The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

Systematic review and meta-analysis of controlled trials assessing spinal cord stimulation for inoperable critical leg ischaemia.

BACKGROUND: Spinal cord stimulation (SCS) may have a place in the treatment of patients with inoperable chronic critical leg ischaemia. METHODS: A systematic review and meta-analysis was performed of all controlled studies comparing SCS in addition to any form of conservative treatment for inoperable chronic critical leg ischaemia. Main endpoints were limb salvage, pain relief and clinical situation. Systematic methodological appraisal and data extraction were performed by independent reviewers. RESULTS: Of the 18 reports found, nine trials, comprising 444 patients, matched the selection criteria. After pooling, limb salvage at 12 months appeared significantly greater in the SCS group (risk difference (RD) -0.13 (95 per cent confidence interval (c.i.) -0.04 to -0.22)). Significant pain relief occurred in both treatment groups, but patients who received SCS required significantly less analgesia and reached Fontaine stage 2 more often than those who did not have SCS (RD 0.33 (95 per cent c.i. 0.19 to 0.47)). Complications of SCS were problems of implantation (8.2 per cent), changes in stimulation requiring reintervention (14.8 per cent) and infection (2.9 per cent). CONCLUSION: The addition of SCS to standard conservative treatment improves limb salvage, ischaemic pain and the general clinical situation in patients with inoperable chronic critical leg ischaemia. These benefits should be weighed against the cost and the (minor) complications associated with the technique.

[Use of electrostimulation for treatment of critical lower limb ischemia]. / Elektrostimuliatsiia pri lechenii kriticheskoi ishemii nizhnikh konechnostei.

The analysis of efficiency of bone electrostimulation in the treatment of lower limb arteries occlusions was carried out. The method was used in a combination with lumbar sympathectomy and revascularising osteotrepanation in 52 patients with chronic critical limb ischaemia, in whom reconstructive operation was impossible. Short-term good results were achieved in 69.2% of the patients. The method allows to accelerate compensation of circulation in ischaemic limb.

Prospective study of transcutaneous oxygen tension (TcPO2) measurement in the testing period of spinal cord stimulation in diabetic patients with critical lower limb ischaemia.

BACKGROUND: Spinal cord stimulation improves microcirculatory blood flow, relieves diabetic neuropathic and ischaemic pain and reduces the amputation rate in patients with severe peripheral arterial occlusive disease. AIM: To evaluate whether transcutaneous oxygen tension (TcPO2) measurements can be used as a specific prognostic parameter in the assessment of suitability for permanent device implantation in a prospective controlled study on diabetic patients with peripheral arterial occlusive disease. METHODS: Sixty patients (39 men, 21 women; mean age: 60 years; range: 46-75) were submitted to implantation of a spinal cord electrical generator for severe peripheral vascular disease, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stage III and IV and the main pathology was diabetic vascular disease. Pedal TcPO2 was assessed on the dorsum of the foot and ankle and toe pressure Doppler measurements were performed before, two weeks and four weeks after implantation. RESULTS: Pain relief of over 75% and limb salvage were achieved in 35 diabetic patients, while in 12 a partial success with pain relief over 50% and limb salvage for at least 6 months was obtained. In 13 patients the method failed and the affected limbs were amputated. Clinical improvement and spinal cord stimulation success were associated with increases of TcPO2, within the first two weeks after implantation (temporary period). Limb salvage was achieved with significant increase of TcPO2 within the first two weeks of the testing period (from 21.4 to 31.5 mmHg in rest pain patients, p=0.030, from 15.1 to 22.0 mmHg, p=0.030 in patients with trophic lesions under 3 cm2 in size and in those with trophic lesions over 3 cm2, from 12.1 to 17.9 mmHg, p=0.025) unrelated to the stage of the disease and the initial TcPO2 value. TcPO2 changes were related to the presence of adequate paraesthesias and warmth in the painful area during the trial period. The systolic ankle/brachial blood pressure index and toe pressure did not change under stimulation. CONCLUSIONS: A two-week testing period should be performed in all diabetic patients treated with spinal cord stimulation for peripheral arterial occlusive disease to identify the candidates for permanent implantation. Only diabetic patients with significant increases of TcPO2 and clinical improvement, during the test period, should be considered for permanent implantation and not merely all patients with pain relief. TcPO2 changes could be used as a predictive index of the therapy success and should be considered in terms of cost effectiveness before the final decision to permanent implantation.

The differential effect of the level of spinal cord stimulation on patients with advanced peripheral vascular disease in the lower limbs.

Percutaneous spinal cord stimulation (SCS) (Medtronic model 3487A PISCES-Quad lead) was carried out in 10 patients with rest pain from advanced peripheral vascular disease of the lower limb, who were unsuitable for conventional treatment. Trial stimulation ranged from 1-20 weeks and was associated with pain relief in nine of the patients. Claudication distance was improved in six patients. Trophic lesions improved in one patient with small artery disease. Spinal cord stimulation did not reverse the course of acute gangrenous lesions. The distal arterial pressure measured by Doppler Ankle/Brachial Pressure Index, (ABPI), showed no change. The capillary blood flow and skin temperature of both feet, measured, respectively, by Laser Doppler flowmetry and skin thermistor, showed a tendency to decrease when the stimulation was at the higher level, above T10, compared with an increase when the stimulation was at the lower level T12. Transcutaneous oxygen tension monitoring of the symptomatic foot showed an increase in four out of five patients. Pain relief was not dependent on circulatory changes, but it was more significant when the circulatory changes showed an impressive increase in the blood flow. The mechanism of these circulatory changes is probably by modulation of the sympathetic nervous system. Recognition of the optimal sitting of SCS may be critical in the clinical use of this technique, which seems to be a valuable option in the treatment of patients with advanced peripheral vascular disease (PVD).

[Physiologic approach to promoting circulation in acute labyrinth ischemia. A new treatment concept]. / Physiologischer Ansatz zur Durchblutungsförderung bei der akuten Labyrinth-Ischämie. Ein neues Behandlungskonzept.

BACKGROUND: One of the main factors of sudden hearing impairment, acute vestibular disturbance, and acute tinnitus is generally thought to be an acute labyrinthine ischemia of varying degrees. However, the scientific basis for this assumption has not yet been proven, and there is a great variety of treatment modalities. Recent circulation research and fundamental physiological considerations led to the development of a new concept of treatment of these diseases. METHODS: In order to enhance the labyrinthine blood circulation, physiological and physical methods were tested in 42 patients, especially with regard to patient compliance and in addition to conventional therapy. The methods tested included active circulation training. Finnish bath observing certain precautions, sequentially increased temperature bathing, massage, and fango therapy of the neck. RESULTS: The compliance of the patients to the new concept was good, in some cases even enthusiastic, either to the "total body" methods or to the local neck treatment. CONCLUSION: The principle of active and/ or passive stimulation of blood circulation in acute labyrinthine ischemia has been well accepted by all patients. A study including functional results is in preparation.

[The muscle in the rehabilitation process]. / Der Muskel in der Rehabilitation.

After orthopedic surgery, skeletal muscle will enter the rehabilitation process in weakened condition due to the following characteristics. After use of a tourniquet during surgery, the muscle suffers ischemia/reperfusion damage due to oxidative stress, resulting in structural impairment. The resulting immobilization leads to muscular atrophy, with a loss of calcium homeostasis and oxidative stress being of etiological significance. Degeneration of muscle fibers as well as regeneration occurs in muscle while still immobilized. After remobilization, the muscle has impaired functional capacity and frequently shows disturbances in its innervation pattern. High mechanical loading should therefore be avoided, and electrical stimulation may be applied to facilitate recovery. Considering the role of oxygen radicals, supplementation with vitamin E appears generally recommendable.

Entrenamiento físico: terapia alternativa para pacientes con enfermedad oclusiva arterial periférica de extremidades inferiores / Physical training: alternative therapy for patients with peripheral arterial oclussive disease of legs

La enfermedad oclusiva arterial periférica es causa frecuente de discapacidad en la población adulta mayor. El tratamiento conservador consiste en la eliminación de los factores de riesgo y medición activa. Una terapia alternativa la constituye el entrenamiento físico, el cual desde hace mucho tiempo ha sido descrito en la literatura como un método para el tratamiento de estas afecciones. Todos los estudios han manifestado un aumento en la capacidad de ejercicio ejecutable, una disminución del dolor experimentado y un mejoramiento del paciente en lo personal, social y cultural. Este trabajo pretende definir la eficacia de dichos sistemas de entrenamientos en los pacientes claudicantes y proponer un protocolo de entrenamiento físico