Free flap for lower limb salvage in infectious purpura fulminans.

BACKGROUND: Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life. METHODS: This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically. RESULTS: The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204±108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30±9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6±9.4 and mental component score was 44.6±13.2 (minimum 0, maximum 100). CONCLUSIONS: Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.

Medical and surgical management of lower extremity war-related injuries. Experience of the French Military Health Service (FMHS).

Lower extremity war wounds are characterized by high-energy trauma occasioning loss of complex and pluritissular substances. The support pipeline put into place by the French defense health service (SSA) is designed to rapidly evacuate the injured person from the scene of injury to mainland France, following initial surgery in the framework of a sequential tactic known as "Damage Control Surgery". This strategy is aimed at stabilizing the traumatized individual and enabling his evacuation. Patients are subsequently treated in a restorative surgery unit in a Hôpital d'Instruction des Armées (HIA), a level 1 trauma center (HIA Percy, HIA Saint-Anne) Cooperation between the plastic and orthopedic surgery specialties is essential insofar as it allows for surgical optimization aimed at saving the limb while restoring function to the greatest possible extent. Notwithstanding painstaking application of this common strategy, septic pseudoarthrosis remains the principal and most feared complication, at times rendering impossible any therapeutic solution other than amputation. Whether prosthetic or non-prosthetic, the rehabilitation provided by doctor/physiotherapists is conducive to patients' social and professional reintegration. The nation's duty to assist its wounded veterans is carried out with determination by the French defense ministry. As concerns lower extremity war wounds, the authors detail the reconstruction doctrine based on the 6/7/8/9 rule, in accordance with which strategies for repair of soft tissue and reconstruction of the lost bone substance have been developed.

The interest of "ortho-plastic" collaboration in management of complex limb injury.

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

[Treatment of below the knee lesions: Broadening the limits of vascular surgery]. / Traitement de l'artérite jambière : les frontières de la chirurgie vasculaire sont repoussées.

One third of patients with critical limb ischemia (CLI) has below the knee lesions and requires a restoration of direct blood flow into the foot. However, many of these patients are ineligible for open surgery. The primary goals thus become pain relief and limb salvage over patency. The angiosome concept helps determine the target artery to treat in priority. The endovascular approach has decreased morbidity and mortality rates compared to distal bypass surgery; while subintimal retrograde, trans-collateral and loop techniques push the limits of open surgery by reopening the plantar arch, thereby improving run-off. Early restenosis phenomena after angioplasty have been improved by the use of - limus drug eluting balloons and balloon expandable stents in case of flow limiting dissection or recoil with increased limb salvage rates. Moreover, drug-eluting stents have been proposed, and allow a reduction in reintervention and in-stent restenosis rates in short lesions; however, results on amputation rates or survival are limited. Vessel preparation is a key to overcoming some current limitations, including atherectomy, which increases technical success rates and reduces restenosis rates, especially in calcified lesions, chronic total occlusions and restenosis. These advanced techniques in distal endovascular revascularization have revolutionized limb salvage and support the interest of an endovascular first approach in CLI treatment.