 0-6 months from surgery showed hyperintense T1-weighted signal within the muscle flap, consistent with fatty infiltration, but after 2 years, 100% (20) showed a hyperintense T1-weighted signal. The 'local recurrence' group comprised 20 patients (six female, 14 male, mean age 45.7 years, range 14-69 years), with 30 examinations demonstrating recurrent disease or metastasis. There were 23 recurrent tumours, of which 43% (10) were in the muscle component of the amputation flap, 13% (3 of 23) were in subcutaneous tissues of the flap, 13% (3 of 23) were at the posterior margin of the bone resection and 13% (3 of 23) were paraspinal. All recurrent tumours demonstrated hyperintense T2 and STIR signals. The signal intensity pattern of recurrence closely followed that of the original tumour. The 'muscle texture sign' was absent in all examinations demonstrating recurrence in muscle flap. A pattern of time-related signal intensity and morphological changes is observed within normal hindquarter amputation flaps on MRI. Recurrent disease is most likely to occur within the muscle flap, typically of high T2-weighted signal intensity and characteristically follows the signal pattern of the original tumour.

Some historical aspects of diabetic foot disease

During the 19th century and for much of the 20th century, disease of the lower limb in diabetic patients was conceptualized not, as it is now, as 'the diabetic foot' or as 'a diabetic foot ulcer' but as 'gangrene in the diabetic foot' or as 'diabetic gangrene'. The prognostically and therapeutically important distinction between gangrene due to vascular insufficiency and gangrene due to infection in a limb with a normal or near normal blood supply was not made until about 1893. The advent of aseptic surgery improved the survival of amputation flaps, but surgery remained a hazardous undertaking until the discovery of insulin. Although insulin therapy reduced the risk of surgical intervention, diabetic foot disease now replaced hyperglycaemic coma as the major cause of diabetic mortality. The increasing workload attributable to diabetic foot disease after the introduction of insulin is reflected in the publications on diabetes in the 1920s. In some hospitals in North America this led to initiatives in prophylactic care and patient education, the importance of which were only more widely appreciated some 60 years later. A continuing emphasis on ischemia and infection as the major causes of diabetic foot disease led to a neglect of the role of neuropathy. In consequence, the management of diabetic neuropathic ulceration entered a prolonged period of therapeutic stagnation at a time when significant advances were being made in the management of lepromatous neuropathic ulceration. Reasons for the revival of progress in the management of diabetic neuropathic ulceration in the 1980s will be discussed.

Circumferential skin blood flow measurements in the ischaemic limb.

Skin blood flow (SBF) values were estimated on the posterior, medial and lateral aspects of the lower leg in 47 patients presenting for assessment of amputation level. Measurement was made using a radioisotope (iodoantipyrine) clearance technique. Medial SBF was 9.0 +/- 5.2 ml 100 g-1 min-1; posterior SBF was 8.3 +/- 5.0 ml 100 g-1 min-1 and lateral SBF was 6.5 +/- 4.1 ml 100 g-1 min-1. The results gave significantly higher SBFs on the medial and posterior aspects of the ischaemic leg. The finding of an uneven distribution of blood flow at the below knee amputation level has important implications in the planning of amputation flaps.

V-Y ???cup??? flap for volar oblique amputation of fingers

For fingers left shorter volarly after finger-tip amputation, a volar V-Y amputation flap designed with the V-Y portion at the middle phalanx level and using the Snow cupping technique for reconstruction of the pulp and tip has provided good sensation, padding and contour. Hypersensitivity and beaking of the nail have not been problems.

V—Y “Cup” Flap for Volar Oblique Amputation of Fingers

For fingers left shorter volarly after finger-tip amputation, a volar V-Y amputation flap designed with the V-Y portion at the middle phalanx level and using the Snow cupping technique for reconstruction of the pulp and tip has provided good sensation, padding and contour. Hypersensitivity and beaking of the nail have not been problems.