RESUMEN
Several challenges exist for the foot and ankle surgeon when addressing the complications associated with ankle fracture repair. The risk of joint destruction, debilitation, and even limb loss may be amplified by the noncompliant patient. There is an abundance of literature documenting the management of fracture nonunions in the setting of infection with a variety of techniques proven successful in managing large osseous defects and eradicating infection. We present a particularly challenging case in which we modified an existing method of treatment to preserve the ankle joint of a failed reduction complicated by septic nonunion following placement of a fibular intramedullary nail.
Asunto(s)
Fijación Intramedular de Fracturas , Fracturas no Consolidadas , Recuperación del Miembro , Humanos , Fracturas no Consolidadas/cirugía , Fracturas no Consolidadas/etiología , Fijación Intramedular de Fracturas/efectos adversos , Recuperación del Miembro/métodos , Peroné/cirugía , Peroné/lesiones , Masculino , Clavos Ortopédicos/efectos adversos , Fracturas de Tobillo/cirugíaRESUMEN
OBJECTIVE: To evaluate presentations, aetiologies, interventions, and outcomes of patients presenting with acute limb ischaemia (ALI). STUDY DESIGN: An observational study. Place and Duration of the Study: Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2000 to December 2020. METHODOLOGY: Record of 104 patients who underwent surgical interventions for ALI was retrospectively evaluated. The diagnosis was confirmed on imaging (ultrasound / CTA / conventional angiography). Demographic characteristics, co-morbidities, aetiologies, and outcomes were analysed using descriptive statistics and logistic regression. RESULTS: The cohort's mean age was 58.89 ± 12.6 years, with (54.8%, n = 57) females and (45.2%, n = 47) males. Hypertension (54.8%, n = 57), diabetes (46.2%, n = 48), and atrial fibrillation (34.6%, n = 36) were common comorbidities. Thromboembolism (67.3%, n = 70) and thrombotic occlusion (32.7%, n = 34) were primary aetiologies, predominantly affecting the lower limb (66.3%, n = 58) and femoral artery (51.9%, n = 54). The majority of cases were classified as Rutherford classification 2A (53.8%; 56 cases) and 2B (44.2%; 46 cases); 58 (55.8%) patients were classified as ASA Class III, while 36 (34.6%) patients were categorised as ASA Class IV. Embolectomy (80.8%, n = 84) was the prevailing intervention, with an amputation rate (17.3%, n = 18) and a mortality rate (5.8%, n = 6). CONCLUSION: Most patients with ALI presented with Rutherford Class II and had thromboembolism aetiology. Embolectomy was the most commonly performed procedure with a high amputation rate and mortality. KEY WORDS: Acute limb ischaemia, Embolectomy, Amputation, Thromboembolism.
Asunto(s)
Amputación Quirúrgica , Isquemia , Humanos , Femenino , Masculino , Persona de Mediana Edad , Isquemia/cirugía , Estudios Retrospectivos , Pakistán/epidemiología , Anciano , Enfermedad Aguda , Amputación Quirúrgica/estadística & datos numéricos , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Embolectomía/métodos , Recuperación del Miembro/métodos , AdultoRESUMEN
OBJECTIVE: Reversed great saphenous vein (GSV) graft is widely used for revascularization in limb-sparing surgery for sarcoma invading great vessels. However, a mismatch in caliber between the reverse graft and cut end of the artery can threaten graft patency. Recently, we introduced the use of a venous valvulotome to allow nonreversed GSV graft. The purpose of this study was to evaluate the safety and versatility of this technique. DESIGN: We retrospectively compared long-term patency and limb salvage rates between nonreversed GSV and reversed GSV in patients undergoing limb-sparing surgery for sarcoma. METHODS: Thirty-seven patients were included, with 21 in the nonreversed GSV group and 16 in the reversed GSV group. Patient characteristics, surgical details, and complications were reviewed from the hospital records. The patency of the reconstructed vessels was assessed using contrast-enhanced CT or MRI. Statistical analyses, including Kaplan-Meier survival analysis, were employed for comparisons. RESULTS: The median follow-up was 38 months. Overall graft patency was 90.4% (19 of 21 patients) in the nonreversed GSV group and 81.2% (13 of 16) in the reverse GSV (RGSV) group. In the nonreversed GSV group, there was 1 case of graft occlusion each in the acute and chronic phases, but limb circulation remained intact and all limbs were spared. CONCLUSION: Nonreversed GSV grafting with valvulotome offers a safe and versatile alternative to reversed GSV grafts in limb-sparing sarcoma surgery. It eliminates the need for vein reversal and minimizes diameter mismatch, potentially expanding the indication for autologous revascularization to previously ineligible cases.
Asunto(s)
Recuperación del Miembro , Extremidad Inferior , Vena Safena , Sarcoma , Grado de Desobstrucción Vascular , Humanos , Vena Safena/trasplante , Masculino , Femenino , Estudios Retrospectivos , Sarcoma/cirugía , Persona de Mediana Edad , Adulto , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Anciano , Recuperación del Miembro/métodos , Procedimientos de Cirugía Plástica/métodos , Adolescente , Adulto Joven , Resultado del Tratamiento , Neoplasias de los Tejidos Blandos/cirugíaRESUMEN
Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment.
Asunto(s)
Colgajos Quirúrgicos , Humanos , Colgajos Quirúrgicos/irrigación sanguínea , Extremidad Superior/cirugía , Extremidad Superior/lesiones , Recuperación del Miembro/métodos , Procedimientos de Cirugía Plástica/métodos , Traumatismos del Brazo/cirugíaRESUMEN
Pediatric bone sarcomas, particularly osteosarcomas, present unique challenges in the realm of orthopedic oncology, given their predilection for the metaphyseal regions of long bones and the intricate balance required between achieving oncologic control and preserving limb function. This abstract encapsulates findings from a comprehensive review aimed at advancing pediatric bone sarcoma care, focusing on navigating the complications and innovating solutions for complications of limb salvage and reconstruction focusing on limb length inequalities and accompanying bone defects. Advancements in imaging, surgical techniques, and adjuvant therapies have shifted the paradigm from amputation to limb-sparing surgeries, albeit with significant challenges, especially in young patients where growth potential complicates reconstructive outcomes. The series highlights the complexity of managing limb length discrepancies (LLD), the cornerstone of limb salvage challenges, and the innovative approaches to address them, including modular endoprosthetic reconstruction with expandable prostheses, magnetic lengthening nails and biological reconstruction strategies like vascularized fibula grafts. This review underlines the importance of a multidisciplinary approach in managing pediatric bone sarcomas, where the aim extends beyond mere survival to ensuring quality of life through functional limb preservation. It highlights the need for ongoing innovation in surgical and reconstructive techniques tailored to the pediatric population's unique needs, emphasizing the potential of emerging technologies and methodologies to improve outcomes. Future research should aim to fill the existing knowledge gaps, particularly in comparing pediatric and adult surgical outcomes, to refine treatment protocols and improve patient care in this challenging domain.
Asunto(s)
Neoplasias Óseas , Recuperación del Miembro , Osteosarcoma , Procedimientos de Cirugía Plástica , Humanos , Recuperación del Miembro/métodos , Neoplasias Óseas/cirugía , Niño , Osteosarcoma/cirugía , Procedimientos de Cirugía Plástica/métodos , Diferencia de Longitud de las Piernas/cirugía , Diferencia de Longitud de las Piernas/etiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
Chronic limb-threatening ischemia is defined as ischemic rest pain or tissue loss (eg, ulceration/gangrene) that has been present for greater than 2 weeks. Workup includes a careful history, physical examination focused on evaluation of pulses and wounds, lower extremity noninvasive vascular studies (eg, ankle-brachial indices, toe pressures), saphenous vein mapping, and imaging of the lower extremity arterial anatomy (eg, computed tomography, magnetic resonance, or subtraction angiography) if a revascularization intervention is planned.
Asunto(s)
Procedimientos Endovasculares , Isquemia , Humanos , Procedimientos Endovasculares/métodos , Isquemia/cirugía , Isquemia/etiología , Enfermedad Crónica , Procedimientos Quirúrgicos Vasculares/métodos , Extremidad Inferior/irrigación sanguínea , Isquemia Crónica que Amenaza las Extremidades/cirugía , Recuperación del Miembro/métodosRESUMEN
PURPOSE OF REVIEW: The prevalence of peripheral artery disease is growing, with millions of people globally suffering its end-stage manifestation, chronic limb-threatening ischemia (CLTI). Revascularization procedures like lower extremity bypass play a vital role in limb salvage but optimal medical therapy is essential for maximizing the benefit of these procedures and reducing long-term risks of cardiovascular and limb-related events. RECENT FINDINGS: Patients with PAD who undergo lower extremity bypass warrant a comprehensive approach to risk factor modification for both primary and secondary prevention of cardiovascular and limb-related complications. This includes appropriate use of high-intensity statins, smoking cessation, and management of hypertension and diabetes. Additionally, antiplatelet therapy is indicated for all patients with CLTI and additional treatment with low-dose anticoagulation may also be beneficial. SUMMARY: Optimal medical therapy is essential for optimizing outcomes in patients with PAD undergoing lower extremity bypass.
Asunto(s)
Extremidad Inferior , Enfermedad Arterial Periférica , Humanos , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/tratamiento farmacológico , Extremidad Inferior/cirugía , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Isquemia Crónica que Amenaza las Extremidades/cirugía , Cese del Hábito de Fumar/métodos , Factores de Riesgo , Anticoagulantes/uso terapéutico , Recuperación del Miembro/métodosRESUMEN
BACKGROUND: Limb salvage surgery is an important method for treating malignant tumors of the bone involving the adjacent parts of the major joints in children. This technique allows for preservation of limb function, especially in the lower limb. However, the reconstruction of the proximal end of the tibia after removing the tumor mass with a rational scale to preserve the total knee joint and reduce limb length discrepancy presents a challenge. CASE PRESENTATION: We present a case of osteosarcoma of the proximal tibia. After being treated with an extended tumor resection, the proximal tibia of the child was restructured using endoprosthetic replacement with epiphyseal preservation. This procedure preserves the entire articular surface and growth plate of the knee joint of the affected limb and provides a feasible alternative protocol for retaining the function and growth potential of the affected limb. The patient remained disease-free and normal limb motor function was observed during the 3.5 year follow-up since the initial surgery. CONCLUSIONS: Preservation of the epiphysis enabled our patient to perform better limb function after limb-saving surgery as a result of his undamaged knee joint and minimized limb-length discrepancy. We believe that endoprosthetic replacement with preservation of the epiphysis can provide the best strategy for reconstruction after resection of focal malignant tumors in long bones without epiphytic involvement.
Asunto(s)
Neoplasias Óseas , Epífisis , Recuperación del Miembro , Osteosarcoma , Tibia , Humanos , Osteosarcoma/cirugía , Tibia/cirugía , Tibia/diagnóstico por imagen , Neoplasias Óseas/cirugía , Epífisis/cirugía , Masculino , Recuperación del Miembro/métodos , Niño , Procedimientos de Cirugía Plástica/métodos , Articulación de la Rodilla/cirugía , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/fisiopatología , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Bases de Datos Factuales , Pie Diabético , Osteomielitis , Infecciones de los Tejidos Blandos , Humanos , Pie Diabético/cirugía , Pie Diabético/epidemiología , Masculino , Femenino , Persona de Mediana Edad , Osteomielitis/epidemiología , Osteomielitis/cirugía , Anciano , Infecciones de los Tejidos Blandos/epidemiología , Resultado del Tratamiento , Estudios Prospectivos , Recuperación del Miembro/estadística & datos numéricos , Recuperación del Miembro/métodosRESUMEN
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.
Asunto(s)
Amputación Traumática , Lesiones por Aplastamiento , Traumatismos del Antebrazo , Procedimientos de Cirugía Plástica , Traumatismos de la Muñeca , Humanos , Estudios Retrospectivos , Adulto , Masculino , Persona de Mediana Edad , Traumatismos del Antebrazo/cirugía , Procedimientos de Cirugía Plástica/métodos , Lesiones por Aplastamiento/cirugía , Femenino , Traumatismos de la Muñeca/cirugía , Amputación Traumática/cirugía , Adulto Joven , Recuperación del Miembro/métodos , Protocolos Clínicos , Colgajos Tisulares Libres/trasplante , Colgajos Tisulares Libres/irrigación sanguínea , Colgajos Quirúrgicos/irrigación sanguínea , Colgajos Quirúrgicos/trasplante , Resultado del Tratamiento , Desbridamiento/métodosRESUMEN
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.
Asunto(s)
Fémur , Humanos , Fémur/cirugía , Recuperación del Miembro/métodos , Resultado del Tratamiento , Masculino , Femenino , Neoplasias Femorales/cirugía , Insuficiencia del TratamientoRESUMEN
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.
Asunto(s)
Colgajos Tisulares Libres , Congelación de Extremidades , Recuperación del Miembro , Microcirugia , Procedimientos de Cirugía Plástica , Humanos , Congelación de Extremidades/cirugía , Estudios Retrospectivos , Recuperación del Miembro/métodos , Colgajos Tisulares Libres/trasplante , Masculino , Femenino , Adulto , Microcirugia/métodos , Procedimientos de Cirugía Plástica/métodos , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven , Adolescente , Puntaje de Gravedad del Traumatismo , Traumatismos de los Tejidos Blandos/cirugía , NiñoRESUMEN
BACKGROUND: Although comminuted fractures, osteomyelitis, large skin ulcers, and malignant tumors are rarely seen in the calcaneus, it is a problematic region to treat because it is not an actual compartment and has insufficient blood supply. Few foot and ankle surgeons would recommend total calcanectomy in various cases of malignant tumors, comminuted fractures, ulcerations of the heel often seen in diabetic patients, and chronic osteomyelitis. After calcanectomy, if functional reconstruction is not performed, the patient will experience loss of function, pain, wound problems, talonavicular dislocations, and additional surgical interventions. In this study, we demonstrate calcanectomy and simultaneous functional reconstruction techniques while discussing the patients' results. METHODS: We retrospectively evaluated three patients who underwent total calcanectomy between January 1, 2001, and December 31, 2020.Two of these procedures were due to osteomyelitis of the calcaneus after trauma, and one was due to a chondroblastic osteosarcoma of the calcaneus. RESULTS: The patients were followed up for an average of 116 months. None of the patients developed problems with their wounds in the postoperative term or during follow-up. CONCLUSIONS: Total calcanectomy as a surgical method of limb salvage yields successful results. We believe that these results can be improved with functional reconstruction and rehabilitation with custom-made shoes, and the results do not entail additional morbidity or require additional hindfoot bone reconstruction.
Asunto(s)
Calcáneo , Procedimientos de Cirugía Plástica , Humanos , Calcáneo/cirugía , Estudios Retrospectivos , Masculino , Femenino , Adulto , Procedimientos de Cirugía Plástica/métodos , Persona de Mediana Edad , Osteomielitis/cirugía , Recuperación del Miembro/métodos , Neoplasias Óseas/cirugíaRESUMEN
AIMS: This study assessed whether changes associated with cerebral small vessel disease (CSVD) evaluated from head computed tomography (CT) images captured for non-related clinical purposes predict overall survival (OS), leg salvage (LS), and amputation-free survival (AFS) after lower extremity amputation (LEA). METHODS: We retrospectively included a cohort of 240 patients who had undergone a lower extremity amputation in Tampere University Hospital between the years 2007 and 2020 and had a head CT scan (within one year before amputation). A neuroradiologist graded the white matter lesions (WMLs) and reported infarcts, and the latter's effects on OS, LS, and AFS were evaluated. RESULTS: Altogether, 162 (67.5 %) and 91 (38.1 %) patients had WMLs and infarcts, respectively. Mild/moderate (HR 1.985, CI 95 % 1.317-2.992) and severe (HR 2.259, CI 95 % 1.501-3.399) WMLs and infarcts (HR 1.413, CI 95 % 1.029-1.940) were associated with inferior OS. After a minor amputation, mild/moderate (HR 2.012, CI 95 % 1.054-3.843) and severe (HR 3.879, CI 95 % 2.096-7.180) WMLs were similarly associated with inferior AFS. CONCLUSIONS: Overall, WML and infarcts detected on head CT scans were associated with impaired OS after LEA and AFS after minor LEA. Evaluation of CSVD could provide useful prognostic information for clinicians.
Asunto(s)
Amputación Quirúrgica , Enfermedades de los Pequeños Vasos Cerebrales , Extremidad Inferior , Humanos , Masculino , Amputación Quirúrgica/estadística & datos numéricos , Femenino , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Enfermedades de los Pequeños Vasos Cerebrales/complicaciones , Enfermedades de los Pequeños Vasos Cerebrales/epidemiología , Enfermedades de los Pequeños Vasos Cerebrales/cirugía , Enfermedades de los Pequeños Vasos Cerebrales/diagnóstico por imagen , Enfermedades de los Pequeños Vasos Cerebrales/diagnóstico , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Tomografía Computarizada por Rayos X , Recuperación del Miembro/estadística & datos numéricos , Recuperación del Miembro/métodos , Pronóstico , Resultado del Tratamiento , Angiopatías Diabéticas/epidemiología , Angiopatías Diabéticas/cirugía , Angiopatías Diabéticas/diagnóstico , Angiopatías Diabéticas/diagnóstico por imagen , Anciano de 80 o más AñosRESUMEN
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.
Asunto(s)
Sistema de Registros , Sirolimus , Humanos , Masculino , Femenino , Anciano , Singapur , Estudios Prospectivos , Sirolimus/administración & dosificación , Resultado del Tratamiento , Angioplastia de Balón/métodos , Persona de Mediana Edad , Recuperación del Miembro/métodos , Isquemia Crónica que Amenaza las Extremidades , Isquemia/terapia , Extremidad Inferior/irrigación sanguíneaRESUMEN
OBJECTIVE: To determine the utility of Autologous Skin Cell Suspension (ASCS) in closing full-thickness (FT) defects from injury and infection. BACKGROUND: Although ASCS has documented success in closing partial-thickness burns, far less is known about the efficacy of ASCS in FT defects. METHODS: Fifty consecutive patients with FT defects (burn 17, necrotizing infection 13, crush 7, degloving 5, and other 8) underwent closure with the bilayer technique of 3:1 widely meshed, thin, split-thickness skin graft and 80:1 expanded ASCS. End points were limb salvage rate, donor site reduction, operative and hospital throughput, incidence of complications, and re-epithelialization by 4, 8, and 12 weeks. RESULTS: Definitive wound closure was achieved in 76%, 94%, and 98% of patients, at 4, 8, and 12 weeks, respectively. Limb salvage occurred in 42/43 patients (10 upper and 33 lower extremities). The mean area grafted was 435 cm 2 ; donor site size was 212 cm 2 , representing a potential reduction of 50%. The mean surgical time was 71 minutes; the total operating room time was 124 minutes. The mean length of stay was 26.4 days; the time from grafting to discharge was 11.2 days. Four out of 50 patients (8%) required 6 reoperations for bleeding (1), breakdown (4), and amputation (1). Four out of 50 patients (8%) developed hypertrophic scarring, which responded to silicone sheeting (2) and laser resurfacing (2). The mean follow-up was 92.7 days. CONCLUSIONS: When used for the closure of FT wounds, point-of-care ASCS is effective and safe. Benefits include rapid re-epithelialization, high rate of limb salvage, reduction of donor site size and morbidity, and low incidence of hypertrophic scarring.
Asunto(s)
Trasplante de Piel , Trasplante Autólogo , Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Trasplante de Piel/métodos , Anciano , Curva de Aprendizaje , Centros Traumatológicos , Quemaduras/cirugía , Quemaduras/terapia , Cicatrización de Heridas , Adolescente , Resultado del Tratamiento , Adulto Joven , Recuperación del Miembro/métodosRESUMEN
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.
Asunto(s)
Amputación Quirúrgica , Oclusión de Injerto Vascular , Enfermedad Arterial Periférica , Humanos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Amputación Quirúrgica/estadística & datos numéricos , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/epidemiología , Recuperación del Miembro/estadística & datos numéricos , Recuperación del Miembro/métodos , Injerto Vascular/métodos , Injerto Vascular/mortalidad , Injerto Vascular/estadística & datos numéricos , Injerto Vascular/efectos adversos , Factores de Riesgo , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/mortalidad , Supervivencia sin ProgresiónRESUMEN
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.
Asunto(s)
Neoplasias Femorales , Humanos , Femenino , Adulto Joven , Neoplasias Femorales/cirugía , Osteosarcoma/cirugía , Recuperación del Miembro/métodosRESUMEN
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.
Asunto(s)
Procedimientos de Cirugía Plástica , Traumatismos de los Tejidos Blandos , Colgajos Quirúrgicos , Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Estudios Retrospectivos , Adolescente , Adulto Joven , Anciano , Procedimientos de Cirugía Plástica/métodos , Traumatismos de los Tejidos Blandos/cirugía , Traumatismos de la Pierna/cirugía , Resultado del Tratamiento , Extremidad Inferior/cirugía , Extremidad Inferior/lesiones , Extremidad Inferior/irrigación sanguínea , Recuperación del Miembro/métodosRESUMEN
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.