Limb Salvage Using Microsurgical Free Tissue Transfer in Severe Frostbite.

PURPOSE: Frostbite is often managed conservatively; however, in severe cases, microsurgical free tissue transfer is required for soft tissue coverage and limb salvage. Given its rarity, the techniques and outcomes of these cases are not well described. The purpose of this report is to present the largest case series, to date, of frostbite injuries requiring microsurgical reconstruction for limb salvage. METHODS: A single-center retrospective review was conducted of all patients who underwent free tissue transfer by a single surgeon from 2008 to 2022. Patients of all ages were included if they suffered a frostbite injury requiring free tissue transfer. Demographics, operative details, and surgical outcomes were recorded. RESULTS: Eight patients with frostbite injuries were included in the report. Patients had frostbite injuries either to the lower extremities (n = 4) or to both upper and lower extremities (n = 4). Sixteen free flaps were done in total including four paired chimeric and eight single free flaps. Flap recipient sites included knees (n = 5), foot/ankle (n = 3), dorsal hands (n = 2), and thumbs (n = 2). All 16 flaps survived. Five patients had complications: four with major complications requiring operative management and two with minor complications requiring conservative management. Mean follow-up time was 505.7 days (range 115-1564). All lower extremity reconstructions were able to weight-bear at an average of 125.2 days post-injury (range 87-164). CONCLUSIONS: This case series demonstrates that free tissue transfer is a robust option for soft tissue coverage and functional limb salvage in patients with severe frostbite injuries to both upper and lower extremities.

Clinical outcomes in people with diabetes-related foot infections: Analysis from a limb preservation service infection database.

BACKGROUND: Diabetes-related foot infections are common and represent a significant clinical challenge. There are scant data about outcomes from large cohorts. The purpose of this study was to report clinical outcomes from a large cohort of people with diabetes-related foot infections. METHODS: A tertiary referral hospital limb preservation service database was established in 2018, and all new episodes of foot infections were captured prospectively using an electronic database (REDCap). People with foot infections between January 2018 and May 2023, for whom complete data were available on infection episodes, were included. Infection outcomes were compared between skin and soft tissue infections (SST-DFI) and osteomyelitis (OM) using chi-square tests. RESULTS: Data extraction identified 647 complete DFI episodes in 397 patients. The data set was divided into two cohorts identifying each infection episode and its severity as either SST-DFI (N = 326, 50%) or OM (N = 321, 50%). Most infection presentations were classified as being moderate (PEDIS 3 = 327, 51%), with 36% mild (PEDIS 2 = 239) and 13% severe (PEDIS 4 = 81). Infection resolution occurred in 69% (n = 449) of episodes with failure in 31% (n = 198). Infection failures were more common with OM than SST-DFI (OM = 140, 71% vs. SST-DFI = 58, 29%, p < 0.00001). In patients with SST-DFI a greater number of infection failures were observed in the presence of peripheral arterial disease (PAD) compared to the patients without PAD (failure occurred in 30% (31/103) of episodes with PAD and 12% (27/223) of episodes without PAD; p < 0.001). In contrast, the number of observed infection failures in OM episodes were similar in patients with and without PAD (failure occurred in 45% (57/128) of episodes with PAD and 55% (83/193) of episodes without PAD; p = 0.78). CONCLUSIONS: This study provides important epidemiological data on the risk of poor outcomes for DFI and factors associated with poor outcomes in an Australian setting. It highlights the association of PAD and treatment failure, reinforcing the need for early intervention to improve PAD in patients with DFI. Future randomised trials should assess the benefits of revascularisation and surgery in people with DFI and particularly those with OM where outcomes are worse.

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach.

BACKGROUND: Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT). METHODS: A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications. RESULTS: Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria. CONCLUSIONS: For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

Comparative Outcomes and Failure Rates of Total Femur Replacement in Oncologic and Nononcologic Indications: A Systematic Review and Meta-analysis.

BACKGROUND: Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication. METHODS: This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models. RESULTS: A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery. CONCLUSION: TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

The Utility of Sirolimus Eluting Balloons in the Setting of Chronic Limb Threatening Ischaemia in Asian Patients from Singapore - 12 Months Results of the PRISTINE Registry.

PURPOSE: The aim of PRISTINE was to evaluate the 6 and 12 months safety and efficacy of the Selution Sustained Limus Release (SLR)™ sirolimus-coated balloon for treatment of complex lower limb occlusive lesions (TASC II C & D) in patients with chronic limb threatening ischemia (CLTI) from Singapore. METHODS: PRISTINE was a prospective, non-randomized, single arm, observational, multi-investigator, single-center clinical study. Complication-free survival at 30 days was the safety clinical endpoint. Immediate technical success (ability to cross and dilate the lesion and achieve residual angiographic stenosis < 30%), 6-month primary vessel patency, limb salvage, clinically driven target lesion revascularization (TLR) and amputation free survival (AFS) were the efficacy endpoints of interest. RESULTS: Seventy five patients were included. There were 50 (68.0%) males; mean age, 69.0 ± 10.7 years. CLTI severity was based on the Rutherford Scale (R5 = 51; R6 = 17). Significant co-morbidities included diabetes mellitus (n = 68; 91.0%) and end-stage renal failure (n = 28; 37.0%). 112 atherosclerotic lesions were treated (TASC II D = 58 (52%); 76 (67%) de novo). There was 100% technical success. Mean lesion length treated was 22.4 ± 13.9 cm. Primary vessel patencies at 6 and 12 months were 64/86 (74%) and 43/74 (58%) and freedom from clinically driven TLR were 72/86 (84%) and 55/74 (74%) respectively. AFS was 61/73 (84.0%; five deaths and seven major lower extremity amputation) at 6-months. Mean Rutherford score improved from 5.1 ± 0.55 at baseline to 1.1 ± 2.05 (p < 0.05) at one year and there was a wound healing rate of 38/48 (79%) at the same timepoint. CONCLUSIONS: The Selution SLR™ drug eluting balloon is safe and efficacious in treating highly complex infra-inguinal atherosclerotic lesions in an otherwise challenging frail population of CLTI patients with a high incidence of diabetes and end-stage renal failure. It is associated with highly satisfactory acute technical and clinical success, 12-month target lesion patency and AFS. LEVEL OF EVIDENCE: Level 2b, Individual Cohort Study.

Descriptive Analysis of Amputation-Free Survival After First Time Infra-Inguinal Bypass Occlusion.

INTRODUCTION: Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass. METHODS: Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes. RESULTS: Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass. CONCLUSIONS: Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes.

Cross-leg flaps: A nonmicrosurgical alternative treatment method in complex lower extremity trauma reconstruction.

OBJECTIVES: This study aimed to present our experiences with cross-leg flap surgery, which demonstrates successful outcomes in lower limb soft tissue defects without the necessity of microsurgical intervention. PATIENTS AND METHODS: The retrospective study included 26 patients (18 males, 8 females; mean age: 35.6±12.2 years; range, 18 to 65 years) between January 2015 and September 2019. A fasciocutaneous cross-leg flap was applied to the recipient extremity, and the extremities were immobilized by a tubular external fixator. Flap divisions were performed on the 21st postoperative day. At least two years of clinical outcomes were presented. RESULTS: Twenty-five flaps survived and recovered completely without any complication at the donor site, flaps, or the recipient area. In one diabetic patient, partial flap loss was encountered, which granulated with secondary healing. All patients demonstrated stable wound coverage, with none demanding additional soft tissue surgeries. All patients resumed normal ambulation and physical activity without any residual joint stiffness. CONCLUSION: Cross-leg flap method is an effective and respectable option for extremity salvage as a good alternative to free flaps for the management of traumatic complex lower limb defects. This method is simple, provides abundant blood supply to the wound, and does not require microsurgical experience or a good working recipient artery.

The Utility of Advanced Lower-Extremity Duplex Using Pedal Acceleration Time in the Management of the Threatened Diabetic Foot.

BACKGROUND: Patients with diabetes and diffuse infrageniculate arterial disease who present with chronic limb-threatening ischemia require an exact anatomical plan for revascularization. Advanced pedal duplex can be used to define possible routes for revascularization. In addition, pedal acceleration time (PAT) can predict the success or failure of both medical and surgical interventions. METHODS: A retrospective review of patients who were referred to our group for unilateral limb-threatening ischemia with isolated infrageniculate disease was conducted. Pedal duplex and PAT at the base of the wound was performed before and 1 week after intervention. The primary endpoint was limb salvage at 1 year. Revascularization was defined as direct or indirect based on the angiosome concept. RESULTS: Fifty-four patients meeting inclusion criteria presented over a 5-year period (toe wound, n = 42; heel wound, n = 8; both, n = 4). At 1 year, 10 (18.5%) had required below-knee amputation, whereas the remainder had healed/improved. Limb salvage was predicted by absence of ongoing smoking, absence of dialysis, and postprocedural PAT (class I/II). Limb salvage did not correlate with direct versus indirect revascularization. CONCLUSIONS: Advanced lower-extremity duplex in conjunction with determining PAT at the area of concern is a useful technique for mapping the vasculature and identifying targets for revascularization in patients with diffuse infrageniculate disease. Target artery revascularization to the wound bed resulting in a PAT less than 180 msec is predictive of limb salvage, regardless of whether perfusion is direct or indirect.

Limb salvage and systemic management of gouty tophi: Case series.

INTRODUCTION: Gout is a chronic disease characterized by deposition of monosodium urate crystals. Tophi develop in some individuals with untreated or uncontrolled gout, which leads to ulcerations, cosmetic problems, mechanical obstruction of joint movement, joint damage and musculoskeletal disability. Currently, the treatment of gouty tophi is controversial and challenging. Both surgical and internal medical treatments have limitations and require further exploration in clinical practice. PATIENT CONCERNS: In Case 1, we treated a patient with severe infection of diabetic foot ulcers with concomitant multiple gouty tophi in the same limb. A systematic management strategy was formulated to close the wound and save the limb. The ulcers healed successfully after half a year. In Case 2, a giant gouty tophi located in the first metatarsophalangeal joint of the left foot was removed by surgical treatment and vancomycin-loaded bone cement implantation. In Case 3, we present a case of gouty tophi that was resolved by standardized systemic medical management. DIAGNOSIS: Three patients were all diagnosed with gout accompanied by gouty deposition, although there were other different comorbidities. INTERVENTIONS: In case 1, we used debridement to gradually remove gouty tophi. In case 2, the giant gouty tophi was removed by surgical operation. In case 3, the gouty tophi disappeared after standardized treatment with medicine, diet and lifestyle management. OUTCOMES: Three patients underwent different treatment therapies to remove gouty tophi based on their specific conditions. LESSONS: We explored effective interventions for tophi in gout by surgical or other interventions in combination with pharmacotherapy.

Alternative vein bypass in octogenarians with chronic limb-threatening ischaemia.

BACKGROUND: Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. METHODS: A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. RESULTS: In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. CONCLUSION: Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.

Fibular hemimelia: reconstruction of difficult cases with tibial lengthening and ankle arthrodesis.

PURPOSE: Management of fibular hemimelia includes either prosthetic care with or without a suitable amputation or tibial lengthening. Many studies have documented the success of both procedures. Most parents of these children refuse an amputation or have no access to good prosthetic care. The author presents a limb-salvage procedure with tibial lengthening and ankle stabilization. METHODS: Twelve children of fibular hemimelia with 14 extremities had been subjected to limb lengthening after lateral leg release. To correct the valgus procurvatum, double oblique diaphyseal osteotomy (DODO) of the tibia was performed in 11 extremities. The age of the patients ranged from two to 15 years with the median of five years. All were male. The proposed procedure included three stages of loosening, lengthening, and stabilization with ankle arthrodesis at a later stage. RESULTS: All patients returned for follow-up for the first four years and had been walking on their sensate feet. With DODO followed by fixator/traction could straighten and lengthen the tibia simultaneously and correct the valgus procurvatum. Ankle stabilization provided stability and a plantigrade foot. A follow-up of six to 30 years with a median of ten years has been reported. CONCLUSION: A new procedure of loosening, lengthening, and stabilization of the leg with ankle arthrodesis has been proposed. A follow-up of 30 years with a median of ten years of the said procedure has been reported. The procedure provides a long-lasting plantigrade and painless foot that has sensation and proprioception. An amputation at any level has not been recommended.

Soft Tissue Coverage for Foot and Ankle Trauma.

Lower extremity trauma can result in extensive soft tissue loss, which can require a staged multispecialty approach. Flaps can be an excellent choice for significant soft tissue loss. A variety of variables goes into the selection of a flap including understanding what the recipient site needs, available donor sites, nature of trauma, and utilization of indices to predict limb salvageability in order to strategically select the correct flap option.

A Successful Clinical Outcome 29 Months Following Improper Placement of the Compress Implant: A Case Report.

CASE: A 24-year-old woman presented with dedifferentiated parosteal osteosarcoma of the proximal femur and was treated with limb salvage surgery using the Compress implant. It was implanted with a technical error, was not revised, and has demonstrated no negative outcomes 29 months postoperatively. CONCLUSION: An instance of incorrect pin placement during the implantation of a Zimmer Compress implant is presented with good survivorship. This report acts as information for other surgeons who might inadvertently obtain unicortical fixation. In this patient, revision surgery was avoided and an excellent, short-term outcome was achieved while avoiding the potentially devastating complications associated with revision implantation.

Total Humeral Endoprosthetic Reconstruction: A Systematic Review.

BACKGROUND: Total humeral endoprosthetic reconstruction (THER) is a rare reconstruction option for limb salvage surgery for large humeral neoplasms or bone destruction. MATERIALS AND METHODS: Because of the limited data and need for this procedure, we reviewed the literature surrounding THER and assessed functionality, complications, and revisions using the PubMed, Embase, Ovid, and Scopus databases. RESULTS: Among 29 articles and 175 patients, the most common indication was neoplasm (n=25, 86%), mean follow-up was 61.98 months (SD=55.25 months), and mean Musculoskeletal Tumor Society score was 73.64% (SD=10.69%). Reported complications included 26 (23%) revisions in 7 studies, 35 (36%) cases of shoulder instability in 7 studies, and 13 (13.54%) cases of deep infection in 4 studies. CONCLUSION: THER should be considered with a thorough knowledge of outcomes and potential complications to guide patient and clinician expectations. [Orthopedics. 2024;47(3):e106-e113.].

Biomechanical and clinical outcomes of 3D-printed versus modular hemipelvic prostheses for limb-salvage reconstruction following periacetabular tumor resection: a mid-term retrospective cohort study.

BACKGROUND: Debates persist over optimal pelvic girdle reconstruction after acetabular tumor resection, with surgeons grappling between modular and 3D-printed hemipelvic endoprostheses. We hypothesize superior outcomes with 3D-printed versions, yet scarce comparative research exists. This study fills the gap, examining biomechanics and clinical results retrospectively. METHODS: From February 2017 to June 2021, we retrospectively assessed 32 patients undergoing en bloc resection for malignant periacetabular tumors at a single institution. PRIMARY OUTCOME: limb function. SECONDARY OUTCOMES: implant precision, hip joint rotation center restoration, prosthesis-bone osteointegration, and complications. Biomechanical characteristics were evaluated through finite element analysis on pelvic defect models. RESULTS: In the 3D-printed group, stress distribution mirrored a normal pelvis, contrasting the modular group with elevated overall stress, unstable transitions, and higher stress peaks. The 3D-printed group exhibited superior functional scores (MSTS: 24.3 ± 1.8 vs. 21.8 ± 2.0, p < 0.05; HHS: 79.8 ± 5.2 vs. 75.3 ± 3.5, p < 0.05). Prosthetic-bone interface osteointegration, measured by T-SMART, favored 3D-printed prostheses, but surgery time (426.2 ± 67.0 vs. 301.7 ± 48.6 min, p < 0.05) and blood loss (2121.1 ± 686.8 vs. 1600.0 ± 505.0 ml, p < 0.05) were higher. CONCLUSIONS: The 3D-printed hemipelvic endoprosthesis offers precise pelvic ring defect matching, superior stress transmission, and function compared to modular endoprostheses. However, complexity, fabrication expertise, and challenging surgical implantation result in prolonged operation times and increased blood loss. A nuanced consideration of functional outcomes, complexity, and patient conditions is crucial for informed treatment decisions. LEVEL OF EVIDENCE: Level III, therapeutic study (Retrospective comparative study).

Functional and oncological outcomes of patients with proximal humerus osteosarcoma managed by limb salvage.

BACKGROUND: Osteosarcoma is the most common primary bone malignancy in skeletally immature patients. The proximal humerus is the third most common site of osteosarcoma. The literature shows a paucity of published data concerning the outcome of proximal humerus osteosarcoma managed by limb salvage. The purpose of this study was to answer the following questions: (1) do patients with proximal humerus osteosarcoma managed by limb salvage and neoadjuvant chemotherapy show good functional and oncological outcomes, and (2) are there any prognostic factors that are associated with better oncological and functional outcomes? MATERIALS AND METHODS: The study was a retrospective case series study assessing the overall outcome of 34 patients with proximal humerus osteosarcoma. Eighteen patients were males (53%) while 16 were females. Biological reconstruction was done in 15 patients (44%), while nonbiological reconstruction was done in 19 patients. Resections were mainly intraarticular (82%). Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score, while oncological outcome was assessed based on local recurrence and development of chest metastasis. Comparisons between quantitative variables were done using the nonparametric Mann-Whitney test. To compare categorical data, the chi-square (χ2) test was performed. The exact test was used instead when the expected frequency was less than 5. Correlations between quantitative variables were examined using the Spearman correlation coefficient. RESULTS: The mean MSTS score was 25.5 (range 23-29). A younger age was statistically correlated with a poorer MSTS score (P = 0.0016). Six patients out of 34 (17.6%) had local recurrence and four of them (67%) were treated by forequarter amputation. 41% of patients developed chest metastasis, and the majority of them were treated by chemotherapy (71%). In comparison with patients with osteosarcoma at other sites who were also managed in our institution, proximal humerus osteosarcoma patients showed higher incidence rates of local recurrence and chest metastasis along with lower 5-year patient and limb survivorships compared to distal femur, proximal tibia and proximal femur osteosarcoma patients. CONCLUSION: Treatment of osteosarcoma of the proximal humerus by limb salvage and chemotherapy yields a good functional outcome. The method of reconstruction does not impact the resultant function. The 5-year survivorship of these patients is 65%. Younger patients have a better oncological outcome and an inferior functional outcome. LEVEL OF EVIDENCE: Level IV therapeutic study.

Predicting Outcomes Following Lower Extremity Endovascular Revascularization Using Machine Learning.

BACKGROUND: Lower extremity endovascular revascularization for peripheral artery disease carries nonnegligible perioperative risks; however, outcome prediction tools remain limited. Using machine learning, we developed automated algorithms that predict 30-day outcomes following lower extremity endovascular revascularization. METHODS AND RESULTS: The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity endovascular revascularization (angioplasty, stent, or atherectomy) for peripheral artery disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day postprocedural major adverse limb event (composite of major reintervention, untreated loss of patency, or major amputation) or death. Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Overall, 21 886 patients were included, and 30-day major adverse limb event/death occurred in 1964 (9.0%) individuals. The best performing model for predicting 30-day major adverse limb event/death was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92-0.94). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.70-0.74). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.09. The top 3 predictive features in our algorithm were (1) chronic limb-threatening ischemia, (2) tibial intervention, and (3) congestive heart failure. CONCLUSIONS: Our machine learning models accurately predict 30-day outcomes following lower extremity endovascular revascularization using preoperative data with good discrimination and calibration. Prospective validation is warranted to assess for generalizability and external validity.

Acute limb ischemia in nonagenarians: Characteristics and factors related to outcomes in a single-center consecutive series.

BACKGROUND: The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. RESULTS: A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. CONCLUSION: Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.

Multi-disciplinary diabetic limb salvage programme in octogenarians with diabetic foot ulcers is not futile: An observational study with historical controls.

This study evaluated the effectiveness of a multi-disciplinary diabetic limb salvage programme in improving clinical outcomes and optimising healthcare utilisation in 406 patients aged ≥80 years with diabetic foot ulcers (DFUs), compared to 2392 younger patients enrolled from June 2020 to June 2021 and against 1716 historical controls using one-to-one propensity score matching. Results showed that elderly programme patients had lower odds of amputation-free survival (odds ratio: 0.64, 95% CI: 0.47, 0.88) and shorter cumulative length of stay (LOS) compared to younger programme patients (incidence rate ratio: 0.45, 95% CI: 0.29, 0.69). Compared to the matched controls, participating in the programme was associated with 5% higher probability of minor lower extremity amputation, reduced inpatient admissions and emergency visits, shorter LOS but increased specialist and primary care visits (all p-values <0.05). The findings suggest that the programme yielded favourable impacts on the clinical outcomes of patients aged≥80 years with DFUs. Further research is needed to develop specific interventions tailoring to the needs of the elderly population and to determine their effectiveness on patient outcomes while accounting for potential confounding factors.

Complications after limb salvage surgeries for musculoskeletal malignancies: 10-year experience of the main sarcoma center in Bulgaria.

INTRODUCTION: Limb salvage surgery is currently the most frequently used treatment option in Bulgaria for individuals with musculoskeletal malignancies. Clinical data about complications from these procedures is limited in the country, with only a few studies currently available.