Day-of-Free Tissue Transfer Qualitative Cultures Do Not Predict Limb Salvage Outcomes.

BACKGROUND: Successful free tissue transfer is critical for lower extremity salvage in the chronic wound population. The rates of lower extremity free tissue transfer success lag behind those for other anatomical sites. The aim of this study was to evaluate whether positive qualitative day-of-free tissue transfer cultures or pathogen virulence negatively impacts short- and long-term outcomes of lower extremity free tissue transfer. METHODS: Between April of 2011 and January of 2018, 105 lower extremity free tissue transfer procedures were performed. Growth level and speciation were identified from qualitative cultures taken during free tissue transfer. The relationship between demographics, comorbidities, culture data, postoperative infection, free tissue transfer survival, and long-term limb salvage was examined using logistic regression. RESULTS: The median Charlson Comorbidity Index was 3. Intraoperative free tissue transfer cultures were positive in 39.1 percent. Flap survival was 93.3 percent. Postoperative infection developed in 12.4 percent. The limb salvage rate was 81.0 percent. Positive culture was not significant for flap survival, postoperative infection, or amputation. Cultures positive for Enterococcus species had a significant relationship with flap success (OR, 0.08; p = 0.01) and amputation (OR, 7.32; p = 0.04). Insufficient antimicrobial coverage had a significant relationship with postoperative infection (OR, 6.56; p = 0.01) despite the lack of pathogen concordance. On multivariate analysis, postoperative infection (OR, 12.85; p < 0.01) and Charlson Comorbidity Index were predictive of eventual amputation (OR, 1.44; p = 0.01). CONCLUSIONS: Positive day-of-free tissue transfer cultures, regardless of pathogen, had limited predictive value for short- and long-term outcomes of free tissue transfer in the authors' cohort. These findings call for a broader multicenter prospective analysis and consideration of health care-associated infections and their impact on limb salvage outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

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.

Varying rates of patient identity verification when using computerized provider order entry.

OBJECTIVE: We sought to determine rates of computerized provider order entry (CPOE) patient identity verification and when and where in the ordering process verification occurred. MATERIALS AND METHODS: Fifty-five physicians from 4 healthcare systems completed simulated patient scenarios using their respective CPOE system (Epic or Cerner). Eye movements were recorded and analyzed. RESULTS: Across all participants patient id was verified significantly more often than not (62.4% vs 37.6%). Vendor A had significantly higher verification rates than not; vendor B had no difference. Participants using vendor A verified information significantly more often before signing the order than after (88.4% vs 11.6%); there was no difference in vendor B. The banner bar was the most frequent verification location. DISCUSSION: Factors such as CPOE design, physician training, and the use of a simulated methodology may be impacting verification rates. CONCLUSIONS: Verification rates vary by CPOE product, and this can have patient safety consequences.