Lower Limb Salvage Research Articles

The Impact of Geniculate Artery Collateral Circulation on Lower Limb Salvage Rates in Injured Patients

This study aimed to determine the association between geniculate artery flow on admission computed tomography (CT) angiography and limb salvage outcomes in patients with lower extremity arterial injury. All injured patients at a level I trauma center with CT angiogram (CTA) confirmed limited or no flow to the tibial vessels were included. Demographics, injury severity score (ISS), mechanism of injury, physiological parameters, the presence of geniculate artery collateral circulation (superior medial, superior lateral, medial, inferior medial, inferior lateral), and 30-day limb salvage outcome were recorded. Statistical analysis was completed using descriptive statistics and the chi-squared tests. From 2009 to 2012, a total of 84 patients with lower extremity arterial injury underwent diagnostic evaluation with CTA on admission that confirmed limited or no flow to the tibial vessels. A total of 10 patients (12%) underwent amputation. Primary amputation was performed in 3 (4%) patients, and secondary amputation was performed in 7 (8%) patients. There was no difference in age, gender, ISS, extremity abbreviated injury score, mechanism of injury, admission systolic blood pressure, heart rate, respiratory rate, transfusion volume, or type of vascular interventions between patients who had successful limb salvage and those who received an amputation. The number of patent geniculate arterial vessels was inversely associated with amputation with 3.3 patent geniculate arteries in the limb salvage group compared to 2.1 in the amputation group (P < 0.05). The 2 geniculate artery vessels that were significantly associated with limb salvage were the superior lateral geniculate and the inferior medial geniculate arteries (P < 0.05). Geniculate collateral circulation may have an important role in limb salvage after lower extremity vascular injury. The geniculate arteries that are associated with the highest rates of limb salvage appear to be the superior lateral geniculate and the inferior medical geniculate artery.

Total and subtotal amputation of lower limbs treated by acute shortening, revascularization and early limb lengthening with ilizarov ring fixation – A retrospective study

We present the results of 15 patients who sustained total or subtotal traumatic amputation of the lower limbs who were treated by acute limb shortening and stabilisation with external fixator, revascularization and early lengthening with Ilizarov ring fixator. The mean age of the patients was 28 years [5–38]. There were three females and 12 males. The mean Mangled Extremity Severity Score was 8.5 [range 6–11]. The mean amount of shortening done was 6.9cm [range 3–12.5] to enable revascularization and soft tissue repair. Three cases had to be amputated early because of failure of vascular repair. In the remaining 12 patients who were followed up the mean interval between revascularization and application of Ilizarov ring fixator was 4.7 weeks [range 3–10]. The mean follow up was 6.5 years [3–16 years]. Union occurred in all patients. Ten of the 12 patients returned to work and residual shortening was present in two cases. We conclude that whenever possible lower limb salvage should be undertaken.

Management of Acute Upper Extremity Ischemia: Treatment Strategies and Outcome

The aim of the study was to evaluate etiology, type of procedure, limb salvages attempted, and outcomes in acute upper limb ischemia (AULI). Patients from January 2013 to December 2014 with AULI (excluding trauma, iatrogenic) admitted at our hospital (Jain Institute of Vascular Sciences, Bengaluru, India) were included in the study. The analysis included 43 patients (53% males), mean age of 51 ± 12 years. Three patients presented ≤6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. AULI constitutes ∼12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.

Multicenter Randomized Clinical Trial of Four Different Devices for Endovascular Aneurysm Repair: Design of the LEOPARD Trial

Results: The analysis included 43 patients (53% males), mean age of 51 6 12 years. Three patients presented #6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. Conclusions: AULI constitutes w12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.

What Is the Outcome of Allograft and Intramedullary Free Fibula (Capanna Technique) in Pediatric and Adolescent Patients With Bone Tumors?

After bone tumor resection, reconstruction for limb salvage surgery can be challenging because of the resultant large segmental bony defects. Structural allografts have been used to fill these voids; however, this technique is associated with high complication rates. To circumvent the complications associated with this procedure, massive bony allografts have been supplemented with an intramedullary vascularized free fibula. However, few studies have examined the outcomes using this technique in the pediatric and adolescent populations. The purpose of this study was to examine the revision-free survival using he Capanna technique for limb salvage for pediatric lower limb salvage. We attempted to answer the following questions: (1) What was the overall limb salvage rate along with incidence of reoperation and complications? (2) How did pediatric and adolescent patients functionally perform after this technique? (3) What was the incidence of late complications including infection and fracture? (4) What was the incidence of limb length discrepancy? Eighteen pediatric patients who underwent lower extremity limb salvage with the use of cadaveric allograft and intramedullary free fibular transfer (Capanna technique) were identified. There were nine boys males and nine girls with a mean age of 11years (range, 5-18years) and mean followup of 8years (range, 2-15years), respectively. All patients had at least 2years followup. Three patients have not been seen in followup during the past 5-years; however, all had made it to their 5-year clinical followup. The patients' medical records were reviewed for clinical and functional outcomes as well as postoperative complications. Time to union was recorded through an evaluation of radiographs. Mankin functional outcome and Musculoskeletal Tumor Society (MSTS) rating scale were recorded for each patient. The overall limb salvage rate was 94%. Fourteen patients underwent an additional surgical procedure. Six patients underwent additional procedure(s) to treat a symptomatic nonunion. Seventeen of the patients had a good or excellent Mankin score with a mean MSTS rating of 93% at last followup. Six of the patients underwent a limb length modification procedure. Use of large allografts in conjunction with intramedullary vascularized free fibulas appears to be a reliable method for the reconstruction of large bony tumors of the lower extremity in this population, although we did not directly compare this with allografts alone in our study. The use of locked plates may improve union times. The proportion of patients achieving limb preservation was high and complication rates are acceptable. Level IV, therapeutic study.

English

INTRODUCTION: Reconstruction of lower 3rd of extremity poses great challenge to reconstructive surgeon. Free flap coverage brings a striking difference in lower limb salvage. Lower extremity defects can be managed by direct closure, skin grafting, local flaps, cross leg flap and free flap. The versatility of free flaps in covering a defect of any size irrespective of their locality keeps them in the top rung of the reconstructive ladder. MATERIALS AND METHODS: We present a retrospective study of 12 patients who underwent free flap reconstruction for lower extremity defects between august 2012 to June 2014. Different flaps were chosen based on the size and location of the defect. Radial forearm flap was done in 6 patients, anterolateral thigh flap in 4, latissimus dorsi flap in 1 and free fibula flap in 1 patient with a success rate of 91.6%. CONCLUSION: Free flap is the most cost effective and stable solution for lower extremity reconstruction. It is the best solution to manage large defects. They play a major role in limb salvage. In spite of the steep learning curve, practicing micro surgical principles can save a limb and influence the life of the person in a positive way.

Upper and Lower Limb Salvage with Omental Free Flaps

Upper and Lower Limb Salvage with Omental Free Flaps

Endovascular revascularization and free tissue transfer for lower limb salvage

Combined bypass surgery with free flap reconstruction is an established method for lower limb salvage. But the success of the combination of endovascular revascularization together with free tissue transfer has so far not been well established. A retrospective review of all patients who had undergone endovascular revascularization and reconstructed with free tissue transfer for lower limb salvage at Tzu Chi Dalin General Hospital between 2008 and 2012 was performed. A total of 26 legs underwent limb salvage in 24 patients. There were 10 male and 14 female patients. Their average age was 71.4 years. The average time interval between endovascular intervention and free tissue transfer was 8 days. There was 100% flap survival but partial flap necrosis was seen in three patients. A high rate of wound infection was seen in eight patients, all requiring further debridement. The total limb salvage rate at 1-year follow-up was 96% and 92% at the 2-year follow-up. In conclusion, the success rate of lower limb salvage using a combination of endovascular revascularization and free tissue reconstruction is comparable to using a combination of bypass surgery and free tissue transfer. It is associated with a high flap success rate and a high limb salvage rate. It provides physicians with a further treatment option in the management of ischemic lower limbs with extended tissue loss.

How does ankle-foot orthosis stiffness affect gait in patients with lower limb salvage?

Ankle-foot orthoses (AFOs) are commonly prescribed during rehabilitation after limb salvage. AFO stiffness is selected to help mitigate gait deficiencies. A new custom dynamic AFO, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), is available to injured service members but prescription guidelines are limited. In this study we ask (1) does dynamic AFO stiffness affect gait parameters such as joint angles, moments, and powers; and (2) can a given dynamic AFO stiffness normalize gait mechanics to noninjured control subjects? Thirteen patients with lower limb salvage (ankle arthrodesis, neuropathy, foot/ankle reconstruction, etc) after major lower extremity trauma and 13 control subjects who had no lower extremity trauma and wore no orthosis underwent gait analysis at a standardized speed. Patients wore their custom IDEO with posterior struts of three different stiffnesses: nominal (clinically prescribed stiffness), compliant (20% less stiff), and stiff (20% stiffer). Joint angles, moments, powers, and ground reaction forces were compared across the varying stiffnesses of the orthoses tested and between the patient and control groups. An increase in AFO compliance resulted in 20% to 26% less knee flexion relative to the nominal (p = 0.003) and stiff (p = 0.001) conditions, respectively. Ankle range of motion and power generation were, on average, 56% (p < 0.001) and 63% (p < 0.001), respectively, less than controls as a result of the relatively fixed ankle position. Patients with limb salvage readily adapted to different dynamic AFO stiffnesses and demonstrated few biomechanical differences among conditions during walking. None of the stiffness conditions normalized gait to controls. The general lack of differences across a 40% range of strut stiffness suggests that orthotists do not need to invest large amounts of time identifying optimal device stiffness for patients who use dynamic AFOs for low-impact activities such as walking. However, choosing a stiffer strut may more readily translate to higher-impact activities and offer less chance of mechanical failure.

Zachování dolní končetiny: indikace a rozhodování o replantaci, revaskularizaci a amputaci

Zachování dolní končetiny: indikace a rozhodování o replantaci, revaskularizaci a amputaci

Treatment of necrotising fasciitis using glycerol-preserved skin allografts for temporary wound coverage

Allografts of human skin have been used for both temporary and permanent wound coverage. They are useful as temporary bridges for the critically ill patient who is not allowed to receive definite wound coverage, or for wound bed preparation before permanent grafting. Glycerol-preserved skin allografts have several benefits including good adherence to the wound bed, water vapour transport, antimicrobial characteristics, low toxicity and antigenicity, ease of application and removal, a long shelf-life, and minimal storage requirements. We achieved lower limb salvage using a glycerol-preserved skin allograft for temporary wound coverage in the treatment of necrotising fasciitis.

Tumor Endoprosthesis Revision Rates Increase With Peri-Operative Chemotherapy But Are Reduced With the Use of Cemented Implant Fixation

Chemotherapy may reduce osseointegration of tumor endoprosthesis, while delaying chemotherapy may reduce survival. We studied the effects of chemotherapy and cemented fixation on tumor endoprosthesis survivorship with a retrospective analysis of 50 consecutive patients receiving lower limb salvage surgery. We compared rates of radiographic loosening/revision and effect of cement fixation between chemotherapy/no chemotherapy cohorts. Chemotherapy increased the total revision rate (HR=3.8 [1–14], P=0.033), but did not affect aseptic loosening. Cement fixation reduced revision for loosening (HR=0.09 (0.008–0.98),P=0.012) and showed less radiographic loosening (HR=0.09 (0.02–0.51),P=0.00066). Cement fixation had lower rates of revision for loosening and radiographic loosening regardless of whether chemotherapy was given. We conclude that for these implants, cement fixation provides superior results to uncemented fixation.

A New Classification (Grading System) of Debridement in Diabetic Lower Limbs - an Improvization and Standardization in Practice of Diabetic Lower Limb Salvage Around the World

Debridement is one of the most common and also a most underestimated surgical procedure performed by surgeons. For specialist like Podiatric surgeons and qualified wound care nurses, debridement of diabetic foot wounds has been an essential day to day common surgical practice. Inspite of being such a common procedure, there is no classification of debridement when it comes to diabetic limb salvage practice till date. The word debridement is used loosely and equally for all diabetic foot lesions without specification. The author, being one of the few handful specialist podiatric surgeons in India, proposes a new simple classification [grading system] for surgical debridement of diabetic lower limb wounds which could be used in day to day practice and which will help in standardizing the practice of diabetic lower limb salvage in developed, developing and underdeveloped countries and thus can form a language of medical communication in field of diabetic limb salvage. There is currently an urgent need for newer concepts, standardization and recent advances in diabetic foot practice in developing countries where this speciality is neglected. This new grading system is one such novel step by the author towards improvisation of diabetic foot practice.

Association of Sex with Long-Term Outcomes after Popliteal Artery Aneurysm Repair

We compared initial and long-term outcomes between men and women after endovascular and open repair of popliteal artery aneurysms (PAAs). Between January 1993 and July 2011, 202 patients (185 men [92%]), underwent open (n = 186) or endovascular (n = 16) repair of a PAA. Data were retrospectively analyzed. Significant differences in baseline characteristics were determined between men and women with regard to aneurysm diameter (men: 30 mm [range: 14-90]; women: 26 mm [range: 13-70]; P = 0.02) and age (men: 66 ± 10 years; women: 71 ± 9 years; P = 0.05). The 30-day mortality rate was 0% in both groups. No significant differences were determined concerning 30-day complications. The median follow-up was 55 months (range: 1-121 months) in men, compared with 35 months (range: 1-183 months) in women (P = 0.74). The primary patency rates at 1, 3, and 5 years were 88%, 82%, and 76% in men compared with 64%, 64%, and 48% in women, respectively (P = 0.007). The limb salvage rates in men at 1, 3, and 5 years were 97%, 97%, and 96%, and in women were 87%, 87%, and 87%, respectively (P = 0.07). When correcting for potential confounders with multivariable regression analysis, sex was independently associated with primary patency (hazard ratio: 2.98 [95% confidence interval: 1.39-6.42]; P = 0.005). No significant differences between men and women were observed in 30-day mortality and morbidity rates after PAA repair. In the long run, women are associated with lower primary patency rates and a trend toward lower limb salvage rates compared to men.

Long-Term Results and Costs of Muscle Flap Coverage With Ilizarov Bone Transport in Lower Limb Salvage

To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage. Case series with retrospective review of outcomes with at least 6-year follow-up. Academic tertiary care medical center. Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005. Flap reconstruction and Ilizarov bone transport. Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for reoperations. A cost analysis was performed comparing this treatment modality to amputation. Thirty-four patients (mean age: 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty-five muscle flaps were performed with 1 flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required reoperations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation. The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population.

Sequential free tissue transfers for simultaneous upper and lower limb salvage

The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free-flap limb salvage cohorts. Seventy-four free flap limb salvage cases were performed over the 10-year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626). The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients.

Novel Biomarkers of Arterial and Venous Ischemia in Microvascular Flaps

The field of reconstructive microsurgery is experiencing tremendous growth, as evidenced by recent advances in face and hand transplantation, lower limb salvage after trauma, and breast reconstruction. Common to all of these procedures is the creation of a nutrient vascular supply by microsurgical anastomosis between a single artery and vein. Complications related to occluded arterial inflow and obstructed venous outflow are not uncommon, and can result in irreversible tissue injury, necrosis, and flap loss. At times, these complications are challenging to clinically determine. Since early intervention with return to the operating room to re-establish arterial inflow or venous outflow is key to flap salvage, the accurate diagnosis of early stage complications is essential. To date, there are no biochemical markers or serum assays that can predict these complications. In this study, we utilized a rat model of flap ischemia in order to identify the transcriptional signatures of venous congestion and arterial ischemia. We found that the critical ischemia time for the superficial inferior epigastric fasciocutaneus flap was four hours and therefore performed detailed analyses at this time point. Histolgical analysis confirmed significant differences between arterial and venous ischemia. The transcriptome of ischemic, congested, and control flap tissues was deciphered by performing Affymetrix microarray analysis and verified by qRT-PCR. Principal component analysis revealed that arterial ischemia and venous congestion were characterized by distinct transcriptomes. Arterial ischemia and venous congestion was characterized by 408 and 1536>2-fold differentially expressed genes, respectively. qRT-PCR was used to identify five candidate genes Prol1, Muc1, Fcnb, Il1b, and Vcsa1 to serve as biomarkers for flap failure in both arterial ischemia and venous congestion. Our data suggests that Prol1 and Vcsa1 may be specific indicators of venous congestion and allow clinicians to both diagnose and successfully treat microvascular complications before irreversible tissue damage and flap loss occurs.

Epidurals for Free-Flap Grafts: Optimizing Graft Survival and Preventing Complications in the Anticoagulated Patient

OPEN ACCESSMay 10, 2013Epidurals for Free-Flap Grafts: Optimizing Graft Survival and Preventing Complications in the Anticoagulated Patient Kirk Lalwani, MD, Kate Maureen Ropp, MD Kirk Lalwani, MD Oregon Health & Science University School of Medicine Google Scholar More articles by this author , Kate Maureen Ropp, MD Oregon Health & Science University School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9415 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstract Introduction: This narrative problem-based learning module is designed to facilitate group discussion with the integration of clinical knowledge and self-directed learning. It addresses a complex situation involving trauma, neuraxial anesthesia, anticoagulation, free-flap physiology, and compartment syndrome in a setting of multiple treatment teams. Methods: After a case presentation, the instructor guides the group through a series of questions, each of which promotes discussion and reviews the available data on the subject. The module provides multiple diagnostic and decision points in which learners must balance the risk versus benefit of available options, and choose a management strategy on the basis of existing and new knowledge of current practice. The module was created based on the authors' personal experience with a similar situation and a subsequent literature search on the issues covered in the module. Selected significant references and current national guidelines were added to the bibliography to enhance the learner experience and highlight current evidence to support the management options presented in the discussion. Results: This module was developed for use at the 2004 and 2006 American Society of Anesthesiologists Annual Scientific Meetings and was presented twice to learners (residents, anesthesiology faculty in academic practices, and private practice anesthesiologists) at each meeting. It was also utilized with pediatric anesthesiology fellows at the primary author's institution. In all, the module has been used in a small-group roundtable format six times, with positive feedback from conference attendees and pediatric anesthesiology fellows. Discussion: The module can easily be incorporated into a residency, fellowship, or CME curriculum. It has the potential to be implemented as a single 2-hour team exercise, or be divided into two 1-hour sessions depending on time available. Educational Objectives By the end of this module, learners will be able to: Discuss the effects of anesthetic drugs and epidural anesthesia on free-flap graft survival.Compare the risks and benefits of epidural anesthesia for management of trauma patients who require anticoagulation.Describe the recognition and treatment of compartment syndrome in trauma patients following epidural anesthesia.Interpret and practice the latest American Society of Regional Anesthesia guidelines regarding neuraxial anesthesia and anticoagulation. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide.docx References.docx Stem Case with Model Discussion.docx Stem Case.docx To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2013 Lalwani and Ropp. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsCompartment SyndromesAnesthesiaAnticoagulationTraumaFree Flap SurgeryWounds and Injuries Disclosures None to report. Funding/Support None to report. Prior Presentations Management of Latissimus Dorsi Free-Flap for Lower Limb Salvage Following Traumatic Bilateral Near-Amputation: Does an Epidural Really Help? Problem-based learning discussion at: American Society of Anesthesiology Annual Scientific Meeting; 2004; Las Vegas, Nevada. Epidurals for Free-Flap Grafts; Optimizing Graft Survival and Preventing Complications in the Anticoagulated Patient. Problem-based learning discussion at: American Society of Anesthesiology Annual Scientific Meeting; 2006; Chicago, Illinois. Loading ...

Lower limb salvage surgery using Ilizarov circular external frame for a landmine injury about the knee

Limb salvage for severe trauma has been replaced amputation as the primary treatment in many trauma centers. However, the long-term outcomes after limb reconstruction or amputation have not been fully evaluated. In this report, we present the treatment results of limb salvage surgery using Ilizarov external circular frame in a male case who had a-22-cm bone loss on the left distal femur and left proximal tibia and large soft tissue defect around the knee due to stepping on a landmine with his knee. The decision to amputate a severely injured limb, being irreversible, is challenging and significantly affects the body image and the patient. Extremity salvage surgery should be considered initially when evaluating patients with high-energy injured limbs at high risk for amputation.

Analysis of immediate vascular reconstruction for lower-limb salvage in patients with lower-limb bone and soft-tissue sarcoma

Limb amputation has historically been the first choice of treatment for patients with bone or soft-tissue sarcomas involving major blood vessels. However, recent advances in surgical technique have allowed limb-salvage surgery. We reviewed our experiences with limb-salvage surgery and immediate vascular reconstruction following en bloc resection of bone or soft-tissue sarcomas of the lower extremity. We reviewed 23 patients (15 male and eight female; mean age, 43.6 years) who underwent limb-salvage surgery and immediate vascular reconstruction. Details of surgical factors and postoperative complications were evaluated. Reconstructed vessels remained patent in 21 cases. The rate of limb oedema was higher in patients who underwent only arterial reconstruction after arteriovenous resection. Twenty patients could walk well without crutches a few months after reconstructive surgery. All patients avoided amputation. Two patients died of disseminated disease within 3 years after surgery. The high rate of limb oedema suggests that venous reconstruction is necessary after arteriovenous resection. Vascular reconstruction and musculocutaneous flap techniques are useful in limb-salvage surgery and are indicated for patients who have achieved good disease control. Evidence Rating Scale for Therapeutic Studies: Level III.