Viable Option For Limb Salvage Research Articles

Below-Knee Prosthetic Bypass Is a Viable Option for Limb Salvage in Patients with Extensive Femoropopliteal Occlusive Disease.

This study aimed to (1) evaluate the outcomes of below-knee prosthetic bypass (BKPB) in the absence of the great saphenous vein, and (2) identify risk factors associated with these outcomes. This study included 37 consecutive patients who underwent BKPB with or without distal modification between 2010 and 2022. We further assessed the following treatment outcomes: primary patency (PP), secondary patency (SP), limb salvage (LS), and amputation-free survival (AFS) rates. The risk factors for PP were also examined. Most patients (n=31) were male. In 32 (86.5%) patients, BKPBs were performed for chronic limb-threatening ischemia. At the time of initial admission, two (5.4%) early deaths and three (8.1%) major amputations were noted. At 1 year after BKPB, the overall PP, SP, LS, and AFS rates were 78%, 85%, 85%, and 70%, respectively; at 3 years, they were 58%, 70%, 80%, and 52%, respectively; and at 5 years, they were 35%, 58%, 62%, and 29%, respectively. Notably, PP was significantly lower in limbs with ≤1 patent tibial arteries than in limbs with ≥2 patent artery (hazard ratio [HR], 3.80; 95% confidence interval [CI], 1.14-12.69 for overall; and HR, 12.97; 95% CI, 2.15-78.08 for distal anastomosis to below-knee popliteal artery). However, the PP was unaffected by the distal modification. BKPB is a viable option for LS in patients with extensive femoropopliteal disease. Tibial runoff was significantly correlated with patency; therefore, decision-making for BKPB and follow-up must involve careful evaluation of the outflow arteries.

FREE VASCULARIZED FIBULA GRAFTING AS MANAGEMENT FOR LARGE SKELETAL DEFECTS IN HUMERAL OSTEOMYELITIS IN NORTHERN IRELAND

IntroductionThe purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration.Materials & MethodsSixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents.ResultsSix patients in Northern Ireland have been treated with free fibula grafting for humeral defects secondary to osteomyelitis. Regarding aetiology of osteomyelitis, five patients had sustained humeral fractures which were initially managed with open reduction internal fixation and complicated by infected non-union. These cases required removal of metalwork, segmental resection and placement of cement spacer with prolonged antibiotic therapy before return to theatre for vascularised fibula grafting. One patient developed native humeral osteomyelitis, the exact cause of which was unclear. Four patients were contactable for outcome score completion. The average DASH score was 45.5. (range 11.1 – 70.4). The median score was 50.2. With regard to post-operative complications, four of the six patients required return to theatre. Reasons were flap congestion, failure of metalwork at three months, donor site skin grafting for delayed healing and external fixation of graft fracture following trauma. Three patients experienced donor site morbidity in the form of delayed healing or infection requiring admission for intravenous antibiotics. One patient died due to cerebrovascular accident (CVA) within one month of return to theatre for a graft related complication - radiographic osteointegration was not assessed for this patient. At the time of this study, three of the remaining five patients have achieved graft osteointegration. Two patients are within 6 months of grafting procedure therefore too early to comment on radiographic osteoingreration. Radiographs to date are encouraging.ConclusionsFree vascularised fibula grafting for humeral shaft bone defects is a viable option for limb salvage but carries significant risk of complications. Our study highlights the need for proper informed consent regarding risk for this uncommon complex procedure which should only be undertaken by a multidisciplinary team in a specialist orthoplastic unit. This procedure is performed infrequently and our study has given us more information on risk and clinical outcomes to provide full and informed consent for patients in the future.

Knee arthrodesis using a custom modular intramedullary nail in failed, infected knee arthroplasties: A concise follow-up note of 31 cases at a median of 13 years post-arthrodesis

IntroductionKnee arthrodesis utilizes an arthrodesis nail as a salvage technique for infected total knee arthroplasty (TKA), especially when the extensor mechanism is damaged, or the skin is compromised. This implant helps to minimize or prevent leg length discrepancy, while allowing immediate weight bearing without requiring bone fusion. However, there is a risk of infection. Surgical revisions were required in 19% of patients at 50 months’ follow-up in our team's initial 31-patient case series. Since there is little long-term outcome data, we reviewed this same group of patients after a mean of 13 years to determine: (1) the implant's long-term survival, (2) the functional outcomes, (3) the microbiological changes in revision cases. HypothesisThe long-term survival of knee arthrodesis using an arthrodesis nail for failed infected TKA is acceptable. Material and methodsThirty-one patients operated on between January 2005 and December 2008 were retrospectively included in the initial study. The functional outcomes consisted of pain on a visual analog scale (VAS), neuropathic pain (DN4) and the Oxford Knee Score. All surgical revisions were documented with repeat microbiology samples. ResultsThe median follow-up time was 13.1 years [11.5–13.5]. No mechanical failure (implant failure or aseptic loosening) was observed. Eight patients were re-operated on due to new infections. The nail had to be removed in five of these patients. None of the patients required an amputation. Among the eight patients who were re-operated on, only two (25%) had been re-operated on since the initial study and underwent a two-stage arthrodesis revision. At 10 years, the cumulative incidence of surgical revision at the knee was 26% [95% CI: 12%–43%] and 16% [95% CI: 5.7%–31%] for an implant change. Six (75%) of the re-operated patients had their revision within the first 72 months of the initial TKA, while 4 (50%) had it within the first 26 months. Among the 15 patients who were still alive, the median Oxford Knee Score was 17/48 [12–28]. At the final assessment, the median pain level was 0 [0–5], although 4 of the 10 analyzable patients (of the 15 living patients, 3 had a cognitive impairment and 2 refused to participate) had neuropathic pain and pain on VAS of 3/10. The microbiologic findings were the same during the surgical revision in five of the eight re-operated patients (62%); however, one patient who had a Staphylococcus aureus infection had acquired a resistance to methicillin. In one patient, only one of the two bacteria identified initially was still present (methicillin-susceptible Coagulase-negative staphylococci [CNS]) and while in two patients, the infectious agent changed completely (shift from Gram-negative bacilli to methicillin-susceptible CNS, and the opposite for the other patient). DiscussionKnee arthrodesis with a custom modular intramedullary nail is a viable limb salvage option in failed infected TKA cases with long-term survival, and it is comparable to other arthrodesis techniques. In most cases, recurrence of the infection occurred in the short term (<72 months). Later recurrences of the infection (>72 months) were rarer and were found in only two of our patients (6%). There were no mechanical failures. Level of evidenceIV; Retrospective cohort study.

Temporal hemiarthroplasty for distal femoral osteosarcoma in early childhood: a case report

BackgroundProsthetic reconstruction for distal femoral osteosarcoma is challenging for younger children. We herein report a successful case of limb-sparing surgery for a younger patient with distal femoral osteosarcoma requiring osteo-articular resection.Case presentationA 5-year-old girl with high-grade conventional osteosarcoma in the left distal femur underwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb-salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned.ConclusionsThis case report provides an example of limb-salvage surgery after distal femoral resection in a small child. The use of a temporary spacer utilizing partial cementation and preservation of the periosteum and induced membrane appears to afford a viable limb-salvage option after distal femoral resection for younger children.

Clinical Outcome of Free Latissimus Dorsi Flaps for Coverage of Soft Tissue Defects in Multiply Revised Total Knee Arthroplasties

BackgroundMultiply revised total knee arthroplasties (TKAs) may present with large anterior soft tissue defects, which can be challenging to reconstruct. In the rare cases where local flaps are insufficient, we use free latissimus dorsi (LD) myocutaneous flaps to achieve soft tissue coverage. This study looked to determine implant survivorship, infection status, and patient-reported outcomes of patients undergoing simultaneous revision TKA and LD flaps in a tertiary unit. MethodsThis was a retrospective study of 18 consecutive patients who had revision TKA and free LD flap reconstruction. Twelve were male and the median age was 65 years (range, 35-83). Patients had undergone a median of 4 previous arthroplasty procedures (range, 3-6). Median follow-up was 49 months (range, 18 to 110). The primary outcome was revision-free implant survival. Secondary outcomes included soft tissue integrity, Oxford Knee Score, and EuroQol 5-domain score at latest follow-up. ResultsAt latest follow-up, 14 of 18 patients had maintained their implant. Seven patients were infection-free, 7 were on suppressive antibiotics with the implant in situ, and 4 had undergone above-knee amputation. Five-year implant survival was 75% (95% confidence interval, 46-90). At median follow-up (49 months), mean Oxford Knee Score was 13.4 (range, 2-35) and mean EuroQol 5-domain index was 0.071 (range:−0.427 to 0.747). ConclusionLD free flap is a viable option for limb salvage in patients with large anterior soft tissue defects following multiple revisions of TKA. However, functional outcomes can be poor and there is a significant risk of ongoing infection and amputation in this complex patient cohort.

Lower Extremity Limb Salvage with Cross Leg Pedicle Flap, Cross Leg Free Flap, and Cross Leg Vascular Cable Bridge Flap.

Lower extremity salvage following significant soft tissue loss can be complicated by lack of recipient vessel for free tissue transfer. We describe our experience in lower limb salvage for patients with no recipient vessels with the use of pedicle, free and cable bridge flaps. A retrospective review from 1985 to 2017 of patients undergoing lower limb salvage using a contralateral pedicle cross leg (PCL) flaps, free cross leg (FCL) flaps, or free cable bridge (FCB) flaps was conducted. Demographics, etiology of the reconstruction, type of flap used, donor-site vessels, defect size, operating time, time of pedicle division, length of hospital stay, time to ambulation, and complications were analyzed. A total of 53 patients (48 males and 5 females) with an average age of 35 years (range, 29-38 years) were identified. The etiology for the reconstruction was trauma in 52 patients and oncological resection in 1 patient. There were 18 PCL, 25 FCL, and 10 FCB completed. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operating room times for PCL, FCL, and FCB flaps were 4, 9, and 10 hours, respectively. The average length of hospital stay was 5 weeks and average time to ambulation was 4 weeks. The average follow-up time was 7.5 years (range, 3-12 years). Complications encountered were hematoma (six), prolonged pain (six), total flap loss (two), reoperation (five), and infection (four). Limb salvage rates were 96.2%. When ipsilateral limb vessels are not available, and other reconstructive options have been exhausted, cross leg flaps can be a viable option for limb salvage in the setting of extensive defects.

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty.

Revision total knee arthroplasty (rTKA) is a challenging problem in the setting of soft tissue defects. The purpose of this study was to evaluate patients who underwent rTKA requiring flap coverage and determine patient factors that predisposed them to failure. Forty-three consecutive patients (mean follow-up, 46.5 months) who underwent rTKA requiring flap coverage were retrospectively reviewed between January 1, 2000 and December 31, 2010. Sixteen of 43 patients experienced failure requiring either flap revision (n = 2) or above the knee amputation (n = 14). Patients with heart failure (p = 0.008), cancer (p = 0.049), or infection with Klebsiella pneumoniae (p = 0.002) had greater rates of failure. Smoking (p = 0.287), diabetes (p = 0.631), and flap type (p = 0.634, p = 0.801) were not associated with increased failure. Mean survival was 46.4 months. Survival of patients with a history of cancer (34.3 months) was less (p = 0.033) than those without (49.2 months). Flap coverage in rTKA is a viable limb salvage option for patients with soft tissue defects; however, failure rates are much higher than in patients not requiring flap coverage.

Outcomes of Chopart Amputation in a Tertiary Referral Diabetic Foot Clinic: Data From a Consecutive Series of 83 Hospitalized Patients

The purpose of the present retrospective study was to evaluate the outcomes (ie, ulcer recurrence, major amputation, death) in diabetic patients undergoing Chopart amputation because of deep infection or gangrene extending to the midfoot. From 2009 to 2011, 83 patients, aged 71.4 ± 9.3 years, underwent a midtarsal amputation and were followed up until December 31, 2012 (mean follow-up 2.8 ± 0.8 years). Of the 83 patients, 26 were female, 61 required insulin, 47 had renal insufficiency, 19 underwent hemodialysis, 65 had hypertension, 34 had a history of cardiac disease, and 4 had a history of stroke. Chopart amputation was performed in 38 patients (45.8%) with gangrene, 31 (37.4%) with abscess, and 14 (16.9%) with osteomyelitis. Urgent surgery was performed in 56 patients (67.5%). Effective revascularization was performed in 64 patients (77.1%) patients. Of the 83 patients, 47 had healed at a mean period of 164.7 (range 11 to 698) days. Ulcer recurrence developed in 15 patients (31.9%). A major amputation was necessary in 23 patients (27.7%), with an annual incidence of 13.0%. None of the included variables on logistic regression analysis was significantly associated with proximal amputation. Of the 83 patients, 38 (45.8%) died, with an annual incidence of 25.8%. On logistic regression analysis, age (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.01 to 1.16), history of stroke (OR 9.94, 95% CI 3.16 to 31.24), and urgent surgery (OR 2.60, 95% CI 1.14 to 5.93) were associated with mortality. Chopart amputation represents the last chance to avoid major amputation for diabetic patients with serious foot complications. Our success rate was great enough to consider Chopart amputation a viable option for limb salvage in this high-risk population.

Topology Optimization of Total Femur Structure: Application of Parameterized Level Set Method Under Geometric Constraints

Optimization of the femur prosthesis is a key issue in femur replacement surgeries that provide a viable option for limb salvage rather than amputation. To overcome the drawback of the conventional techniques that do not support topology optimization of the prosthesis design, a parameterized level set method (LSM) topology optimization with arbitrary geometric constraints is presented. A predefined narrow band along the complex profile of the original femur is preserved by applying the contour method to construct the level set function, while the topology optimization is carried out inside the cavity. The Boolean R-function is adopted to combine the free boundary and geometric constraint level set functions to describe the composite level set function of the design domain. Based on the minimum compliance goal, three different designs of 2D femur prostheses subject to the target cavity fill ratios 34%, 54%, and 74%, respectively, are illustrated.

Partial or Total Calcanectomy as an Alternative to Below-the-Knee Amputation for Limb Salvage

Below-the-knee amputations are regarded as definitive treatment for calcaneal osteomyelitis. They may be less than desirable in patients with a viable midfoot and forefoot. Partial and total calcanectomies have been reported as an alternative for limb salvage. However, the durability of the residual limb is questionable. A systematic review was undertaken to identify material relating to the potential for limb salvage with partial or total calcanectomy in ambulatory patients with calcaneal osteomyelitis. Studies eligible for inclusion consecutively enrolled ambulatory patients older than 18 years who underwent partial or total calcanectomy without adjunctive free tissue transfer for the treatment of calcaneal osteomyelitis and had a mean follow-up of 12 months or longer. Sixteen studies involving 100 patients (76 partial and 28 total calcanectomies) met all of the inclusion criteria. Weighted mean follow-up was 33 months. Minor complications with subsequent healing occurred in less than 24% of patients. Most major complications were related to residual soft-tissue infection and osteomyelitis. Approximately 10% of patients required a major lower-extremity amputation. Major complications and major lower-extremity amputations occurred more frequently after total calcanectomy and in patients with a diagnosis of diabetes. Eighty-five percent of patients maintained or improved their ambulatory status postoperatively. Only 3% of patients decreased their ambulatory status postoperatively, becoming unlimited household ambulators. This systematic review provides evidence that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis.

Syme Amputation for Limb Salvage: Early Experience with 26 Cases

The Syme amputation is often overlooked as an alternative to below-knee amputation or above-knee amputation in cases of limb-threatening foot infections and gangrene. Even though the advantages of the Syme amputation over major amputation are well cited in the literature, many surgeons do not view this amputation as a viable option for limb salvage. We herein present our initial experience with this operation in a series of patients at imminent risk for major lower extremity amputation. This study included our initial 26 patients at high risk (92% had diabetes) with infection and/or significant peripheral arterial disease who underwent ankle disarticulation for limb salvage. Medical records were abstracted for pertinent demographic and clinical data. Variables of interest included diabetes status and duration, presence of peripheral arterial disease, infection, osteomyelitis, and gangrene. Our primary outcome variable was a healed amputation, whereas secondary outcomes included time to healing, subsequent major amputations, and complications. Despite prior recommendation for below-knee amputation or above-knee amputation in each of these patients, 50% remained healed at an average of 49.3 weeks of follow-up. Although 17 patients (65.4%) ambulated in a Syme prosthesis after healing of the original Syme operation, several patients went on to major amputation for progressive sepsis or recurrent ulcers, and 1 patient subsequently died. Because of the relatively small number of study subjects, we could find no significant predictors of success or failure of this procedure. However, all 10 patients eventually succumbing to major amputation and all 3 patients who died during follow-up had diabetes mellitus. At the end of follow-up, 46.2% (12/26) patients were functioning well in a Syme prosthesis. In this high-risk cohort of patients in whom major amputation had been recommended, we achieved a healing rate of 50% at an approximate 1-year follow-up. With the majority of patients having diabetes and peripheral vascular disease, we could not find any clear predictive factors for failure or successful outcome in this small population. Nonetheless, the Syme amputation deserves further study and consideration as a viable limb salvage option in patients threatened with major lower extremity amputation.

Pedal branch artery bypass: A viable limb salvage option

Purpose: We reviewed our experience with pedal branch artery (PBA) bypass to confirm the role of these target arteries for limb salvage and to identify patient and technical factors that may be associated with graft patency and limb salvage. Methods: In this retrospective study we analyzed 24 vein grafts to PBAs performed from 1988 to 1998 for limb salvage in 23 patients who had no suitable tibial, peroneal, or dorsal pedal target arteries. These PBA grafts were compared with 133 perimalleolar posterior tibial, defined at or below the ankle, or dorsalis pedis bypass grafts performed contemporaneously; the Kaplan-Meier life table was used in the analysis of graft patency and limb salvage. Life table analyses and logistic regression analysis of prognostic patient variables were also performed. Results: The PBA bypass represented 3% of infrainguinal revascularizations for chronic critical limb ischemia at our institution over the study period. Patients who received PBA bypasses were more likely to be male (92% vs 69%, P =.02) with lower incidences of overt coronary artery disease (33% vs 50%, P =.12) and stroke (0% vs 15%, P =.04), and a higher incidence of end-stage renal disease (21% vs 8%, P =.06) than those undergoing perimalleolar bypass. Seventeen percent of PBA bypasses were performed with the anterior lateral malleolar artery, a vessel not previously described as a common bypass target. Two-year primary patency and limb salvage for PBA versus perimalleolar bypass was 70% versus 80% (P =.16) and 78% versus 91% (P =.28), respectively. Patency and limb salvage rates were no different in bypasses with above-knee or below-knee inflow arteries. Conclusion: An autogenous vein bypass to the PBA, though rarely required, provides acceptable primary patency and limb salvage when compared with perimalleolar tibial artery bypass when no suitable, more proximal target arteries are available. The PBA bypass should be considered before major amputation is undertaken. (J Vasc Surg 2000;32:1071-9.)

Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer.

Ten male patients with previously infected bony defects involving both sides of an articulation underwent arthrodesis using a vascularized fibular transfer. The average age of these patients was 38 years (range, 20 to 60 years). The size of the bony defect averaged 9 cm (range, 3 to 21 cm). The ankle was involved in five patients, the knee in two patients, the wrist in two patients, and the elbow in one patient. Nine cases represented septic pseudarthroses (eight after trauma and one after attempted ankle arthrodesis). One patient had a defect across the wrist after debridement of a chronic infection. The patients were followed for an average of 71 months (range, 26 to 144 months). Nine patients healed after the index vascularized fibular transfer, and one patient (ankle arthrodesis) required a second cancellous bone-grafting procedure for delayed union at the junction of the fibula with the talus. Four of seven patients with lower limb involvement had residual leg length discrepancies averaging 5 cm (range, 3 to 8 cm), and one had a persistent 20-degree internal rotation deformity. Two of the patients with upper limb involvement had stiff digits. Five of the nine previously employed patients returned to their former occupation (including heavy labor in four cases). Complications included two wound separations, one case of instability of the donor ankle after removal of a large fibular graft (related in part to a prior injury), and one fracture at the junction of the fibular graft with the local bone 10 months after the index procedure, which united after plate fixation and application of autogenous cancellous bone graft. Arthrodesis using a transfer of vascularized fibular bone represents a viable option for limb salvage in the face of an infected transarticular bony defect.