Secondary Amputation Research Articles

The perioperative and long-term fates of patients with chronic limb-threatening ischaemia who underwent secondary major amputations.

This study investigated the perioperative and long‐term fates of patients with chronic limb‐threatening ischemia (CLTI) who underwent secondary major amputations. From April 2010 to December 2018, 1653 CLTI patients primarily underwent endovascular therapy (EVT). Of these patients, 138 who underwent secondary major amputations were included in this study. The primary outcome measure was the mortality. Prognostic factors associated with perioperative (30‐day) and late mortality (after 30 days) were assessed. The 30‐day mortality was 9.6%. Patients who died during the perioperative period had lower ejection fractions on echocardiography than those in the perioperative survivors (49.5 ± 14.9% vs 58.6 ± 12.4%, P = .018). None of the other clinical characteristics were significantly associated with perioperative death. Two‐years postoperatively, 49.6%, 12.2%, and 4.3% of the patients had died, had contralateral amputations, and had additional above‐knee amputations, respectively. In the alive patients who had not undergone additional amputation at 2 years, only 25.9% were ambulatory, whereas 51.7% and 22.4% were in wheelchairs and bedridden, respectively. An age ≥80 years and serum albumin <3.0 g/dL were significantly associated with late mortality (P = .032 and P = .042, respectively). In conclusion, the perioperative and long‐term fates after secondary major amputation in CLTI patients who underwent EVT were considerably poor.

Management of severe lower limb injuries: a 4-year experience with a revisited recent approach at Zagazig University Hospital, Plastic Surgery Department

Background Management of complex open fractures of the lower extremities needs a special multidisciplinary team in major trauma centers. Limb salvage is attempted in appropriately selected patients via joint orthopedic and plastic surgery care. Recent guidance shows strong evidence of better long-term functional outcomes and decrease of complications when coordinated combined orthoplastic approach can be successfully delivered. Patients and methods A total of 52 patients were included in this retrospective comparative study of the outcomes from two approaches, managed either by single-team approach, plastic or orthopedic (group A), or by orthoplastic setting (group B), in Zagazig University Hospitals between August 2016 and July 2020. All data were collected from the patient records. Follow-up outcomes involved fracture union, weight bearing, persistent deep infection, and secondary amputations. Results The most encountered injury pattern in both groups was Gustilo IIIb. The majority of those injuries were sustained owing to road traffic accidents in both groups. The mean bone loss was 2.05±2.3 cm in group A and 2.06±2.2 cm in group B. There was a statistically significant difference between the mean time to initial debridement, where in group B, it was 8±2.04 h, whereas in group A, it was 10.7±4.2 h (P=0.05). The time to definitive fixation showed a highly significant difference from 9.8±2.9 weeks in group A to 4.4±0.8 weeks in group B. The relative risk for flap loss showed significant reduction in group B (P=0.021). Conclusion Overall outcomes showed obvious improvement with less complication rate of the combined orthoplastic approach over the previous single-team speciality. Nonetheless, certain complications like nonunion and need for secondary amputation did not show quite a significant difference, which may indicate that our early experience with orthoplastic approach for the management of open tibia fracture is in need for further audit and refinements to take place.

Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy

PurposeBlunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF).MethodsRetrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined.ResultsOf 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication.ConclusionBlunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors?

Total humeral replacement is an option to reconstruct massive bone defects after resection of locally advanced bone tumors of the humerus. However, implant survivorship, potential risk factors for implant revision surgery, and functional results of total humeral replacement are poorly elucidated because of the rarity of the procedure. We asked: (1) What is the revision-free implant and overall limb survivorship after total humerus replacement? (2) What factors are associated with implant revision surgery? (3) What is the functional outcome of the procedure as determined by the Musculoskeletal Tumor Society (MSTS) score and the American Shoulder and Elbow Surgeons (ASES) score? Between August 1999 and December 2018, 666 patients underwent megaprosthetic reconstruction after resection of a primary malignant or locally aggressive/rarely metastasizing tumor of the long bones at our department. In all, 23% (154) of these patients had a primary tumor located in the humerus. During the study, we performed total humeral replacement in all patients with a locally advanced sarcoma, in patients with pathological fractures, in patients with skip metastases, or in patients with previous intralesional contaminating surgery, who would have no sufficient bone stock for a stable implant fixation for a single joint megaprosthetic replacement of the proximal or distal humerus. We performed no biological reconstructions or reconstructions with allograft-prosthetic composites. As a result, 5% (33 of 666) of patients underwent total humerus replacement. Six percent (2 of 33) of patients were excluded because they received a custom-made, three-dimensionally (3-D) printed hemiprosthesis, leaving 5% (31) of the initial 666 patients for inclusion in our retrospective analysis. Of these, 6% (2 of 31) had surgery more than 5 years ago, but they had not been seen in the last 5 years. Median (interquartile range) age at the time of surgery was 15 years (14 to 25 years), and indications for total humeral replacement were primary malignant bone tumors (n = 30) and a recurring, rarely metastasizing bone tumor (n = 1). All megaprosthetic reconstructions were performed with a single modular system. The implanted prostheses were silver-coated beginning in 2006, and beginning in 2010, a reverse proximal humerus component was used when appropriate. We analyzed endoprosthetic complications descriptively and assessed the functional outcome of all surviving patients who did not undergo secondary amputation using the 1993 MSTS score and the ASES score. The median (IQR) follow-up in all survivors was 75 months (50 to 122 months), with a minimum follow-up period of 25 months. We evaluated the following factors for possible association with implant revision surgery: age, BMI, reconstruction length, duration of surgery, extraarticular resection, pathological fracture, previous intralesional surgery, (neo-)adjuvant radio- and chemotherapy, and metastatic disease. The revision-free implant survivorship at 1 year was 77% (95% confidence interval 58% to 89%) and 74% (95% CI 55% to 86%) at 5 years. The overall limb survivorship was 93% (95% CI 75% to 98%) after 1 and after 5 years. We found revision-free survivorship to be lower in patients with extraarticular shoulder resection compared with intraarticular resections (50% [95% CI 21% to 74%] versus 89% [95% CI 64% to 97%]) after 5 years (subhazard ratios for extraarticular resections 4.4 [95% CI 1.2 to 16.5]; p = 0.03). With the number of patients available for our analysis, we could not detect a difference in revision-free survivorship at 5 years between patients who underwent postoperative radiotherapy (40% [95% CI 5% to 75%]) and patients who did not (81% [95% CI 60% to 92%]; p = 0.09). The median (IQR) MSTS score in 9 of 13 surviving patients after a median follow-up of 75 months (51 to 148 months) was 87% (67% to 92%), and the median ASES score was 83 (63 to 89) of 100 points, with higher scores representing better function. Total humeral replacement after resection of locally advanced bone tumors appears to be associated with a good functional outcome in patients who do not die of their tumors, which in our study was approximately one- third of those who were treated with a resection and total humerus prosthesis. However, the probability of early prosthetic revision surgery is high, especially in patients undergoing extraarticular resections, who should be counseled accordingly. Still, our results suggest that if the prosthesis survives the first year, further risk for revision appears to be low. Future studies should reexamine the effect of postoperative radiotherapy on implant survival in a larger cohort and evaluate whether the use of soft tissue coverage with plastic reconstructive surgery might decrease the risk of early revisions, especially in patients undergoing extraarticular resections. Level III, therapeutic study.

Effect of Cisplatin Arterial Infusion (CAI) on Primary Nonmetastatic Pelvic Osteosarcoma: A Preliminary Study.

PurposeThe critical role of arterial infusion chemotherapy in the multimodal treatment of extremity bone cancer has been investigated extensively, but few studies have focused on pelvic osteosarcoma. Therefore, we attempted to evaluate the clinical significance of arterial infusion chemotherapy in the treatment of pelvic osteosarcoma.Patients and MethodsWe combined a cisplatin arterial infusion regimen with multidrug systematic chemotherapy as a neoadjuvant protocol for the treatment of pelvic osteosarcoma. The course number and dosage of cisplatin arterial infusion were adjusted to achieve a maximal tumor response evaluated by contrast-enhanced MRI per RECIST 1.1. Good responders received the same systematic combination for postoperative chemotherapy, and poor responders received second-line therapy. Twelve patients with nonmetastatic high-grade pelvic osteosarcoma were included. Survival, chemotherapy response and adverse events data were analyzed.ResultsThe mean follow-up period was 56.1 months. Four patients died of refractory tumor progression, and 1 patient with local recurrence had no evidence of disease for 27 months after receiving secondary amputation and resection. Kaplan-Meier survival analysis demonstrated a 57.8% overall survival and 52.5% event-free survival rate at 5 years. Eight of 12 patients had a >90% tumor necrosis rate according to histopathologic examinations. The rates of local adverse events were lower than those reported for extremity osteosarcoma.ConclusionOur study initially indicated that the cisplatin arterial infusion regimen was a potential therapy with good tolerance in the treatment of pelvic osteosarcoma.

Reconstructive Approaches in Surgical Management of Congenital Pseudarthrosis of the Tibia.

Treatment of congenital pseudarthrosis of the tibia remains a major challenge in pediatric orthopedics. Ideal timing and preference of surgical procedures are discussed controversially. A variety of reconstructive treatment strategies have been described in literature, but so far none has proven its superiority. The aim of treatment is to obtain long-term bone union, to prevent refracture, and to correct angular deformities and leg length discrepancies. This study retrospectively evaluates the outcome of different reconstructive strategies. Sixty-nine patients were identified who presented to our outpatient department between 1997 and 2019. Twenty-six of these patients underwent reconstructive surgical treatment and were included in this study. The study cohort was divided into three groups. Excision of the pseudarthrosis was performed in all patients in Group A and B, and in two patients of Group C. Group A (six/26 patients) received subsequent bone transport through external fixation maintaining original length. In Group B (15/26 patients), patients underwent either previous, simultaneous, or subsequent extrafocal lengthening through external fixation to reconstitute length. In Group C (five/26 patients), internal fixation with intramedullary nails was applied. Radiological and clinical evaluation was performed to assess bone union and complication rates. Results varied considerably between the study groups. Overall, the primary bone fusion rate was 69.2%. There were four refractures, all occurring in Group B. The long-term bone union rate without refracture was 53.8%. The overall complication rate was 53.8% and 23.1% showed persistent pseudarthrosis. Two secondary amputations were performed due to failed bone fusion. In conclusion, excision of the pseudarthrosis and extrafocal lengthening achieves a satisfying bone union rate and limb reconstruction, while bone transport does not offer significant advantages but shows higher complication rates. Intramedullary stabilization should be applied to maintain bone union, but shows lower bone union rates when used as a stand-alone treatment regimen. Regardless of the primary bone fusion rates, the probability of long-term bone union remains unpredictable.

Development and Validation of Scoring System to Predict Secondary Amputations in Free Flap Reconstruction.

Background:Need for amputation is a potential complication when limb salvage is attempted. The present study aimed to develop a risk assessment tool to predict the risk of future amputation when counseling patients about their reconstructive options.Methods:All patients undergoing a free flap lower extremity soft tissue reconstruction by the senior author from 2005 to 2019 were retrospectively identified. Patient’s demographics, comorbidities, and technical aspects of the operation were extracted. Logistic regressions were used to create a predictive scoring system for future amputation.Results:A total of 277 patients were identified. Of these patients, two-thirds (183) were used to derive the scoring system and one-third (94) were used to validate the score. In total, 25 of 183 patients (14%) underwent an amputation. A stepwise forward logistic regression identified age > 55 years, smoking, acute wound, aggressive fluid resuscitation intra-operatively, inability to use a superficial vein for drainage, and inability to use the posterior tibialis artery for anastomosis as independent predictors of need for future amputations. The beta co-efficients were used to create the scoring system, and the patients were categorized into mild, moderate, and severe risk based on their cumulative score. The validity of the scoring system was verified by using the one-third validation cohort.Conclusions:In patients undergoing free flap reconstruction of the lower extremity, the need for future amputation is 14%. The use of a scoring system can guide the surgeon’s and patient’s decision regarding limb salvage.

Management of vascular injuries during war in Jazan (Saudi Arabia): epidemiology and tips for vascular surgeons deploying to wars

Background Extremity vascular injuries represent 50–70% of all injuries treated during wars. Hence, our objectives are to elaborate the challenges of vascular war injuries and to clarify their mechanisms, pattern, effectiveness of management and outcomes during war in Jazan. Patients and methods This is a descriptive study of patients with war-related vascular injuries treated in King Fahd Teaching Hospital during the war in Jazan (Saudi Arabia) from February 2016 to May 2016. The study included age, mechanism of injury, site of vascular injury, pattern of repair, and clinical outcome. Results This study included 56 patients with a mean age of 37 years. All patients were men (100%); four (7.1%) patients were civilians; 23 (41%) patients presented with blast injuries; and 33 (59%) patients presented with gunshot injuries. There were 40 (71.4%) arterial injuries, 16 (28.6%) venous injuries, and seven combined injuries (arterial and venous). Repair was done in 37 patients and ligation in 19 patients. Primary amputation was done in eight patients and secondary amputation in one patient. Conclusion Management of vascular injuries during wars presents a unique challenge to surgeons; standard vascular technical repair remains the gold standard management in vitally stable patients; primary extremity amputation is a lifesaving procedure in unstable patients with other life-threatening injuries.

A Novel Approach to Limb Salvage: Healing Transmetatarsal Amputations without a Viable Plantar Flap

The lack of a viable plantar flap in patients undergoing transmetatarsal amputation has been considered an indication for below-knee amputation (BKA). In an effort to reduce limb loss in this patient population, we sought to review our experience with transmetatarsal amputation salvage in patients with an open, guillotine transmetatarsal amputation. We hypothesized that performing a transmetatarsal amputation without a viable flap would extend time of independent ambulation and improve limb salvage. This is a retrospective review of 27 consecutive patients who did not have a viable plantar flap and who underwent an open, guillotine transmetatarsal amputation. Patients presented with a nonviable plantar flap due to either extensive tissue loss on initial presentation, or secondary transmetatarsal amputation (TMA) flap necrosis. Patients initially underwent an open, guillotine TMA for control of infection and debridement of nonviable tissue. To achieve best results, during procedure, the metatarsals were resected to be as flush with soft tissue as possible. Once infection was resolved and all nonviable tissue debrided, negative pressure wound therapy (NPWT) was applied to the open wound. NPWT was continued until a base of granulation tissue covered the previously exposed bone. Wound closure was obtained by either the application of a split-thickness skin graft (STSG) or through continued NPWT allowing the wound to heal by secondary intention. Between January 2016 and December 2018, there were 27 open TMAs performed in 27 patients. Two patients did not granulate sufficiently and underwent BKA. Fourteen patients underwent STSG for closure, whereas 11 patients continued with NPWT. In the STSG group, 12 (86%) of the patients are healed, with a median time to complete healing of 75days (range 28-330days); the remaining 2 are ambulatory and undergoing continued wound care. In the 11 patients who did not receive STSG, 7 (64%) are healed with a median time to heal of 165days. Of the remaining 4 patients in this group, 3 are ambulatory and still undergoing wound care, one was lost to follow-up. Overall, 19 patients (70%) have completely healed with a median time to heal of 82days. Limb salvage in patients with a nonviable plantar flap for TMA is possible and should be a considered procedure. This technique has the potential to improve functional outcomes and limb salvage in patients who might otherwise undergo BKA.

Traumatismes artériels des membres supérieurs : particularités de la population en Tunisie et facteurs de risque d’amputation

Aim of the studyThe purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss. MethodsThis was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate. ResultsThe average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma. ConclusionPrompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

Improvement in activities and participation in an adolescent following secondary foot amputation

Abstract Background When severe limb trauma occurs in a child, all efforts are made to preserve the limb as far as possible. In rare cases, however, secondary amputation may be necessary to improve functional outcome and participation. Case report In this paper, we report on a young adolescent male with a severe loss of function following foot trauma, who underwent secondary trans-tibial amputation 17 months post injury. This paper describes how a structured multidisciplinary approach around the child and his family led to a successful outcome. Clinical rehabilitation impact It is hoped that this case report may help other health professionals with decision-making in cases of secondary amputations, and to implement appropriate follow-up for such patients.

Outcomes of Popliteal Artery Injuries Repair: Autologous Vein versus Prosthetic Interposition Grafts

The aim of this study is to compare wound infection, graft infection, and secondary amputation rates in patients who had popliteal artery injury repair with interposition vein versus prosthetic grafts. This retrospective comparative study included all adult patients (>18years) who had interposition grafting for popliteal artery injuries between January 2008 and August 2018 at a university hospital. Patients were divided into 2 groups. Popliteal arteries were repaired with venous graft in Group "A" and with prosthetic graft in Group "B." The outcome measures were wound infection, graft infection, and secondary amputation rates. Forty patients fulfilled the inclusion criteria. Twenty-two patients had arterial repair with venous while 18 with polytetrafluoroethylene grafts. All were male with median age of 32 (interquartile range [IQR] 19.5) years. Both groups were comparable in terms of median age (32.5 [19] vs. 30.5 [23]), Mangled Extremity Severity Score (6 [5] vs. 7 [7]), median hospital stay (7 [5] vs. 7 [9] days), and perioperative complications (2/22 vs. 3/18). In Group "A," no patient had graft infection or secondary amputation while in Group "B," 1 patient had secondary amputation and another had graft infection (P>0.99). There is no statistical difference in secondary amputation rate, wound infection, or graft infection in patients undergoing popliteal artery repair with interposition vein versus prosthetic grafts in trauma setting.

Risk Factors for Lower Extremity Amputation Following Attempted Free Flap Limb Salvage.

Traumatic limb salvage with free flap reconstruction versus primary amputation for lower extremity (LE) injuries remains an oft debated topic. Limb salvage has well-studied benefits and advances in microsurgery have helped reduce the complication rates. A subset of patients eventually requires secondary amputation after a failed attempt at limb salvage. A better understanding of risk factors that predict subsequent amputation after failed free flap reconstruction of LE injuries may improve operative management. A retrospective study (2002-2019) was conducted on all patients who underwent free flap reconstruction of the LE within 120 days of the original inciting event at a single institution. Patient and operative factors were reviewed including comorbidities, severity of the injury, flap choice, outcomes, and complications. Predictors of subsequent amputation were analyzed. A total of 129 patients requiring free flap reconstructions for LE limb salvage met inclusion criteria. Anterolateral thigh flaps (70.5%) were performed most frequently. Secondary amputation occurred in 10 (7.8%) patients. Preoperative factors associated with eventual amputation include diabetes mellitus (p = 0.044), number of preoperative debridements (p = 0.013), evidence of any arterial injury/pathology (p = 0.008), specifically posterior tibial artery (p = < 0.0001), and degree of three-vessel runoff (p = 0.007). Operative factors associated with subsequent amputation include evidence of recipient artery injury/pathology (p = 0.008). Postoperative factors associated with secondary amputation include total flap failure (p = 0.001), partial flap failure (p = 0.002), minor complications (p = 0.037), and residual osteomyelitis (p = 0.028). Many factors contribute to the reconstructive surgical team's decision to proceed with limb salvage or perform primary amputation. Several variables are associated with failed limb salvage resulting in secondary amputation. Further studies are required to better guide management during the limb salvage process.

Comparing the performance of different open injury scores in predicting salvage and amputation in type IIIB open tibia fractures.

Various open injury scores have been devised to aid the difficult decision of salvage or amputation following open fractures of the lower limb. Our aim of the study was to compare the performance of mangled extremity severity score (MESS), limb salvage index (LSI), orthopaedic trauma association-open fracture classification (OTA-OFC) and Ganga hospital score (GHS) in our population of type IIIB injuries. A total of 219 patients with 225 type IIIB open fractures of the tibia were studied prospectively between July 2016 and June 2017. The decision of salvage or amputation was taken by a combined consensus of senior orthopaedic and plastic surgeons, blinded to the scores. All four open injury scores were calculated by an independent reviewer following initial debridement. The follow-up period was one to twoyears. After final follow-up, there were 193 (85.7%) successfully salvaged limbs, 19 primary amputations without attempt of debridement (8.4%), three primary delayed amputations within 72hours (1.3%) and six secondary amputations after 72hours from initial debridement (2.7%). Of these, fourpatients died within oneyear and were excluded. All four scores performed well for salvage, while GHS was superior when considering amputation. MESS, LSI and OTA-OFC underscored amputations, since these scoring systems award more points for vascular injuries. There were both salvaged and amputated patients around the threshold value of amputation for all scores, which was only acknowledged by GHS in its unique 'grey zone'. It includes patients who are neither easily salvageable nor definitely requiring amputation. The performance of the GHS was superior to MESS, LSI and OTA-OFC in our study, since it was developed for type IIIB injuries and includes the 'grey zone', where decisions need to be undertaken on a case to case basis. GHS has an improved ability to determine amputation in IIIB open tibia fractures.

Factors Associated with Primary and Secondary Amputation following Limb-Threatening Upper Extremity Trauma.

The aim of this study was to assess the factors associated with primary and secondary amputation in patients with limb-threatening trauma to the upper extremity, describe the incidence of these injuries, and describe the procedures involved in the treatment of these difficult injuries. A retrospective study of 49 cases (in 47 patients) with acute limb-threatening trauma of the upper extremity proximal to the carpometacarpal joint level treated with either amputation or limb salvage was performed in two urban level I trauma centers between January of 2001 and January of 2018. Bivariate analysis demonstrated that cases of primary amputation more frequently had a higher Injury Severity Score, higher Abbreviated Injury Scale score, more proximal fractures, more severe muscle injuries, and a larger number of major nerve injuries. Secondary amputation, compared with limb salvage, was more frequently performed in patients who were younger, in cases with a higher Injury Severity Score, where there was more proximal soft-tissue injury, in case of nonsharp mechanism of injury, and in cases that required local flap procedures for wound closure. The authors found a yearly incidence of 62 cases of acute limb-threatening upper extremity trauma per 100,000 trauma admissions. Multiple factors influence the surgical decision to perform primary amputation or to attempt a salvage procedure following limb-threatening upper extremity trauma. Knowing which patients will have the most favorable outcomes of a salvage procedure is important, because salvage procedures impose a greater burden on the health care system and the patient, even more so in the case of secondary amputation. Risk, III.

Comparative Study between Negative Pressure Wound Therapy (NPWT) and Standard Moist Wound Dressing (SMWD) In Management of Diabetic Non- Ischemic Foot Ulcers

Abstract Background Diabetic Foot Ulcer(DFU) is a common complication of diabetis that has shown an increasing trend over previous decades, 15% of patients with diabetes will suffer from DFU. and approximately 20% of hospital admissions among patients with DM are the result of DFU. Standard moist wound dressing (SMWD) is considered the traditional method for management of DFU. Supporting evidence for NPWT in the treatment of diabetic foot wounds include numerous prospective and multi-centered randomized controlled trials. Aim of the Work This study aimed to compare wound outcome, limb salvage between NPWT and SMWT in management of diabetic non ischemic foot ulcers. Patients and Methods This is a randomized controlled study involving 60 patients with active diabetic foot ulcers. A computer generated randomization pattern will be used to segregate the patients into 2 groups (NPWT and SMWD groups). Primary end point of the study is to achieve full healthy granulating wound (without necrotic tissues, bone or tendon exposure and without local signs of infection). follow up included change in wound diameter, depth, up or down scaling along UTWC, wound status every 2 weeks. Results there was a statistically significant difference in rate of depth improvement for the NPWT group in 2 and 4 weeks. In six weeks follow up, the rate of depth reduction was better in NPWT group but it wasn’t statistically significant (p-value 0.14). There was a statistically significant difference in reaching full healthy granulation in 4 and 6 weeks in favor of the NPWT group compared to the SMWD, there was no statistically significant difference in number of cases reaching full healthy granulation in 8 weeks as many cases of SMWD group started to achieve full healthy granulation. Number of bed side debridement or surgical debridement was not statistically significant between the 2 groups. major amputation was seen in 4 cases of the SMWD group, and one trans-metatarsal amputation and 2 toes amputation was seen in NPWT group and none of these was statistically significant. Conclusion NPWT use in DFU provides a significant reduction in duration till reaching full healthy granulation. No significant difference was observed in ulcer related complications such as infection, cellulitis, and osteomyelitis. However, the study showed that SMWD patients had more secondary amputations than those receiving NPWT but it wasn’t statistically significant

Anastomotic Technique and Preoperative Imaging in Microsurgical Lower-Extremity Reconstruction: A Single-Surgeon Experience.

The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes. A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test. One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62). In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.

Complication management following resection and reconstruction of the upper limbs and shoulder girdle

Sarcomas of the upper limbs commonly affect the proximal humerus or scapula. Complications after tumor resection and reconstruction are rare but cannot be neglected, particularly after tumor endoprosthetic reconstructions. The most common complications after resection of sarcomas of the upper limbs and shoulder girdle are described, and current knowledge regarding complication management is presented. Additionally, a selective literature search was performed, incorporating personal experiences. Wound healing disorders and infections after tumor resection without specific reconstruction (clavicle resection, scapulectomy) usually respond well to conservative or surgical treatment. However, periprosthetic infections after reconstruction using amegaendoprosthesis constitute asevere and frequent complication, with an incidence of 5-10%. Two-stage implant replacement still represents the gold standard, although in selected cases, one-stage revision with retention of the prosthetic stem appears warranted. Secondary amputation as aresult of periprosthetic infection is rare compared to the situation with infections of the lower limb. Mechanical complications necessitating surgical revision are mostly limited to joint dislocation after inverse total shoulder replacement (TSR). (Sub)luxation in anatomic TSR can be tolerated provided there is no tendency toward perforation of the skin in aasymptomatic patient. Biological reconstructions are most often indicated for reconstruction of intercalary defects of the humerus, and revision is necessitated most frequently by mechanical complications. Despite multiple surgical revisions, stable reconstructions and limb salvage can usually be achieved in the upper limb.

Effects of Diabetes Mellitus on Functional Outcomes and Complications After Torsional Ankle Fracture.

It is well known that patients with diabetes mellitus experience higher complication rates after torsional ankle fracture; however, the functional consequences remain less clear. The goal of this study was to determine the effects of diabetes on complications, secondary operations, and functional outcomes after torsional ankle fracture. Nine hundred seventy-nine adult patients treated surgically for a torsional ankle injury (Orthopaedic Trauma Association 44B, 44C) over 13 years were retrospectively reviewed. Demographic information, comorbidities, injury characteristics, complications, and secondary procedures were recorded. Patient-reported outcome surveys: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment were obtained after minimum of 12 months. Multivariable analysis was done to account for confounding variables. One hundred thirty-one patients (13.4%) had diabetes. Diabetic patients were older (56.4 versus 43.0 years, P < 0.001), with no difference in sex or race. Body mass index was higher among diabetics (36.0 versus 30.4, P < 0.001) as were most medical comorbidities, including stroke, neuropathy, pulmonary disease, and renal disease (all P < 0.03). There were no differences in rates of dislocations or open injuries. Diabetics experienced more complications (26.0% versus 14.6%, P = 0.001), specifically deep infections (6.9% versus 1.3%, P = 0.001), and had more secondary procedures (18.3% versus 9.1%, P = 0.001), including débridement, arthrodesis, and amputation (all P < 0.02). Diabetes was a significant independent predictor of worse FFI activity limitation scores (P = 0.032), but was not predictive of worse outcomes on any other subscore of the FFI or Short Musculoskeletal Function Assessment. Diabetes was associated with more complications and secondary operations. However, functional outcomes including pain and dysfunction were not markedly affected by these clinical outcomes, potentially due to diminished sensory function and less baseline physical activity among diabetic patients. Prognostic level III.

Factors associated with secondary ray amputation after initial finger amputation at the traumatic level

Objectives: To assess if surgeon specialty, demographics or injury-related variables are related to a second operation to convert a finger amputation at the level of injury to a ray amputation. Methods: We identified 869 patients that had a finger (non-thumb) amputation at the level of injury over a period between 2000 and 2015. Bivariable analyses were used to identify factors associated with a second operation for ray amputation. Results: Eighteen patients had secondary ray amputation (2.1%), 8 for stiffness and contracture, 5 for pain, and 5 for necrosis of the stump. Factors associated with secondary ray amputation include central finger, amputation at a more proximal part of the finger, and other injured fingers that were not amputated. Conclusion: A second operation for ray resection is uncommon after major trauma, more likely proximal and central, and usually for pain or dysfunction, in patients treated by both plastic surgery and orthopedic surgery trained hand surgeons.