Amputation Acceptance: A Survey of Factors Influencing the Decision to Undergo Lower Extremity Amputation.

Accepting to undergo amputation is an arduous process often fraught with confusion, fear, and uncertainty. To assess how to best facilitate discussions with at-risk patients, we surveyed lower extremity amputees about their experiences surrounding this decision-making process. Patients who underwent lower extremity amputation at our institution from October 2020 to October 2021 were asked to complete a 5-item telephone survey assessing their decision to undergo amputation and postoperative satisfaction. Retrospective chart review of respondent demographics, comorbidities, operative details, and complications was conducted. Of 89 lower extremity amputees identified, 41 (46.07%) responded to the survey, with the majority undergoing below-knee amputations (n = 34, 82.93%). At a mean follow-up of 5.90 ± 3.45 months, 20 patients (48.78%) were ambulatory. Surveys were completed at a mean of 7.74 ± 4.03 months since amputation. Factors that helped patients decide to undergo amputation included discussions with doctors (n = 32, 78.05%) and concern for worsening health (n = 19, 46.34%). Deteriorating ability to walk (n = 18, 45.00%) was the most common concern prior to surgery. Recommendations by survey respondents to ease the decision-making process included speaking with amputees (n = 9. 22.50%), more discussions with doctors (n = 8, 20.00%), and access to mental health and social services (n = 2, 5.00%); however, many had no recommendations (n = 19, 47.50%), and most were pleased with their decision to undergo amputation (n = 38, 92.68%). Despite most patients primarily citing satisfaction with their decision to undergo lower extremity amputation, it is critical to consider factors that affect patient decisions and recommendations to improve this decision-making process.

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review.

Background: Propeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction. Methods: A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected. Results: Out of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%. Conclusion: PPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

The Use of Flap Techniques to Preserve Limb Length in Patients with Transmetatarsal Amputations.

BACKGROUND: Chronic lower extremity wounds affect up to 13% of the US population. Transmetatarsal amputation (TMA) is frequently performed in patients with chronic forefoot wounds. TMA allows limb salvage and preserves functional gait, without need for prosthesis. Traditionally, when tension-free primary closure is not possible, a higher-level amputation is performed. This is the first series to evaluate the outcomes of local and free flap coverage of TMA stumps in patients with chronic foot wounds. METHODS: A retrospective cohort of patients who underwent TMA with flap coverage from 2015 through 2021 was reviewed. Primary outcomes included flap success, early postoperative complications, and long-term outcomes (limb salvage and ambulatory status). Patient-reported outcome measures using the Lower Extremity Functional Scale (LEFS) were also collected. RESULTS: Fifty patients underwent 51 flap reconstructions (26 local, 25 free flap) after TMA. Average age and body mass index were 58.5 years and 29.8 kg/m 2 , respectively. Comorbidities included diabetes [ n = 43 (86%)] and peripheral vascular disease [ n = 37 (74%)]. Flap success rate was 100%. At a mean follow-up of 24.8 months (range, 0.7 to 95.7 months), the limb salvage rate was 86.3% ( n = 44). Forty-four patients (88%) were ambulatory. The LEFS survey was completed by 24 surviving patients (54.5%). Mean LEFS score was 46.6 ± 13.9, correlating with 58.2% ± 17.4% of maximal function. CONCLUSIONS: Local and free flap reconstruction after TMA are viable methods of soft-tissue coverage for limb salvage. Applying plastic surgery flap techniques for TMA stump coverage allows for preservation of increased foot length and ambulation without a prosthesis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Functional and Patient-reported Outcomes following Transmetatarsal Amputation in High-risk Limb Salvage Patients.

Background: Transmetatarsal amputation (TMA) is performed in patients with nonhealing wounds of the forefoot. Compared with below-knee amputations, healing after TMA is less reliable, and often leads to subsequent higher-level amputation. The aim of this study was to evaluate the functional and patient-reported outcomes of TMA. Methods: A retrospective review of patients who underwent TMA from 2013 to 2021 at our limb-salvage center was conducted. Primary outcomes included postoperative complications, secondary proximal lower extremity amputation, ambulatory status, and mortality. Univariate and multivariate analyses were performed to evaluate independent risk factors for higher-level amputation after TMA. Patient-reported outcome measures for functionality and pain were also obtained. Results: A total of 146 patients were identified. TMA success was achieved in 105 patients (72%), and 41 patients (28%) required higher-level amputation (Lisfranc: 31.7%, Chopart: 22.0%, below-knee amputations: 43.9%). There was a higher incidence of postoperative infection in patients who subsequently required proximal amputation (39.0 versus 9.5%, P < 0.001). At mean follow-up duration of 23.2 months (range, 0.7-97.6 months), limb salvage was achieved in 128 patients (87.7%) and 83% of patients (n = 121) were ambulatory. Patient-reported outcomes for functionality corresponded to a mean maximal function of 58.9%. Pain survey revealed that TMA failure patients had a significantly higher pain rating compared with TMA success patients (P = 0.016). Conclusions: TMA healing remains variable, and many patients will eventually require a secondary proximal amputation. Multi-institutional studies are warranted to identify perioperative risk factors for higher-level amputation and to further evaluate patient-reported outcomes.

Postoperative Patellar Height After Undergoing Total Knee Arthroplasty: Mechanical Axis Versus Kinematic Axis.

Introduction When performing total knee arthroplasty (TKA), surgeons may use either the mechanical alignment (MA) or the kinematic alignment (KA) to guide implant placement and joint balancing. By measuring preoperative and postoperative patellar height (PH), surgeons can predict knee stability after TKA. Improper PH is associated with knee instability which may complicate the postoperative course and lead to patient dissatisfaction or need for revision. The purpose of this study is to measure patellar height using the Insall-Salvati Index (ISI), Caton-Deschamps Index (CDI), and Blackburne-Peel Index (BPI) preoperatively and postoperatively in patients who underwent TKA with either MA or KA to assess for changes in patellar height. Methods We performed a retrospective eight-year review of 256 patients who underwent TKA with either MA or KA by a single surgeon at a single hospital site. We obtained demographic data, including gender, age, and BMI, via the electronic health record. Furthermore, we calculated the ISI, CDI, and BPI using necessary parameters from preoperative and postoperative radiographs. We used these measurements to assess any statistically significant difference in postoperative PH. Results The MA cohort consisted of 104 patients with an average age of 63 years and an average BMI of 34.1 kg/m2. The KA cohort included 152 patients with an average age of 64 years and an average BMI of 34.9 kg/m2.  For the MA population, the average postoperative score with ISI was 1.10 [1.05 to 1.16] (p < 0.001), with CDI was 1.05 [0.98 to 1.11] (p < 0.001), and with BPI was was 0.94 [0.89 to 0.99] (p < 0.001). While for the KA population, the average postoperative score with ISI was 1.03 [0.99 to 1.06] (p = 0.17), with CDI was 0.87 [0.82 to 0.91] (p = 0.15), and with BPI was 0.82 [0.78 to 0.86] (p = 0.34). Conclusion TKA with a KA has a statistically significant improvement in postoperative PH and better postoperative maintenance of preoperative PH. Improved PH may lead to increased patellofemoral stability and superior postoperative outcomes in patients undergoing TKA. Future studies should focus on whether differences in preoperative and postoperative PH measurements result in changes in clinical outcomes in patients with MA versus KA TKA.