A Pilot Randomized Clinical Trial of Early Ambulation after Groin Reconstruction with Sartorius Muscle Flaps.

The use of muscle flaps, such as the sartorius muscle, for groin coverage in high-risk vascular patients has been shown to reduce complication rates. However, it remains unknown whether earlier postoperative ambulation is associated with improved postoperative outcomes for groin muscle flaps following infrainguinal vascular surgery. Methods: We performed a pilot randomized trial to analyze the effect of early ambulation on postoperative outcomes in patients who had groin reconstruction with sartorius muscle flaps following infrainguinal vascular surgery at our academic institution. Results: Fourteen patients were randomized to standard ambulation (on postoperative day 6), and 14 patients were randomized to early ambulation (on postoperative day 2). The treatment arms were similar with respect to age, body mass index, risk category, smoking status, and comorbidities. Median length of stay was 6 days in the early group versus 7 days in the standard group. Immediate and long-term physical function and general health were better in the early group There were slightly more wound complications in the standard (57.1%) versus the early group (42.9%), and the early group had more lymphatic complications (35.7% versus 14.3%). Conclusions: The decision to ambulate a patient after this surgery continues to be a decision between the vascular and plastic surgeons. However, this pilot trial has shown the safety profile of early ambulation and that it should be considered for specific patients. Additionally, this trial has provided valuable information for performing a larger scale randomized controlled trial to determine the optimal postoperative protocol for patients with these reconstructions.

Mycotic aneurysm of the distal radial artery after cardiac catheterisation.

A mycotic aneurysm of the distal radial artery following access for cardiac catheterisation is a rare complication that has not been described in the literature. We present the case of an 84-year-old man who developed bacteraemia and cellulitis over his left first dorsal webspace 2 days after undergoing cardiac catheterisation through the distal radial artery at the anatomic snuffbox. Ultrasound scanning and CT imaging were concerning for a possible pseudoaneurysm at that location. Once we confirmed that the patient had adequate flow through his hand with angiography and an Allen's test, we explored his left hand and found a mycotic aneurysm of the distal radial artery with surrounding frank purulence. We resected the aneurysm and ligated the artery. Pathology confirmed that this was a mycotic aneurysm. The patient quickly recovered from his infection after this definitive treatment.

Craniectomy with microvascular flap reconstruction in a patient taking infliximab for vasculitis.

For patients whose vasculitis is managed with biologic medications, no reports or evidence-based guidance exists regarding the perioperative management of microvascular flaps. We present a case of a 78-year-old patient with Takayasu's arteritis (TA) and diabetes mellitus who was taking infliximab and underwent wide local excision of squamous cell carcinoma, craniectomy and reconstruction with a latissimus dorsi flap. TA, an immune-mediated large cell vasculitis characterised by granuloma formation, tends to affect larger vessels and aortic branches. The typical localisation of this condition raises concerns about potentially compromised pedicle and recipient vessels (ie, superficial temporal arteries), which could hinder postoperative flap success. Discontinuation of infliximab 4 weeks before surgery and resumption 6 weeks after led to favourable results. This case addresses the gap in the literature concerning stopping and restarting biologic drugs in the perioperative setting and documents a successful course of a microvascular procedure in a patient with vasculitis.

A Cross-sectional Study of the Association between Homelessness and Facial Fractures.

BACKGROUND: Little is known about the risk factors for facial fractures among homeless patients. We investigated the association between homelessness, mechanism of injury, and type of facial fracture in patients treated at an urban trauma center. METHODS: Data for 2,221 adults with facial fractures were obtained retrospectively from a standardized registry of trauma patients at Zuckerberg San Francisco General Hospital from 2011 to 2016. Associations between homelessness and mechanism of injury, facial fracture type, and surgical repair type were evaluated with multivariate multinomial logistic regression analysis. RESULTS: Among 2,221 patients with facial fractures, 12% were homeless and, compared with housed patients, more likely to be male, black, and test positive for drug and alcohol use (all P < 0.0001). They had lower injury severity scores but longer hospital stays and were more likely to be discharged to the community than to a rehabilitation facility (all P < 0.0001). After adjusting for confounding variables, homeless patients with facial fractures were nearly 3-fold more likely to have been assaulted than housed patients (OR = 2.8, 95% CI = 1.9-4.1, P < 0.0001) and twice as likely to have mandible fractures (OR = 2.0, 95% CI = 1.3-3.0, P = 0.0030) and to have surgery for these fractures (OR = 2.1, 95% CI = 1.2-3.7, P = 0.0110). CONCLUSIONS: Our novel results demonstrate that homeless patients with facial fractures are at much higher risk than the general population for being assaulted, suffering mandible fractures, and requiring surgery for these fractures. Further investigations could guide identification, treatment, and prevention efforts.