Limb Wounds Research Articles

Impact of the COVID-19 pandemic on the rate of lower limb amputation in Veterans.

The COVID-19 pandemic led to changes in health care, including postponement of nonurgent appointments. These changes, combined with overall decreased activity levels, may have placed individuals with vascular disease at increased risk for skin ulceration and amputation. To determine the rates of lower limb amputation in Veterans due to complications of diabetes and/or vascular disease in the year following onset of the COVID-19 pandemic (March 2020-March 2021) compared to the previous 3 years (March 2017-March 2020). Retrospective chart review. Minneapolis Veterans Affairs Health Care System. Veterans with a vascular consult appointment note between March 1, 2017, and February 28, 2021. Not applicable. Primary outcome was lower limb amputation rate in the year following onset of the COVID-19 pandemic compared to the previous 3 years. Secondary outcome was the rate of lower limb wounds in the same time frame. We hypothesized that rates of lower limb amputation and wounds increased during the pandemic. Vascular consult appointments (n = 4183) were reviewed between March 1, 2017, and February 28, 2021. Significantly higher rates of amputation (7.52% vs. 5.19%; p = .006) and wound presence (16.77% vs. 11.66%; p < .001) were found 1 year postpandemic compared to the previous 3 years. Amputation and wound rates did not significantly increase between pairs of consecutive years prior to the pandemic but significantly increased between the year preceding the pandemic and the first year of the pandemic (amputation p = .047; wound p = .004). Increased rates of amputation and wounds in Veterans following the onset of the COVID-19 pandemic are likely due to disruption of care, lifestyle changes, and other pandemic-related factors. Awareness of COVID-19-related negative health effects is imperative for health care providers to ensure appropriate allocation of resources and alternate models for care delivery for amputation and preventative care as part of disaster response.

Observations on FGF immunoreactivity in the regenerating tail blastema, and in the limb and tail scars of lizard suggest that FGFs are required for regeneration

Tail regeneration in lizards depends on the stimulation of growth factors, including Fibroblast Growth Factors (FGFs). Light and ultrastructural immunolocalization of FGFs was compared between the rege-nerating tail blastema and the limb where no regeneration occurs. A likely epithelial-mesenchymal transition occurs following amputation in both tail and limb and FGFs are present in the wound epidermis of both organs at 7-14 days post-amputation, and at lower intensity in mesenchymal cells of the blastema. Immunoreactivity for FGFs disappears in the limb wound epidermis after 14 days post-amputation and in the epithelium covering tails induced to form scars, whereas it remains in the apical tail epithelium. These observations suggest that scarring in the limb or the induced scarring in the tail correlate with the disappearance of FGFs. Basic FGF is concen-trated in the incomplete basement membrane between the epidermis and the tail blastema where the essential signaling process that allows the continuous growth of the regenerative blastema may occur. The study suggests that the successful regeneration of lizard tail is dependent on the presence of FGFs in the wound epidermis, which are probably released into the blastema.

The effects of a synthetic epidermis spray on secondary intention wound healing in adult horses.

To evaluate secondary intention wound healing in the horse's limbs when treated with the synthetic epidermis spray (Novacika®, Cohesive S.A.S, France) or with a standard bandaging technique. Six Standardbred mares were included in the study. Four 2.5 x 2.5 cm full-thickness skin wounds were created on each thoracic limb. Two wounds were located on the dorsoproximal aspect of the cannon bone and the other two at the dorsoproximal aspect of the fetlock. Six hours after creation, wounds were randomly treated with synthetic epidermis spray or standard bandaging. The wounds were assessed every 4 days by gross visual assessment and using a 3D imaging camera. Analysis was performed with a 3D imaging application. Out of 46 wounds, 22 showed exuberant granulation tissue and were part of the standard bandaging group. Whether the wounds were treated with synthetic epidermis spray or standard bandaging, the time for healing was the same. The synthetic epidermis spray studied in this model has allowed healing without the production of exuberant granulation tissue but did not reduce the median wound healing time compared to a standard bandaging technique. The synthetic epidermis spray is potentially an interesting alternative for the management of secondary intention wound healing of superficial and non-infected distal limb wounds in adult horses on economical and practical aspects. However, all statistical inference (p-values especially) must be interpreted with caution, given the size of the sample.

Wound care in hard-to-reach populations: rough sleepers.

People sleeping rough commonly develop wounds and other skin disorders. Wounds vary and develop for multiple reasons. They include acute wounds such as burns, infected injection sites, abscesses and cellulitis, as well as chronic wounds such as pressure ulcers; rough sleepers have a high prevalence of lower limb wounds. Skin and soft tissue infections are common, especially in people who inject drugs via subcutaneous or intramuscular routes. Emergency departments are often the pathways into healthcare for homeless people as traditional health and care systems often fail to meet their needs. Across England, initiatives have been developed to improve access to wound care for those who sleep rough. A case study illustrates the care of a homeless man presenting with a lower limb wound.

Clinical and microbiological features of host-bacterial interplay in chronic venous ulcers versus other types of chronic skin ulcers.

Chronic venous ulcers of the lower limbs develop in the context of advanced venous disease and have a significant impact on the patient's quality of life, being associated with depression and worrisome suicide rates, as well as with an economic burden caused by increased medical care costs and high epidemiological risks of healthcare associated infections and emergence of strains resistant to multiple classes of antibiotics and/ or antiseptics. Although numerous studies have investigated the composition of the chronic wounds microbiome, either by culture-dependent or independent methods, there are no data on the association between virulence and resistance profiles of strains isolated from venous ulcers and the clinical picture of this pathology. The elucidation of pathogenic mechanisms, at both phenotypic and molecular level, is crucial in the fight against these important human microbial agents, in order to develop novel biomarkers and discover new therapeutic targets. In this study we aimed to characterize the phenotypic virulence profiles (including the ability to develop biofilms) of microorganisms isolated from chronic skin wounds and to correlate them with the clinical symptomatology. Considering the high incidence of Staphylococcus aureus infections in chronic ulcers, but also the ability of this species to develop multi-drug resistance, we performed an more in-depth study of the phenotypic and genotypic virulence profiles of methicillin-resistant Staphylococcus. The study revealed important differences regarding the clinical evolution and virulence profiles of microorganisms isolated from lower limb wounds, as well as between patients diagnosed with chronic venous ulcers and those with lesions of different etiology.

Diagnostic accuracy of plain radiography to identify synovial penetration in horses with traumatic limb wounds.

The diagnostic value of plain radiography for diagnosing synovial penetration in limb wounds near synovial structures has not been determined. To assess diagnostic accuracy of plain radiography to identify synovial penetration in horses with traumatic limb wounds. Retrospective case study. Case records of horses presented to the Faculty of Veterinary Medicine of Ghent University (2011-2021) with limb wounds near synovial structures were categorised in groups with and without synovial penetration using results of synovial fluid analysis and surgical findings. Plain radiographic images were evaluated retrospectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the total study sample and for the cases with and without use of a metallic probe in the wound during radiographic evaluation. Based on the total sample of 141 horses with synovial penetration and 75 cases without synovial involvement, plain radiography presented a sensitivity of 61% (95% CI: 52%-69%), a specificity of 81% (95% CI: 70%-89%), a PPV of 86% (95% CI: 79%-90%) and a NPV of 53% (95% CI: 46%-58%). With the use of a metallic probe, a sensitivity of 54% (95% Cl: 39%-69%), a specificity of 88% (95% Cl: 64%-99%), a PPV of 93% (95% Cl: 78%-98%) and a NPV of 41% (95% Cl: 32%-49%) were obtained. Sample size did not allow comparing different synovial structures. Results can be influenced by individual case characteristics. If findings of a series of plain radiographs suggest synovial penetration in horses with a wound near a synovial cavity, then synovial penetration is likely, but the absence of plain radiographic findings does not rule out synovial penetration. The use of a metallic probe during radiography may be helpful. However, plain radiography should be interpreted cautiously, and clinical decision making should also include other techniques.

Chronic wounds of the lower limbs: a guide for non-specialists

Chronic lower-extremity ulcers are a growing public health problem, resulting in significant costs for society and patients, and having a significant impact on the quality of life of patients and informal caregivers. As general practitioners are often solicited early on, the acquisition of basic knowledge regarding wound care management is therefore essential to initiate local care, to make an early diagnosis and identify emergencies and patients that need a referral. The CASE and TIMERS frameworks enable a holistic assessment of the patient and the wound, to propose a treatment of the wound based on its etiology combined with appropriate local wound care. This framework allows also to identify atypical, severe, or recalcitrant wounds requiring specialized advice.

The Impact of Artificial Intelligence and Deep Learning-Based Family-Centered Care Interventions on the Healing of Chronic Lower Limb Wounds in Children

The Impact of Artificial Intelligence and Deep Learning-Based Family-Centered Care Interventions on the Healing of Chronic Lower Limb Wounds in Children

The Use of Custom-Made Negative Pressure Wound Therapy to Manage Acute Wound Infections: A Retrospective Outcomes Study

Background. NPWT has been used to treat various wounds. Scant evidence exists on the use of custom-made NPWT for infected wounds. NPWT dressings promote wound healing by increasing local blood flow and antibiotic concentration, and by removing exudates from the wound. Objective. To report the use of custom-made NPWT dressings to manage complex infected wounds of the lower limb. Materials and Methods. The authors retrospectively reviewed the records of 43 patients with complex infected wounds of the lower limb treated with debridement and low-cost, custom-made NPWT dressing connected to wall suction from January 1, 2018 to December 31, 2020, at PSG Medical College Hospital, Coimbatore, India. Results. A total of 43 patients with infected wounds of the lower limb were treated with the custom-made NPWT dressings. Second-look debridement was required in 5 patients. An average of 5 dressing changes were required for optimal wound granulation, with 23% of patients (n = 10) requiring secondary suturing and 62% (n = 27) requiring STSG for definitive coverage of the wound. Healing by secondary intention was achieved in 6 patients. The average duration from the start of therapy until the wound was ready for coverage (STSG or secondary suturing) was 2.5 weeks (range, 1–5 weeks), with an average time to complete wound healing of 5 weeks (range, 3–7 weeks). The most common wound isolate was Staphylococcus aureus (60%). No complications occurred. Conclusions. Custom-made NPWT dressings are safe to use in complex infected lower limb wounds. These dressings keep the wound dry and promote healing. Wound debridement followed by NPWT combined with antibiotic therapy can act synergistically to promote wound healing and control infection.

Making a new limb out of old cells: exploring endogenous cell reprogramming and its role during limb regeneration.

Cellular reprogramming is characterized by the induced dedifferentiation of mature cells into a more plastic and potent state. This process can occur through artificial reprogramming manipulations in the laboratory such as nuclear reprogramming and induced pluripotent stem cell (iPSC) generation, and endogenously in vivo during amphibian limb regeneration. In amphibians such as the Mexican axolotl, a regeneration permissive environment is formed by nerve-dependent signaling in the wounded limb tissue. When exposed to these signals, limb connective tissue cells dedifferentiate into a limb progenitor-like state. This state allows the cells to acquire new pattern information, a property called positional plasticity. Here, we review our current understanding of endogenous reprogramming and why it is important for successful regeneration. We will also explore how naturally induced dedifferentiation and plasticity were leveraged to study how the missing pattern is established in the regenerating limb tissue.

Wound healing of experimental equine skin wounds and concurrent microbiota in wound dressings following topical propylene glycol gel treatment.

Topical wound treatments rely on carrier formulations with little to no biological impact. The potential for a common vehicle, a propylene glycol (PG) gel, to affect wound healing measures including microbiota is not known. Microbiome characterization, based on next generation sequencing methods is typically performed on tissue or directly obtained wound fluid samples. The utility for primary wound dressings to characterize equine wound microbiota in the context of topical treatments is currently unknown. This investigation reports the topical effect of an 80% PG based gel on wound healing and microbiota in wound dressings. Experiments were performed in six mature horses utilizing a surgical, distal limb wound model, histology of sequential wound biopsies, photographic wound measurements and microbiota profiling via 16s rRNA sequencing of wound dressing samples. Experimental wounds were surveyed for 42 days and either treated (Day 7, 14, 21 and 28; at 0.03 ml/cm2) or unexposed to the PG gel. Wound surface area, relative and absolute microbial abundances, diversity indices and histologic parameters were analyzed in the context of the experimental group (treatment; control) using qualitative or quantitative methods depending on data characteristics. Compared to controls, treatment slowed the wound healing rate (17.17 ± 4.27 vs. 18.56 ± 6.3 mm2/day), delayed the temporal decline of polymorphonucleated cells in wound beds and operational taxonomic units (OTU) in wound dressings and lowered alpha-diversity indices for microbiota in primary wound dressing. Relative abundances of OTUs were in line with those previously reported for equine wounds. Clinical outcomes 42 days post wounding were considered similar irrespective of PG gel exposure. Results highlight the potential for vehicle exposure to alter relevant wound outcome measures, imposing the need for stringent experimental control measures. Primary wound dressings may represent an alternate sample source for characterization of the wound microbiome alleviating the need for additional interventions. Further studies are warranted to contrast the microbiome in wound dressings against that present on wound surfaces to conclude on the validity of this approach.

"I did not expect the doctor to treat a ghost": a systematic review of published reports regarding chronic postamputation pain in British First World War veterans.

Limb trauma remains the most prevalent survivable major combat injury. In the First World War, more than 700,000 British soldiers received limb wounds and more than 41,000 underwent an amputation, creating one of the largest amputee cohorts in history. Postamputation pain affects up to 85% of military amputees, suggesting that up to 33,000 British First World War veterans potentially reported postamputation pain. This qualitative systematic review explores the professional medical conversation around clinical management of chronic postamputation pain in this patient cohort, its development over the 20th century, and how this information was disseminated among medical professionals. We searched The Lancet and British Medical Journal archives (1914-1985) for reports referring to postamputation pain, its prevalence, mechanisms, descriptors, or clinical management. Participants were First World War veterans with a limb amputation, excluding civilians and veterans of all other conflicts. The search identified 9809 potentially relevant texts, of which 101 met the inclusion criteria. Reports emerged as early as 1914 and the discussion continued over the next 4 decades. Unexpected findings included early advocacy of multidisciplinary pain management, concerns over addiction, and the effect of chronic pain on mental health emerging decades earlier than previously thought. Chronic postamputation pain is still a significant issue for military rehabilitation. Similarities between injury patterns in the First World War and recent Iraq and Afghanistan conflicts mean that these historical aspects remain relevant to today's military personnel, clinicians, researchers, and policymakers.

Comparative Efficacy of Chitosan with or Without Honey on Cutaneous Wound Healing in Donkeys

The domesticated donkey, derived from the African wild ass, has played a crucial role in human history for over 5,000 years, serving as a working and pack animal. However, donkeys often suffer from skin wounds and injuries due to various factors, including equipment use, road accidents, and lack of veterinary care. Wound healing is a complex process involving inflammation, proliferation, and maturation phases, with impaired cell proliferation potentially delaying healing. Equines, including donkeys, are particularly susceptible to traumatic skin wounds, with limb wounds healing more slowly due to factors such as tissue loss, contamination, and excessive skin tension. In such cases, wound healing by second intention is common but can lead to complications. Chitosan, a biopolymer derived from the shells of crustaceans, has shown promise in promoting wound healing. It helps with tissue granulation, collagen deposition, and tissue regeneration, while also preventing wound contamination and maintaining a sterile environment. Honey, with its antimicrobial, anti-inflammatory, and antioxidant properties, is another natural remedy that accelerates wound healing and is often used in combination with chitosan for optimal results. This biologically-based approaches hold potential for improving the healing of donkey wounds and preventing infections, offering safer and more effective alternatives to traditional wound care.

Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis.

Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed. This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure. PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023. Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months. A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively. This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.

Behaviour in Chronic Wounds of Vascular Origin

With an ageing population the number of people with chronic limb wounds of vascular origin is growing steadily. These wounds are managed conservatively, surgically and with hybrid approach. They have been treated by different specialists. The aim of the present study was to compare the results between the different methods of treatment – conservative, surgically and with hybrid approach, as well as to offer an approach to these wounds from vascular origin based on our experience in the clinic. For a period of 3 years 220 patients with venous wounds have been accepted in the department of vascular surgery in UHAT “St. Ekaterina”, Sofia. One hundred of them have been treated conservatively, the rest 120 – with complex approach – surgically, pharmaceutically, elastopia or with bandages. The rate of ageing ulcuses of venous origin did not differ significantly in 3 months in the two groups (55% to 66%), on account of recurrences at 12-month follow-up, which were significantly more common in the conservative therapy group (15% to 30%). We have followed-up the frequency of the healed wounds on the 1st, 3rd and 6th month. A significant difference in healing wounds of vascular origin with a complex approach (with open surgery and conservatively) even during the 1st month has been noticed. The complex approach applied as a treatment of chronic wounds with vascular origin is particularly important. The surgical or interventional correction of pathological changes of the vascular system are of great importance for the successful treatment of these ulcuses.

Anatomic study and clinical application of iliac crest chimeric tissue flap

To conduct anatomical study on the iliac crest chimeric tissue flap and summarize its effectiveness of clinical application in repairing limb wounds. Latex perfusion and anatomical study were performed on 6 fresh adult cadaver specimens with 12 sides, to observe the initial location, distribution, quantity, and direction of the common circumflexa iliac artery, the deep circumflexa iliac artery, and the superficial circumflexa iliac artery, and to measure their initial external diameter. Between December 2020 and September 2022, the iliac crest chimeric tissue flap repair was performed on 5 patients with soft tissue of limbs and bone defects. There were 3 males and 2 females, with an average age of 46 years (range, 23-60 years). Among them, there were 3 cases of radii and skin soft tissue defects and 2 cases of tibia and skin soft tissue defects. The length of bone defects was 4-8 cm and the area of skin soft tissue defects ranged from 9 cm×5 cm to 15 cm×6 cm. The length of the iliac flap was 4-8 cm and the area of skin flap ranged from 12.0 cm×5.5 cm to 16.0 cm×8.0 cm. The donor sites were directly sutured. Anatomical studies showed that there were 10 common circumflex iliac arteries in 5 specimens, which originated from the lateral or posterolateral side of the transition between the external iliac artery and the femoral artery, with a length of 1.2-1.6 cm and an initial external diameter of 0.8-1.4 mm. In 1 specimen without common circumflexa iliac artery, the superficial and deep circumflex iliac arteries originated from the external iliac artery and the femoral artery, respectively, while the rest originated from the common circumflex iliac artery. The length of superficial circumflex iliac artery was 4.6-6.7 cm, and the initial external diameter was 0.4-0.8 mm. There were 3-6 perforator vessels along the way. The length of deep circumflex iliac artery was 7.8-9.2 cm, and the initial external diameter was 0.5-0.7 mm. There were 3-5 muscular branches, 4-6 periosteal branches, and 2-3 musculocutaneous branches along the way. Based on the anatomical observation results, all iliac crest chimeric tissue flaps were successfully resected and survived after operation. The wounds at recipient and donor sites healed by first intention. All patients were followed up 8-24 months, with an average of 12 months. The tissue flap has good appearance and soft texture. X-ray film reexamination showed that all the osteotomy healed, and no obvious bone resorption was observed during follow-up. The common circumflex iliac artery, deep circumflex iliac artery, and superficial circumflex iliac artery were anatomically constant, and it was safe and reliable to use iliac crest chimeric tissue flap in repairing the soft tissue and bone defects of limbs.

Comparison of limb outcomes between bypass surgery and endovascular therapy in dialysis-dependent and -independent patients with chronic limb-threatening ischemia

ObjectiveTo examine limb salvage (LS) and wound healing in dialysis-dependent and -independent patients with chronic limb-threatening ischemia (CLTI) after infrainguinal bypass surgery or endovascular therapy (EVT). MethodsWe retrospectively analyzed the multi-center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) stage 2 to 4 between 2015 and 2020. The primary endpoint was LS. The secondary endpoint included wound healing, amputation-free survival (AFS), periprocedural complications, and 2-year survival. Comparison of these outcomes were made after propensity score matching. ResultsWe analyzed 252 dialysis-dependent (318 limbs) and 305 dialysis-independent (354 limbs) patients. Propensity score matching extracted 202 pairs with no significant differences in characteristics. The LS rate in bypass surgery was better than that in EVT in dialysis-dependent patients (P < .001). There was no significant difference in the LS rates between bypass surgery and EVT in dialysis-independent patients (P = .168). The wound healing rate of bypass surgery was better than that of EVT both dialysis-dependent and -independent patients with CLTI. The AFS rate of bypass surgery was better than that of EVT in dialysis-dependent patients (P < .001). There was no significant difference in the AFS rates between bypass surgery and EVT in dialysis-independent patients (P = .099). There was no significant difference in the occurrence of Clavien-Dindo ≥ IV and V between bypass surgery and EVT in dialysis-dependent and -independent patients. Age ≥75 years, serum albumin levels <3.5 g/dL, and non-ambulatory status were risk factors for 2-year mortality in dialysis-dependent patients. The 2-year survival rates in dialysis-dependent patients with risk factors of 0, 1, 2, and 3 were 82.5%, 67.1%, 49.5%, and 10.2%, respectively (P < .001). ConclusionsFor LS and wound healing, bypass surgery was preferred for revascularization in dialysis-dependent patients with WIfI stage 2 to 4. Although dialysis dependency was one of the risk factors for 2-year mortality, dialysis-dependent patients, who have 0 to 1 risk factors, may benefit from bypass surgery, as 2-year survival of >50% is expected.

Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics.

To investigate the healing rates observed in patients who presented to wound and lymphoedema specialist clinics, located in the south eastern region of England, with venous/lymphovenous ulceration of the lower limb during the COVID-19 pandemic in 2020-2022 (30 months in all). A retrospective analysis of patient outcomes. 1041 patients were referred to the service, with a healing rate of 88.5% over 78 days. When comparing 2013-2019 healing rates/time to healing vs 2020-2022 there was a decrease of 1.5% in the rate of healing and a mean reduction in time to healing of 40 days. Despite the pandemic the service was able to maintain previous levels of outcomes and observed a decrease in the mean time to healing.

Reconstruction of large-area wounds in limbs using two flow-through anterolateral thigh perforator flaps

IntroductionLimb salvage in large wounds is difficult because the disrupted blood supply does not support a flap. This study evaluated the clinical efficacy of using two flow-through anterolateral thigh perforator flaps for reconstructing large-area limb wounds. MethodsThis retrospective study included 45 patients who underwent reconstruction of large limb wounds using two flow-through anterolateral thigh perforator flaps at Ruihua Hospital between January 2015 and December 2020. Wound areas ranged from 15 cm × 13 cm to 46 cm × 18 cm. Single flap areas ranged from 16 cm × 8 cm to 46 cm × 9 cm. Blood supply locations were identified using color Doppler ultrasound or digital subtraction angiography (DSA) images. Primary outcomes were flap survival and complications at recipient or donor sites during at least 6-months follow-up. ResultsThe overall flap survival rate was 97% (87/90). All donor sites healed by first intention. Three cases developed vascular crises, which were alleviated by reoperation. One case had flexor contracture in left toes, relieved by cutting flexor tendons; 13 cases had flap bloat, relieved by flap thinning at 6 months. All cases showed properly healed wounds and functional reconstruction. ConclusionsReconstruction of large-area limb wounds using two flow-through anterolateral thigh perforator flaps provides safe and satisfactory effects without donor-site morbidity, and with proper healing and restored function.

The effects of high quality team medicine on outcomes of chronic limb-threatening ischemia patients with infrapopliteal bypass.

A team approach for treatment of patients with CLTI is used worldwide. However, the quality of team medicine is a concern. The Global Vascular Guidelines provide recommendations for high quality team medicine, but there is limited knowledge of the significance of team quality in CLTI treatment. The objective of this study is to evaluate the effects of team quality on clinical outcomes after infrapopliteal bypass. A retrospective analysis was performed in 337 patients who underwent 414 infrapopliteal bypasses under a team medicine approach at a single center between 2009 and 2021. In 2017, team medicine was reorganized for improvement of quality. Comparisons were made between before (Group 1; 160 patients, 195 limbs) and after (Group 2; 177 patients, 219 limbs) reorganization. The primary endpoints were limb salvage and wound healing after infrapopliteal bypass. The patients included 227 males (67%) and had a median age of 76 [68-83]years. Diabetes mellitus was present in 67% and end-stage renal disease with hemodialysis in 37%. The follow-up rate was 96% in a mean follow-up period of 31±30months. The 3-year limb salvage rate was significantly lower in Group 1 (before reorganization) than in Group 2 (after reorganization) (84% vs 95%, p = .001). The wound healing rates in the whole cohort were 72% at 6months and 85% at 12months, with no significant differences between the groups. In multivariate analysis, the risk factors for major amputation were treatment before reorganization (HR 2.68; p = .017), hemodialysis (HR 2.27; p = .017), and non-ambulatory status (HR 2.63; p = .005). A reorganized team approach with the goal of higher quality was independently associated with reduced major amputation for patients with CLTI treated with infrapopliteal bypass. This result indicates the importance of a high quality team approach for success of this treatment.