The role of split-thickness skin grafting in the treatment of vasculitic and pyoderma gangrenosum ulcers in a multidisciplinary wound centre.

Vasculitic and pyoderma gangrenosum ulcers are traditionally treated with immunosuppressants, and the role of surgery in the treatment of these atypical ulcers remains unclear. This study aimed to investigate the need for surgical intervention as well as the outcome and safety of skin grafting in the treatment of 46 patients with vasculitic ulcers and 34 with pyoderma gangrenosum ulcers using data recorded in the validated Wound Registry. Of the 80 patients with atypical ulcers, 14% (n = 11) were treated surgically; these patients were older (p = 0.039), had lower mobility status (p = 0.002), and more often pulmonary diseases, rheumatoid arthritis, and previous arterial procedures (p = 0.007; p = 0.031; p = 0.031, respectively) than those treated conservatively. Of 181 ulcers, 15% (n = 27) were surgically treated, 78% once and 22% multiple times. During follow-up, 92.3% of both surgically and conservatively treated ulcers with available data healed. Of the surgically treated ulcers, median healing time after first surgical procedure was 96 days, and post-surgical complications were considered mild or unrelated to surgery. Our results suggest that if surgery is indicated, skin grafting is a safe and efficient treatment method provided that multidisciplinary approach is applied.

Multidisciplinary management of diabetic foot infection associated with improved 8-year overall survival.

AIMS: Diabetic foot syndrome is a global challenge best managed through multidisciplinary collaboration. This study aimed to investigate the effect of a systematic multidisciplinary team (MDT) on the overall survival and major amputation-free survival of hospitalized patients with diabetic foot infection (DFI). METHODS: This retrospective cohort study was conducted at Tampere University Hospital. Cohorts of hospitalized patients with DFI before and after the initiation of multidisciplinary wound ward were compared after an 8-year follow-up. RESULTS: Kaplan-Meier analysis revealed significantly higher overall survival in the post-MDT cohort (37.8 % vs 22.6 %, p < 0.05) in 8-year follow-up. Similarly, major amputation-free survival was superior in this cohort (31.8 % vs 16.9 %, p < 0.05). Additionally, early major amputation was associated with inferior overall survival (35.1 % vs 12.0 %, p < 0.05). In a multivariable Cox-regression analysis cohort (hazard ratio [HR] 1.38, 95 % confidence interval [CI95%] 1.01-1.87), early amputation (HR 1.64, CI95% 1.14-2.34) and diagnosed peripheral artery disease (HR 2.23, CI95% 1.61-3.09), congestive heart failure (HR 2.13, CI95% 1.47-3.08), or moderate kidney disease (HR 1.95, CI95% 1.34-2.84) were identified as significant risk factors affecting overall survival. CONCLUSIONS: After systematic MDT approach we found improved long-term overall and major amputation-free survival. Multidisciplinary approach is therefore highly recommended for managing patients hospitalized for DFI.

Myth-busting the zone of injury concept: a prospective study on the vascular response to high-energy lower extremity trauma.

BACKGROUND: Although the zone of injury concept is widely accepted, no histologic studies of vessel wall changes causing the phenomena are reported. This prospective study investigated the vascular response to high-energy lower extremity trauma to evaluate the validity of the zone of injury concept. METHODS: The histologic appearance of arterial and venous walls in the zone of injury was studied in 19 patients (median age 46 [interquartile range 29.5-62.5] years) who underwent osteosynthesis and free-flap reconstruction due to high-energy lower extremity open fracture. Vascular samples were harvested from the injured extremity and control samples were harvested from the free-flap donor site. Histologic and morphometric characteristics of the vessels were analyzed microscopically and using digital pathology QuPath software. RESULTS: Vascular samples were harvested on post-injury days 1-11. Intimal thickness was >3 times greater in arteries harvested from the zone of injury than in control samples (P<0.01) and the intima/media ratio was 2-fold that in control samples (P=0.01). Arterial intimal fibrosis was more evident in vessels harvested from the zone of injury (P<0.01), but medial fibrosis and medial thickness did not differ significantly between groups. Venous intimal thickening (P<0.01) and the intima/media ratio (P=0.02) were superior in samples from the zone of injury. Fibrosis-related changes did not differ between groups (P=0.45). CONCLUSIONS: These findings support the validity of the zone of injury concept by providing a novel histologic basis for this phenomenon. Intimal thickening and arterial intimal fibrosis are prominent histologic features of vessels affected by major lower extremity trauma.

Implementing an orthoplastic treatment protocol for open tibia fractures reduces complication rates in tertiary trauma unit.

INTRODUCTION: Open tibia fracture (OTF) causes a considerable increase in morbidity and risk for complications compared to closed fractures. The most significant OTF complication leading to morbidity is commonly considered to be fracture-related infection (FRI). In September 2016, Tampere University Hospital (TAUH) introduced a treatment protocol for OTFs based on the BOAST 4 guideline. The aim of this study is to investigate the outcomes before and after implementation of the OTF treatment protocol. MATERIALS AND METHODS: A retrospective cohort study was conducted using handpicked data from the patient record databases of TAUH from May 1, 2007, to May 10, 2021. For patients with OTF, we collected descriptive information, known risk factors for FRI and nonunion, bony fixation method, possible soft tissue reconstruction method, information about the timing of internal fixation and soft tissue coverage, and timing of primary operation. As outcome measures, we collected information on FRI, reoperation due to non-union, flap failure, and secondary amputation. We then compared the incidence of complications before and after the implementation of the OTF treatment protocol at TAUH. RESULTS: After predefined exclusions, a total of 203 patients with OTF were included. Of these, 141 were treated before and 62 after the implementation of the OTF treatment protocol. The FRI rate in the pre-protocol group was significantly higher compared to the protocol group (20.6% vs 1.6%, p = 0.0015). The incidence of reoperation due to nonunion was also significantly higher in the pre-protocol group (27.7% vs 9.7%, p = 0.0054). According to multivariable analysis, definitive fixation and soft tissue coverage performed in separate operations was an independent risk factor for both FRI and reoperation due to nonunion. CONCLUSIONS: After implementation, the BOAST 4 based OTF treatment protocol reduced the rate of FRI and reoperation due to nonunion in patients with OTF treated at TAUH during the study period. We, therefore, recommend the implementation of such a treatment protocol in all major trauma centers treating patients with OTF. Furthermore, we also recommend the immediate referral of patients with complex OTF from hospitals lacking the preconditions to provide BOAST 4 based treatment to specialized centers.

Phase 1 Lymfactin® Study: 24-month Efficacy and Safety Results of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema.

BACKGROUND: Lymphedema is a common problem after breast cancer treatment. Lymfactin® is a prolymphangiogenic growth factor vector inducing the expression of human vascular endothelial growth factor C (VEGF-C). It promotes growth and repair of lymphatic vessels. METHODS: Lymfactin® was combined with microvascular lymph node transfer surgery (VLNT) to study the safety and efficacy of the treatment in breast cancer-related upper limb lymphedema (BCRL) patients. This is a continuation study with a 3 year efficacy and 5 year safety follow-up. RESULTS: Fifteen patients were recruited in the study between June 2016 and February 2018. Three patients received a lower dose (1 × 1010 viral particles (vp)), and 12 patients received a higher dose (1 × 1011 vp) of Lymfactin®, respectively. In the higher dose group, the reduction of excess arm volume was on average 46% after the 12 month follow-up, and the transport index was improved in 7/12 patients. At baseline, removal of the compression garment for 7 days resulted in significant arm swelling (105.7±161.0 ml, p=0.0253). However, at 12 months, there was less and not significant swelling after removal of the garment (84.4±143.0 ml, p=0.0682). Lymphedema Quality of Life Inventory (LQOLI or LyQLI) questionnaire showed significant and sustained improvement of quality of life. CONCLUSIONS: During 24 months' of follow-up, the results indicate that Lymfactin® is well tolerated. The most promising findings were a 46% reduction in excess arm volume and a nonsignificant volume increase after garment removal at 12 months, suggesting that there is potential for the reduction of lymphedema.

Surgical and patient-reported outcomes after total knee arthroplasty requiring soft tissue flap reconstruction - A 12-year experience from high-volume arthroplasty hospital.

BACKGROUND: This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital. METHODS: Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups. RESULTS: Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n = 27; EC group n = 31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p = 0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p = 0.36). Oxford Knee Score was 34.5 vs. 25.5 (p = 0.21), and range of motion was 100° vs. 93° (p = 0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p = 0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p = 0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p = 0.03). CONCLUSIONS: Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.

Measuring functional outcome in upper extremity soft-tissue sarcoma: Validation of the Toronto extremity salvage score and the QuickDASH patient-reported outcome instruments.

Interest in functional outcome (FO) and health-related quality of life (HRQL) in extremity soft-tissue sarcoma (STS) patients has increased. The aim of this study was to validate two FO questionnaires for upper extremity STS patients: the Toronto Extremity Salvage Score (TESS) and short version of the Disability of Arm, Shoulder and Hand (QuickDASH), based on Finnish population data. A multi-center study was conducted at two academic sarcoma centers. Surgically treated upper extremity STS patients were invited to participate. Patients completed the TESS and the QuickDASH with HRQL questionnaires the 15D and the QLQ-C30. The scores were analyzed and compared. Fifty-five patients with a mean follow-up period of 4.7 years were included. Mean age was 63 years (standard deviation [SD] 14.6). The mean score for TESS was 88.5 (SD 15.1) and for QuickDASH 17.8 (SD 19.6). The QuickDASH had a statistically significantly better score coverage. A ceiling effect was noted, 27% and 20% for TESS and QuickDASH, respectively. The TESS and QuickDASH scores were strongly correlated (r= -0.89). The TESS score strongly correlated with the QLQ-C30 (r = 0.79) and the 15D score (r = 0.70). The QuickDASH score correlated strongly with the QLQ-C30 score (r=-0.71) and moderately with the 15D score (r= -0.56). The TESS score had a statistically significantly stronger correlation with the 15D score than QuickDASH (p<0.005). Both the TESS and the QuickDASH provide reliable scores for assessing FO in upper extremity STS patients. The QuickDASH has a better coverage, whereas TESS showed a stronger correlation to HRQL scores.

The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study.

OBJECTIVE: To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS: Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS: A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION: The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.

Major Amputation Profoundly Increases Mortality in Patients With Diabetic Foot Infection.

Introduction: An acute diabetic foot infection (DFI) is a serious condition and a leading cause of hospitalization and major amputation in patients with diabetes. Aim of this study was to evaluate the long term survival and risk factors for death and amputation after the DFI requiring hospital treatment. Materials and Methods: A retrospective study included all adult patients hospitalized for DFI treatments during 2010-2014. Overall survival (OS) and amputation free survival (AFS) (without major amputation) was calculated. We performed a Cox regression analysis of several clinical parameters to evaluate the effects of clinical parameters on overall and amputation-free survival. Results: Total of 324 patients with mean age of 66.8 (SD 12.8) years were included. The one- and five-year OS after DFI 81.2% (95%CI 77.5-84.9%) and 49.7% (95%CI 44.8-54.6%), respectively. Major amputation, wound ischemia, older age, and a low glomerular filtration rate reduced the OS after DFI. After a major amputation, the one- and five-year OS was 41.7% (95%CI 13.9-69.5) and 8.3% (95%CI 0.0-24.0%), respectively. Wound ischemia, older age, and elevated C-reactive protein reduced AFS. In contrast, hypertensive medication use was identified as a protective factor. Conclusion: Mortality after a DFI remains high and is significantly increased after a major amputation. Findings highlight the importance of early wound and ischemia management for DFI prevention.

Soft tissue reconstruction after pelvic amputation: The efficacy and reliability of free fillet flap reconstruction.

BACKGROUND: The majority of hindquarter amputation defects can be reconstructed with local anterior or posterior thigh flaps. Less than 5% of soft tissue defects require free flap reconstruction after tumour resection. Lower extremity fillet flap is described for reconstructing such defects, but the majority of publications are case reports or short single institutional series. There is a lack of data regarding the oncological outcomes of this highly selected patient group. METHODS: Three tertiary sarcoma units treated twelve patients with hindquarter amputation or hip disarticulation for oncological indications with a free flap reconstruction of the soft tissue defect. RESULTS: The median age of patients was 60 (range 12-76) years. Bone resection was carried out through the SI-joint in six patients and through the sacrum in five patients, with one patient undergoing hip disarticulation. Nine patients had R0 resection margin and three had R1 resection. The median surgical time and flap ischaemia time was 420 (249-650) and 89 (64-210) min, respectively. Median hospital and ICU stay was 18 (10-42) and 3 (1-8) days, respectively. Median blood loss was 2400 (950-10000) ml. There were three returns to theatre due to vascular compromise, with one total flap loss due to arterial thrombosis. Overall survival was 58% (95%CI 28-91%) both at 1-year and at 3-years. DISCUSSION: Carefully selected patients requiring hindquarter amputation with extensive soft tissue defect necessitating free flap reconstruction can be reconstructed with a lower extremity free fillet flap with low rate of local wound complications. Survival of these patients is similar to that in patients requiring less extensive resection.

Pathogens Causing Diabetic Foot Infection and the Reliability of the Superficial Culture.

Background: Diabetic foot infection (DFI) is a severe complication of diabetes and a leading cause of hospitalization in the population with diabetes. Empirical intravenous antibiotic agents are initiated according to guidelines based on previously published data on typical pathogens. Therefore, regular evaluation of the pathogens in DFI and their resistance is important to validate current therapies. We evaluated the most current data on bacterial cultures in patients treated at our hospital for DFI and the resistance to the most common antibiotic agents, as well as the reliability of superficial cultures compared with deep tissue cultures. Patients and Methods: This retrospective study was performed at the University Hospital of Tampere and comprised 325 patients with 405 hospitalizations for DFI during the years 2010-2014. Results: The most frequent pathogens in superficial and deep samples were Staphylococcus aureus (36.9%), gram-negative bacilli (24.6%), and ß-hemolytic streptococci (BHS, 19.5%). Septicemia was caused most often by Staphylococcus aureus and BHS (34.6% each). The specificity of superficial culture was 91.8%-92.8% and sensitivity 66.7%-87.5%. Conclusions: This study indicates the need to cover Staphylococcus aureus, BHS, and gram-negative bacilli when treating DFI. The reliability of superficial culture was surprisingly good.

Phase 1 LymfactinⓇ Study: Short-term Safety of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema.

OBJECTIVE: To study the safety and tolerability of LymfactinⓇ treatment combined with microvascular lymph node transfer surgery in patients with upper limb lymphedema. BACKGROUND: Upper limb lymphedema is a common clinical challenge after breast cancer surgery and/or radiotherapy. LymfactinⓇ is an adenovirus type 5-based gene therapy involving expression of human vascular endothelial growth factor C (VEGF-C) in the damaged tissue. It aims to correct deficient lymphatic flow by promoting the growth and repair of lymphatic vessels. METHODS: In Phase I, LymfactinⓇ was combined with microvascular lymph node transfer surgery to study the safety and tolerability of LymfactinⓇ and the biodistribution of the viral vector in patients with upper limb lymphedema. RESULTS: Fifteen patients with breast cancer-associated secondary lymphedema of the upper arm were recruited between December 2016 and February 2018. Three patients received a lower dose (1 × 1010) and 12 a higher dose (1 × 1011) of viral particles, respectively. No dose-limiting toxicities were observed, and the study was completed with the pre-determined maximum dose. Commonly reported adverse events during the 12-month follow-up were common cold, fever, gastroenteritis, pain in the operation area, headache, muscle ache and elevated liver enzymes. Serious adverse events consisted of two erysipelas infections in the lymphedema arm (requiring hospitalization) and one hematoma of the flap donor site. CONCLUSIONS: After 12 months' follow-up, results indicate that LymfactinⓇ is well tolerated. The study continues with a 36-months efficacy and 5 years safety follow-up of the patients. The oncological safety aspects of LymfactinⓇ will require a longer follow-up period.

Surgical and oncological outcomes after hindquarter amputation for pelvic sarcoma.

AIMS: Survival rates and local control after resection of a sarcoma of the pelvis compare poorly to those of the limbs and have a high incidence of complications. The outcome for patients who need a hindquarter amputation (HQA) to treat a pelvic sarcoma is poor. Our aim was to evaluate the patient, tumour, and reconstructive factors that affect the survival of the patients who undergo HQA for primary or recurrent pelvic sarcoma. METHODS: We carried out a retrospective review of all sarcoma patients who had undergone a HQA in a supraregional sarcoma unit between 1996 and 2018. Outcomes included oncological, surgical, and survival characteristics. RESULTS: A total of 136 patients, with a mean age of 51 (12 to 83) underwent HQA, 91 for a bone sarcoma and 45 for a soft tissue sarcoma. The overall survival (OS) after primary HQA for a bone sarcoma was 90.7 months (95% confidence interval (CI) 64.1 to 117.2). In patients undergoing a secondary salvage HQA it was 90.3 months (95% CI 58.1 to 122.5) (p = 0.727). For those treated for a soft tissue sarcoma (STS), the mean OS was 59.3 months (95% CI 31.1 to 88.6) for patients with a primary HQA, and 12.5 months (95% CI 9.4 to 15.5) for those undergoing a secondary salvage HQA (p = 0.038). On multivariate analysis, high histological grade (hazard ratio (HR) 2.033, 95% CI 1.127 to 3.676; p = 0.018) and a diagnosis of STS (HR 1.653, 95% CI 1.027 to 2.660; p = 0.039) were associated with a poor prognosis. The 30-day mortality for patients with curative intent was 0.8% (1/128). For those in whom surgery was carried out with palliative intent it was 33.3% (2/6) (p = 0.001). In total, 53.7% (n = 73) of patients had at least one complication with 23.5% (n = 32) requiring at least one further operation. Direct closure was inferior to flap reconstruction in terms of complete primary wound healing (60.0% (3/5) vs 82.0% (82/100); p = 0.023). CONCLUSION: In carefully selected patients HQA is associated with satisfactory overall survival, with a low risk of perioperative mortality, but considerable morbidity. However, caution must be exercised when considering the procedure for palliation due to the high incidence of early postoperative mortality. Cite this article: Bone Joint J 2020;102-B(6):788-794.

Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results.

INTRODUCTION: Pelvic exenteration (PE) is the only curative treatment for certain locally advanced intrapelvic malignancies. PE has high morbidity, and optimal reconstruction of the pelvic floor remains undetermined. MATERIALS AND METHODS: A retrospective chart review was performed at a tertiary university center to assess the surgical and oncological outcomes of 39 PE procedures over a 12-year period. The majority of patients (n = 25) underwent transverse musculocutaneous gracilis (TMG) flap reconstruction for pelvic floor reconstruction. RESULTS: The 1- and 5-year overall survival (OS) was 72% (95%CI 58%-86%) and 48% (95%CI 31%-65%), respectively. In multivariate analysis, lymph node metastasis (HR 3.070, p = 0.024) and positive surgical margins (HR 3.928, p = 0.009) were risk factors for OS. In this population, 71.8% of the patients had at least one complication. The complication rate was 65.4% and 84.6% for patients with versus without flap reconstruction, respectively (p = 0.191). The length of stay was longer for patients with a major complication 16,0 ±â€¯5,9 days vs. 29,4 ±â€¯14,8 days, p = 0,001, but complications did not affect OS. CONCLUSION: For selected patients, PE is a curative option for locally advanced, residual, or recurrent intrapelvic tumors. Pelvic floor and vulvovaginal defects can reliably be reconstructed using TMG flaps. TMG flaps are favored in our institution over abdominal-based flaps because the donor site morbidity is reasonable and TMG does not interfere with enterostomy.

Identification of breast tumors from diathermy smoke by differential ion mobility spectrometry.

INTRODUCTION: Breast cancer is the most frequent cancer in women worldwide. The primary treatment is breast-conserving surgery or mastectomy with an adequate clearance margin. Diathermy blade is used extensively in breast-conserving surgery. Surgical smoke produced as a side product has cancer-specific molecular features. Differential mobility spectrometry (DMS) is a rapid and affordable technology for analysis of complex gas mixtures. In our study we examined surgical smoke from malignant and benign breast tissue created with a diathermy blade using DMS. MATERIAL AND METHODS: Punch biopsies of 4 mm diameter from breast cancer surgical specimens were taken during gross dissection of fresh surgical specimen and placed in a well plate. The measurement system is a custom-built device called automatic tissue analysis system (ATAS) based on a DMS sensor. Each specimen was incised with a diathermy blade and the surgical smoke was analyzed. RESULTS: We examined 106 carcinoma samples from 21 malignant breast tumors. Benign samples (n = 198) included macroscopically normal mammary gland (n = 82), adipose tissue (n = 88) and vascular tissue (n = 28). The classification accuracy when comparing malignant samples to all benign samples was 87%. The sensitivity was 80% and the specificity was 90%. The classification accuracy of carcinomas to ductal and lobular was 94%, 47%, respectively. CONCLUSIONS: Benign and malignant breast tissue can be identified with ATAS. These results lay foundation for intraoperative margin assessment with DMS from surgical smoke.

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy.

BACKGROUND: Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL). METHODS: A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit. RESULTS: The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions. DISCUSSION: Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri­operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

Electronic Nose in the Detection of Wound Infection Bacteria from Bacterial Cultures: A Proof-of-Principle Study.

BACKGROUND: Soft tissue infections, including postoperative wound infections, result in a significant burden for modern society. Rapid diagnosis of wound infections is based on bacterial stains, cultures, and polymerase chain reaction assays, and the results are available earliest after several hours, but more often not until days after. Therefore, antibiotic treatment is often administered empirically without a specific diagnosis. METHODS: We employed our electronic nose (eNose) system for this proof-of-concept study, aiming to differentiate the most relevant bacteria causing wound infections utilizing a set of clinical bacterial cultures on identical blood culture dishes, and established bacterial lines from the gaseous headspace. RESULTS: Our eNose system was capable of differentiating both methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA), Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa, and Clostridium perfringens with an accuracy of 78% within minutes without prior sample preparation. Most importantly, the system was capable of differentiating MRSA from MSSA with a sensitivity of 83%, a specificity of 100%, and an overall accuracy of 91%. CONCLUSIONS: Our results support the concept of rapid detection of the most relevant bacteria causing wound infections and ultimately differentiating MRSA from MSSA utilizing gaseous headspace sampling with an eNose.

Re-organizing inpatient care saves legs in patients with diabetic foot infections.

AIMS: In this study, we evaluated the effects of the re-organization of inpatient care for patients with a diabetic foot infection, and the implementation of a specialized multi-disciplinary wound department at an academic tertiary hospital. METHODS: This was a retrospective cohort study, comprising 272 patients treated for diabetic foot infections in 2006-2007 (Group 1, n=124) and 2013-2014 (Group 2, n=148). In 2012, inpatient care of all chronic wounds was centralized at a single wound department with a multi-disciplinary team. We assessed group outcome before and after the re-organization. RESULTS: During the 7-year study period, the incidence of hospitalized patients with a diabetic foot infection increased 19%. After initiating the re-organization, the below-the-knee amputation rate was significantly reduced (25.8% vs. 9.5%, p<0.001). The median time from admission to surgical intervention decreased from 5days to 2days, p<0.001. The length of hospitalization also tended to decrease after the reorganization. CONCLUSIONS: The findings of this study demonstrate the benefits of treating diabetic foot infections at a specialized wound department with a multi-disciplinary team. The benefits were achieved by simply distributing the workload and organizing schedules, without new investments or additional personnel. The findings of this study indicate that patients with diabetic foot infections present a challenge that is beyond the expertise of a single field of medicine. A working collaboration between disciplines and a specialized wound department are central in achieving better results.

Modified approach for endoscopic harvest of the latissimus dorsi free flap with CO2 insufflation and standard laparoscopic equipment.

OBJECTIVE: The latissimus dorsi (LD) muscle flap is frequently used for free tissue transfer to reconstruct large defects of the extremities. As a free flap, the LD also can be harvested as a muscle-sparing flap (MS-LD), preserving the innervation and insertion of the remaining muscle. Conventional harvesting of the LD flap, however, results in a long scar on the lateral back. Harvesting using an endoscopic approach minimizes donor site morbidity. We present our modified endoscopic technique with CO2 insufflation and standard endoscopic instruments for harvesting the LD or MS-LD muscle flap. PATIENTS AND METHODS: Ten patients (mean age 43 years, range 22-66) underwent endoscopically harvested LD or MS-LD free-flap reconstruction for upper and lower extremity defects. Harvesting required only a short (3-5 cm) incision in the axilla for dissection of the vascular pedicle and the motor nerve, and the remainder of the dissection was performed endoscopically with CO2 insufflation. Dissection was achieved through three of four 5-mm ports and 30° view angle optics. RESULTS: Six of the flaps were MS-LD flaps. The largest flap size was 18 × 16 cm. Mean flap harvest time was 164 min (range 105-270 min). One total flap was lost 3 days postoperatively due to anastomotic thrombosis in a trauma patient who was later diagnosed with hypercoagulopathy. No donor site scar or wound complications were observed during the follow-up (20.1 months). CONCLUSIONS: Endoscopic harvesting of an LD muscle free flap with CO2 insufflation and standard laparoscopic equipment is a feasible option for free-flap reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery 37:383-387, 2017.

[Life-threatening infection after varicose vein surgery]. / Hengenvaarallinen infektio suonikohjuleikkauksen jälkeen.

Necrotizing fascitis is a rare but life-threatening soft tissue infection difficult to diagnose at early stage. We describe two patient cases, in which the patients developed a severe necrotizing soft tissue infection after varicose vein surgery. A quick and sufficiently radical surgical treatment is the most significant factor improving the prognosis. All surgical procedures may result in rare but severe complications, which should, however, be taken into account when assessing procedural indications and risks.