Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths.

BACKGROUND: The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function. METHODS: A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05. RESULTS: BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation. CONCLUSIONS: The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

Nonoperative Molding of Congenital Ear Deformities: The Impact of Birth-Initiation Delay on Correction Outcome.

Ear molding can improve the majority congenital ear deformities when employed early after birth. However, the best time to initiate treatment remains debated. In describing one surgeon's experience over the past near decade, this study aims to highlight differences conferred by treatment timing. The authors hypothesize that auricular outcomes are superior when deformities are molded beginning in the first 3 weeks of life. A retrospective review (2010-2018) of 272 cases was performed to compare early initiation of molding (<3 weeks of birth) and delayed initiation (>3 weeks). The mean patient age was 20.4 days and the mean follow-up was 0.5 months. The overall treatment was approximately 31 days. The number of devices required was similar (2.3 versus 2.5) between early and delayed molding cases, but fall-outs (1.0 versus 0.7, P = 0.02) and replacements (0.9 versus 0.6, P = 0.004) were more common after delayed molding. Skin complications developed in 13.6% (37) of ears overall and did not differ by treatment timing. Follow-up surgery was reported in 2 (0.7%) ears. The 85% of families reported subjective satisfaction with the final outcome; satisfaction was significantly higher for early cases (97% versus 79%, P = 0.03). Ear molding of congenital ear deformities should begin within 3 weeks of birth. From our experience, setting realistic expectations helps limit discrepancies between expectation and outcome.

Proximally Based Split Abductor Hallucis Turnover Flap for Medial Hindfoot Reconstruction: A Case Report.

Limited reconstructive options exist for soft tissue defects of the foot and ankle because of a lack of surrounding tissue. Although microsurgical free flaps have become a popular treatment modality for this anatomic region, pedicled muscle flaps can provide robust coverage of small foot wounds with significantly less donor site comorbidity. One such muscle is the abductor hallucis, which can be used as a proximally based turnover flap to cover medial hindfoot defects. However, complete distal disinsertion of the muscle may lead to loss of support over the medial arch and first metatarsophalangeal joint, leading to pes planus and hallux valgus. In this case report, we describe a modified technique of a split abductor hallucis turnover flap for a young patient with a chronic, traumatic medial heel wound complicated by calcaneal osteomyelitis. By preserving part of the muscle's distal tendinous attachment, this technique allows for adequate soft tissue coverage while maintaining long-term biomechanical function.

Increasing incidence of testicular cancer in the United States and Europe between 1992 and 2009.

PURPOSE: Increasing in incidence, testicular cancer is the most commonly diagnosed cancer in young men in the USA and in Europe. We sought to determine contemporary trends in testicular cancer incidence in the USA and Europe. METHODS: Testicular cancer incidence data covering the USA and Europe were extracted from the SEER-13 (SEER*Stat 8.0.1) and the EUREG databases, respectively. Trends were determined using JoinPoint 3.5.3. RESULTS: Testicular germ cell tumor (TGCT) incidence among US males >15 years increased from 1992 (5.7/100,000) to 2009 (6.8/100,000) with a significant annual percentage change (APC: 1.1%, p < 0.001). Seminomas were 29% of all TGCTs in 15-26 year-olds, increasing to 78% in those 40+ years of age. TGCT rates were highest in White men (1992: 7.5/100,000; 2009: 8.6/100,000) followed by Hispanic men (1992: 4.0/100,000; 2009: 6.3/100,000) and lowest among Asian (1992: 2.0/100,000; 2009: 2.8/100,000) and Black men (1992: 0.7/100,000; 2009: 1.7/100,000). Significantly increasing incidence rates were observed in White men (APC: 1.2%, p < 0.001) and most prominently in Hispanic men, especially from 2002 to 2009 (APC: 5.6%, p < 0.01). Incidence of testicular cancer increased in 15 of 19 (79%) European countries analyzed (p < 0.05). Denmark (13.4/100,000 man-years), Switzerland (12.7/100,000 man-years), and Norway (12.7/100,000 man-years) exhibited the highest age-standardized rates, while Spain had the greatest APC (APC = 5.5, 95% CI 3.9-7.0%, p < 0.001). CONCLUSIONS: Between 1992 and 2009, testicular cancer incidence in the USA and Europe continued to increase, most notably in US Hispanic, Northern European, Spanish, and younger and older populations.

Isolated Compartment Syndrome of the Hand After Intravenous Doxycycline Infiltration Injury.

Isolated compartment syndrome of the hand, although uncommon, can lead to considerable functional deficits if not treated promptly. The most common etiologies are related to trauma, burns, or electric injuries; however, some cases have been reported after intravenous infiltration events, particularly rapid intravenous contrast injection. In this case report, we describe the development of compartment syndrome in the hand of a critically ill patient with COVID-19 pneumonia and sepsis 16 days after doxycycline infiltration injury. She presented with worsening pain, swelling, bullous eruption, and intrinsic minus hand posturing. Emergent surgical release of intrinsic hand compartments and evacuation of a hematoma resolved her symptoms and preserved hand function. Early recognition and surgical intervention of compartment syndrome of the hand after infiltration injury in medically complex patients will reduce morbidity in this patient population.

From pay for performance to collaborative quality initiatives: quality care and implications for the limb salvage center.

Management of chronic wounds, specifically those of the lower extremity, varies considerably by geographic region. The consequences of low-quality care perpetuate poor outcomes and low value for patients and the health care system. The emergence of value-based health care has forced stakeholders to evaluate care from quality and cost perspectives. This review presents a replicable quality assessment model for limb salvage specialists to apply to their practices. This model will foster increased collaboration between caregivers across all disciplines in an effort to increase quality care assurances for patients with chronic wounds of the lower extremity. Current approaches to quality assessment in the management of such wounds are outlined, and areas for innovation, such as collaborative initiatives, are highlighted. Use of the Donabedian model to provide quality and value to patients undergoing treatment for chronic wounds at a tertiary limb salvage center is also described. A value-based care system can be comprehensively assessed using the Donabedian framework. A pay-for-performance approach has largely guided health care reform in the United States; however, the effects of this approach have been incongruent with its intent. Limb salvage centers work to rectify this imbalance and continually evaluate quality measures to improve care. Collaborative quality initiatives have resulted in improved outcomes and cost savings in multiple specialties, and multidisciplinary limb salvage centers may benefit from such infrastructure. Limb salvage specialists have an important role in determining whether health care quality improvements are internally or externally driven. Existing quality assessment tools are imperfect, and the consequences of low-quality care of chronic wounds can be devastating. Through collaboration across institutions and the use of validated quality assessment tools such as the Donabedian model, chronic wound specialists can be leaders in developing and implementing quality care measures.

Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects.

Tendon rupture in the setting of significant soft tissue loss poses a challenging reconstructive situation, which requires (1) recreating a stable gait cycle, (2) reducing shear forces and re-rupture risk, and (3) providing adequate soft tissue coverage. In this study, we outline our experience with composite flaps in single-step reconstruction of various lower extremity tendinous injuries with soft tissue loss. METHODS: A retrospective review of all patients requiring free tissue transfer at our tertiary wound care center between 2011 and 2020 was performed. Patients undergoing single-stage free tissue transfer for both soft tissue coverage and tendon reconstruction were selected. Variables of interest included demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics. Outcomes of interest were flap success, return to ambulation, time to ambulation, and postoperative complications. RESULTS: Nineteen patients were included in this study. Patients were on average 48.0 years old (SD 16.5), with a median Charlson Comorbidity Index of 1.00 (IQR: 0.0-2.5). Defects were most often on the ankle (n = 1 3, 68.4%), with extension to the foot or leg in six of these cases. Median wound size was 68.0 cm2 (IQR: 48.0-120.0). The most common tendon requiring reconstruction was the Achilles (n = 13, 68.4%). An anterolateral thigh flap with attached fascia lata extension rolled into a neotendon was used in all 19 cases. At baseline, all patients were ambulatory. Only one patient (5.3%) required return to the operating room for suspected vascular compromise. At a median of 14.4 months (IQR: 8.5-40.5), all 19 patients were ambulatory. CONCLUSIONS: Simultaneous reconstruction of tendinous injuries and soft tissue defects can be readily achieved via composite free flaps. Although other methods of reconstruction can be considered for smaller soft tissue and tendon loss, this approach has significant utility for patients with large defects and yields robust return to preinjury functionality.

Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps.

BACKGROUND: Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population. METHODS: The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound. RESULTS: The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort. CONCLUSIONS: Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Chlorhexidine Hypersensitivity: A Case Report of Delayed Reactions Associated with Epidermal Preparations.

Chlorhexidine is a topical antiseptic that is generally well tolerated in patients, making it a common preparatory substance in various surgical settings. Sparse case reports have identified immediate hypersensitivity reactions after exposure to this substance, especially in patients with a history of atopy. The purpose of this case report is to describe 3 unique presentations of delayed hypersensitivity to epidermal chlorhexidine preparation. Patients undergoing breast surgery by a single surgeon between December 2018 and January 2019 were retrospectively reviewed for incidence of dermatologic complications. Medical and surgical history of patients as well as dermatologic hypersensitivity course were collected. Three patients presented with a delayed hypersensitivity to the epidermal chlorhexidine surgical preparation, ChloraPrep. Each patient developed an erythematous, pruritic maculopapular rash in the distribution of the chlorhexidine application. This occurred beyond the immediate postoperative period-ranging from postoperative days 5 to 35. Initial treatment included the use of 1% hydrocortisone along with a systemic antihistamine. If there was no improvement in symptoms after 3 days, we transitioned patients to 0.5% triamcinolone ointment. If there was no improvement after 5 days on triamcinolone, the patient was reexamined and systemic steroids were prescribed. In each of our cases, all skin changes had resolved within 7-10 days of initial symptoms. Our findings highlight a series of delayed adverse reactions to epidermal chlorhexidine occurring beyond the intraoperative and immediate postoperative period. This case report serves to recognize a unique presentation pattern to ensure that all patients are accurately diagnosed and promptly treated via a systematic treatment algorithm.

Incidence of Major Arterial Abnormality in Patients with Wound Dehiscence after Lower Extremity Orthopedic Procedures.

BACKGROUND: Surgical dehiscence can occur after lower extremity orthopedic procedures. Underlying vascular aberrancy and localized ischemia contribute to chronic wound development requiring advanced techniques such as free tissue transfer. Localized vascular abnormality is an underrecognized contributing factor to such dehiscence. The authors reviewed their lower extremity free tissue transfer experience in this population to analyze the incidence of arterial abnormality and outcomes. METHODS: The authors conducted a retrospective review of 64 lower extremity free tissue transfers performed for chronic wounds after orthopedic procedures from 2011 to 2018. The primary outcome was major arterial abnormality as identified on angiography. Secondary outcomes were flap success, limb salvage, and ambulation status. RESULTS: The median age was 58 years, and 44 were men (69 percent). Comorbidities included osteomyelitis (77 percent), diabetes (39 percent), and peripheral vascular disease (17 percent). The incidence of arterial abnormality on angiography was 47 percent. Defect location correlated with angiosome of arterial abnormality in 53 percent. The flap success rate was 92 percent. Limb salvage and ambulation rates were 89 and 89 percent, respectively, at an average follow-up of 17.6 months. Men demonstrated an increased rate of limb salvage (p = 0.026). Diabetes (p = 0.012), arterial abnormality (p = 0.044), and arterial flap complication (p = 0.010) correlated with amputation. CONCLUSIONS: The high incidence of arterial abnormality in this population highlights the importance of expedient multidisciplinary care, including vascular and plastic surgery. Diagnostic angiography is important for identifying major arterial abnormality and the need for free tissue transfer for definitive coverage.

Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction.

The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting. METHODS: From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified. RESULTS: Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain. CONCLUSIONS: This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality.

A simple, safe technique for thorough seroma evacuation in the outpatient setting.

SUMMARY: Seroma formation, a common postoperative complication in reconstructive cases, can lead to capsular contracture and increased office visits and expenses. The authors present a safe, novel technique for ensuring the thorough removal of serous fluid in the outpatient setting. By relying on access with an angiocatheter, potential injury to permanent implants is minimized. The use of low continuous wall suction obviates the need of manual suction via multiple syringes and offers a rapid and thorough evacuation of all types of seromas.