A systematic review and meta-analysis of endovascular angiosomal revascularization in the setting of collateral vessels.

OBJECTIVE: Endovascular procedures for targeted treatment of lower extremity wounds can be subdivided as direct revascularization (DR), indirect revascularization (IR), and IR via collateral flow (IRc). Although previous systematic reviews assert superiority of DR when compared with IR, the role of collateral vessels in clinical outcomes remains to be defined. This systematic review and meta-analysis aims to define the usefulness of DR, IR, and IRc in treatment of lower extremity wounds with respect to (1) wound healing, (2) major amputation, (3) reintervention, and (4) all-cause mortality. METHODS: A meta-analysis was performed in accordance with PRISMA guidelines. Ovid MEDLINE was queried for records pertaining to the study question using appropriate Medical Subject Heading terms. Studies were limited to those using DR, IR, or IRc as a primary intervention and reporting information on at least one of the primary outcomes of interest. No limitation was placed on year of publication, country of origin, or study size. Studies were assessed for validity using the Newcastle-Ottawa Scale. Study characteristics and patient demographics were collected. Data representing the primary outcomes-wound healing, major amputation, reintervention, and all-cause mortality-were collected for time points ranging from one month to four years following intervention. A meta-analysis on sample size-weighted data assuming a random effects model was performed to calculate odds ratios (ORs) for the four primary outcomes at various time points. RESULTS: We identified 21 studies for a total of 4252 limbs (DR, 2231; IR, 1647; IRC, 270). Overall wound healing rates were significantly superior for DR (OR, 2.45; P = .001) and IRc (OR, 8.46; P < .00001) compared with, IR with no significant difference between DR and IRc (OR, 1.25; P = .23). The overall major amputation rates were significantly superior for DR (OR, 0.48; P < .00001) and IRc (OR, 0.44; P = .006) compared with IR, with DR exhibiting significantly improved rates compared with IRc (OR, 0.51; P = .01). The overall mortality rates showed no significant differences between DR (OR, 0.89; P = .37) and IRc (OR, 1.12; P = .78) compared with IR, with no significant difference between DR and IRc (OR, 0.54; P = .18). The overall reintervention rates showed no significant difference between DR and IR (OR, 1.05; P = .81), with no studies reporting reintervention outcomes for IRc. CONCLUSIONS: Both DR and IRc offer significantly improved wound healing rates and major amputation rates compared with IR when used to treat critical limb ischemia. Although DR should be the preferred method of revascularization, IRc can offer comparable outcomes when DR is not possible. This analysis was limited by a small sample size of IRc limbs, a predominance of retrospective studies, and variability in outcome definitions between studies.

Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis.

Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.

Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening.

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.

Management of complications following implant-based breast reconstruction: a narrative review.

Background and Objective: Complications associated with implant-based reconstruction have a spectrum of severity with sequelae ranging from mild aesthetic deformities to additional surgery, reconstructive failure and systemic illness. The purpose of this narrative review of the literature is to provide updated evidence-based information on the management of complications in implant-based reconstruction. Methods: A systematic search of PubMed, OVID MEDLINE and the Cochrane Library databases was performed to identify common complications associated with implant-based breast reconstruction, incidences of occurrence as well as preventative and management strategies. Key Content and Findings: Pertinent short and long-term complications of implant-based breast reconstruction include hematoma, implant infection, seroma, skin envelope necrosis, capsular contracture, rupture, malposition, animation and contour deformities, implant-associated anaplastic large cell lymphoma, and breast implant illness. Important preventative measures for short term complications include meticulous sterile technique and antibiotic irrigation, adequate drainage and critical evaluation of mastectomy flaps. Management of short-term complications requires early recognition and aggressive treatment to prevent reconstructive failure as well as long-term complications such as capsular contracture. Important technological advances include dual-port expanders for seroma drainage, indocyanine green angiography for mastectomy flap perfusion evaluation, cohesive form-stable implants for treatment of rippling, and various biologic and synthetic mesh products for pocket control and correction. Conclusions: Important principles in management of short-term complications in implant-based reconstruction include aggressive and early intervention to maximize the chance of reconstructive salvage. Contemporary technological advances have played an important role in both prevention and treatment of complications. Over-arching principles in management of implant-based reconstruction complications focus on preventative techniques and preoperative patient counseling on potential risks, their likelihood, and necessary treatments to allow for informed and shared decision-making.

Effect of Function-Based Approach to Nontraumatic Major Lower Extremity Amputation on 5-Year Mortality.

BACKGROUND: Five-year mortality rates after lower extremity amputation in the chronic wound population have long been regarded as high and inevitable. We theorize that function-based surgical technique and multidisciplinary care improve mortality and assess our institution's mortality rates after major lower extremity amputation (MLEA). STUDY DESIGN: We performed a retrospective review of patients who underwent primary nontraumatic MLEA at our institution from 2010 to 2013. Major amputations included below knee amputation, through knee amputation, and above knee amputation. Our function-based surgical approach to MLEA is guided by 4 tenets: (1) optimization of limb biomechanics, (2) maximal soft tissue preservation, (3) multidisciplinary team approach, and (4) addressing nerves during primary amputation to prevent postamputation pain. Kaplan-Meier analysis and Cox regression were performed to estimate cumulative 5-year mortality and to identify predictors of 5-year mortality, respectively. RESULTS: A total of 188 patients underwent MLEA. Median Charlson Comorbidity Index was 4. Estimated 5-year mortality was 40% overall and 43% for diabetic patients. When stratified by amputation level, 5-year mortalities were 36.3% for below knee amputation, 60.9% for through knee amputation, and 44.0% for above knee amputation. Charlson Comorbidity Index (hazard ratio 1.24, p < 0.001) and end-stage renal disease (hazard ratio 3.38, p < 0.001) were the strongest predictors of 5-year mortality. CONCLUSIONS: We demonstrate the lowest mortality rate reported for MLEA. Improved functional and mortality outcomes can be achieved with a function-based surgical approach to MLEA and close follow-up by a multidisciplinary team. Future studies, using standardized reporting of mortality data and incorporating patient-reported outcomes, are warranted to correlate return to function and mortality.

Long-Term Outcome Assessment Between Antiseptic and Normal Saline for Negative Pressure Wound Therapy with Instillation.

Objective: To analyze long-term outcomes following inpatient treatment of infected wounds with antimicrobial or normal saline instillation during negative pressure wound therapy (NPWT). Approach: This was a single-center retrospective study analyzing the course of patients receiving 0.9% normal saline or 0.1% polyhexanide plus 0.1% betaine as instillation for wounds requiring surgery. Measured outcomes included rates of dehiscence, new wounds, re-operations, amputations, and mortality over 5 years. The article adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Results: Forty-two patients received normal saline instillation and 41 the antiseptic solution. Rates of dehiscence, wound recurrence, and re-operations in the saline and antiseptic cohorts were 6.3% and 5.6%, 9.4% and 5.6%, and 14.3% and 9.8%, respectively (p > 0.05). In patients requiring further surgery, time to wound closure averaged 104 and 130 days in the saline and antiseptic cohorts, respectively (p = 0.81). Five-year amputation and mortality rates were 14.3% and 22% (p = 0.36) and 24% and 17% (p = 0.45) in the saline and antiseptic cohorts, respectively. Innovation: To compare clinical outcomes associated with two fundamentally different instillation solutions over the full wound care episode and elucidate the potential impact of these results for future applications. Conclusion: This is the first evaluation of nonsurrogate outcomes of different instillations for NPWT in infected wounds. The results indicate that normal saline instillation outcomes are comparable to those of 0.1% polyhexanide plus 0.1% betaine. The clinical success, cost benefit, and accessibility of normal saline can expand the utilization of this therapeutic approach for larger patient populations.

A Plastic-neuro Effort: Vascularized Soft-tissue Coverage for Hostile Wound Bed with Multiple Ventricular Shunt Failures.

Cerebral ventricular shunt placements are the most common neurosurgical procedure performed today, which play a life-long role in the care of patients with hydrocephalus. Complication rates requiring shunt replacement are as high as 25%, and the potential need for multiple revisions throughout a patient's life may result in the formation of scar tissue and compromised wound healing. Without addition of vascularized tissue, patients with scalp scarring and impaired wound healing then enter a cycle of impaired skin closure followed by shunt infection, failure, and revision with little promise of long-term operative or therapeutic success. This plastics-neuro collaboration is the first known report of a free vastus lateralis muscle flap for coverage of a cerebral ventricular shunt, in a patient with congenital hydrocephalus and 17 previous ventricular shunts revisions due to infections and soft tissue exposure from scarring and a hostile wound bed. In the setting of extensive scarring, the free vascularized muscle flap provides soft tissue and vascular supply capable of promoting wound healing, maintaining scalp integrity, and reducing the incidence of shunt infection and the subsequent need for future revision, as supported by the complication-free status of the same patient now 16 months since the date of operation.