Mary Edwards Walker (1832-1919): Approach to limb salvage therapy.

Mary Edwards Walker (1832-1919) was the first female surgeon in the United States. Her upbringing and unique medical training led her to practice medicine in a way that was revolutionary for the time. During the Civil War, her approach to wound care rivaled the current standard of care. During an era that predated antiseptic surgical technique, she prioritized cleanliness and hygiene. She opposed amputation for its surgical risks and decreased postoperative quality of life. She believed that many wounds, when appropriately attended to, would heal without amputation. She advocated for patients who she believed did not require amputations and counseled them on their rights to refuse surgical care.

Godina's Principles in the Twenty-First Century and the Evolution of Lower Extremity Trauma Reconstruction.

BACKGROUND: February of 2016 marked 30 years since the passing of Marko Godina, a pioneer and prodigy in the field of reconstructive microsurgery. Most noteworthy among his many contributions was his method of radical debridement of contaminated compound fractures followed by early free tissue transfer for wound closure. In the last three decades, the landscape of reconstructive surgery has undergone significant transformation owing to advances in reconstructive techniques and wound care technology, as well as new data. METHODS: Dr. Godina's work and legacy are reviewed, compared and contrasted with new and evolving data regarding lower extremity trauma reconstruction. RESULTS: Advancements in technique and technology have greatly molded lower extremtiy reconstruction over the past thirty years. Nonetheless, Dr. Godina's principles of timely care and early vascularized soft tissue coverage have withstood the test of time. CONCLUSION: Marko Godina's contribution to reconstructive microsurgery cannot be overstated and his groundbreaking work continues to serve as the foundation of lower extremity trauma reconstruction. Three decades after his seminal work, we honor Dr. Godina's legacy and explore how his principles have endured, evolved, or been replaced.

The History of Bone Tumour Treatment and the State of the Art in Vienna.

PURPOSES: Bone tumours have been a tragedy for the patient in any time period. In the majority of the cases it occurs in children or young adults. In the past the affected limbs could not be spared and the overall prognosis was poor. METHODS: Chemotherapy successfully introduced for the purpose of overcoming the poor overall prognosis (Rosen and Jaffe) and tumour prostheses were invented for the purpose of salvaging the affected limbs (Marcove, Scales, Campanacci, Sivas, Salzer). According to the Vienna Tumour Registry in 1968, the first custom-made Vitallium prosthesis for the proximal femur was implanted in a parosteal osteosarcoma. RESULTS: In Vienna, as a result of the successful chemotherapy the surgical methods for bone tumours changed to limb sparing methods also. A modular ceramic prosthesis for the proximal humerus was introduced by Salzer. From 1975 -1982 16 custom-made endoprosthesis (1) for the knee region were implanted which were replaced by the KMFTR in 1982 (2, Kotz modular femur tibia reconstruction system) which was introduced at the "2nd ISOLS" to an international group of experts. The successful system was followed by the HMRS (Howmedica modular resection system) in 1988. At that time, especially in children, the rotation-plasty of Borgreve was adopted for tumours of the knee region (2). A scientific survey of 70 patients with rotation-plasty until 1991 showed excellent clinical and oncologic results. Later a similar approach was used in upper extremity tumours as "resection replantation" with surprisingly good results. Sophisticated technologies with growing mechanisms allowed the use of endoprostheses even in children (3) for the purpose of substitution since the mutilating rotation-plasty in 1996. CONCLUSION: For almost 100 years efforts have been undertaken to improve the treatment of bone tumours. Surgery was aiming to keep the function of the limbs by tumour resection instead of amputation. Together with successful chemotherapy, which saves lives, an adequate surgery could stepwise salvage the function of the limb. Body integrity was the final aim for the diseased. Finally, by the effort of the International Societies like ISOLS and EMSOS the survival of malignant bone tumour patients improved from 20% to 80 % with good function quality by sophisticated operative techniques and improved tumour prostheses.

Lead, Follow, or Get out of the Way-How Bold Young Surgeons Brought Vascular Surgery into Clinical Practice from the Korean War Battlefield.

The maturation of vascular surgery into widespread clinical practice was accelerated by events that took place in Korea during the conflict of 1950-1953. Early research and anecdotal clinical trials were just then resulting in publication of cases of the successful vascular repairs and replacements. Noncrushing vascular clamps were being developed and limited manufacture begun. The stage was set for a major advance in the treatment of arterial injury, just as war commenced in Korea, which provided a clinical laboratory. When the war on the Korean Peninsula erupted in June 1950, the policy of the Army Medical department was to ligate all arterial injuries unless a simple transverse or end-to-end anastomosis could be performed, and repair was "contrary to policy and orders." Despite pressure and threats of "courts martial for vascular repairs" from the senior military medicine leaders-clinical experiments in arterial repair were carried out at Mobile Army Surgical Hospital facilities at battlefield locations across Korea. The young surgeons, mostly draftees and reservists, resisted rigid doctrine and orders to desist, and in the face of threatened punishment, were committed to do the right thing, and ultimately went on to change military medicine and vascular surgery. The "on-the-job" training in vascular surgery that was carried out in Korea by military surgeons who demonstrated substantially higher limb salvage rates energized the field from the battlefield laboratory. Many wounded soldiers had limbs saved by the new techniques in vascular repair pioneered by surgeons in the Korean War, and countless thousands who entered civilian hospitals for emergency vascular surgery in subsequent years also ultimately benefited from their work.

History of lower limb reconstruction after trauma.

BACKGROUND: The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important. METHODS: This is a structured review of historical and recent literature pertinent to lower limb reconstruction. The outcomes assessed in the pre-modern era were wound mortality, amputation mortality and amputation rate. In the modern era, infection and non-union emerged as measures of outcome, which are morbidity- rather than mortality-based. Indications for amputation published during the eras are taken to reflect the reconstructive practices of the time. RESULTS: Amputation and wound mortality fell throughout the pre-modern era, from 70% and 20% to 1.8% and 1.8%, respectively. Amputation rates peaked in the American Civil War (53%) but have remained less than 20% since then. Infection and non-union rates in the modern era have fluctuated between 5% and 45%. CONCLUSIONS: Priority areas for research include refinement of soft tissue reconstruction, injury classification, standardization of outcome measures and primary prevention. The impact of débridement and antisepsis on outcomes should not be forgotten as progress is made.

The path from art to evidence in treating critical limb ischaemia--reflections on 35 years' experience.

Despite numerous attempts, chronic critical limb ischaemia (CLI) has not been unequivocally defined as yet. Its epidemiology is poorly investigated and its prevalence probably higher than anticipated. It is accompanied by high mortality and morbidity irrespective of the way it is treated. Its management is very expensive. Additionally, the prevailing diabetes epidemic is increasing the need for revascularizations although there is a clear lack of evidence as to when to revascularize an ulcerated diabetic foot. The fast development of endovascular techniques blurs the vision as the window of opportunity for gathering proper evidence keeps narrowing. The notion of endovascular artistry prevails, but attempts to conduct proper studies with clear definitions, strict criteria and appropriate outcome measures in a standardised manner should continue--preferably using propensity scoring if randomised controlled trials are not possible. This review highlights some of the steps leading from art to evidence and illustrates the difficulties encountered along the path. In parallel with this overview, the progress of the treatment for CLI in Finland is described from the perspective of the work concluded at Helsinki University Central Hospital.

History of the team approach to amputation prevention: pioneers and milestones.

BACKGROUND: This historical perspective highlights some of the pioneers, milestones, teams, and system changes that have had a major impact on the management of the diabetic foot during the past 100 years. In 1934, American diabetologist Elliott P. Joslin noted that mortality from diabetic coma had fallen from 60% to 5% after the introduction of insulin, yet deaths from diabetic gangrene of the lower extremity had risen significantly. He believed that diabetic gangrene was preventable. His remedy was a team approach that included foot care, diet, exercise, prompt treatment of foot infections, and specialized surgical care. RESULTS: The history of a team approach to management of the diabetic foot chronicles the rise of a new health profession, Podiatric Medicine and Surgery, as well as the emergence of the specialty of Vascular Surgery. The partnership between the diabetologist, vascular surgeon, and podiatrist is a natural one. The complementary skills and knowledge of each can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot care programs have been shown to increase quality of care and reduce amputation rates by 36% to 86%. The development of distal revascularization techniques to restore pulsatile blood flow to the foot has also been a major advancement. CONCLUSION: Diabetic foot patients are among the most complex and vulnerable of all patient populations. Specialized diabetic foot clinics of the 21st century should be multidisciplinary and equipped to coordinate diagnosis, off-loading, and preventive care; perform revascularization procedures; aggressively treat infections; and manage medical comorbidities.