Resection of Anterior and Lateral Muscle Compartments Does Not Preclude Limb Salvage and Functions.

BACKGROUND: Fasciotomy with resection of nonviable muscle is often necessary when there is a delay in compartment syndrome (CS) diagnosis after revascularization. The reported rate of major amputation following missed CS or delayed fasciotomy ranges from 12% to 35%. Herein, the authors present a series of critically ill patients who experienced delayed CS diagnosis and required complete resection of the anterior and/or lateral compartments but still achieved limb salvage and function. METHODS: A retrospective chart review identified five patients from April 2018 to April 2019 within a single institution who met the inclusion criteria. Patient charts were reviewed for demographic data, risk factors, time to diagnosis following revascularization, muscle compartments resected, operative and wound care details, and functional outcome at follow-up. RESULTS: All of the patients developed CS of the lower extremity following revascularization secondary to acute limb ischemia and required two-incision, four-compartment fasciotomies. Further, they all required serial operative debridements to achieve limb salvage; however, there were no major amputations, and all of the patients were walking at follow-up. CONCLUSIONS: Delay in CS diagnosis can have devastating consequences, resulting in major amputation. In cases where myonecrosis is isolated to two or fewer compartments, complete compartment muscle resection can be safely performed, and limb preservation and function can be maintained with aggressive wound management and physical therapy.

Contemporary Endovascular Outcomes for Critical Limb Ischemia Are Still Failing to Meet Society for Vascular Surgery Objective Performance Goals.

OBJECTIVES: The Society for Vascular Surgery (SVS) created Objective Performance Goals (OPGs) for critical limb ischemia (CLI) in 2009. It was previously shown that endovascular therapy for CLI was not meeting these benchmarks. The OPG for all peripheral interventions is <8% for major adverse cardiac events (MACE), <8% for major adverse limb events (MALE), and <3% for major amputation. The goal of this study is to evaluate if outcomes have improved for CLI in recent years, specifically 2015-2018. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients who underwent endovascular intervention for critical limb ischemia from 2011-2018. Cohorts were divided into 2011-2014 and 2015-2018. Primary 30-day outcomes were MACE, MALE, and major amputation. Univariate analyses were performed using the Fisher's exact test and the Wilcoxon rank-sum test. Multivariate analysis comparing groups was performed using inverse probability weights and trend over time analysis was performed using logistic regression with year of intervention as a continuous variable. RESULTS: From 2011 to 2018, 7,168 patients underwent an endovascular intervention for CLI. 28% were classified as "OPG high anatomic risk," and 17% were classified as "OPG high clinical risk." The 2015-2018 cohort vs. the 2011-14 cohort experienced MACE in 3.3% vs. 2.7% (p = .23), MALE in 9.1% vs. 8.9% (p = 0.83), and amputation in 4.0% vs. 4.2% (p = 0.71). When only high anatomic risk patients were considered (n = 1988), MACE was experienced in 2.4% vs. 2.2% (p = 0.87), MALE by 9.5% vs. 10.6% (p = 0.47) and amputation by 5.1% vs. 6.0% (p = 0.40). When only high clinical risk patients were considered (n = 1224), MACE was experienced in 5.2% vs. 3.9% (p = 0.33), MALE by 8.0% vs. 7.4% (p = 0.74) and amputation by 3.9% vs. 3.7% (p = 0.88). Comparing 2015-2018 to the reference 2011-2014, MALE adjusted odds ratio (AOR) = 0.99, 95% CI [0.83-1.18], MACE AOR = 1.19 95% CI [0.88-1.60], and major amputation AOR = 0.91 95% CI [0.70-1.17]. There were no decreases in the trend over time for MALE (AOR per year 0.97, CI [.94-1.02], major amputation (AOR per year: 0.97, CI [0.91-1.03], nor for MACE (AOR per year: 1.05, CI [.98-1.13]). CONCLUSION: Outcomes following endovascular interventions for CLI continue to underperform when compared to OPG benchmarks for MALE and amputations. There is no decrease over time for these target outcomes. Target MACE events remain acceptable despite the increasing clinical complexity of patients being treated.

Negative-Pressure Wound Therapy With Instillation: A Tool in the Multidisciplinary Approach to Limb Function Preservation.

SUMMARY: The multidisciplinary approach to lower extremity function preservation is well established and is globally considered the standard of care. Every member of the team contributes their unique skills and knowledge to patient care. The effective integration of negative-pressure wound therapy with instillation (NPWTi) has fundamentally changed the approach to the infected or contaminated wound. Initially, in conjunction with excisional debridement, NPWTi has demonstrated its utility of expediting wound bed preparation for closure or coverage. With the introduction of a novel foam design, the effectiveness has increased and provided an option in cases where surgical intervention is not available or recommended. The successful implementation and continued monitoring of NPWTi provides an efficient tool to expedite ultimate wound healing and involves all members of the team.

Bone sarcoma surgery in times of COVID-19 pandemic lockdown-early experience from a tertiary centre in India.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) lockdown has presented a unique challenge for sarcoma care. The purpose of this study is to evaluate the early results and feasibility of surgeries for bone sarcomas during the COVID-19 lockdown. METHODS: Our prospectively collected orthopaedic oncological database was reviewed to include two groups of patients- those who underwent surgery in the immediate 4 weeks before lockdown (non-lockdown group) and those operated in the first 4 weeks of lockdown (lockdown group). All patients were followed-up clinically and telephonically to collect the outcome data. RESULTS: Out of the 91 patients who qualified for inclusion, fifty were classified into the non-lockdown group while 41 patients formed the lockdown group. Both the groups were comparable with respect to baseline demographic parameters. However, during the lockdown period 37 patients (90%) had undergone a major surgical intervention as against 24 patients (48%) in the non-lockdown group (P < .001). There was no significant difference in type of anaesthesia, median estimated blood loss and procedure duration. None of the patients/health care workers had evidence of severe acute respiratory syndrome-coronavirus 2 infection at 15 days follow-up. CONCLUSION: Our study results suggest that appendicular bone tumours can be safely operated with adequate precautions during the lockdown period.

Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

A Global Vascular Guidelines-Based Bypass-Preferred Population and Their Surgical Risk Among CLTI Patients Treated With Endovascular Therapy in a Real-World Practice.

PURPOSE: To determine in a chronic limb-threatening ischemia (CLTI) population who underwent endovascular therapy (EVT) how many patients would have been categorized as preferred for bypass surgery according to the Global Vascular Guidelines (GVG) and ascertain their surgical risk. MATERIALS AND METHODS: The current study analyzed 1043 CLTI patients who presented WIfI (wound, ischemia, and foot infection) stage ≥2 and underwent EVT between April 2010 and December 2017. Of these, 176 were excluded for lack of angiographic or other data, leaving 867 CLTI patients (mean age 74±10 years; 523 men) for stratification according to the GVG into bypass-preferred, indeterminate, or EVT-preferred groups. The GVG recommend bypass as the first-line treatment when the wound is severe (WIfI stage ≥3) and lesions are complex (GLASS stage III). Surgical risk was estimated using the modified PREVENT III risk score. To further stratify the bypass-preferred population according to mortality risk, a survival decision tree was constructed using recursive partitioning. RESULTS: The bypass-preferred group accounted for 55% [95% confidence interval (CI) 51% to 58%] of the overall population. The decision tree analysis extracted a low-mortality risk subgroup with a survival rate of 99% (95% CI 98% to 100%) at 1 month and 80% (95% CI 73% to 87%) at 2 years. According to the PREVENT III score, 34% (95% CI 27% to 42%) of the low mortality risk subgroup were classified as high surgical risk. CONCLUSION: A high proportion of patients undergoing EVT were considered bypass preferred based on the GVG, and the survival of these patients was not significantly different whether they were high or low surgical risk.

Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage.

Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still being debated. As a result, care is inconsistent, with many CLI patients undergoing an amputation prior to what many consider to be mandatory: consultation with an interdisciplinary specialty care team and a comprehensive imaging assessment. More importantly, quality imaging is critical in CLI patients with below-the-knee disease. Therefore, the CLI Global Society has put forth an interdisciplinary expert recommendation for superselective digital subtraction angiography (DSA) that includes the ankle and foot in properly indicated CLI patients to optimize limb salvage. A recommended imaging algorithm for CLI patients is included.

Establishing an Evaluation System and Limb-Salvage Protocol for Mangled Lower Extremities in China.

Road traffic accident-related severely injured extremities account for the majority of disabilities in young people in China. Limb-salvage concepts and techniques vary greatly from physician to physician and from district to district in China. Current severity-scoring systems for lower-extremity injuries lack sensitivity and cannot be used as the sole criterion by which amputation decisions are made. China lacks a national database of mangled lower extremities, which is a priority for both limb-salvage protocols and scoring system development.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.

GUIDELINE SUMMARY: Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Survival prediction in patients with chronic limb-threatening ischemia who undergo infrainguinal revascularization.

OBJECTIVE: Accurate survival prediction critically influences decision-making in caring for patients with chronic limb-threatening ischemia (CLTI). The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial demonstrated that in patients who survived >2 years, there was a significant advantage to infrainguinal bypass compared with endovascular intervention, which increased with time. Validated survival models for patients with CLTI are lacking. METHODS: The Vascular Quality Initiative was interrogated for patients who underwent infrainguinal bypass or endovascular intervention for CLTI (January 2003-February 2017). Cox survival models were generated using only preoperative variables. Survival at 30 days, 2 years, and 5 years was modeled separately. Patients were defined as low risk (30-day survival >97% and 2-year survival >70%), medium risk (30-day survival 95%-97% or 2-year survival 50%-70%), and high-risk (30-day survival <95% or 2-year survival <50%). RESULTS: Among 38,470 unique CLTI patients, 63% (n = 24,214) underwent endovascular intervention and 37% (n = 14,256) underwent infrainguinal bypass. Kaplan-Meier estimates of overall survival at 30 days, 2 years, and 5 years were 98%, 81%, and 69%, respectively. The proportion of patients in the low-, medium-, and high-risk groups was 84%, 10%, and 6.5%, respectively. Patients in the low-risk group were significantly less likely to undergo endovascular intervention compared with those in the high-risk group (low risk, 59% endovascular; high risk, 75% endovascular; P < .0001). Independent predictors of death were similar in all three models, with greatest magnitude of effect associated with age >80 years, oxygen-dependent chronic obstructive pulmonary disease, stage 5 chronic kidney disease, and bedbound status. The C index for the 30-day model, 2-year model, and 5-year model was 0.76, 0.72, and 0.71, respectively. Procedure type (open or endovascular) was not significant in any models and did not have an impact on C indices. CONCLUSIONS: These survival prediction models, derived from a large U.S. cohort of patients who underwent revascularization for CLTI, demonstrated good performance and should be validated. Most CLTI patients considered candidates for limb salvage were of average perioperative risk and were predicted to survive beyond 2 years. These models can differentiate patients into low-, medium-, and high-risk groups to facilitate evidence-based revascularization recommendations that are consistent with current treatment guidelines.

Type III open tibia fractures in low-resources setting. Part 1: strategy and principles of limb salvage.

In developing countries, road traffic accidents result in many cases of open trauma, especially fractures, with the tibia area at particular risk in motorcycle crashes. Despite a high prevalence of severe leg trauma with multi-tissue injuries, few studies have focused on the challenge of their reconstruction in these limited-resource settings. The first part of this review presents the surgical strategy. Limitations and principles of initial limb salvage are detailed. Orthopedic procedures for early damage control, based on debridement and temporary bone stabilization, are often required. The priority is to shorten the time to initial surgical management to avoid infection, which jeopardizes reconstruction.

Lower extremity bypass and endovascular intervention for critical limb ischemia fail to meet Society for Vascular Surgery's objective performance goals for limb-related outcomes in a contemporary national cohort.

OBJECTIVE: In 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks in critical limb ischemia (CLI) based on outcomes from randomized trials of lower extremity bypass (LEB). Current performance relative to these benchmarks in both LEB and infrainguinal endovascular intervention (IEI) remains unknown. The objective of this study was to determine whether LEB and IEI performed for CLI in a contemporary national cohort met OPG 30-day safety thresholds. METHODS: SVS OPG criteria were applied to 11,043 revascularizations for CLI performed from 2011 to 2015 in the National Surgical Quality Improvement Program (NSQIP) vascular targeted modules. Primary 30-day safety OPGs including major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and amputation were calculated for the NSQIP LEB (n = 3833) and IEI (n = 3526) cohorts as well as for subgroups at "high anatomic risk" (infrapopliteal revascularization) and "high clinical risk" (age >80 years and tissue loss). These were compared with SVS OPG benchmarks using χ2 comparisons. RESULTS: Compared with the SVS OPG cohort, both the NSQIP LEB and IEI cohorts had fewer patients at high anatomic risk (LEB, 51%; IEI, 27%; SVS OPG, 60%; both P < .0001). The LEB cohort had fewer patients with high clinical risk than the SVS OPG cohort (LEB, 11%; SVS OPG, 16%; P < .0001). The 30-day MALE was significantly higher in the NSQIP LEB (9.0% [8.7%-9.2%]) and IEI (9.7% [9.4%-10.0%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-9.0%]; both P ≤ .007), including significantly higher rates of amputation. MACE was significantly lower in the NSQIP LEB (4.2% [4.1%-4.3%]) and IEI (3.1% [3.0%-3.2%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-8.1%]; both P ≤ .013). Among patients at high anatomic risk, 30-day MALE was significantly higher after LEB (9.5% [9.1%-9.8%]) and IEI (11.1% [10.4-11.8%]) compared with the SVS OPG cohort (6.1% [4.2%-8.6%]; P ≤ .002). Among patients with high clinical risk, IEI was associated with lower MACE compared with the SVS OPG cohort, with similar limb-related outcomes. CONCLUSIONS: In contemporary real-world practice, LEB and IEI for CLI failed to meet SVS OPG limb-related 30-day safety benchmarks for the entire CLI cohort as well as for the patients at high anatomic risk. Additional investigation using SVS OPGs as consistent end points is required to determine why limb-related outcomes after revascularization for CLI remain suboptimal. LEB and IEI surpassed OPG benchmarks for 30-day cardiovascular morbidity and mortality. OPGs for cardiovascular morbidity in patients undergoing revascularization for CLI deserve re-evaluation using contemporary data.

Indicators of outcome quality in peripheral arterial disease revascularisations - a Delphi expert consensus.

INTRODUCTION: Peripheral arterial disease (PAD) affects a continuously increasing number of people worldwide leading to more invasive treatments. Indication to perform invasive revascularisations usually arises from consensus-based recommendations of practice guidelines and from few randomized controlled trials where outcome measures focus mainly on risk factors associated with mortality and morbidity. To date, no broad consensual agreement of experts on valid indicators of outcome quality exists for PAD. METHODS: A literature review was conducted to collect indicators of outcome quality from studies of PAD. The Delphi technique was used to achieve a consensual agreement on a set of core indicators. The expert panel of the two-round Delphi approach was formed by leading vascular specialists joining the IDOMENEO study, physician assistants, wound nurses, and patient representatives. Items were scored via a web-based anonymised electronic questionnaire using a five-point Likert-scale. RESULTS: Out of 40 invited experts 30 joined the panel and completed round one. Twenty-four experts completed the second and final round. Forty-three indicators of outcome quality were initially identified and validated by the panel. After two Delphi rounds, 12 indicators (27.9 %) achieved the limit of agreement for relevance and four (9.3 %) for practicability. Major adverse limb events (MALE), major amputation, and major re-intervention (or re-operation) were consented as both highly relevant and practicable. Additionally, major adverse cardiovascular events (MACE), myocardial infarction, stroke or transient ischaemic attack, all-cause death, all re-intervention (or re-operation), wound infection, vascular access-related major complication, walking distance, and Rutherford-classification were consented as highly relevant. Ankle-brachial-index was consented as highly practicable. CONCLUSIONS: This Delphi approach of vascular experts identified three indicators as highly relevant and clinically practicable to be recommended as indicators of outcome quality in invasive PAD treatment. Among others, these consented items may help in harmonising future studies and quality benchmarking increasing their comparability, validity, and efficiency.

Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer.

AIM: To evaluate the outcomes of diabetic dialysis patients with critical limb ischemia and foot ulcer. METHODS: The study group included 599 diabetic, 99 dialyzed (Ds) (16.5%) and 500 not dialyzed (NDs) (83%) patients with critical limb ischemia and foot ulcers identified as stage C (ischemia) or D (ischemia plus infection) of Texas Wound Classification. All patients were treated by endovascular revascularization. Outcomes were expressed as healing, major amputation, death and non healing after 12months. The mean follow-up was 15±13months. RESULTS: The outcomes of the whole population were: 48.9% healing, 11.3% major amputation, 12.7% death, 27.1 non healing. At the multivariate analysis dialysis was a negative predictor of healing and a positive predictor of major amputation. Outcomes for Ds and NDs were respectively: healing (30.3 vs 52.6%), major amputation (14.4 vs 10.8%), death (21.1 vs 11%) and non-healing (34.2 vs 25.6%) (X=0.0004). Amputation occurred earlier in Ds than in NDs. According to the multivariate analysis in Ds ischemic heart disease and lower ΔTcPO2 were negative predictors for healing. Successful revascularization was a negative predictor for major amputation. HDL and carotid artery disease were predictive factors of death among NDs. Among Ds high blood pressure values were the only predictor of amputation while no variable resulted predictive of healing or death. CONCLUSIONS: Our study shows that our limb salvage protocol ensures a good rate of limb salvage in Ds even if they have a higher risk of amputation and death compared to NDs.

Optimization of Free-Flap Limb Salvage and Maximizing Function and Quality of Life Following Oncologic Resection: 12-Year Experience.

INTRODUCTION: A knowledge gap exists regarding factors to optimize limb salvage and function following oncologic resection. METHODS: We conducted a retrospective review of all free flaps performed for upper extremity (UE) and lower extremity (LE) salvage from 2000 to 2012. RESULTS: Overall, 220 patients underwent free-flap reconstruction for limb salvage (UE: 64, and LE: 156). Flaps were classified as muscle-only (n = 77), myocutaneous (MC; n = 67), or fasciocutaneous (FC; n = 76). Smoking, diabetes, peripheral vascular disease, and prior chemotherapy or radiation had no impact on complications, while osteomyelitis significantly increased the risk of infection (odds ratio [OR] 19.5, confidence interval [95% CI] 3.77-100.64; p = 0.0004), wound healing complications (OR 7.51, 95% CI 2.21-25.49; p = 0.001), and amputation (OR 4.63, 95% CI 1.41-15.19; p = 0.01). Hardware increased the risk for flap loss (OR 4.92, 95% CI 1.33-18.23; p = 0.017). MC and FC flaps had increased risks for hematoma (p = 0.02) and reoperation for microvascular complications (p = 0.005) but were at lower risk for infection (OR 0.14, 95% CI 0.02-0.87; p = 0.03) compared with muscle-only flaps. There were a total of seven total flap losses (3.2%), with significantly increased risks for MC/FC flaps (OR 2.58, 95% CI 1.06-6.26; p = 0.03). For LE, 103 patients (66.3%) were fully ambulatory, while 23 (14.7%) were ambulatory with assistance (mean Musculoskeletal Tumor Society score (MSTS) 80.2, and Karnofsky score 84.0). For UE, 49 patients (76.6%) were able to perform their activities of daily living independently (mean MSTS 80.2, and Karnofsky score 86.0). Overall, 190 patients (86.4%) were successfully salvaged. CONCLUSIONS: Free flaps can be performed reliably for limb salvage following tumor extirpation. While MC/FC flaps demonstrated improved postoperative function, they were at significantly higher risk for take-backs and total flap loss.

Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system.

BACKGROUND: In the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. However failed attempt to limb salvage is related to high risk of mortality for the patient. Several scores were developed to establish guidelines for the decision to amputate or not, however in literature there is no consensus about the reliability of this scores. METHODS: The authors focused their attention on the most used score system to provide guidance of the management of a mangled lower limb. The search term used included mangled lower extremity, MESS, PSI, LSI and NISSSA. The inclusion criteria were: studies dealing with mangled lower extremity; articles reporting MESS, PSI, LSI or NISSSA scores; articles published in English in PubMed, Cochrane, Scopus and web of science in the last 30 years, minimum number of cases in study of 15, minimum follow up of 1 year. RESULTS: According with the criteria described above, we found 134 articles in PubMed, 165 articles in Scopus, 111 articles in the Cochrane Library and 108 articles in Web of Science. The most used score in literature is the MESS. Few results are shown using the other severity scores. There are a lot of controversies in literature about the use of this scale. MESS seems to be more accurate than the LSI in prediction of limb salvage. LSI score shows better results when applied to type III tibial fractures. High sentivity of the PSI score is described when applied to predict successful limb salvage. Low sensitivity and specificity are described for the NISSSA score. The literature is very poor of articles related to mangled lower extremity in children. Higher sensitivity and specificity are described for these scores in children when compared to adult population. CONCLUSION: The mangled lower extremity treatment is a challenge for the surgeon. Many scores were developed to help the surgeon, however they cannot be used as the sole criterion by which amputation decision are made and, in case of succesful limb salvage, they are not predictive of the functional recovery. Moreover, undue enthusiasm for new surgical techniques can lead to increased morbidity and mortality in case of secondary amputation.

Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE).

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

Standardization of rehabilitation after limb salvage surgery for sarcomas improves patients' outcome.

BACKGROUND AND OBJECTIVE: The purpose of this study is to establish a standardized postoperative rehabilitation protocol following limb salvage surgery (LSS) in patients with primary bone sarcoma in five major anatomical locations: distal femur, proximal tibia, proximal and total femur, humerus and shoulder girdle and pelvic resections. SETTING AND DESIGN: Retrospective study. PATIENTS AND METHODS: All LSSs were performed by an orthopedic oncology surgeon, and rehabilitation of all patients was based on a devised standardized rehabilitation protocol. Patient outcomes were measured using the modified Musculoskeletal Tumor Society-International Symposium on the Limb Salvage (MSTS-ISOLS) scoring system. RESULTS: A total of 59 patients received LSS in the above mentioned locations; endoprostheses were used in 49, bone allograft in five, while no replacements were made in five patients. At a mean follow-up of 24 months, the mean modified MSTS-ISOLS score for all patients was 87% (95% CI; 0.85-0.89). The highest scores were encountered for patients with distal femur replacement: 93% (95% CI; 0.91-0.95). Seven patients had interruption of more than six weeks in their rehabilitation and had a mean score of 71% (95% CI; 0.64-0.82). CONCLUSION: The proposed rehabilitation protocol is a comprehensive, organized and applicable guideline to be used after performing LSS at the above mentioned anatomical locations. The use of standardized rehabilitation protocol resulted in improved patient functional outcome.