Lower Limb Salvage Research Articles

Below-knee amputation with an ultrasonic scalpel: evaluation of early postoperative clinical outcomes.

Despite the development of microscopic reconstructive techniques for lower limb salvage, major limb amputation is still required for critical, unsalvageable lower leg wounds, with steadily increasing estimates of major limb amputations. In this study, the authors highlight a surgical technique for below-knee (BK) amputation using an ultrasonic scalpel, and evaluate its safety and effectiveness compared with the conventional method of using surgical blades. A retrospective chart review was conducted at the Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, Republic of Korea, on patients who underwent BK amputation between October 2012 and January 2021. Patients were assigned to two groups: amputation using classical methods, such as surgical blades and electrocautery (group A); and amputation using an ultrasonic scalpel (group B). Numerous perioperative factors, such as operation time, intraoperative blood loss, postoperative complications and recovery time were examined. The present study adhered to the STROBE guidelines. A total of 41 patients (16 in group A and 25 in group B) were included in this study. Operation time was significantly shorter in group B (p=0.001) and intraoperative blood loss was lower (p=0.011). Wound healing time did not vary between groups. In this study, the use of an ultrasonic scalpel for lower limb amputation was effective in reducing operation time and blood loss, which may be helpful in improving outcomes for patients with comorbidities.

Lower limb salvage in an interesting case of recurrent calf cellulitis

Cellulitis of the lower limb is a complex pathologic entity which might progress to life-threatening complications, such as sepsis, without a prompt and appropriate treatment. Therefore, a delayed diagnosis often requires life-saving amputations. This paper outlines the therapeutic approach in such situations by describing a patient who had already undergone amputation of the right lower limb and where the rapid institution of targeted therapy saved the left lower limb affected by cellulitis. The conclusion of this research is that in extensive infections of the extremities, the institution of triple antibiotic therapy in combination with staged surgical treatment may avoid limb amputation and save the lives of these patients.

Predictors of limb saving in diabetic foot ulcer.

This study was aimed to determine the various factors which could serve as predictor of saving of lower limb from amputation in patients with diabetic foot ulcer (DFU). This three-year retrospective study was conducted in the Diabetes and Endocrinology Unit of Hayatabad Medical complex Peshawar, Pakistan. Demographic, clinical, laboratory and radiological information of the diabetic patients with DFU admitted between January 2020 to December 2022 was retrieved from the hospital files. Information regarding initial and final decision regarding amputation and the outcome of the ulcer was also recorded. A total of 502 patients of diabetes mellitus (DM) with DFU were included in the study, of whom there were 279 (55.6%) males and 223 (44.4%) females. The mean age of the study population, mean duration of DM and mean HbA1c were 55.2 ± 9.8 years, 13.7 ± 6.7 years and 11.2 ± 2.4 %, respectively. Patients who had an amputation of their lower limbs had an increased age (p= 0.034), raised total leucocyte count (TLC) (p= <0.001), higher HbA1c (p= 0.025), had osteomyelitis (p= <0.001), and had a higher-grade ulcer (p= <0.001). On binary logistic regression analysis, ulcer grade (OR=7.4, p= <0.001), osteomyelitis (OR=11.8, p= <0.001), and initial decision of no amputation at the time of admission (OR=33.6, p=<0.001) were independently associated with the lower limb salvage. DFU which were of grade I to II, had no evidence of osteomyelitis and for which an initial decision was of no amputation were more likely to be salvaged.

Case Series: Fibula Free Flap with Bone Allograft as the Gold Standard in Lower Limb-Salvage Surgery for Adolescent Patients with Primary Bone Tumors Located within Tibial Diaphysis: Technical Modifications and Short-Term Follow-Up.

Background: Primary malignant bone tumors are most commonly associated with mutilating surgical procedures that can significantly disturb the motor development of a young patient and are frequently affiliated with major postoperative complications. Unfortunately, despite available autologous tissue donor sites, artificial materials are still most commonly used for the reconstruction of post-resection defects. Reconstructive microsurgery is increasingly recognized as an effective method of functional reconstruction, creating the possibility of performing limb-sparing surgery (LSS) with significant limitation of major postoperative complications at the same time. Methods: The study group consisted of 9 pediatric patients diagnosed with primary malignant bone tumor in the limb location. In order to perform microvascular reconstruction, 9 free fibula flaps were used in combination with a bone allograft (Capanna method). The functional outcome of the reconstruction was assessed on the basis of the MSTS (Musculoskeletal Tumor Society Scoring System) scale. Results: The presented analysis proves the effectiveness of this reconstructive procedure and the possibility of performing LSS with reasonable functional outcomes after appropriate patient qualification. In this study, all limbs included were spared. In all cases, the R0 surgical margins were achieved and no reports of local recurrences were reported during the follow-up. The average score on the MSTS scale was 27/30 points. Conclusions: Microvascular reconstructive surgery is an individually personalized and highly effective method of treating patients with primary bone tumors in the limb location and provides satisfactory functional outcomes.

A Data-Driven Method to Discriminate Limb Salvage from Other Combat-Related Extremity Trauma.

The aim of this study was to address and enhance our ability to study the clinical outcome of limb salvage (LS), a commonly referenced but ill-defined clinical care pathway, by developing a data-driven approach for the identification of LS cases using existing medical code data to identify characteristic diagnoses and procedures, and to use that information to describe a cohort of US Service members (SMs) for further study. Diagnosis code families and inpatient procedure codes were compiled and analyzed to identify medical codes that are disparately associated with a LS surrogate population of SMs who underwent secondary amputation within a broader cohort of 3390 SMs with lower extremity trauma (AIS > 1). Subsequently, the identified codes were used to define a cohort of all SMs who underwent lower extremity LS which was compared with the opinion of a panel of military trauma surgeons. The data-driven approach identified a population of n = 2018 SMs who underwent LS, representing 59.5% of the combat-related lower extremity (LE) trauma population. Validation analysis revealed 70% agreement between the data-driven approach and gold standard SME panel for the test cases studied. The Kappa statistic (κ = 0.55) indicates a moderate agreement between the data-driven approach and the expert opinion of the SME panel. The sensitivity and specificity were identified as 55.6% (expert range of 51.8-66.7%) and 87% (expert range of 73.9-91.3%), respectively. This approach for identifying LS cases can be utilized to enable future high-throughput retrospective analyses for studying both short- and long-term outcomes of this underserved patient population.

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

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

Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis.

Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.

Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19.

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. 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. 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). 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.

Lower Limb Salvage For Tumours Around The Knee Using Oncological Resections And Megaprosthetic Reconstructions.

This descriptive case series documented the clinical presentation of tumours around the knee in our population and explored the outcome of lower limb salvage with oncological resections and megaprosthetic reconstructions. The variables analysed included return of knee function, disease free survival and any complications observed over a follow up period of 5-years. The study spanned over a period of 13-years. It included adult patients of all genders who presented with tumours around the knee and underwent tumour resections followed by megaprosthetic reconstructions at our institute. Out of 73 patients, there were 43 (58.90%) males and 30 (41.09%) females. Their ages ranged between 16-53 years with a mean of 32.97±10.68 years. The tumours included giant cell tumours (n=41), osteosarcomas (n=24), Spindle cell sarcoma (n=5), chondrosarcoma (n=2) and Ewing's sarcoma (n=1). The average postoperative musculoskeletal tumour society (MSTS) score was 84.65%. Various complications encountered included superficial infections/ delayed wound healing among 9 (12.32%) patients, local recurrence in 6 (8.21%), deep infections among 5 (6.84%) and transient palsy of peroneal nerve in 3 (4.10%) cases. There was aseptic loosening and traumatic disruption of extensor mechanism one each (1.36%). There were 7 (9.58%) mortalities in our series. Giant cell tumours and osteosarcomas were the most frequent tumours observed around the knee. The tumours affected relatively younger population. Safe oncological resections of the tumours followed by megaprosthetic reconstructions provided reasonable outcome in the majority of patients.

Role of solitary peroneal artery angioplasty for lower limb salvage in patients with critical limb ischemia

Role of solitary peroneal artery angioplasty for lower limb salvage in patients with critical limb ischemia

Diabetic patients with inadequate flow of the posterior tibial artery and in dialysis are not good candidates for Syme amputation

Objective: There is a renewed interest in Syme amputation (SA) as it is considered a “lower limb salvage” procedure. The aim of this study was to describe the characteristics and evolution of diabetic patients who underwent SA to search for factors that would affect the outcome by comparing a group of patients who had a successful amputation against those who required a major amputation. Methods: Seventeen diabetic patients submitted to non-traumatic SA between 2008 and 2016 were analyzed retrospectively. Results: Eight patients required a higher level of amputation. In this group, six patients continued with the posterior tibial artery (PTA) occluded despite the revascularization, and seven were on dialysis. When assessing the permeability of PTA and dialysis as predictors of failure, they multiplied the risk by 20 (cOR of 24 and 21, respectively). However, after adjusting for both factors, there was only clinical significance. Conclusion: SA in diabetic patients may be an alternative in those with a preserved heel pad tissue vascularization and permeable posterior tibial artery at the time of surgery. Patients on dialysis are likely to fail with this level of amputation. Level of Evidence IV; Therapeutic Studies; Retrospective Cohort Study.

Outcomes of Infrapopliteal Bypass for Chronic Limb-Threatening Ischemia are Worse in Renal Transplant Patients than in Hemodialysis-Dependent Patients

Comparisons of distal bypass outcomes between hemodialysis-dependent (HD) and renal transplant (RT) patients have been reported, but the influences of immunosuppressive therapy on the outcomes remain unclear because of the limited number of RT patients who underwent distal bypass or cohort heterogenicity. We compared outcomes of distal bypass for chronic limb-threatening ischemia (CLTI) with homogenous ischemic limb pathology. Between January 2014 and December 2019, we performed 334 infrapopliteal bypass procedures using vein grafts for 275 consecutive CLTI patients with tissue loss. Among them, there were 130 HD patients (47.3%) (163 limbs) and 11 RT patients (4%) (15 limbs), and 30-day mortality, 5-year primary and secondary patency (PP and SP), limb salvage (LS), amputation-free survival rates, and wound healing (WH) status were compared between the HD and RT patient groups. Nine HD patients died within 30days after surgery (7%), whereas no deaths were observed among the RT patients. Five-year PP and SP rates in the RT group 39% and 41%, which were significantly worse compared to 64% and 82% in the HD group (P<0.01). Unsuccessful rate of revision surgery including hemodynamically failed grafts after revision reached over 80% in the RT group, which was technically unfeasible pathology for graft salvage (vs. 3% in the HD group), and WH, and LS rates were significantly worse in the RT group. In comparison with HD patients, RT patients showed a lower LS rate for CLTI. The lower LS rate was associated with a lower SP rate, which was caused by disease progression of distal arteries in the foot.

Effectiveness of the Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model in Patents with Distal Bypass

The purpose of this study is to evaluate the effectiveness of mortality prediction using the Vascular Quality Initiative (VQI) chronic limb-threatening ischemia (CLTI) model in patients with distal bypass. Patients who underwent distal bypass for CLTI from 2009 to 2020 at a single center were retrospectively reviewed. Distal bypass was defined as any bypass with a distal anastomosis to the posterior tibial, anterior tibial, dorsalis pedis, plantar, or peroneal artery. Baseline characteristics, operative details, hospital outcomes, and medium-term outcomes were compared among patients with a low-, medium-, and high-risk of mortality based on a VQI CLTI calculation. The primary endpoints were survival and limb salvage. A total of 287 distal bypasses were performed in 230 patients (153 males; median age, 74years; diabetes mellitus, 70%; end-stage renal disease [ESRD] with hemodialysis, 38%). These patients were stratified into 153 (66%) low-, 35 (15%) medium-, and 42 (18%) high-risk cases based on the VQI CLTI model. There were two hospital deaths (1%) within 30days. During a mean follow-up period of 33±29months, 105 patients died and 26 limbs (9%) required major amputation. The 2-year survival rate of 81% in the low-risk group was significantly higher than those of 41% in the medium-risk group and 46% in the high-risk group (both P<0.001). The 2-year survival rates did not differ significantly between the medium- and high-risk groups (P=0.81). The 2-year limb salvage rate of 93% in the low-risk group was significantly higher than those of 81% in the medium-risk (P=0.023) and those of 87% in the high-risk (P=0.039) groups. There were no significant differences in graft patency and wound healing among the three groups. These results suggest that distal bypass is optimal treatment for patients with a low VQI-predicted risk of mortality. However, the lower limb salvage and higher mortality rates at 2years suggest that the decision-making for VQI medium- and high-risk patients may be carefully considered.

Endovascular therapy and free flap transfer in chronic limb-threatening ischemia

Although revascularization has evolved, treating foot gangrene with chronic limb-threatening ischemia remains challenging. There have been many reports on bypass surgery and free flap transfer. Meanwhile, few studies have reported on endovascular therapy and free flap transfer, with high flap survival rates and high wound complication rates. Wound complications are a serious problem that can lead to limb amputation, but previous studies have failed to identify risk factors for wound complications. In this study, we evaluated the results of endovascular therapy and free flap transfer for chronic limb-threatening ischemia and analyzed risk factors for wound complications. A total of 31 legs from 28 patients who underwent endovascular therapy and free flap transfer for lower limb salvage between August 2016 and April 2020 were retrospectively reviewed. The primary endpoints were flap survival and limb salvage rates and wound complication rates. In addition, we performed a statistical analysis of risk factors for wound complications. The flap survival rate was 100%, with partial necrosis in 6% of the patients. The limb salvage rate was 100%. The wound complication rate was 45%. The multivariate analysis showed end-stage renal failure on dialysis as a significant risk factor for wound complications (odds ratio = 133, 95% confidence interval = 2.74–6430, p = 0.014). Endovascular therapy and free flap transfer in chronic limb-threatening ischemia achieved high flap survival rate and limb salvage, but had a high incidence of wound complications. We identified end-stage renal failure on dialysis was a significant risk factor for wound complications.

A comparison of cemented and cementless intra-neck curved stem use during hip-preserving reconstruction following massive femoral malignant tumor removal.

BackgroundPatients who undergo massive femoral malignant tumor (MFMT) resection often exhibit shortened femoral metaphyseal juxta-articular segments. The use of a customized femoral endoprosthesis (CFE) with an intra-neck curved stem (INCS) has emerged as a viable reconstructive surgical strategy for these individuals. Relative to a cemented INCS, it remains unclear as to whether cementless INCS use is associated with improvements in functionality or reconstructive longevity. As such, the present study was conducted to compare functional outcomes, endoprosthetic survival, and endoprosthesis-related complication rates in patients undergoing cemented and cementless INCS implantation.MethodsA total of 24 patients undergoing lower limb salvage and reconstructive surgical procedures utilizing cemented or cementless INCS endoprostheses were retrospectively included. Patient-functional outcomes, endoprosthetic survival, and complication rates were compared as a function of age; diagnosis; the length of femoral resection; residual proximal femur length; Musculoskeletal Tumor Society (MSTS) scores; visual analog scale (VAS) scores; and the rates of implant breakage, periprosthetic infections, periprosthetic fractures, and aseptic loosening.ResultsThe mean follow-up was 56 months. Significant differences in the length of femoral resection (p<0.001) and residual proximal femur length were observed (p<0.001) between the cemented and cementless INCS groups. There were no differences in overall patient survival and aseptic loosening-associated endoprosthesis survival in the cemented and cementless groups. None of the included patients experienced periprosthetic fractures, infections, or implant breakage. Average respective MSTS and VAS scores did not differ between groups.ConclusionFor patients undergoing treatment for MFMTs, the use of a CFE with an INCS has emerged as a viable approach to hip-preserving reconstructive surgery. With appropriately designed individualized rehabilitative programs, good functional outcomes can be achieved for these endoprostheses, which are associated with low complication rates. Moreover, the selection between cemented or cementless INCS in the clinic should be made based on patient-specific factors, with cementless INCS implementation being preferable in younger patients with good-quality bone, the potential for long-term survival, and the osteotomy site near the lesser trochanter, whereas cemented INCS use should be favored for individuals who are older, have a shorter life expectancy, or have poor bone quality.

Complex limb salvage with an orthoplastic approach: a case report

Lower extremity trauma is an important cause of patient morbidity and disability-adjusted life years (DALYs). It also presents a significant reconstructive challenge for surgeons. Mangled extremity injuries can result in an amputation when limb salvage procedures are unsuccessful. Identifying strategies to optimize limb salvage attempts is necessary to improve postoperative outcomes. Establishing a constructive relationship between orthopaedic and plastic surgeons has been shown to be beneficial and subject to a growing interest in the trauma literature. We present the case of a 42-year-old male referred to our institution for limb salvage after sustaining severe bilateral lower extremity injuries. These included a right open Gustilo 3B tibia shaft fracture with a critical bone defect combined with a left floating knee (closed femur fracture and open Gustilo 3C tibia fracture). Bilateral tibia fracture-related infections were treated in conjunction with successful flap coverage. Following eradication of the infections, adequate soft tissue coverage and stable bony fixation, the tibia critical bone defect of close to 8 cm was treated with bone transport. Limb salvage was successful; amputation was avoided, and good function of both limbs was achieved. This manuscript shares a great clinical success in the extensive collaboration between two surgical subspecialties. • Successful complex lower limb salvage. • Orthopedic and plastic surgery collaboration can avoid the need for amputation. • Tertiary care centres are best equipped to manage Orthoplastic trauma. • Tertiary care centres are best equipped to manage Orthoplastic trauma.

334.9: Custom Bone Massive Allograft for Lower Limb Salvage Surgery, the Impact of Imaging and 3D Printing. Experience of the Tissue Bank of the Hospital Luis Vernaza (2016-2021)

Introduction: Luis Vernaza Hospital tissue bank implemented the anatomical engineering service, which performs the activities of digitizing stored tissues, virtual surgical planning of custom tissues, and the generation of cutting guides for efficient osteotomies between donor and recipient. The main use of this technology is to provide allografts of the proximal tibia or distal femur for salvage surgery of the lower limb, with which it has been possible to restore the mobility and functionality of the knee to patients with bone tumors. With this technology, we have managed to deliver custom allografts with a discrepancy of 1 to 2 mm between the measurements of the recipient and that of the donor, in addition to obtaining three-dimensional measurements such as the curvature of the femoral condyle and the curvature of the femorotibial joint. Objective: To present the results obtained by the anatomical engineering service in the development of custom fabrics for lower limb salvage surgery. Materials and Methods: The complete knee joint, including 20 cm of the distal femur and 20 cm of the proximal tibia, is obtained from cadaveric donors. Then we proceed with the digitalization of the tissues using computed axial tomography, a service provided by the imaging center of the Luis Vernaza Hospital. At the time of requesting a graft, the specialist attaches the tomography of the recipient with the indications and measurements of the graft to be requested. The search for the graft is carried out with it in the digital catalog of the tissue bank and using the Mimics anatomical engineering software using segmentation in volumes, the approximate measurements between recipient donors are obtained. Analyzing the curvature of the femoral condyle and the surface of the tibial plateau. With the indicated stockings, we proceed with the processing of the tissue, extracting the required tissue and the ligamentous elements necessary for its subsequent fixation. Results: Thanks to this technology, it has been possible to restore mobility to 10 patients aged between 15 and 56 years. The most frequent pathology was osteosarcoma (6) followed by giant cell tumor and metastasis from other sites. The most requested graft was the proximal tibia 6 requested units, distal femur 3 units, and 1 humerus. Approximately the amount of tissue replaced was 15 cm. Discussions and Conclusions: It is difficult to obtain a synthetic replacement for the proximal tibia or distal femur, due to their multiple compositions (bone tissue, cartilage, and ligamentous fixing elements). Applying this technology to the tissue bank avoids the amputation of limbs due to lack of elements for reconstruction, because of which the allograft from a cadaveric donor with the exact stockings allows rapid restoration of the patient’s mobility and return to their usual activities.

Epiploic bypass flap for lower limb salvage in patients with critical ischemia: Long-term results

Critical ischemia (CI) involves important losses of substance and is a threat for the limb. Revascularization only can be insufficient to reduce the risk of amputation in case of osseous, tendinous, nervous or vascular exposure. Coverage with a flap is then necessary. The technique of epiploic bypass flap (EBF) allows the reconstruction and the revascularization of the limb simultaneously with a single anatomical unit. The objective of this study was to evaluate the long-term limb salvage rate in CI patients treated with EBF.

Rotationplasty after failed limb salvage: an alternative to amputation.

Limb salvage procedures for musculoskeletal tumors have inherent complications. Though most complications can be managed with retention of the reconstructions, occasionally salvaging these reconstructions is not possible. We evaluated the outcomes of patients undergoing rotationplasty after multiple failed revisions of limb salvage surgery and document the success rate of this "salvage" technique and the subsequent functional outcome of these patients. Between January 1, 1999, and December 31, 2018, 14 patients (12 male and 2 female) with a median age of 24years (11-51years) underwent rotationplasty after multiple failed revisions of limb salvage surgery. Indication for rotationplasty was infection (10 patients), failed megaprosthesis (2 patients), unstable biological reconstruction (1 patient) and local recurrence (1 patient). The mean number of surgeries done before the patient underwent rotationplasty was 5 (range 2-7). One patient developed a vascular complication (venous congestion) immediately after rotationplasty and underwent an early amputation. The remaining 13 patients had no surgical complications. Mean Musculo Skeletal Tumor Society score in 13 evaluable patients was 26 (23-30). Our study demonstrates the utility of rotationplasty as a "salvage" procedure after multiple failed lower limb salvage surgeries. It offers good success rates, low rates of complications and good functional outcomes in carefully selected cases.

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.