Free Tissue Transfer in Pressure Ulcer Reconstruction: A Systematic Review

Abstract Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review. Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance. Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications. Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.

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Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1694734 ◽

2019 ◽

Vol 36 (01) ◽

pp. 032-040 ◽

Cited By ~ 3

Author(s):

Jacob R. Rinkinen ◽

Shawn Diamond ◽

Jonathan Lans ◽

Curtis L. Cetrulo ◽

Kyle R. Eberlin

Keyword(s):

Systematic Review ◽

Soft Tissue ◽

Activities Of Daily Living ◽

Free Flap ◽

Daily Living ◽

Free Tissue Transfer ◽

Free Flaps ◽

Ulcer Formation ◽

Soft Tissue Reconstruction ◽

Tissue Transfer

Background Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. Methods A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. Results A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Conclusion Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

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RE: Free-Tissue Transfer for the Reconstruction of War-Related Extremity Injuries: A Systematic Review of Current Practice

Military Medicine ◽

10.7205/milmed-d-16-00027 ◽

2016 ◽

Vol 181 (6) ◽

pp. 511-511

Author(s):

Franck Marie Leclère ◽

Casoli Vincent

Keyword(s):

Systematic Review ◽

Current Practice ◽

Free Tissue Transfer ◽

Tissue Transfer ◽

Extremity Injuries

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Análise da Revisão Cochrane: Pregabalina no Tratamento da Dor Crónica Moderada a Grave em Adultos com Fibromialgia. Cochrane Database Syst Rev. 2016;9:CD011790 e 2016;4:CD009002

Acta Médica Portuguesa ◽

10.20344/amp.10433 ◽

2018 ◽

Vol 31 (7-8) ◽

pp. 376 ◽

Cited By ~ 2

Author(s):

Guilherme Ferreira-Dos-Santos ◽

David Cordeiro Sousa ◽

João Costa ◽

António Vaz-Carneiro

Keyword(s):

Systematic Review ◽

Severe Pain ◽

Treatment Options ◽

The United States ◽

Major Effect ◽

Cochrane Database ◽

Noradrenaline Reuptake ◽

Daily Dose ◽

Reduction Of Pain

Fibromyalgia can be clinically defined by widespread pain lasting for longer than 3 months with tenderness on palpation in 11 or more of 18 specified tender points. Many people with fibromyalgia are significantly disabled, and experience moderate to severe pain for many years, for which conventional analgesics are usually not effective. For these patients treatment options generally include antidepressants like tricyclic agents, serotonin and noradrenaline reuptake inhibitors, or anticonvulsants like pregabalin or gabapentin. Pregabalin is a drug licensed for the treatment of fibromyalgia in the United States of America, with a mechanism of action similar to gabapentin. This mode of action confers antiepileptic, analgesic, and anxiolytic effects. This Cochrane systematic review included 8 randomized, placebo-controlled trials with low risk of bias, which studied the effect of a daily dose of pregabalin for the treatment of moderate to severe pain in adult patients suffering from fibromyalgia. Of the main results of this systematic review we highlight the major effect that a daily dose of 300 to 600 mg of pregabalin had in the reduction of pain intensity over a follow-up period of 12 to 26 weeks, with tolerable adverse effects, for a minority of people with moderate to severe pain due to fibromyalgia. This paper aims to summarize and discuss the main results and conclusions of this systematic review, as well as its implications for the daily clinical practice.

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Cross-Leg Flaps for Lower Extremity Salvage: A Scoping Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1679955 ◽

2019 ◽

Vol 35 (07) ◽

pp. 505-515

Author(s):

Melody Scheefer Van Boerum ◽

Thomas Wright ◽

Mary McFarland ◽

Michelle Fiander ◽

Christopher J. Pannucci

Keyword(s):

Lower Extremity ◽

Scoping Review ◽

Free Tissue Transfer ◽

The United States ◽

Posterior Tibial Artery ◽

Tissue Loss ◽

Peroneal Artery ◽

Tissue Transfer ◽

Reconstructive Option ◽

Soft Tissue Loss

Abstract Background Lower extremity trauma with soft tissue loss presents a challenge to the reconstructive surgeon. Cross-leg flaps, first described by Hamilton in 1854, are still used to salvage traumatized lower extremities in patients not suitable for free tissue transfer, or those who are receiving care in locations with limited resources. Methods A scoping review methodology was used to examine the evidence supporting the use of cross-leg flaps in modern healthcare. Results There have been 409 cases of cross-leg flaps reported in the modern literature, with the majority of flap cases occurring outside the United States in Turkey, India, and Japan. The most common indication was trauma, mentioned in 93.2% of patients (n = 353 of 379), and anatomic limitation, including inadequate vasculature, was the main reason for not performing free tissue transfer (52.8% of patients; n = 170 of 322). The majority are cross-leg fasciocutaneous flaps (85.8%, n = 273 of 318), based off the posterior tibial artery (27.5%, n = 50 of 182) and peroneal artery (26.9%, n = 49 of 182) and, covering defects of the distal third of the leg (55.5%, n = 151 of 272), or the foot (27.9%, n = 76 of 272). The pedicles are typically divided at 3 weeks (mean 20.9 days) after external fixation is used as the immobilization method (57.7%, n = 184 of 319). Flap survival was 100% across all publications except one (n = 349 of 350 patients), making cross-leg flaps a robust and reliable reconstructive option. Conclusion In resource-limited environments or in patients who are unsuitable for microvascular free tissue transfer, the cross-leg flap remains an impactful and reliable option for limb salvage.

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The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0040-1713598 ◽

2020 ◽

Vol 36 (09) ◽

pp. 634-644

Author(s):

Carol E. Soteropulos ◽

Nikita O. Shulzhenko ◽

Harry S. Nayar ◽

Samuel O. Poore

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Complication Rate ◽

Perforator Flap ◽

Free Tissue Transfer ◽

Cochrane Central Register ◽

Fasciocutaneous Flaps ◽

Tissue Transfer ◽

Individual Participant ◽

The Impact

Abstract Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity. Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used. Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01). Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

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Yoga as an Alternative and Complementary Treatment for Patients With Low Back Pain

Journal of Evidence-Based Complementary & Alternative Medicine ◽

10.1177/2156587212458693 ◽

2012 ◽

Vol 18 (1) ◽

pp. 23-28 ◽

Cited By ~ 4

Author(s):

Manoj Sharma ◽

Taj Haider

Keyword(s):

Systematic Review ◽

Low Back Pain ◽

Back Pain ◽

English Language ◽

Holistic Approach ◽

The United States ◽

Low Back ◽

Inclusion Criteria ◽

Complementary Treatment ◽

Study Inclusion

Low back pain is not only a leading cause of disability in the United States but also one of the most expensive to treat. Exercise proves to be inconsistent, and surgery often leads to disease reappearance. Yoga offers a holistic approach to overcome the psychological and physical aspects of low back pain. A systematic review was performed to determine the efficacy of yoga for low back pain. Study inclusion criteria were studies ( a) published in the English language, ( b) published between January 2000 and June 2012, ( c) included any form of yoga as an intervention, ( d) used any quantitative study design, and (5) measured low back pain as an outcome. Of the 13 studies included, 9 demonstrated a reduction in low back pain using yoga as part of the intervention. Limitations include lack of theory-based approaches, unclear definitions of low back pain, and multiple instruments used to measure the outcome.

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Yoga as an Alternative and Complementary Therapy for Patients Suffering From Anxiety

Journal of Evidence-Based Complementary & Alternative Medicine ◽

10.1177/2156587212460046 ◽

2012 ◽

Vol 18 (1) ◽

pp. 15-22 ◽

Cited By ~ 18

Author(s):

Manoj Sharma ◽

Taj Haider

Keyword(s):

United States ◽

Systematic Review ◽

Side Effects ◽

English Language ◽

Complementary Therapy ◽

The United States ◽

Alternative Methods ◽

Restless Leg Syndrome ◽

Alternative And Complementary Therapy ◽

Methods Of Treatment

Anxiety disorders are one of the most common psychiatric disorders plaguing the United States. Comorbidities include depression, restless leg syndrome, cancer, and hypertension. The side effects and the high-costs associated with the current pharmacological therapies necessitate exploration of alternative methods of treatment. To determine the efficacy of yoga as a treatment option a systematic review is presented here. The criteria for inclusion in this review were as follows: ( a) published in the English language ( b) published between the period January 2010 and May 2012, ( c) include any form of yoga as a part of or an entire intervention, ( d) use any quantitative study design, and ( e) measure anxiety as an outcome. A total of 27 studies met these criteria. Of these, 19 demonstrated a significant reduction in state and/or trait anxiety. Limitations include a lack of theory-based approaches, subjects experiencing comorbidities, and the use of numerous instruments to measure anxiety outcomes.

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Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

Infection Control and Hospital Epidemiology ◽

10.1086/678057 ◽

2014 ◽

Vol 35 (10) ◽

pp. 1209-1228 ◽

Cited By ~ 57

Author(s):

Brittin Wagner ◽

Gregory A. Filice ◽

Dimitri Drekonja ◽

Nancy Greer ◽

Roderick MacDonald ◽

...

Keyword(s):

Systematic Review ◽

Patient Outcomes ◽

Antimicrobial Stewardship ◽

English Language ◽

Guideline Implementation ◽

Hospital Setting ◽

The United States ◽

Prescribing Patterns ◽

Audit And Feedback ◽

Cochrane Library

ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

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Microvascular Free Tissue Transfer in the Reconstruction of Scalp and Lateral Temporal Bone Defects

Craniomaxillofacial Trauma & Reconstruction ◽

10.1055/s-0031-1286119 ◽

2011 ◽

Vol 4 (4) ◽

pp. 179-187 ◽

Cited By ~ 23

Author(s):

Daniel A. O'Connell ◽

Marita S. Teng ◽

Eduardo Mendez ◽

Neal D. Futran

Keyword(s):

Temporal Bone ◽

Case Series ◽

Free Tissue Transfer ◽

Wound Dehiscence ◽

Free Flaps ◽

Bone Defects ◽

Unique Challenge ◽

Cosmetic Results ◽

Tissue Transfer ◽

Anterolateral Thigh

Defects of the scalp and lateral temporal bone (LTB) represent a unique challenge to the reconstructive surgeon. Simple reconstructive methods such as skin grafts, locoregional flaps, or tissue expanders are often not feasible due to a myriad of reasons. Vascularized free tissue transfer coverage offers distinct advantages in managing these defects. A retrospective case series was performed on all patients at the University of Washington Medical Center who had scalp or LTB defects reconstructed with free tissue transfer from May 1996 to July 2009. Cases were analyzed for defect characteristics, flap type, vessel selection, radiation status, dural exposure, complications, and outcomes. Sixty-eight free flaps were performed in 65 patients with scalp or LTB defects. Twenty-two resections included craniotomy, and 48 patients had pre- or postoperative radiation. Defects ranged from 6 to 836 cm2. All flaps (46 latissimus, 11 rectus, 4 radial forearm, 6 anterolateral thigh, and 1 omental) were transferred successfully. Vein grafts were required in five cases. Complications included delayed flap failure requiring secondary reconstruction, neck hematoma, venous thrombosis, skull base infection, large wound dehiscence, small wound dehiscence, donor site hematoma and seroma, and cerebrospinal fluid leak. Cosmetic results were consistent and durable. Microvascular free tissue transfer is a safe, reliable method of reconstructing scalp and LTB defects and offers favorable cosmetic results. We favor the use of latissimus muscle-only flap with skin graft coverage for large scalp defects and rectus or anterolateral thigh free flaps for lateral temporal bone defects.

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