Lower Extremity Wounds Research Articles

Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n=0) versus 4.17% (n=2; p=0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p=0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n=10) in the muscle group versus 2.08% (n=1; p=0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.

Extracorporeal Pedicles for Free Flap Reconstruction in Diabetic Lower Extremity Wounds.

Diabetic foot ulcers are a severe complication of diabetes, and their management requires a multidisciplinary approach for optimal management. When treating these ulcers, limb salvage remains the ultimate goal. In this article, we present the "hanging" free flap for the reconstruction of chronic lower extremity diabetic ulcers. This two-staged approach involves standard free flap harvest and inset; however, following inset the "hanging" pedicle is covered within a skin graft instead of making extraneous incisions within the undisturbed soft tissues or tunnels that can compress the vessels. After incorporation, a second-stage surgery is performed in 4 to 6 weeks which entails pedicle division, flap inset revision, and end-to-end reconstruction of the recipient vessel. Besides decreasing the number of incisions on diabetic patients, our novel technique utilizing the "hanging" pedicle simplifies flap monitoring and inset and allows reconstruction of recipient vessels to reestablish distal blood flow.

Microvascular Lower Extremity Reconstruction after Oncologic Resection and Revascularization: A Single-Center 21-Year Experience

INTRODUCTION: Tumors of the lower extremity necessitating vascular resection and reconstruction increase the complexity of flap reconstruction. We present the reconstructive outcomes of these composite defects at a large center. METHODS: A prospectively maintained database was used to identify patients who underwent lower extremity tumor resection requiring both bony or soft tissue reconstruction and vascular reconstruction. The study included all patients from 2000 to 2021. RESULTS: A total of 18 patients met inclusion criteria. Mean age was 50.1 years (range 15–83) and mean BMI was 26.5 kg/m2 (range 18.5–45.5). Pathology was sarcoma in 14 patients and squamous cell carcinoma in 4 patients. Radiation was given to 11 patients. Vascular reconstruction consisted of prosthetic and autologous grafts. Tissue reconstruction consisted of pedicled muscle flaps in 11 patients and free tissue transfer in 7 patients. Bone resection was performed in 4 patients, of which 3 were reconstructed with metallic implants and 1 with fibula osteocutaneous free flap. Overall complication rate was 61% (11 of 18 patients) and consisted of hematomas in 3 patients, infections in 7 patients, delayed wound healing in 5 patients, and partial flap loss in 1 patient. All patients underwent limb salvage. Mean follow-up duration was 23.89 months (range 1.48 months to 45.8). Functional outcomes were independent ambulation 13 (72.2%) patients, ambulation with assistive devices in 3 (16.6 %) patients and no ambulation in 2 (11.11 %) patients. CONCLUSION: Free flap reconstruction of lower extremity wounds after tumor resection results in excellent rates of limb salvage with good functional outcomes.

Evaluating The Use Of Glass, Wifi And Mac Scores As Predictors Of Limb Salvage Success In Patients Receiving Free Tissue Transfer For Chronic Lower Extremity Wounds

The WIfI (wound, ischemia, and foot infection), MAC (medial arterial calcification), and GLASS (global limb anatomic staging system) grading scales have recently been adopted by the Society of Vascular Surgery as predictors of amputation rates and failure of revascularization in patients with chronic limb-threatening ischemia (CLTI). However, these metrics have not taken into account the ability of free tissue transfer (FTT) to shift these outcomes. This study seeks to characterize whether the addition of free tissue transfer can facilitate limb salvage in patients who would otherwise be deemed as high risk for failure using these grading systems.

Challenges of Large-scale Patient-reported Outcome Measures Collection in a Multidisciplinary Limb Salvage Center.

Challenges of Large-scale Patient-reported Outcome Measures Collection in a Multidisciplinary Limb Salvage Center.

33396 Nonuremic calciphylaxis precipitated by COVID 19 infection

A 40-year-old female with a medical history of hypertension, anxiety, and COVID-19 pneumonia in May 2021 that was complicated by cardiac arrest, presented in July 2021 with bilateral lower extremity wounds. Wounds initially were described as ‘sunburns’ that progressed to form multiple large retiform purpura with black necrotic eschars and surrounding induration on bilateral thighs and lower legs. A telescoping punch biopsy was performed showing calciphylaxis with intravascular thrombosis. Labs were significant for a mildly elevated phosphorus, PT/PTT, lupus anticoagulant antibody, and positive ANA. Creatinine, BUN, calcium, PTH, and GFR were within normal limits. Patient had no prior personal or family history of coagulopathies or renal dysfunction. The patient was diagnosed with nonuremic calciphylaxis (NUC) precipitated by a COVID-19 induced coagulopathy. Intravenous sodium thiosulfate and sevelamer was started for treatment. NUC is a rare disease characterized by arterial calcification leading to ischemia and skin necrosis that occurs in the setting of normal renal function. Other conditions associated with NUC include prothrombotic states like Protein C and S deficiency, antithrombin III deficiency, antiphospholipid antibody, cryofibrogenemia, and malignancy. COVID-19 has been demonstrated to generate a prothrombotic state leading to hypercoagulability. The patient’s recent COVID-19 infection and positive lupus anticoagulant antibody together promoted a hypercoagulable state that was the nidus for cutaneous calciphylaxis and making this case of NUC induced by COVID-19 hypercoagulability a novel presentation of an uncommon disease.

The Past, Present, and Future of Podiatry.

The Past, Present, and Future of Podiatry.

An improved bone transport surgical method for treating chronic ischemic ulcers (thromboangiitis obliterans).

IntroductionThe chronic ischemic injury of the upper/lower limbs caused by thromboangiitis obliterans (TAO, Buerger's disease) is difficult to heal, leading to high morbidity and amputation risk, seriously lowering the quality of life of patients. So far, the pathogenesis of this disease is still not clear, and there are still no effective therapeutic approaches. Here, we first use an improved bone transport technique to treat TAO-related foot ulcers and achieve good therapeutic effects.Materials and MethodsIn this report, 22 patients met the inclusion criteria, and we provide an improved bone transport technique to repair TAO-related chronic lower limb wounds, which have a minimally surgical incision and a satisfying surgical field.ResultsThe improved bone transport technique resulted in TAO-related chronic lower extremity wound healing in most patients (18, M:F 16:2) within the first treatment cycle. All wounds healed completely after two treatment cycles. After these cycles, the cold sensation in the patients’ feet was significantly relieved, and the rest pain in the lower extremities was significantly relieved (Visual Analog Scale, P < 0.0001). Furthermore, the Laser Doppler flowmeter showed that the blood perfusion and percutaneous oxygen pressure of the affected foot were higher than in preoperation (P < 0.0001). To conclude, bone transport technology is available for the refractory wounds of the extremity, which may promote healing by increasing blood circulation and tissue oxygen supply.ConclusionsIn summary, the improved surgical method of the bone transport technique is worth considering in the treatment of thromboangiitis obliterans–related foot ulcers.

Clinical Evaluation of a Synthetic Hybrid-Scale Matrix in the Treatment of Lower Extremity Surgical Wounds.

Lower extremity operative wounds can be difficult to treat and are associated with social challenges. New treatment options are needed to mitigate the clinical and social challenges and potentially lower the treatment cost and time. A synthetic hybrid-scale fiber matrix, which has an architecture similar to native tissue, a tailored resorption rate, and excellent durability and handling characteristics, is gaining popularity due to its effectiveness in treating different kinds of wounds. In this retrospective study, nine patients with a total of nine lower extremity wounds and multiple comorbidities were included. The hybrid-scale fiber matrix was cut to wound size, fenestrated as deemed appropriate, and secured to the wound bed using staples or sutures. Wound healing was monitored at subsequent visits, and the synthetic fiber matrix was re-applied as needed. Healing was considered complete when 100% epithelialization and closure of the wound site occurred. Overall, seven out of nine wounds exhibited complete healing and wound closure. For fully healed wounds, the average time to heal was 135.6 days, and good scar quality was observed. This retrospective case series demonstrates the versatility of synthetic hybrid-scale fiber matrices as part of an effective treatment regimen for difficult-to-treat lower extremity operative wounds.

Next-Generation Diagnostic Wound Dressings for Diabetic Wounds.

Chronic lower extremity wounds (diabetic foot ulcers) are a serious and prevalent complication of diabetes. These wounds exhibit low healing rates and present a high risk of amputation. Current diagnostic options for foot ulcers are limited to macroscopic wound analysis such as wound depth, implicated tissues, and infection. Molecular diagnostics promises to improve foot ulcer diagnosis, staging, and assessment of the treatment response. In this perspective, we report recent progress in understanding the pathophysiology of diabetic wound healing and point to recently emerged novel molecular targets for wound diagnostics. We discuss selected diagnostic wound dressings under preclinical development that detect one or several inflammatory markers, bacterial secretions, hyperglycemia, and mechanical stress. We also highlight key translational challenges of investigational diagnostic bandages for diabetic foot ulcers.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction. We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS). A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p= 0.043). Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.

Facilitators and Barriers to Clinical Pathway Uptake and Utilization Among Primary Care Providers in Saskatchewan - A Qualitative Study.

Clinical Pathways (CPWs) are multidisciplinary, evidence-based, complex interventions designed to standardize patient care. In Saskatchewan, development, implementation and evaluation of the seven provincial CPWs (Hip & Knee, Spine, Pelvic Floor, Prostate Assessment, Fertility Care, Lower Extremity Wound Care and Acute Stroke) present significant challenges, leading to low utilization. This study aimed to identify facilitators and barriers to CPW utilization by Saskatchewan family physicians. To identify the facilitators and barriers to CPWs, a qualitative interpretive approach consisted of eight one-on-one key informant interviews and five focus groups held with 30 family physicians in two larger urban and two smaller Saskatchewan cities. Inductive, thematic analysis of the interviews based on the Theoretical Domain Framework for behavioral changes was used to identify facilitators and barriers to CPW uptake and utilization. Fifty-one themes were mapped under 14 Theoretical Domain Framework domains. Major barriers included the following: system-level (knowledge and communication, social/professional identity, family physician engagement and education); objective clarification (goals, belief about consequences of implementing CPW); and technical and resource related (administrative, access to local specialists, enforcement and incentives). The most prominent barrier was lack of systematic CPW promotion and inconsistencies in communication between the following: organization-to-practitioner; organization-to-organization; and practitioner-to-practitioner. Facilitators who mitigated barriers were need for optimized and integrated information technology services (i.e., Electronic Medical Records) and optimism towards CPW usage and patient outcomes. This exploratory study identified specific improvements and recommendations required to promote uptake of CPWs based on perceived facilitators and barriers.

QS27. Surgical Outcomes of Postoperative Intensive Care Unit Versus General Floor Management Following Lower Extremity Free Flap Reconstruction in the Comorbid Chronic Wound Population

Purpose: Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted towards admitting FTT patients to the general floor postoperatively instead of the ICU. This is the first study to compare surgical outcomes in patients admitted to the floor versus ICU immediately following free flap reconstruction for chronic LE wounds. Methods: A retrospective review was performed of patients undergoing FTT to LE from 2011 to 2021 by the senior author (K.K.E.). In March 2020, our institution began admitting our free flap patients to the general floor post-operatively. In patients admitted to the floor postoperatively, flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or specialty floor in the immediate postoperative period. Primary outcomes were postoperative complications, hospital length of stay (LOS), flap takeback and salvage, and flap success. Statistical significance was set at values of p < 0.05. Results: A total of 255 patients underwent FTT to LE during the 10-year period. Forty-two patients (16.5%) were admitted to the floor postoperatively and 213 patients (83.5%) went to the ICU. Average age and body mass index were 55.8 years and 29.4 kg/m2, respectively. Comorbidities among the two groups were similar, except floor patients had a higher prevalence of diabetes (69.0% vs. 49.3%, p=0.019). Overall microsurgical success rate was 97.3%, which was similar for floor and ICU patients (100% vs. 96.7%, p=0.604). Flap takeback occurred in 3 floor patients (1.2%) and 13 ICU patients (5.1%) (p=0.733). Flap salvage was higher in floor patients, although not statistically significant (7.1% vs. 3.3%, p=0.250). Average hospital LOS did not significantly differ among patients admitted to the floor versus ICU (16.1 vs. 17.7 days, p=0.628). Conclusion: Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. Efforts should be focused on training floor nurses to use the Cook Doppler and ViOptix devices to monitor flaps. While we expect hospital costs to decrease with floor admission, future studies should focus on the cost impact of postoperative floor management in this patient population.

54. Implementation of a Risk-stratified Anticoagulation Protocol Increases Free Flap Success in Thrombophilic Patients With Chronic Lower Extremity Wounds

Purpose: A hypercoagulable state is one of the most challenging preoperative conditions that reconstructive microsurgeons face. Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and to achieve high rates of microsurgical success in patients undergoing lower extremity (LE) free tissue transfer (FTT). At our institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. After six years of experience with this protocol, we present an updated analysis of surgical outcomes and the utility of risk-stratified AC in thrombophilic patients who underwent FTT reconstruction for chronic LE wounds. Methods: We conducted a retrospective review of patients who underwent FTT to the LE at our institution from January 2012 to August 2021. Patients were preoperatively assessed for hypercoagulability based on history and a screening panel. Our risk-stratification AC protocol was implemented in July 2015. Low-risk (<3 hypercoagulable traits) and moderate-risk (>3 hypercoagulable traits or history of venous thromboembolism) patients were anticoagulated with subcutaneous heparin (SQH). Any intraoperative risk factor (thrombosis, anastomotic revision, presence of calcified vessels) upstaged patients to high microvascular risk. High-risk patients received heparin infusion titrated to a goal PTT of 50-70 seconds. Prior to July 2015, non-stratified patients were treated with SQH for uncomplicated microvascular anastomoses, while patients with microvascular compromise were converted to a low-dose heparin infusion (500 units/hour). Patients were divided into two cohorts (non-stratified and risk-stratified) based on the date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success. Results: A total of 219 hypercoagulable patients who underwent FTT to LE were treated with either non-stratified (n=26) or risk-stratified (n=193) thromboprophylaxis. Overall flap success rate was 96.8% (n=212). Lower rates of flap loss (1.6% vs. 15.4%, p=0.004) were observed among risk-stratified patients, which paralleled a significant reduction in the prevalence of postoperative thrombotic events (2.6% vs. 15.4%, p=0.013). Flap salvage, in the setting of postoperative thrombosis, was accomplished in 80% of cases in the risk-stratified cohort compared to 0% in the non-stratified group (p=0.048). Bleeding complications and transfusion requirements were similar among the two cohorts. On multivariate analysis, intraoperative anastomotic revision (OR: 3.10; p<0.001) and non-risk stratification (OR: 11.2; p=0.001) were independently associated with flap failure. Non-risk stratification for thromboprophylaxis was an independent predictor of perioperative microvascular thrombosis (OR: 3.71; p=0.041). Conclusion: Hypercoagulability can significantly impact microsurgical outcomes. Preoperative identification of hypercoagulable traits and intraoperative risk factors can successfully guide perioperative thromboprophylaxis. Implementation of a risk-stratified AC protocol at our institution has contributed to significant improvements in flap success without creating an increased need for blood transfusion.

QS26. Predictors for Secondary Amputation Following Lower Extremity Free Tissue Transfer in Comorbid Patients With Chronic Lower Extremity Wounds

QS26. Predictors for Secondary Amputation Following Lower Extremity Free Tissue Transfer in Comorbid Patients With Chronic Lower Extremity Wounds

Cancer as a Consideration for a Non-healing Lower Extremity Wound

Cancer as a Consideration for a Non-healing Lower Extremity Wound

The Ability of Clinical Decision Rules to Detect Peripheral Arterial Disease: A Narrative Review.

Peripheral arterial disease (PAD) is a common cause of lower extremity wound. Consequently, PAD leads to a cause of leg amputation nowadays, especially in diabetic patients. In general practice (GP), confrontation with PAD prevention is a challenge. In general, ankle-brachial index (ABI) measurement can be used as a PAD diagnostic tool, but this takes some time. The tool is not generally available and this need to train healthcare workers to perform. Multiple independent predictors developed the diagnostic prediction model known as clinical decision rules (CDRs) to identify patients with high-risk PAD. This might therefore limit the number of patients (only high-risk patients) to refer for ABI evaluation. This narrative review summarized existing CDRs for PAD.

Long-term Outcomes in Patients With Peripheral Arterial Disease Who Undergo Free Flap Reconstruction for Chronic Lower Extremity Wounds

Free tissue transfer (FTT) is critical for limb salvage of chronic lower extremity (LE) wounds. In patients with peripheral arterial disease (PAD), FTT to the LE may be challenging owing to limited vessel selection for anastomosis. Herein, we evaluate our surgical and functional outcomes following FTT to LE in patients with PAD.

Endovascular Interventions and Flap Outcomes in Peripheral Arterial Disease Patients Undergoing Fasciocutaneous Versus Muscle Free Tissue Transfer in Lower Extremity Reconstruction

Endovascular Interventions and Flap Outcomes in Peripheral Arterial Disease Patients Undergoing Fasciocutaneous Versus Muscle Free Tissue Transfer in Lower Extremity Reconstruction

Are We Misrepresenting Superficial Femoral Artery Stenting? High Rates of Restenosis and Limb Loss Are Seen With Long-term Follow-up

Are We Misrepresenting Superficial Femoral Artery Stenting? High Rates of Restenosis and Limb Loss Are Seen With Long-term Follow-up