Cross-leg flaps: A nonmicrosurgical alternative treatment method in complex lower extremity trauma reconstruction.

OBJECTIVES: This study aimed to present our experiences with cross-leg flap surgery, which demonstrates successful outcomes in lower limb soft tissue defects without the necessity of microsurgical intervention. PATIENTS AND METHODS: The retrospective study included 26 patients (18 males, 8 females; mean age: 35.6±12.2 years; range, 18 to 65 years) between January 2015 and September 2019. A fasciocutaneous cross-leg flap was applied to the recipient extremity, and the extremities were immobilized by a tubular external fixator. Flap divisions were performed on the 21st postoperative day. At least two years of clinical outcomes were presented. RESULTS: Twenty-five flaps survived and recovered completely without any complication at the donor site, flaps, or the recipient area. In one diabetic patient, partial flap loss was encountered, which granulated with secondary healing. All patients demonstrated stable wound coverage, with none demanding additional soft tissue surgeries. All patients resumed normal ambulation and physical activity without any residual joint stiffness. CONCLUSION: Cross-leg flap method is an effective and respectable option for extremity salvage as a good alternative to free flaps for the management of traumatic complex lower limb defects. This method is simple, provides abundant blood supply to the wound, and does not require microsurgical experience or a good working recipient artery.

Evaluation of Prosthesis Satisfaction, Psychological Status, and Quality of Life in Lower-Extremity Amputee Patients: A Pilot Study.

BACKGROUND: There are various factors affecting the use of prostheses. This study was aimed to examine satisfaction, psychological state, quality of life, and the factors affecting these in individuals who use prostheses because of lower-extremity amputation. METHODS: Sixty-three patients were included in this study. Demographic data and features related amputation and prosthesis were recorded. Quality of life was evaluated with the Nottingham Health Profile (NHP), anxiety and depression levels were evaluated with the Hospital Anxiety Depression Scale (HADS), body image was evaluated by the Amputee Body Image Scale (ABIS), prosthesis satisfaction was evaluated with the Prosthesis Satisfaction Questionnaire (PSQ), and the relationship between them was examined. RESULTS: There was a positive correlation between all HADS scores, NHP-emotional reactions, NHP-sleep, NHP-social isolation, NHP-total, and ABIS (P < .05). A negative correlation was found between HADS-anxiety and PSQ results (r = -0.394, P = .003). A positive correlation was found between HADS-depression scores and NHP-pain, NHP-emotional reactions, NHP-social isolation, NHP-total, and ABIS (P < .05); and a negative correlation was found with PSQ questionnaire scores (r = -0.427, P = .001). There was a positive correlation between HADS-total scores and all parameters except NHP-energy level and ABIS (P < .05). A positive correlation was found between ABIS and all parameters except NHP-energy level (P < .05). A negative correlation was found between PSQ and NHP-social isolation, NHP-physical activity, and NHP-total scores (r = -0.312, P = 0.019; r = -0.312, P = .019; and r = -0.277, P = .039, respectively). The presence of residual extremity pain was found to be an effective factor on the psychological state (ß = 0.429, P = .001). The presence of residual limb pain and phantom pain were found to be effective factors on the prosthesis satisfaction (ß = -0.41, P = .001; and ß = -0.406, P = .001, respectively). The presence of residual extremity pain and anxiety level were found independent risk factors on the NHP (ß = -0.401, P = .006; and ß = -0.445, P = .006, respectively). CONCLUSIONS: Individuals using prostheses because of lower-extremity amputation should be examined in detail from various perspectives.

Nursing interventions to empower the family caregiver of person with lower limb amputation: scoping review.

OBJECTIVES: to map nursing interventions that empower the Family caregiver of the person with lower limb amputation for is role. METHODS: scoping review guided by Joanna Briggs Institute methodology conducted in different databases (including gray literature). RESULTS: six studies published between 2009 and 2021 were included. Interventions of counselling and support for patients and family; peer support interventions performed by a certified pair; involvement of caregivers or family members in support groups; and key interventions for patient and family caregiver psychological balance. Two studies discussed the importance of caregiver and amputee training and development of coping skills. Another study recommended Interventions of informative support for caregivers regarding care for the amputee and adaptation to home. CONCLUSIONS: results of this review allow the identification of recommendations (guidelines) for practice and recommendations/suggestions for interventions according with identified needs of family caregivers of patients with lower limb amputation.

[Value of serum levels in predicting lower extremity deep vein thrombosis after hip joint surgery in the elderly].

OBJECTIVE: To explore the value of serum D-dimer (D-D), fibrinogen (FIB), platelet (PLT), C-reactive protein (CRP) and tissue plasminogen activator inhibitor (PAI)-1 levels in predicting lower extremity deep vein thrombosis (DVT) after hip joint surgery in the elderly. METHODS: A retrospective analysis was performed on 165 elderly patients with hip joint surgery admitted from February 2020 to May 2022, including 89 males and 76 females, aged from 60 to 75 years old with an average of (66.43±5.48) years, and there were 102 cases of femoral neck fracture and 63 cases of femoral head necrosis. Serum levels of D-D, FIB, PLT, CRP and PAI-1 tests were performed in all patients within 24 hours after admission, and the patients were divided into DVT group and non-DVT group according to whether they developed DVT. RESULTS: The levels of D-D, FIB, PLT, CRP, and PAI-1 in the DVT group were higher than those in the non-DVT group (P<0.001). Spearman analysis showed that DVT was positively correlated with PLT, CRP, D-D, FIB, and PAI-1 levels (r=0.382, 0.213, 0.410, 0.310, 0.353, all P<0.001). The results of binary Logistic regression analysis showed that D-D and PLT were independent factors affecting the occurrence of DVT (OR=0.038, 0.960, P=0.032, 0.011). The area under curve (AUC) of D-D, FIB, PLT, CRP, PAI-1, and the five combined predictions for DVT were 0.843, 0.692, 0.871, 0.780, 0.819, and 0.960, respectively. The AUC of the five combined predictions was higher than that of the single prediction (P<0.05). CONCLUSION: D-D, FIB, PLT, CRP and PAI-1 are effective in predicting DVT after hip surgery in the elderly, and the combined prediction of the five factors has higher efficacy.

Is Upper Extremity or Lower Extremity Function More Important for Patient Satisfaction? An Analysis of 24-Month Outcomes from the QOD Cervical Spondylotic Myelopathy Cohort.

STUDY DESIGN: Retrospective analysis of a prospective, multicenter registry. OBJECTIVE: To assess whether upper or lower limb mJOA improvement more strongly associates with patient satisfaction after surgery for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: The modified Japanese Orthopaedic Association (mJOA) is commonly used to assess functional status in patients with CSM. Patients present with upper and/or lower extremity dysfunction, and it is unclear whether improvement in one and/or both symptoms drives postoperative patient satisfaction. METHODS: This study utilizes the prospective Quality Outcomes Database (QOD) CSM data set. Clinical outcomes included mJOA and North American Spine Society (NASS) satisfaction. The upper limb mJOA score was defined as upper motor plus sensory mJOA, and the lower limb mJOA as lower motor plus sensory mJOA. Ordered logistic regression was used to determine whether upper or lower limb mJOA was more closely associated with NASS satisfaction, adjusting for other covariates. RESULTS: Overall, 1141 patients were enrolled in the QOD CSM cohort. In all, 780 had both preoperative and 24-month mJOA scores, met inclusion criteria, and were included for analysis. The baseline mJOA was 12.1±2.7, and postoperatively, 85.6% would undergo surgery again (NASS 1 or 2, satisfied). Patients exhibited mean improvement in both upper (baseline:3.9±1.4 vs. 24 mo:5.0±1.1, P<0.001) and lower limb mJOA (baseline:3.9±1.4 vs. 24 mon:4.5±1.5, P<0.001); however, the 24-month change in the upper limb mJOA was greater (upper:1.1±1.6 vs. lower:0.6±1.6, P<0.001). Across 24-month NASS satisfaction, the baseline upper and lower limb mJOA scores were similar (pupper=0.28, plower=0.092). However, as satisfaction decreased, the 24-month change in upper and lower limb mJOA decreased as well (pupper<0.001, plower<0.001). Patients with NASS scores of 4 (lowest satisfaction) did not demonstrate significant differences from baseline in upper or lower limb mJOA (P>0.05). In ordered logistic regression, NASS satisfaction was independently associated with upper limb mJOA improvement (OR=0.81; 95% CI: 0.68-0.97; P=0.019) but not lower limb mJOA improvement (OR=0.84; 95% CI: 0.70-1.0; P=0.054). CONCLUSIONS: As the magnitude of upper and lower mJOA improvement decreased postoperatively, so too did patient satisfaction with surgical intervention. Upper limb mJOA improvement was a significant independent predictor of patient satisfaction, whereas lower limb mJOA improvement was not. These findings may aid preoperative counseling, stratified by patients' upper and lower extremity treatment expectations. LEVEL OF EVIDENCE: Level-III.

Comparison of efficacy of nadroparin and fondaparinux sodium for prevention of deep vein thromboembolism in lower extremities after total hip arthroplasty and total knee arthroplasty: a retrospective study of 592 patients.

OBJECTIVES: To compare the efficacy of nadroparin and fondaparinux sodium for prevention of deep vein thromboembolism (DVT) in lower extremities after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A total of 592 patients were enrolled in the study. Clinical data of patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA) in our hospital from December 2021 to September 2022 were retrospectively collected, which mainly included patients' general information, surgery-related information, and DVT-related information. The patients were categorized into the nadroparin group(n = 278) and the fondaparinux sodium group(n = 314) according to the types of anticoagulants used. Anticoagulant therapy began 12-24 h after operation and continued until discharge. DVT prevalence between two groups was compared. The Statistical Package for Social Sciences (SPSS) software version 25 (SPSS, Armonk, NY, USA) was used for statistical analysis. RESULTS: The prevalence of DVT in the nadroparin group and the fondaparinux sodium group was 8.3% (23/278) and 15.0% (47/314), respectively(p = 0.012). Statistical analysis showed that nadroparin group showed a lower prevalence of thrombosis than fondaparinux group (OR = 1.952, P = 0.012). Subgroup analyses showed that nadroparin group had a lower prevalence of DVT than fondaparinux group in some special patients groups such as female patients (OR = 2.258, P = 0.007), patients who are 65-79 years old (OR = 2.796, P = 0.004), patients with hypertension (OR = 2.237, P = 0.042), patients who underwent TKA (OR = 2.091, P = 0.011), and patients who underwent combined spinal-epidural anesthesia (OR = 2.490, P = 0.003) (P < 0.05). CONCLUSION: Nadroparin may have an advantage over fondaparinux sodium in preventing DVT in lower extremities after THA and TKA.

The Effect of Lower Limb Alignment on Tibiofemoral Joint Contact Biomechanics after Medial Meniscus Posterior Root Repair: A Finite-Element Analysis.

INTRODUCTION: The purpose of this study was to determine how variations in lower limb alignment affect tibiofemoral joint contact biomechanics in the setting of medial meniscus posterior root tear (MMPRT) and associated root repair. METHODS: A finite-element model of an intact knee joint was developed. Limb alignments ranging from 4° valgus to 8° varus were simulated under a 1,000 N compression load applied to the femoral head. For the intact, MMPRT, and root repair conditions, the peak contact pressure (PCP), total contact area, mean and maximum local contact pressure (LCP) elevation, and total area of LCP elevation of the medial tibiofemoral compartment were quantified. RESULTS: The PCP and total contact area of the medial compartment in the intact knee increased from 2.43 MPa and 361 mm 2 at 4° valgus to 9.09 MPa and 508 mm 2 at 8° of varus. Compared with the intact state, in the MMPRT condition, medial compartment PCP was greater and the total contact area smaller for all alignment conditions. Root repair roughly restored PCPs in the medial compartment; however, this ability was compromised in knees with increasing varus alignment. Specifically, elevations in PCP relative to the intact state increased with increasing varus, as did the total contact area with LCP elevation. After root repair, medial compartment PCP remained elevated above the intact state at all degrees tested, ranging from 0.05 MPa at 4° valgus to 0.27 MPa at 8° of varus, with overall PCP values increasing from 2.48 to 9.09 MPa. For varus alignment greater than 4°, root repair failed to reduce the total contact area with LCP elevation relative to the MMPRT state. DISCUSSION: Greater PCPs and areas of LCP elevation in varus knees may reduce the clinical effectiveness of root repair in delaying or preventing the development of tibiofemoral osteoarthritis.

Creating an autoencoder single summary metric to assess gait quality to compare surgical outcomes in children with cerebral palsy: The Shriners Gait Index (SGI).

Gait for individuals with movement disorders varies widely and the variability makes it difficult to assess outcomes of surgical and therapeutic interventions. Although specific joints can be assessed by fewer individual measures, gait depends on multiple parameters making an overall assessment metric difficult to determine. A holistic, summary measure can permit a standard comparison of progress throughout treatments and interventions, and permit more straightforward comparison across varied subjects. We propose a single summary metric (the Shriners Gait Index (SGI)) to represent the quality of gait using a deep learning autoencoder model, which helps to capture the nonlinear statistical relationships among a number of disparate gait metrics. We utilized gait data of 412 individuals under the age of 18 collected from the Motion Analysis Center (MAC) at the Shriners Children's - Chicago. The gait data includes a total of 114 features: temporo-spatial parameters (7), lower extremity kinematics (64), and lower extremity kinetics (43) which were min-max normalized. The developed SGI score captured more than 89% variance of all 144 features using subject-wise cross-validation. Such summary metrics holistically quantify an individual's gait which can then be used to assess the impact of therapeutic interventions. The machine learning approach utilized can be leveraged to create such metrics in a variety of contexts depending on the data available. We also utilized the SGI to compare overall changes to gait after surgery with the goal of improving mobility for individuals with gait disabilities such as Cerebral Palsy.

Quantifying Bone and Skin Movement in the Residual Limb-Socket Interface of Individuals With Transtibial Limb Loss Using Dynamic Stereo X-Ray: Protocol for a Lower Limb Loss Cadaver and Clinical Study.

BACKGROUND: Relative motion between the residual limb and socket in individuals with transtibial limb loss can lead to substantial consequences that limit mobility. Although assessments of the relative motion between the residual limb and socket have been performed, there remains a substantial gap in understanding the complex mechanics of the residual limb-socket interface during dynamic activities that limits the ability to improve socket design. However, dynamic stereo x-ray (DSX) is an advanced imaging technology that can quantify 3D bone movement and skin deformation inside a socket during dynamic activities. OBJECTIVE: This study aims to develop analytical tools using DSX to quantify the dynamic, in vivo kinematics between the residual limb and socket and the mechanism of residual tissue deformation. METHODS: A lower limb cadaver study will first be performed to optimize the placement of an array of radiopaque beads and markers on the socket, liner, and skin to simultaneously assess dynamic tibial movement and residual tissue and liner deformation. Five cadaver limbs will be used in an iterative process to develop an optimal marker setup. Stance phase gait will be simulated during each session to induce bone movement and skin and liner deformation. The number, shape, size, and placement of each marker will be evaluated after each session to refine the marker set. Once an optimal marker setup is identified, 21 participants with transtibial limb loss will be fitted with a socket capable of being suspended via both elevated vacuum and traditional suction. Participants will undergo a 4-week acclimation period and then be tested in the DSX system to track tibial, skin, and liner motion under both suspension techniques during 3 activities: treadmill walking at a self-selected speed, at a walking speed 10% faster, and during a step-down movement. The performance of the 2 suspension techniques will be evaluated by quantifying the 3D bone movement of the residual tibia with respect to the socket and quantifying liner and skin deformation at the socket-residuum interface. RESULTS: This study was funded in October 2021. Cadaver testing began in January 2023. Enrollment began in February 2024. Data collection is expected to conclude in December 2025. The initial dissemination of results is expected in November 2026. CONCLUSIONS: The successful completion of this study will help develop analytical methods for the accurate assessment of residual limb-socket motion. The results will significantly advance the understanding of the complex biomechanical interactions between the residual limb and the socket, which can aid in evidence-based clinical practice and socket prescription guidelines. This critical foundational information can aid in the development of future socket technology that has the potential to reduce secondary comorbidities that result from complications of poor prosthesis load transmission. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57329.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction.

BACKGROUND: Skin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects. METHODS: Patients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain. RESULTS: Ten patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05). CONCLUSION: Mechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

The effectiveness of targeted muscle reinnervation in reducing pain and improving quality of life for patients following lower limb amputation.

BACKGROUND: Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation. METHODS: A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures. RESULTS: In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores. CONCLUSION: The systematic review underscores TMR's potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees.

Preliminary comparative study of lower extremity pressure measurements under the conditions using former models and new lithotomy stirrups in rectal cancer surgery.

BACKGROUND: This study aimed to investigate the effect of the use of new lithotomy stirrups-2 on the pressure dispersal on lower limbs, which may lead to the prevention of well-leg compartment syndrome (WLCS) and deep venous thrombosis (DVT), which are the most commonly associated adverse events with laparoscopic and robot-assisted rectal surgery. METHODS: A total of 30 healthy participants were included in this study. The pressure (mmHg) applied on various lower limb muscles when using conventional lithotomy stirrups-1 and new type stirrups-2 was recorded in various lithotomy positions; 1) neutral position, 2) Trendelenburg position (15°) with a 0° right inferior tilt, and 3) Trendelenburg position (15°) with a 10° right inferior tilt. Using a special sensor pad named Palm Q®, and the average values were compared between two types of stirrups. RESULTS: The use of new lithotomy stirrups-2 significantly reduced the pressure applied on the lower limb muscles in various lithotomy positions compared with the use of lithotomy stirrups-1. The most pressured lower limb muscle when using both lithotomy stirrups was the central soleus muscle, which is the most common site for the development of WLCS and DVT. In addition, when using the conventional lithotomy stirrups-1, the pressure was predominantly applied to the proximal soleus muscle; however, when using lithotomy stirrups-2, the pressure was shifted to the more distal soleus muscle. CONCLUSION: These results suggest that the new lithotomy stirrups-2 is useful in reducing the pressure load on leg muscles, especially on the proximal to central soleus, and may reduce the incidence of WLCS and DVT after rectal surgery performed in the lithotomy position. Further clinical studies are needed to determine whether the use of lithotomy stirrups-2 prevents these complications in various clinical settings.

Distribution of pathogens and risk factors for post-replantation wound infection in patients with traumatic major limb mutilation.

PURPOSE: Even though replantation of limb mutilation is increasing, postoperative wound infection can result in increasing the financial and psychological burden of patients. Here, we sought to explore the distribution of pathogens and identify risk factors for postoperative wound infection to help early identification and managements of high-risk patients. METHODS: Adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group between November 09, 2014, and September 6, 2022 were included in this retrospective study. Demographic, and clinical characteristics, treatments, and outcomes were collected. Data were used to analyze risk factors for postoperative wound infection. RESULTS: Among the 249 patients, 185 (74.3%) were males, the median age was 47.0 years old. Postoperative wound infection in 74 (29.7%) patients, of whom 51 (20.5%) had infection with multi-drug resistant bacteria. Ischemia time (OR 1.31, 95% CI 1.13-1.53, P = 0.001), wound contamination (OR 6.01, 95% CI 2.38-15.19, P <0.001), and stress hyperglycemia (OR 23.37, 95% CI 2.30-236.93, P = 0.008) were independent risk factors, while the albumin level after surgery (OR 0.94, 95% CI 0.89-0.99, P = 0.031) was significant associated with the decrease of postoperative wound infection. Ischemia time (OR 1.21, 95% CI 1.05-1.40, P = 0.010), wound contamination (OR 8.63, 95% CI 2.91-25.57, P <0.001), and MESS (OR 1.32, 95% CI 1.02-1.71, P = 0.037 were independent risk factors for multi-drug resistant bacteria infection. CONCLUSIONS: Post-replantation wound infection was common in patients with severe traumatic major limb mutilation, and most were multi-drug resistant bacteria. Ischemia time and wound contamination were associated with the increase of postoperative wound infection, including caused by multi-drug resistant. Positive correction of hypoproteinemia and control of stress hyperglycemia may be beneficial.

The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection.

We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study.

BACKGROUND: The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction. METHODS: We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis. RESULTS: The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases. CONCLUSIONS: Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction. DATA ACCESS STATEMENT: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Predictive Ability of LRINEC Score for Lower Extremity Amputation in Moderate to Severe Diabetic Foot Infection.

OBJECTIVE: To assess the predictive ability of the laboratory risk indicator for necrotising fasciitis (LRINEC) score for lower extremity amputation in patients with moderate to severe diabetic foot infection (DFI). STUDY DESIGN: Observational study. Place and Duration of the Study: Department of General Surgery, Combined Military Hospital, Rawalpindi, Pakistan, from June to September 2023. METHODOLOGY: Patients admitted to the surgical ward with moderate to severe DFI were included by convenience sampling. Patients with severe sepsis, unstable haemodynamics, pressure injuries, and terminal illnesses were excluded. Demographic and clinical data of patients were noted down. LRINEC score was calculated on the day of admission. Final outcome (amputation or otherwise) was recorded on the 30th day the since the day of admission. RESULTS: Two hundred patients with moderate to severe DFI were included. The median age of patients was 56 years (IQR 49-66 years). The median duration of diabetes was 11 years (IQR 4 - 18.75 years). The median LRINEC score at admission was 6 (IQR 3-9). The majority of the patients (65.5%) had some other medical comorbid besides diabetes. Patients who had amputation due to DFI at 30 days post-admission had higher LRINEC scores on admission as compared to those patients who did not have amputation (Median 8 vs. 2, p <0.001). The cut-off point of LRINEC score ≥6.5 at admission had sensitivity of 74% and specificity of 94% in predicting amputation. CONCLUSION: The LRINEC score may be used as an objective scoring system to predict the risk of amputation in patients with moderate to severe DFI in indoor clinical settings. KEY WORDS: Diabetic foot, LRINEC score, Limb loss, Necrotising fasciitis.

Application of double plate fixation combined with Masquelet technique for large segmental bone defects of distal tibia: a retrospective study and literature review.

BACKGROUND: There is no effective consensus on the choice of internal fixation method for the Masquelet technique in the treatment of large segmental bone defects of the distal tibia. Thus, the study aimed to investigate the outcomes of the Masquelet technique combined with double plate fixation in the treatment of large segmental bone defects. METHODS: This was a retrospective study involving 21 patients with large segmental bone defects of the distal tibia who were treated between June 2017 and June 2020. The length of bone defect ranged from 6.0 cm to 11 cm (mean, 8.19 cm). In the first stage of treatment, following complete debridement, a cement spacer was placed to induce membrane formation. In the second stage, double plate fixation and autologous cancellous bone grafting were employed for bone reconstruction. Each patient's full weight-bearing time, bone healing time, and Iowa ankle score were recorded, and the occurrence of any complications was noted. RESULTS: All patients were followed up for 16 to 26 months (mean, 19.48 months). The group mean full weight-bearing time and bone healing time after bone grafting were 2.41 (± 0.37) months and 6.29 (± 0.66) months, respectively. During the treatment, one patient had a wound infection on the medial side of the leg, so the medial plate was removed. The wound completely healed after debridement without any recurrence. After extraction of iliac bone for grafting, one patient had a severe iliac bone defect, which was managed by filling the gap with a cement spacer. Most patients reported mild pain in the left bone extraction area after surgery. The postoperative Iowa ankle score range was 84-94 (P < 0.05). In this cohort, 15 cases were rated as "excellent", and 6 cases as "good" on the Iowa ankle scoring system. CONCLUSION: The Masquelet technique combined with double plate fixation is a safe and effective method for the treatment of large segmental bone defects of the distal tibia.

Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?

Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.

Fatigue, fear of being mobilized and residual limb pain limit independent basic mobility and physiotherapy for patients early after major dysvascular lower extremity amputation: A prospective cohort study.

AIM: Early mobilization of patients with a major lower extremity amputation (LEA) is often a challenge because of lack of compliance. Therefore, we investigated factors limiting independent mobility and physiotherapy on the first day with physiotherapy (PTDay1) and the following 2 days after LEA. METHODS: A total of 60 consecutive patients, mean age 73.7 years (SD 12.1 years), undergoing LEA were included over a period of 7 months. The Basic Amputee Mobility Score was used to assess basic mobility. Predefined limitations for not achieving independent mobility or not completing physiotherapy were residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea/vomiting, acute cognitive dysfunction or "other" factors reported on PTDay1 and the following 2 days after LEA. RESULTS: Fatigue and fear of being mobilized were the most frequent limitations for not achieving independent mobility on PTDay1 and the following 2 days after LEA. Patients (n = 55) who were not independent in the Basic Amputee Mobility Score activity transferring from bed to chair on PTDay1 were limited by fatigue (44%) and fear of being mobilized (33%). A total of 21 patients did not complete planned physiotherapy on PTDay1, and were limited by fatigue (38%), residual limb pain (24%) and "other" factors (24%). CONCLUSION: Fatigue and fear of being mobilized were the most frequent factors that limited independent mobility early after LEA. Fatigue, residual limb pain and "other" factors limited completion of physiotherapy. Geriatr Gerontol Int 2024; 24: 470-476.