Amputations versus Salvage: Reconciling the Differences.

BACKGROUND: There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. METHODS: In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. RESULTS: The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. CONCLUSION: Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.

Postoperative wound dehiscence: Predictors and associations.

The Agency for Healthcare Research and Quality patient safety indicators (PSI) were developed as a metric of hospital complication rates. PSI-14 measures postoperative wound dehiscence and specifically how often a surgical wound in the abdominal or pelvic area fails to heal after abdominopelvic surgery. Wound dehiscence is estimated to occur in 0.5-3.4% of abdominopelvic surgeries, and carries a mortality of up to 40%. Postoperative wound dehiscence has been adopted as a surrogate safety outcome measure as it impacts morbidity, length of stay, healthcare costs and readmission rates. Postoperative wound dehiscence cases from the Nationwide Inpatient Sample demonstrate 9.6% excess mortality, 9.4 days of excess hospitalization and $40,323 in excess hospital charges relative to matched controls. The purpose of the current study was to investigate the associations between PSI-14 and measurable medical and surgical comorbidities using the Explorys technology platform to query electronic health record data from a large hospital system serving a diverse patient population in the Washington, DC and Baltimore, MD metropolitan areas. The study population included 25,636 eligible patients who had undergone abdominopelvic surgery between January 1, 2008 and December 31, 2012. Of these cases, 786 (2.97%) had postoperative wound dehiscence. Patient-associated comorbidities were strongly associated with PSI-14, suggesting that this indicator may not solely be an indicator of hospital safety. There was a strong association between PSI-14 and opioid use after surgery and this finding merits further investigation.

Oxygen and wound care: a review of current therapeutic modalities and future direction.

While the importance of oxygen to the wound healing process is well accepted, research and technological advances continue in this field and efforts are ongoing to further utilize oxygen as a therapeutic modality. In this paper, the authors briefly review the role of oxygen in wound healing and discuss the distinct mechanism of action as well as the advantages and disadvantages of the three major oxygen-based therapies currently in clinical use (Hyperbaric Oxygen and Topical Oxygen and Continuous Diffusion of Oxygen), as well as review the existing literature regarding these distinct therapeutic modalities.

Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients.

BACKGROUND: Lower extremity soft tissue defects pose a challenging problem to patients with comorbidities. Reconstruction with tissue transfer offers an effective alternative to amputation in this population. Although abundant with data on success and complication rates, the literature has not focused on assessing patient-centered outcomes of these reconstructive procedures. METHODS: A systematic review was performed by searching an electronic database for relevant studies. The full text of relevant articles was retrieved and the reference lists of those articles reviewed. Single case reports or articles reporting data on wounds sustained from trauma were excluded. RESULTS: In total, 318 articles were identified. After applying inclusion and exclusion criteria, 50 articles reporting data on 1,079 flaps remained for inclusion in this review. Ambulation outcomes were reported by 35 articles with a weighted mean rate of postoperative ambulation of 77.4%. Postoperative time to ambulation ranged from an average of 9 months to 22 months. Quality of life and patient satisfaction outcomes were infrequently and inconsistently reported in the literature. CONCLUSION: There is a dearth of patient-centered outcomes for lower extremity flap reconstruction currently in the literature. A standardized method to assessing patient-centered outcomes should be employed to better understand the effectiveness of these procedures.Level of Evidence III Therapeutic.

The Utility of Preoperative Venous Testing for Lower Extremity Flap Planning in Patients with Lower Extremity Wounds.

BACKGROUND: Although venous thrombosis is a leading cause of flap failure, the majority of lower extremity free flap planning is centered on arterial system evaluation. Preoperative identification of relevant abnormality in lower extremity venous systems by means of duplex ultrasound may aid in the diagnosis of clinically important abnormality that could affect lower extremity flap outcomes. METHODS: Between November of 2014 and August of 2017, 57 patients underwent preoperative lower extremity venous duplex imaging and free tissue transfer for lower extremity wounds. A retrospective review was performed to describe lower extremity venous pathologic findings, relevant patient demographic data, comorbid conditions, and outcomes. Discovery of venous abnormality helped guide recipient vein selection. RESULTS: Fifty-seven consecutive patients underwent 59 free flap operations to treat chronic lower extremity wounds. Venous duplex ultrasonography detected venous insufficiency (defined as >0.5 second of reflux) in 23 patients (39.0 percent), including 16 (27.2 percent) with deep thigh reflux, six (10.2 percent) with superficial calf reflux, and four (6.78 percent) with deep calf reflux. Deep venous thrombosis was found in four patients (6.78 percent) and treated with anticoagulation. The flap success rate was 98.3 percent. Five patients (8.47 percent) progressed to amputation. At a mean follow-up time of 15.1 ± 9.51 months (range, 1.67 to 35.2 months), 53 patients (89.8 percent) were able to continue community ambulation. CONCLUSIONS: Lower extremity venous duplex testing before free tissue transfer may be useful for optimizing flap recipient vessel selection and for detecting potentially unknown venous abnormality. Development of free flap planning protocols incorporating preoperative vascular imaging is important to achieving good functional outcomes in this comorbid patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Pedicled and Free Tissue Transfers.

Tissue defects that result from diabetic foot infections are often complex and necessitate reconstructive soft-tissue surgery to achieve closure. Intrinsic muscle flaps of the foot require attention to major vascular pedicles and are useful for closing smaller ulcerations. Microvascular free flaps are beneficial for large defects and provide long-term survivability. Perioperative planning is an important aspect of caring for diabetic patients requiring reconstructive surgery. These techniques are valuable tools for use in efforts to preserve a functional limb in this patient population.

Negative pressure wound therapy with intermittent instillation of rifampin for the treatment of an infected vascular bypass graft.

Negative pressure wound therapy with intermittent instillation, especially with the addition of antibiotics in the case of infection, is a versatile treatment modality for the closure of wounds and can be used both primarily after débridement and secondarily after failure of muscle flap coverage. We present a case in which negative pressure wound therapy with intermittent instillation of rifampin was used to successfully close a groin wound secondary to an infected prosthetic vascular graft that initially failed to close with a muscle flap. Consideration of this approach to wound closure and graft salvage is important because of the seriousness and relatively common incidence of prosthetic vascular graft infection after infrainguinal arterial bypass revascularization.

The Utility of Preoperative Arteriography for Free Flap Planning in Patients with Chronic Lower Extremity Wounds.

BACKGROUND: In patients with lower extremity wounds, free tissue transfer is often the last option before amputation, making it crucial to optimize preoperative planning to prevent flap breakdown. No consensus exists regarding preoperative vascular workup before lower extremity free tissue transfer. In this study, the authors analyzed the utility of using arteriography for lower extremity free flap planning. METHODS: A retrospective review was performed of 57 patients who underwent lower extremity arteriography and 59 free flap operations for lower extremity wounds between November of 2014 and August of 2017. Findings were used to guide flap recipient vessel selection. Arterial abnormality was addressed by means of endovascular intervention, where appropriate. Encountered abnormality was described and patient demographics, comorbidities, and outcomes were analyzed for correlation with abnormal angiographic studies. RESULTS: Angiographic abnormalities were observed in 40 patients (67.8 percent), including 23 (57.5 percent) with stenosis/occlusion, 20 (50.0 percent) with atretic/nonvisualized vessels, and 11 (27.5 percent) requiring endovascular intervention. Stenosis/occlusion was detected in nine patients (15.3 percent) with no previously known arterial disease, leading to a new diagnosis of peripheral vascular disease. The flap survival rate was 98.3 percent, six patients (10.2 percent) ultimately progressed to amputation, and 53 patients (89.8 percent) were able to continue community ambulation at a mean follow-up time of 15.1 ± 9.51 months (range, 1.67 to 35.2 months). After arteriography, two patients (3.39 percent) suffered contrast-induced acute kidney injury. No other complications were noted. CONCLUSION: Preoperative lower extremity arteriography aids in the diagnosis of peripheral vascular disease, allows for timely endovascular intervention, and allows for optimal flap recipient vessel selection with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENC: Diagnostic, IV.

Outcomes of Split-thickness Skin Grafting for Foot and Ankle Wounds in Patients With Peripheral Arterial Disease.

INTRODUCTION: Tissue ischemia resulting from arterial insufficiency is a major factor affecting lower extremity wound healing in patients with peripheral arterial disease (PAD). Accelerated wound closure with split-thickness skin grafting (STSG) provides a durable barrier to infection and can prevent limb loss. Published STSG outcomes data are minimal in the post endovascular intervention population. OBJECTIVE: In this study, the authors examine factors predictive of STSG healing in patients with PAD following vascular intervention, including the effect of non-inline flow via arterial-arterial and non-arterial collateralization. MATERIALS AND METHODS: Patients with PAD and wounds of the foot and ankle who underwent STSG between January 2014 and December 2016 were retrospectively reviewed. All patients received angiographic evaluation and endovascular or open revascularization where necessary. Effects of extremity revascularizations, STSG percent take, and amputation rate were evaluated. RESULTS: Thirty-five patients with 47 wounds underwent STSG. There were 21 men and 14 women with a mean age of 64 ± 13 years. Revascularization was required in 23 patients (25 extremities) before STSG, with balloon angioplasty for tibial artery lesions as the most common revascularization. Patent pedal arch was present in 8 patients; 35 patients had an absent or incomplete pedal arch. Patients with a fully patent pedal arch healed at a significantly higher rate than those with an absent or incomplete pedal arch at 1 month (62.5% vs. 17.1%, P ⟨ .05). At 90-day follow-up, 9 of 35 (25.7%) patients with 9 of 47 (19.1%) wounds were lost to follow-up, leaving 18 of 38 (47.37%) wounds healed and 20 (52.63%) still open. Ultimately, 36 of 47 (76.60%) wounds healed and 6 major amputations in 6 patients were required at a mean 502 ± 342 days follow-up. CONCLUSIONS: These results suggest the importance of arterial-arterial connections such as the pedal arch to the healing potential of foot and ankle wounds after STSG in this high-risk patient population.

Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty.

BACKGROUND: In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. METHODS: A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. RESULTS: A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. CONCLUSIONS: Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.

Functional reconstruction of a combined tendocutaneous defect of the achilles using a segmental rectus femoris myofascial construct: a viable alternative.

The composite anterolateral thigh flap with vascularized fascia lata has emerged as a workhorse at our institution for complex Achilles defects requiring both tendon and soft tissue reconstruction. Safe elevation of this flap, however, is occasionally challenged by absent or inadequate perforators supplying the anterolateral thigh. When discovered intraoperatively, alternative options derived from the same vascular network can be pursued. We present the case of a 74-year-old male who underwent composite Achilles defect reconstruction using a segmental rectus femoris myofascial free flap. Following graduated rehabilitation, postoperatively, the patient resumed full activity and was able to ambulate on his tip-toes. At 1-year follow-up, active total range of motion of the reconstructed ankle exceeded 85% of the unaffected side, and donor site morbidity was negligible. American Orthopaedic Foot and Ankle Society and Short Form-36 scores improved by 78.8% and 28.8%, respectively, compared to preoperative baseline assessments. Based on our findings, we advocate for use of the combined rectus femoris myofascial free flap as a rescue option for reconstructing composite Achilles tendon/posterior leg defects in the setting of inadequate anterolateral thigh perforators. To our knowledge, this is the first report to describe use of this flap for such an indication.

Survey on ventral hernias: surgeon indications, contraindications, and management of large ventral hernias.

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons' perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons' perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

The importance of limb preservation in the diabetic population.

OBJECTIVE: Limb salvage in the diabetic population is complex, controversial, costly and variable throughout the world. Within the diabetic population, the indications and morbidity surrounding major leg amputation have not been well defined. RESEARCH DESIGN AND METHODS: A retrospective study of the Georgetown Limb Salvage Registry was conducted to determine outcomes in diabetic patients undergoing proximal forefoot/midfoot (PF/M) amputations and to help define the indications for major leg amputation in ambulatory diabetic patients. RESULTS: Of the 937 ambulatory diabetic patients identified during this time period, 808 who presented with superficial ulcers or distal forefoot disease and who did not go on to PF/M or higher amputation were eliminated. Records of 88 patients (92 limbs) in the PF/M amputation group and 25 patients in the below the knee amputation (BKA) group were reviewed (no above knee amputations were performed). At 2 years in the PF/M amputation group, 80% (70/88) of patients were still alive, 73% (68/92) of the limbs remained intact, and 64% of patients (56/88) were ambulatory. In contrast, in the BKA population at 2 years, 52% (13/25) of patients were deceased and 64% (16/25) were ambulating with a prosthetic limb (or had been ambulating at the time of death). The only statistically significant difference between these two groups was the presence of Charcot collapse and rear-foot disease in the BKA group. CONCLUSION: Aggressive efforts at salvage with PF/M amputation procedures should be entertained prior to higher level amputations due to the increased morbidity and mortality evidenced.

Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization.

BACKGROUND: Ian Taylor introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries. Understanding the angiosomes of the foot and ankle and the interaction among their source arteries is clinically useful in surgery of the foot and ankle, especially in the presence of peripheral vascular disease. METHODS: In 50 cadaver dissections of the lower extremity, arteries were injected with methyl methacrylate in different colors and dissected. Preoperatively, each reconstructive patient's vascular anatomy was routinely analyzed using a Doppler instrument and the results were evaluated. RESULTS: There are six angiosomes of the foot and ankle originating from the three main arteries and their branches to the foot and ankle. The three branches of the posterior tibial artery each supply distinct portions of the plantar foot. The two branches of the peroneal artery supply the anterolateral portion of the ankle and rear foot. The anterior tibial artery supplies the anterior ankle, and its continuation, the dorsalis pedis artery, supplies the dorsum of the foot. Blood flow to the foot and ankle is redundant, because the three major arteries feeding the foot have multiple arterial-arterial connections. By selectively performing a Doppler examination of these connections, it is possible to quickly map the existing vascular tree and the direction of flow. CONCLUSIONS: Detailed knowledge of the vascular anatomy of the foot and ankle allows the plastic surgeon to plan vascularly sound reconstructions, the foot and ankle surgeon to design safe exposures of the underlying skeleton, and the vascular surgeon to choose the most effective revascularization for a given wound.

The use of calcium hydroxylapatite for nipple projection after failed nipple-areolar reconstruction: early results.

Numerous studies have shown that the final stage in breast reconstruction, creation of the nipple-areolar complex, correlates highly with patient satisfaction and acceptance of body image. There are many different techniques, including nipple sharing, free-composite grafts, and local "pull-out" flaps, all of which are vulnerable to an unpredictable degree of loss of projection and possible need for reoperation. This leads to problems with symmetry and overbuilding the initial reconstruction with wider-based, larger flaps, which may cause breast-contour changes. We have used calcium hydroxylapatite (Radiesse, Bioform Inc., Franksville, WI) following nipple-areolar reconstruction to maintain or restore projection in selected breast-reconstruction patients. Approximately 0.4-1 mL of calcium hydroxylapatite was injected subdermally using a 27-gauge needle in 6 selected patients. All patients tolerated the office procedure well without the need for local anesthesia. We report initial short-term success, with 100% patient satisfaction, minimal loss of projection, and no complications. Semipermanent injectable soft-tissue fillers such as calcium hydroxylapatite may be useful in selected patients as a simple solution to the difficult problem of the lack of nipple projection following reconstruction.