The Utility of Flap Coverage for Limb Salvage in Patients With Severe Prosthetic Joint Infections of the Knee Requiring Implant Exchange.

BACKGROUND: Prosthetic joint infection (PJI) is a challenging complication of knee arthroplasty, which can require amputation in severe cases. This study analyzes the utility of flap reconstruction in PJIs requiring hardware removal and extensive soft tissue debridement. METHODS: This was a retrospective analysis of patients who were treated according to a multistage extremity salvage protocol between 2018 and 2022. The protocol involved at least 3 planned surgeries including (1) hardware removal with antibiotic spacer placement and soft tissue debridement, (2) spacer exchange with flap coverage, and (3) hardware reimplantation with simultaneous or delayed extensor mechanism reconstruction. All patients had large periprosthetic tissue defects that would necessitate an amputation if not reconstructed. Primary outcomes were extremity salvage and successful defect coverage. RESULTS: Fifty-two patients (25 female) underwent 62 reconstructions (52 primary, 10 salvage). Flap techniques included pedicled muscular (n = 32), fasciocutaneous (n = 4), combined muscular and fasciocutaneous (n = 2), and free flaps (n = 24). Overall rate of successful defect coverage was 95% (98% in primary and 80% in salvage reconstructions). At a median follow-up of 11 months, 41 patients completed the treatment protocol with a 68% (n = 28) extremity salvage rate (reimplantation arthroplasty, n = 15; permanent knee fusion, n = 13). On the multivariate model including demographic factors, defect size, and flap type, no single factor independently predicted limb salvage. CONCLUSIONS: Alongside intensive orthopedic surgical treatment, flap coverage may aid in extremity salvage in severe knee PJIs by reestablishing healthy soft tissue coverage and allowing reimplantation arthroplasty. We recommend a multispecialty approach including plastic surgeons for this challenging condition.

Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review.

INTRODUCTION: Different elbow flap reconstructions have been described in the literature. We aim to define the optimal flap technique based on defect size and etiology. METHODS: A systematic review was undertaken using the terms "(Elbow reconstruction) AND ((Soft tissue) OR (flap))". Flaps were grouped under fasciocutaneous (FCF), muscular (MF), distant pedicled (DPF), and free flaps (FF). The primary outcome was flap survival. The secondary outcomes were postoperative complications and range of motion (pROM). RESULTS: Twenty articles with 224 patients were included. Defect sizes were small (<10 cm2) (18%), medium (10-30 cm2) (23%), large (30-100 cm2) (43%), and massive (>100 cm2) (16%). Etiologies included trauma (26%), burn contractures (26%), infection (26%), hardware coverage (16%), and others (6%). FCF (54%) was the preferred flap followed by MF (28%), DPF (13%), and FF (5%). The rate of flap necrosis was 4% and that of other complications was 10%. The postoperative range of motion (pROM) (reported in 154 patients) was >100°, 50-100°, and <50° in 82%, 17%, and 1% of the cases, respectively. Small defects were most commonly reconstructed with MFs (83%), medium defects were reconstructed with MFs (52%) or FCFs (46%), and large defects were reconstructed with FCFs (91%). Massive defects predominantly required DPFs (60%) and FFs (26%). FCFs were the most common reconstruction method for burn contractures (84%), infections (55%), and traumatic defects (51%). Hardware coverage was predominantly performed using MFs (86%). No difference in complications and pROM was found between flap techniques. CONCLUSION: Elbow flap reconstruction can be performed using different techniques. FCFs are the most commonly used reconstruction method. MFs are useful for smaller defects and hardware coverage. DPFs and FFs are needed for massive injuries.

Vascularized Fibula Epiphysis Transfer for Pediatric Extremity Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Vascularized fibula epiphysis transfer for pediatric extremity reconstruction intends to preserve growth potential. However, few cases are reported, and outcomes are poorly characterized. METHODS: Systematic review was performed through a MEDLINE search using keywords "pediatric" or "epiphyseal" and "vascularized fibula." Patients were divided into upper extremity or lower extremity groups. Functional and growth outcomes were assessed, and indications, pedicle, complications, and need for secondary surgery were recorded. RESULTS: Twenty publications with 62 patients were included. Mean age was 5.9 years, and mean follow-up was 5.8 years. Indications included sarcoma (60%), congenital deformity (21%), trauma (13%), and infection (6%). Anterior tibial pedicle was most common (63%) and was associated with significantly improved growth outcomes compared with the peroneal pedicle (23%; P < 0.001). Fifty-three patients underwent upper extremity reconstruction, with the most common complication being fracture (35%) and most common secondary surgery flap salvage (7%). Among upper extremity patients, full function was achieved in 25% and impaired function in 75%. Full growth was observed in 63% of patients, partial growth in 31%, and no growth in 4%. Nine patients underwent lower extremity reconstruction, with the most common complication being fracture (22%) and most common secondary surgery derotational osteotomy (22%). Among lower extremity patients, full function was achieved in 44% and impaired function in 56%. Full growth was observed in 56% of patients, partial growth in 22%, and no growth in 22%. CONCLUSIONS: Vascularized fibula epiphysis transfer can accomplish full long-term growth and function. However, complications, revision surgery, and chronic impairment are common.

Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing.

Backround: Marko Godina suggested in 1986 that soft tissue coverage of traumatic extremity wounds within 72 h of injury optimizes outcomes. Decades later, these recommendations remain controversial. Methods: We performed systematic review of the literature using keywords 'free flap coverage' OR 'soft-tissue reconstruction' AND 'lower extremity trauma' OR 'tibial or fibular fractures'. Patients receiving free flap or local muscle or fascia flaps were included. Patients were divided into two groups, one receiving coverage within 72 h of injury (<72 h) and one after 72 h (>72 h). Primary outcome measures were partial and total flap loss, as well as infection. Use of negative pressure wound therapy (NPWT) was noted. Descriptive statistics were performed. Results: Twenty-one publications from 1986 to 2015 were included. The <72 h group had 295 patients and the >72 h group 972 patient. Total flap failure rate was 1.4% if coverage was performed <72 h after injury and 8.8% if >72 h after injury. Partial flap failure rate was 0.4% if coverage was performed <72 h after injury and 1.8% if >72 h after injury. Infection rate was 7.7% if coverage was performed <72 h after injury and 11.6% if >72 h after injury. Among the 182 patients in the >72 h group receiving NPWT, total flap failure rate was 3.6% and total infection rate 7.3%. Conclusions: Total and partial flap loss rates, as well as infection rates, were lower when coverage was performed within 72 h of injury. Supporting Godina's recommendation, early soft tissue coverage may be beneficial when circumstances permit. NPWT may be useful when reconstruction is not feasible within 72 h.

Prospective, Randomized, Controlled Comparison of Bupivacaine versus Liposomal Bupivacaine for Pain Management after Unilateral Delayed Deep Inferior Epigastric Perforator Free Flap Reconstruction.

Effective postsurgical analgesia is a critical aspect of patient recovery. The goal of this prospective, randomized, controlled, blinded study was to examine the effect that liposomal bupivacaine delivered by means of a transversus abdominis plane block has on pain control in women undergoing unilateral deep inferior epigastric perforator flap reconstruction. Institutional review board approval was granted for this prospective study. Patients were eligible if they were undergoing unilateral, delayed deep inferior epigastric perforator flap reconstruction. Patients were randomized to one of three groups: liposomal bupivacaine transversus abdominis plane block, or bupivacaine pain pump. Charts were reviewed for demographics, length of stay, and postoperative narcotic use. There were eight patients in the liposomal bupivacaine and bupivacaine transversus abdominis plane block groups and five patients in the pain pump group. A retrospective cohort of six patients who did not receive any intervention was included. Patients who received a liposomal bupivacaine transversus abdominis plane block used statistically significantly less intravenous and total postoperative narcotics in milligrams and milligrams per kilogram per day compared with all other cohorts. They were able to get out of bed at an earlier time point. Overall hospital costs were similar among the groups. This is the first study to investigate liposomal bupivacaine delivered as a transversus abdominis plane block in a prospective, randomized, blinded study in women undergoing unilateral, delayed, abdominally based autologous breast reconstruction. The authors were able to demonstrate a significant reduction in intravenous and total narcotic use when a liposomal bupivacaine transversus abdominis plane block was used. Future studies are needed to prospectively investigate the effect that liposomal bupivacaine would have on immediate and bilateral reconstructions.

An analysis of 72% chromated glycerin used for sclerotherapy: sterility, potency, and cost after extended shelf life.

BACKGROUND: Sclerotherapy is the treatment of reticular veins and telangiectasias of the lower extremities. Sclerosants destroy endothelial tissue and expose subendothelial collagen fibers, which lead to subsequent fibrosis of vessels, thus preventing recanalization. There are several available sclerosants including sodium tetradecyl sulfate (STS), polidocanol (POL), and chromated glycerin (CG) with varying efficacy, potency, side effect profile, and cost. OBJECTIVE: To identify the possible bacterial contamination and potency of CG beyond the current recommended shelf life of 3 months and to prove if CG is as cost effective as other available sclerosants. METHODS: Samples of 72% CG underwent bacterial endotoxin, sterility, and potency analysis at Days 0, 24, and 183. In addition, cost comparison was performed with other commercially available sclerosants including STS and POL. RESULTS: No samples of CG showed any bacterial contamination. All aliquots of glycerin remained sterile at Day 14. Potency at Day 24 was 99.2%, which was the same at Day 183. Cost comparison with other sclerosants revealed that CG is lower cost per milliliter than STS and POL. CONCLUSION: Seventy-two percent CG has no contamination and maintains its reported potency up to 6 months while comparable with the cost of other commercially available sclerosants.

Recurring pressure ulcers: identifying the definitions. A National Pressure Ulcer Advisory Panel white paper.

Currently, there is a lack of consensus regarding the accepted terminology pertaining to the pressure ulcer healing progression and recidivism. This lack of uniformity can negatively impact initiation of treatment pathways, completion of appropriate interventions, clinical documentation, medical coding, patient education, discharge planning and healthcare revenue through out the healthcare system. The purpose of this paper is to introduce a standard nomenclature as it pertains to pressure ulcer healing progression and any recidivism that may occur. The National Pressure Ulcer Advisory Panel has formulated a framework of terms regarding pressure ulcer progression. We also developed a clearer nomenclature for lack of progress and recidivism of pressure ulcers. This document should serve as a starting point for the discussion of the pressure ulcer care, research, and terminology.

Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit.

BACKGROUND: Critically ill patients are vulnerable to the development of hospital-associated pressure ulcers (HAPUs). Positioning of patients is an essential component of pressure ulcer prevention because it off-loads areas of high pressure. However, the effectiveness of such positioning is debatable. A continuous bedside pressure mapping (CBPM) device can provide real-time feedback of optimal body position though a pressure-sensing mat that displays pressure images at a patient's bedside, allowing off-loading of high-pressure areas and possibly preventing HAPU formation. METHODS: A prospective controlled study was designed to determine if CBPM would reduce the number of HAPUs in patients treated in our medical intensive care unit. In 2 months, 422 patients were enrolled and assigned to beds equipped with or without a CBPM device. Patients' skin was assessed daily and weekly to determine the presence and progress of HAPUs. All patients were turned every 2 hours. CBPM patients were repositioned to off-load high-pressure points during turning, according to a graphic display. The number of newly formed HAPUs was the primary outcome measured. A χ(2) test was then used to compare the occurrence of HAPUs between groups. RESULTS: HAPUs developed in 2 of 213 patients in the CBPM group (0.9%; both stage II) compared with 10 of 209 in the control group (4.8%; all stage II; P = .02). CONCLUSION: Significantly fewer HAPUs occurred in the CBPM group than the control group, indicating the effectiveness of real-time visual feedback in repositioning of patients to prevent the formation of new HAPUs.

Incorporation of double-walled microspheres into polymer nerve guides for the sustained delivery of glial cell line-derived neurotrophic factor.

The purpose of this study was to develop a biodegradable polymer nerve guide that locally delivers bioactive neurotrophic factors in physiologically relevant concentrations for the period required by transected peripheral nerves to cross from the proximal to distal nerve stump. Delivery of a neurotrophic factor may enhance nerve regeneration and could potentially be used to overcome the current limitations in nerve repair across large defects. Glial Cell Line-Derived Neurotrophic Factor (GDNF) is a known promoter of axonal elongation and branching and has shown promising pre-clinical results in analysis of nerve regeneration with nerve guides. In addition, GDNF has been shown to promote Schwann cell proliferation and migration. In this study we have created a double-walled microsphere delivery system for bioactive GDNF with a sustained release profile>50 days in vitro. Microspheres were incorporated within degradable poly(caprolactone) nerve guides in a reproducible distribution. Implantation of nerve guides across a 1.5 cm defect in a rat sciatic nerve gap resulted in an increase in tissue integration in both the proximal and distal segments of the lumen of the nerve guide after 6 weeks. In addition, transverse sections of the distal region of the explanted guides showed the presence of Schwann cells while none were detectable in negative control guides. Migration of Schwann cells to double-walled microspheres indicated that bioactive GDNF was encapsulated and delivered to the internal environment of the nerve guide. Because GDNF increased tissue formation within the nerve guide lumen and also promoted the migration and proliferation of Schwann cells, the nerve guides presented within this study show promise toward the development of an off-the-shelf product alternative that promotes nerve regeneration beyond that capable with currently available nerve guides.

Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized controlled trial.

BACKGROUND: A standard approach for postoperative analgesia in laparoscopic surgery is to infiltrate the incisions with local anesthetic in combination with systemic opioids. The intraperitoneal introduction of local anesthetic in this setting has the potential to provide appropriate analgesia without the side effects of systemic opioids. We performed a randomized clinical trial of the On-Q pump delivery system to determine the safety and efficacy of this device for this novel purpose. METHODS: Thirty patients undergoing laparoscopic adjustable gastric banding were randomly assigned to one of two groups. The treatment group received On-Q pump systems filled with 0.375% bupivacaine, while the control group received pumps filled with 0.9% normal saline. The pump's catheter was introduced intraperitoneally, and bupivacaine or saline was then delivered for the first 48 h after surgery. Patient's subjective pain scores were evaluated at preset intervals. In addition, shoulder pain, morphine requirements, and anti-emetic requirements were tabulated. RESULTS: A statistically significant decrease in patient's subjective reports of pain by visual analog score was noted in the On-Q group 1.8+/-1.93 vs. control 3.5+/-2.4, p<0.046 and remained significant until the end of the study (48 h). No statistical difference was noted in shoulder pain, morphine requirements, or anti-emetic requirements at any time point. CONCLUSION: Our trial was able to provide evidence of significant reduction in postoperative pain as measured by subjective pain scores with the use of continuous intraperitoneal bupivacaine using the On-Q pain pump system. Further investigation is warranted to evaluate the cost effectiveness of this technique.