Concomitant Orthopedic Injury is the Strongest Predictor of Amputation in Extremity Vascular Trauma.

BACKGROUND: Although the risk of extremity amputation related to an isolated vascular injury is low, it increases significantly with concomitant orthopedic injury. Our study aims to evaluate and quantify the impact of risk factors associated with trauma-related extremity amputation in patients with vascular injury. We sought to determine whether there are other potential predictors of amputation. METHODS: A retrospective review of patients with extremity vascular injury presenting to a single level 1 academic trauma center between January 1, 2007, and December 31, 2018, was performed. All patients diagnosed with major vascular injury to the upper or lower extremity were included. Data on patient demographics, medical comorbidities, anatomic location of vascular injury, and the presence of soft tissue or orthopedic injury were collected. The main outcome measure was major amputation of the affected extremity. Major amputation included below-the-knee amputation, above-the-knee amputation, as well as any amputation of the upper extremity at or proximal to the wrist. RESULTS: We identified 250 extremities with major vascular injury in 234 patients. Of these, 216 (86.4%) were male and 34 (13.6%) female. The mean age was 32.2 years (range 18-79 years) and mean follow-up was 6.9 (standard deviation: 3.3) years. Just over half of injuries, 130 (52.0%) involved the lower extremity. Forty extremities (29 lower and 11 upper), or 16.0%, of total injured extremities, required major amputation during the follow-up period. Concomitant orthopedic injury was present in 106 of 250 (42%) injured extremities. Using univariable logistic regression models, variables with a significant association with major amputation included older age, higher body mass index, blunt mechanism of injury, concomitant orthopedic injury, soft tissue injury, and nerve injury, and the need for fasciotomy (P < 0.05). In multivariable analyses, blunt mechanism of injury (odds ratio [OR] (confidence ratio {CI}): 6.51 (2.29, 18.46), P < 0.001) and concomitant orthopedic injury (OR [CI]: 7.23 [2.22, 23.55], P = 0.001) remained significant predictors of amputation. CONCLUSIONS: Concomitant orthopedic injury and blunt mechanism in the setting of vascular injury are associated with a higher likelihood of amputation in patients with extremity vascular injury. Further development of a vascular extremity injury protocol may be needed to enhance limb salvage. Findings may guide patient discussion regarding limb-salvage decision-making.

Resident Attrition in Plastic Surgery: A National Survey of Plastic Surgery Program Directors.

BACKGROUND: Attrition in plastic surgery is poorly characterized in the literature with previous data indicating that independent residents may have a higher rate of voluntary attrition with integrated residents having a higher rate of involuntary attrition. The aim of this study is to identify risk factors, note differences between pathways, and provide insight into resident attrition from plastic surgery residencies. METHODS: An institutional review board-approved anonymous, multiple-choice and short answer, online survey regarding resident attrition was sent to all plastic surgery program directors (PDs) in the United States focusing from 2003 to 2013. Outcomes measured included demographics of the program and attritional resident, timing and reasons for attrition, and possibility of preventing attrition. RESULTS: Thirty-three (35%) of 95 PDs responded. Average attrition rates were calculated at 2.15% for independent and 0.85% for integrated programs. Risk factors for attrition included being single, divorced, male, and having no dependents. One hundred percent of independent residents left by year 2, and 86% of integrated residents left by year 4. Lifestyle and loss of interest were most sited reasons for attrition. Most independent residents returned to their original field of training, whereas integrated residents were more likely to transfer to another integrated program. Only 17% of PDs believed attrition could have been prevented. CONCLUSIONS: Approximately 3.0% of all plastic surgery residents underwent attrition. Being single, male, divorced, or having no dependents increases the risk of attrition in plastic surgery residencies. This is the first study to demonstrate potential risks factors for plastic surgery residents undergoing attrition.

Intramedullary Free Gracilis for Dead-Space Obliteration and Stump Resurfacing in a Transfemoral Amputee With Recurrent Osteomyelitis.

Background: A 72-year-old man with a history of delayed presentation for severe right lower extremity burns underwent through-knee amputation complicated by periprosthetic distal femur osteomyelitis. Subsequent transfemoral amputation was complicated by Stage IVB Cierny-Mader osteomyelitis despite appropriate medical and surgical treatment. Methods: Due to the presence of threatened proximal femur intramedullary nail from prior intertrochanteric femur fracture, inability to further shorten femur, and lack of local soft-tissue options, we performed soft tissue reconstruction with free gracilis flap. The free gracilis flap was pulled proximally through the femoral canal to obliterate intramedullary dead space and provide distal femoral stump coverage. Results: The stump was fully healed upon 6-month follow-up with computerized tomography demonstrating continued presence of gracilis flap within the femoral canal and no evidence of osteomyelitis. At 1-year follow-up, the patient was ambulatory using a prosthetic without recurrence of osteomyelitis. Conclusions: Previous descriptions of intramedullary free muscle flaps for the treatment of osteomyelitis are limited in number, with its function being limited to dead-space obliteration. This report presents intramedullary free gracilis flap to be a viable option in above-knee amputees for combined dead space obliteration and stump resurfacing in the context of recurrent osteomyelitis.

Breast reconstruction with tissue expanders: implementation of a standardized best-practices protocol to reduce infection rates.

BACKGROUND: Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors' goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections. METHODS: A comprehensive, best-practices protocol was introduced and implemented in November of 2010. All patients undergoing breast reconstruction using tissue expanders at the authors' institution in the 5 years before the protocol, and in the 2 years after, were analyzed. RESULTS: Three hundred five patients underwent 456 tissue expander reconstructions in the 5 years before the protocol, and 198 patients underwent 313 reconstructions in the 2 years after. Significantly fewer patients developed periprosthetic infection after protocol (11.6 percent versus 18.4 percent; p=0.042), and the number of infected tissue expanders trended toward a decrease (9.3 percent versus 13.2 percent; p=0.097). On multivariate analysis, the protocol significantly reduced the odds of periprosthetic infection (OR, 0.45; p=0.022). Predictors of infection included obesity (OR, 2.01; p=0.045) and preoperative breast size larger than C cup (OR, 2.83; p=0.006). CONCLUSIONS: The authors' comprehensive, best-practices protocol allowed them to reduce the odds of tissue expander infections by 55 percent (OR, 0.45; p=0.022). The authors were able to identify several potential areas of improvement that may help them lower the rate of infection further in the future. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.