Differences In Limb Salvage Rates Research Articles

Duplex ultrasound for surveillance of lower limb revascularisation.

Duplex ultrasound for surveillance of lower limb revascularisation.

Outcomes of Patients With Acute Limb Ischemia in Patients With COVID-19: A Systemic Review and Meta-Analysis.

A systemic review and meta-analysis of perioperative outcomes of acute limb ischemia (ALI) in patients with and without coronavirus disease-2019 (COVID-19) to determine the outcomes of ALI and compare the outcomes in patients with and without COVID-19 infection. A literature search of the Medline, Science Direct and Cochrane Library was performed from inception to July 15, 2021. Studies involving ALI in patients with COVID-19 were searched through three electronic databases. The endpoints include limb salvage, re-thrombosis, and mortality, and these outcomes were compared between patients with and without COVID-19 infection and type of management. The primary outcome was early limb salvage (till the patient was discharged from the hospital). The other outcomes assessed were re-thrombosis and mortality. These outcomes were compared between patients with and without COVID-19 infection and the type of management. Pooled estimates were presented as odds ratios (ORs) using a random or fixed effect model based on the results of the chi-square test and calculation of I2. Comparing the ALI outcomes in patients with and without COVID-19 infection, there was no significant difference in limb salvage rate (OR=0.26, 95% CI:0.02-3.09), but there was a significantly higher re-thrombosis (OR=2.65, 95% CI:1.34-5.23) and mortality rate (OR=4.71, 95% CI:1.11-19.99) in patients with COVID-19 infection. On comparing outcomes based on management, intervention group, and anticoagulant alone group, no significant difference was noted concerning limb salvage (OR=1.40, 95% CI:0.27-7.13) and mortality rates (OR=0.2, 95% CI:0.04-1.07). This meta-analysis demonstrates a higher re-thrombosis and mortality in ALI patients with COVID-19 infection when compared to patients without COVID-19 but with similar limb salvage.

Comparison of outcome of various modalities in trans-atlantic inter-society consensus d femoropopliteal disease

Background: This study aimed to assess the role of various modalities of treatment for trans-atlantic inter-society consensus document (TASC D) femoropopliteal disease. Methods: This was a retrospective and prospective study from January 2015 to December 2018; 153 patients who were admitted at Army Hospital Research and Referral with TASC D femoropopliteal disease and underwent hybrid procedure, endovascular or open surgery were included in the study. Results: 58.8% (90/153) patients underwent femoropopliteal bypass. 27.4% (42/153) patients underwent the hybrid procedure and 13.72% (21/153) patients underwent endovascular procedure. The primary patency rate of open surgery at 1 year is 85.6%, hybrid procedure (iliac stenting and fem-pop bypass is 78.9%, transfemoral thrombectomy and balloon angioplasty is 91.2%), endovascular procedure (primary superficial femoral artery drug-eluting balloon angioplasty is 94.4%, atherectomy is 70.3%). Secondary patency rate of open surgery and hybrid procedure was 94.6%, endovascular surgery was 50%. There was no significant difference in limb salvage rate in all three groups. Acute coronary syndrome occurred in 4% of patients in open femoro-popliteal bypass group, 5% patients in the endovascular group, 3.8% in the hybrid group. Cerebro-vascular accident (CVA) in 1.5% patients open fem-pop group and 1.5% patients in the endovascular group in follow-up period. Conclusion: Although open revascularization remains the treatment of choice for advanced atherosclerotic diseases involving femoropopliteal segment (TASC D), endovascular and hybrid procedures are not inferior to open surgery. There is a role for hybrid procedures as they augment the technical success rate of pure endovascular interventions for complex TASC D femoropopliteal lesion. Hybrid procedures can be an alternative in patients with multiple comorbidities giving equal short-term results and decreased morbidity.

Application of vacuum sealing drainage in limb salvage of multiple trauma patients with Gustilo type III C open fracture

Objective To investigate the safety and effectiveness of vacuum sealing drainage treatment on limb salvage in multiple trauma patients combined with Gustilo type IIIC fracture. Methods A retrospective case control study was conducted to analyze the clinical data of 102 patients diagnosed with multiple trauma combined with Gustilo type III C fracture admitted to Tongji Hospital from October 2005 to October 2015. There were 66 males and 36 females, aged 17-65 years [(34.2±10.1)years]. The injury severity score (ISS) ranged from 18 to 26 points [(19.8±3.2)points]. There were 34 patients with femur fracture, 66 with tibia/fibula fracture, 35 with femur and tibia/fibula fracture. Among the patients, 58 were treated with VSD (VSD group) and 44 were treated with routine dressing change after emergency operation (routine group). The two groups were compared for active bleeding, re-vascular exploration, osteofascial compartment syndrome, wound infection and necrosis, gas gangrene, delayed amputation, systemic inflammatory response syndrome (SIRS), sepsis, deep venous thrombosis (DVT) incidence, per capita debridement times, length of stay, skin graft/skin flap rate, fracture fixation rate, incidence of refractory wounds, incidence of nonunion, incidence of complete nerve damage, British medical research council (BMRC) score, and amputation rate/salvage rate. Results All patients were followed up for 6-14 months [(8.4±2.1)months]. There was no significant difference in limb salvage rate between the two groups after operation (P>0.05). Among the indexes of limb salvage treatment after operation, no significant differences were found between the routine group and VSD group in active bleeding, gas gangrene, re-vascular exploration and delayed amputation (P>0.05); the wound infection and necrosis rates were 32% and 15% (P<0.05); the incidence rates of osteofascial compartment syndrome were 22% and 7% (P<0.05). During the hospital stay, there were no significant differences in DVT incidence and fracture internal fixation rate between the two groups; SIRS incidence rates of routine group and VSD group were 92% and 73% (P<0.05); the incidence rates of sepsis were 28% and 10% (P<0.05); the per capita debridement times in routine group and VSD group were 4.2 times and 3.2 times, respectively (P<0.05); hospitalization durations were 42.1 days and 30.2 days (P<0.05); skin graft/skin flap rates were 69% and 46% (P<0.05). In the follow-up results, there was no significant difference in the amputation rate/salvage rate between the two groups (P<0.05). The incidence of refractory wounds was 28% in routine group and 10% in VSD group (P<0.05); the incidence of nonunion was 22% and 6% (P<0.05); the incidence of complete neurological damage was 36% and 12% (P<0.05); the excellent and good rate of BMRC score was 83% and 96% (P<0.05). Conclusions VSD technology can promote wound healing after operation, prevent complications, reduce the number of debridement operations and shorten hospital stay, significantly improving the prognosis and limb function of patients. It is a relatively safe and effective method for the treatment of multiple trauma combined with Gustilo type III C fracture. Key words: Multiple trauma; Negative-pressure wound therapy; Fractures, open; Prognosis

Combat vascular injury: Influence of mechanism of injury on outcome

BackgroundHaemorrhage is the leading cause of death on the battlefield. Seventy percent of injuries are due to explosive mechanisms. Anecdotally, these patients have had poorer outcomes when compared to those with penetrating mechanisms of injury (MOI). We wished to test the hypothesis that outcomes following vascular reconstruction were worse in blast-injured than non blast-injured patients. MethodsRetrospective cohort study. British and American combat casualties with arterial injuries sustained in Iraq or Afghanistan (2003–2014) were identified from the UK Joint Theatre Trauma Registry (JTTR). Eligibility included explosive or penetrating MOI, with follow-up to UK hospital discharge, or death. Outcomes were mortality, amputation, graft thrombosis, haemorrhage, and infection. Statistical analysis was performed using Pearson Chi-Square test, t-tests, ANOVA or non-parametric equivalent, and survival analyses. ResultsOne hundred and fifteen patients were included, 80 injured by explosive and 35 by penetrating mechanisms. Evacuation time, ISS, number of arterial injuries, age and gender were comparable between groups. Seventy percent of arterial injuries resulted from an explosive MOI. The explosive injuries group received more blood products (p = 0.008) and suffered more regions injured (p < 0.0001). Early surgical interventions in both were ligation (n = 36, 31%), vein graft (n = 33, 29%) and shunting (n = 9, 8%). Mortality (n = 12, 10%) was similar between groups. Differences in limb salvage rates following explosive (n = 17, 53%) vs penetrating (n = 13, 76.47%) mechanisms approached statistical significance (p = 0.056). Nine (28%) vein grafted patients developed complications. No evidence of a difference in the incidence of vein graft thrombosis was found when comparing explosive with non-explosive cohorts (p = 0.154). ConclusionsThe recorded numbers of vein grafts following combat arterial trauma in are small in the JTTR. No statistically-significant differences in complications, including vein graft thrombosis, were found between cohorts injured by explosive and non-explosive mechanisms.

Extension and grading of osteomyelitis are not related to limb salvage in Charcot neuropathic osteoarthropathy: A cohort prospective study

AimsCharcot neuropathic osteoarthropathy (CN) represents a complication for diabetic patients which involves a progressive alteration of the osteoarticular apparatus with high risk of amputation. The aim of the study was to assess whether the localization of CN and the extent or grading of the osteomyelitis have an influence on the rate of limb salvage and the time to recovery. MethodsWe treated a diabetic population affected by CN complicated by ulceration and widespread osteomyelitic involvement. All patients were treated surgically to eliminate infected tissues, stabilize and correct the bone deformities. Histopathological and microbiological analyses were carried out on the bone specimens. ResultsThirty-three patients affected by CN complicated by large osteomyelitic involvement of midfoot and/or ankle were treated between January 2010 and May 2014. The mean follow-up was 409,35±154,06days. Thirty patients had complete recovery (90.91%) at the end of follow-up. No difference in limb salvage rate and time to recovery was observed when stratifying the population according to CN localization, extent and grading of osteomyelitis. ConclusionsIn this cohort prospective study we observed a high percentage of limb salvage in patients affected by CN complicated by diffuse midfoot/hindfoot osteomyelitis. The localization of Charcot deformity and the extent/stage of osteomyelitis did not change the rate of limb salvage.

Impact of end-stage renal disease in patients with critical limb ischaemia undergoing infrapopliteal intervention.

This study aimed to investigate the impact of end-stage renal disease (ESRD) on clinical outcomes following infrapopliteal intervention in critical limb ischaemia patients with tissue loss. This retrospective single-centre study enrolled 92 consecutive patients (117 limbs) undergoing infrapopliteal intervention for the treatment of ischaemic tissue loss. The primary outcomes were the wound healing rate, the clinically driven reintervention rate and the limb salvage rate. The secondary outcome was amputation-free survival. The pedal arch was significantly (p=0.002) more diseased in ESRD patients than in non-ESRD patients. ESRD patients demonstrated a significantly lower wound healing rate (hazard ratio [HR], 0.552; 95% CI: 0.319-0.957; p=0.034) and a higher reintervention rate (HR, 1.988; 95% CI: 1.135-3.482; p=0.016). However, there was no significant difference in limb salvage rate between patients with and without ESRD. Age (HR, 1.056; 95% CI: 1.020-1.094; p=0.002), ESRD (HR, 2.239; 95% CI: 1.138-4.407; p=0.020), heart failure (HR, 2.360; 95% CI: 1.295-4.302; p=0.005) and infectious wound (HR, 2.017; 95% CI: 1.145-3.552; p=0.015) were independently associated with death or major amputation. ESRD patients yielded a more affected pedal arch and were at approximately twice the risk of wound healing failure, need for reintervention, and death or major amputation compared to non-ESRD patients.

Reconstruction of sarcoma defects following pre-operative radiation: Free tissue transfer is safe and reliable

Neoadjuvant radiotherapy followed by surgical resection and soft tissue reconstruction provides the best possibility of achieving superior limb function in soft tissue sarcomas. The aim of this study was to report our experience of free flap microsurgical reconstruction of recently irradiated soft tissue sarcoma defects. A retrospective study of microsurgical outcome in consecutively treated extremity and trunk sarcoma patients undergoing free tissue transfer between 2007 and 2012 was conducted from a prospectively collected database. Outcomes in pre-operatively irradiated patients were compared with non-irradiated patients. Demographic data, operative details, limb salvage rate, post-operative including microsurgical complications, and long-term limb function (Toronto Extremity Salvage score, TESS; Musculoskeletal Tumour Society Rating Scale, MSTS) were recorded and analysed for differences between the two study groups. Forty-six patients underwent 46 free flaps (pre-irradiated n = 32, non-irradiated n = 14) over the study period. Microvascular complications (intra-operative revision, flap re-exploration, flap loss) were uncommon and similar between the two groups (4/32 and 2/14 respectively, p > 0.05). Recipient site wound healing complications (i.e. not flap related) occurred more frequently in pre-irradiated patients (16 events) compared with the control group (2 events, p = 0.03). There was no significant difference in limb salvage rate, or TESS/MSTS functional outcome scores between the two patient groups. Free tissue transfer is safe and effective in patients undergoing surgical resection and reconstruction following neoadjuvant radiotherapy.

Percutaneous intervention for infrageniculate arterial disease in women may be associated with better outcomes when compared to men

The purpose of this study was to identify any gender-associated differences in the percutaneous treatment of infrageniculate lesions in individuals with chronic critical limb ischemia. A retrospective chart review was performed on 112 index tibial lesions in 81 consecutive patients operated on from January 2005 to February 2011. All patients were treated for critical limb ischemia-defined as rest pain or tissue loss. Patient demographics, comorbidities, clinical presentation, vascular studies, lesion characteristics, procedures, and postoperative complications were entered into a database for review. Patients were evaluated for primary patency, secondary patency, limb salvage, and mortality rates. Sixty-three index tibial lesions were treated percutaneously in 43 women, compared to 49 lesions in 38 men. There was a trend toward increased cardiac disease (65.8% men vs 44.2% women; P = .052) and smoking (52.6% men vs 32.6% women; P = .070) in men. Men were more likely than women to have TransAtlantic Inter-Society Consensus (TASC) C and D lesions (83.7% vs 65.1%; P = .023) and to be treated for total occlusion (44.9% vs 25.4%; P = .031). There were no significant gender-related differences in length of stay or postoperative complications. Women had statistically better primary patency rates than men at 12 and 24 months (77.5% ± 6.9% and 72.9% ± 7.8% in women vs 58.7% ± 9.3% and 45.2% ± 9.9% in men; P = .032). Women also had statistically better secondary patency rates than men at 12 and 24 months (90.4% ± 4.8% and 85.1% ± 6.8% in women vs 76.0% ± 8.1% and 58.5% ± 10.8% in men; P = .028). Female gender remained an independent predictor of superior patency even after controlling for gender-related differences in TASC grade. There were no significant differences in limb salvage rates at 12 and 24 months (92.1% ± 4.4% and 85.0% ± 7.9% in women vs 88.3% ± 6.4% and 83.4% ± 7.7% in men; P = .985). Overall survival rates were similar (59.8% ± 7.6% for women and 68.0% ± 8.1% for men at 24 months; P = .351). Percutaneous intervention may be an equally effective or better treatment option for women with chronic limb ischemia and tibial disease when compared to men. In this study, male gender was an independent predictor of poorer primary and secondary patency rates after infrageniculate intervention. There were no differences in postoperative wound complications between genders. Endovascular procedures may lessen the gap in gender-related treatment outcomes and postoperative complications seen after open arterial reconstructions.

Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series

The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). We abstracted data of a series of 185 consecutive patients with diabetes and foot osteomyelitis undergoing surgery within the first 12 h after admission at a single hospital. Bone infection was confirmed by histopathological studies. Only cases where Staphylococcus aureus was isolated from bone specimens were included in this analysis. We analysed several variables between the two groups: MRSA vs. MSSA. MRSA bone infection was associated with higher body temperature (P = 0.02) and white blood cell count (P = 0.02) than MSSA. Patients with MRSA infections underwent a greater number of surgical procedures (P = 0.03). Limb salvage was achieved in 93.6% of the patients, with no statistically significant difference in limb salvage rates between MRSA and MSSA-related osteomyelitis. From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis.

The Impact of Diabetes on Current Revascularisation Practice and Clinical Outcome in Patients with Critical Lower Limb Ischaemia

Objective To compare current revascularisation practice and outcome in diabetic and non-diabetic patients presenting with critical limb ischaemia (CLI) to a single vascular surgeon. Methods Data for 113 patients presenting with CLI were collected prospectively over a 3-year period. Forty-four (39%) were diabetic. Treatment was classified as percutaneous angioplasty, arterial reconstruction, primary major amputation, and conservative therapy. Main outcome measures were 30-day mortality, major amputation, survival, and amputation-free survival. Results Diabetic patients were more likely to present with gangrene, give a history of angina, be treated with nitrates and statins, and have lower cholesterol levels. No significant differences were found in the initial treatment options between diabetics and non-diabetics: angioplasty 39 vs 26%, surgical revascularisation 34 vs 33%, primary major amputation 9% vs 17%, and conservative treatment 11 vs 19% ( p=ns in all). There were eight deaths (7%) within 30-days. At follow-up (1–44 months, median 14 months), rates of major amputation and death for the entire population were 23 and 8%, respectively. The 12-month cumulative survival and amputation-free survival rates were 90 and 72%, respectively. When comparing diabetic to non-diabetic patients, there were no significant differences in the 30-day mortality (6.8 vs 7.2%, p=0.4), cumulative survival (93 vs 89% at 12 months, log-rank test: 0.00, p=0.9), amputation-free survival (71 vs 73% at 12 months, log-rank test: 0.00, p=0.99), and major amputation rates (22.7 vs 23.1% at 12 months, p=0.96). Similarly, there were no differences in limb salvage rates between diabetic and non-diabetic patients undergoing revascularisation procedures (78 vs 90% at 12 months, log-rank test: 2.04, p=0.15). Conclusions In current practice, an aggressive multidisciplinary approach in diabetic patients presenting with CLI leads to similar limb salvage, amputation-free survival, mortality, and major amputation rates to those seen in non-diabetic patients. The presence of diabetes should not deter clinicians from attempting revascularisation by means of angioplasty or surgical reconstruction.

The Myth of theIn SituGraft: Superiority in Infrainguinal Bypass Surgery?

Objectives:to compare the clinical outcome ofin situand reversed bypass grafting.Design:multicentre, prospective, non-randomised study.Patients and methods:five-hundred patients with anin situgraft and 955 patients with a reversed graft were compared regarding graft occlusion, the need for graft revision, and limb salvage.Results:two-year assisted primary patency of femoropopliteal bypass procedures was 82% forin situand 82% for reversed grafts. The corresponding hazard ratio (HR) for occlusion was 1.27 (95% CI 0.91–1.77). The 2-year assisted primary patency of femorocrural bypass procedures was 69% forin situvs. 70% for reversed grafts. The corresponding HR was 1.13 (95% CI 0.73–1.75). Adjustment for relevant baseline variables did not change the results. More reinterventions were needed to maintain integrity and patency of thein situgraft especially in crural bypasses. No differences in limb salvage rates were seen.Conclusions:reversed andin situvein grafts have similar patency and limb salvage rates for both femoropopliteal and femorocrural bypass procedures. Thein situgraft needs more secondary interventions.