Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness

2021 ◽  
Author(s):  
Sean M Wade ◽  
Colin J Harrington ◽  
Benjamin W Hoyt ◽  
Angelica M Melendez-Munoz ◽  
Benjamin K Potter ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Limb Salvage ◽  
Tertiary Care ◽  
Soft Tissue Coverage ◽  
Acute Management ◽  
Reconstructive Procedures ◽  
Number Of Patients ◽  
Extremity Trauma ◽  
Extremity Reconstruction ◽  
The Impact

ABSTRACT Introduction As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution’s evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. Materials and Methods We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. Results Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist–antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. Conclusion Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.

scholarly journals Clinical Outcomes of Surgical Treatments for Primary Malignant Bone Tumors Arising in the Acetabulum

Sarcoma ◽  
2015 ◽  
Vol 2015 ◽  
pp. 1-9 ◽  
Author(s):  
Tomohiro Fujiwara ◽  
Koichi Ogura ◽  
Eisuke Kobayashi ◽  
Yoshikazu Tanzawa ◽  
Fumihiko Nakatani ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Postoperative Complications ◽  
Functional Outcome ◽  
Clinical Outcomes ◽  
Soft Tissues ◽  
Deep Infection ◽  
Soft Tissue Coverage ◽  
Reconstructive Procedures ◽  
Bone Autograft ◽  
The Impact

The functional and oncologic results of eighteen patients with primary malignant periacetabular tumors were reviewed to determine the impact of surgical treatment. The reconstruction procedures were endoprosthesis (11), hip transposition (4), iliofemoral arthrodesis (2), and frozen bone autograft (1). After a mean follow-up of 62 months, 13 patients were alive and 5 had died of their disease; the 5-year overall survival rate was 67.2%. The corresponding mean MSTS scores of patients with endoprosthesis (11) and other reconstructions (7) were 42% and 55% (49%, 68%, and 50%), respectively. Overall, postoperative complications including deep infection or dislocation markedly worsened the functional outcome. Iliofemoral arthrodesis provided better function than the other procedures, whereas endoprosthetic reconstruction demonstrated poor functional outcome except for patients who were reconstructed with the adequate soft tissue coverage. Avoiding postoperative complications is highly important for achieving better function, suggesting that surgical procedures with adequate soft tissue coverage or without the massive use of nonbiological materials are preferable. Appropriate selection of the reconstructive procedures for individual patients, considering the amount of remaining bone and soft tissues, would lead to better clinical outcomes.

scholarly journals Motorcyclists and pillion passengers with open lower-limb fractures: a study using TARN data 2007–2014

2018 ◽  
Vol 100 (3) ◽  
pp. 203-208 ◽  
Author(s):  
AGC Hay-David ◽  
T Stacey ◽  
I Pallister ◽  
Keyword(s):  
Soft Tissue ◽  
Lower Limb ◽  
Research Network ◽  
Soft Tissue Coverage ◽  
Patient Movement ◽  
Lower Limb Fractures ◽  
Number Of Patients ◽  
Limb Fractures ◽  
The Impact ◽  
Time From Injury

Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the revised 2009 British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4), in terms of time to skeletal stabilisation and soft-tissue coverage, and to observe any impact on patient movement. Methods Retrospective cohort data was collected by the Trauma Audit and Research Network (TARN). A longitudinal analysis was performed between two timeframes in England (pre-and post-BOAST 4 revision): 2007–2009 and 2010–2014. Results A total of 1564 motorcyclists and 64 pillion passengers were identified. Of these, 93% (1521/1628) were male. The median age for males was 30.5 years and 36.7 years for females. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, P < 0.0001), the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, P < 0.0001) and the proportion receiving soft-tissue coverage (26% vs 43%, P < 0.0001). There was no difference in the time from injury to soft-tissue coverage (62.3 hours vs 63.7 hours, P = 0.726). The number of patients taken directly to a major trauma centre (or its equivalent) increased between the two timeframes (12.5% vs, 41%, P < 0.001). Conclusions Since the 2009 BOAST 4 revision, there has been no difference in the time taken from injury to soft-tissue coverage but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint orthopaedic and plastic care.

Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?

2019 ◽  
Author(s):  
Saïd C. Azoury ◽  
John T. Stranix ◽  
Stephen J. Kovach ◽  
L. Scott Levin
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Limb Salvage ◽  
Soft Tissue Coverage ◽  
Soft Tissue Reconstruction ◽  
Treatment Team ◽  
Management Protocol ◽  
Lower Extremity Reconstruction ◽  
Tissue Reconstruction ◽  
Extremity Reconstruction

Abstract Background Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation. Methods A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol. Results Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes. Conclusion The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible.

scholarly journals Paradigm Shift in Clinical Practice of Sexual Health in Men During COVID-19 Pandemic

2021 ◽  
pp. 263183182110323
Author(s):  
Aditya Prakash Sharma ◽  
Japleen Kaur ◽  
Ravimohan S. Mavuduru ◽  
Shrawan K. Singh
Keyword(s):  
Health Care ◽  
Sexual Health ◽  
Surgical Procedures ◽  
Care Center ◽  
Tertiary Care ◽  
Health Care Seeking ◽  
Care Seeking ◽  
Health Seeking ◽  
Number Of Patients ◽  
The Impact

Sexual health-care seeking behavior and practices have been affected during COVID-19 pandemic. The impact of COVID-19 on this subspecialty is far reaching. This study aimed to assess the impact of COVID-19 on health-care seeking practice pertaining to sexual health in men in our tertiary care center and review the relevant literature regarding impact of COVID-19 on sexual health seeking practice and challenges faced. Outpatient data was analyzed from January 2019 to April 2021. Patients awaiting surgical procedures due to COVID were documented. A narrative synthesis of literature based on systematic search using the keywords sexual health, sexual health seeking, sexual health practice, andrology, and COVID with operators “AND” and “OR” was carried out in three search engines PubMed, Scopus, and Embase. The study outcomes were obtained by comparing data of outpatient attendance and compiling the reviewed literature. The mean attendance fell significantly from 95.11±11.17 to 17.25±13.70 persons (P <.0001) per outpatient clinic, March 2020 being the reference point. Teleconsultation has taken over physical consultation. In 98/949 cases, teleconsult could not be provided despite registration. Over 25 patients were waiting for surgical procedures pertaining to andrology due to shut down of elective services. Similar trends have been reported from other countries. Number of patients seeking consultation for sexual health problems has dramatically decreased during COVID-19 era. Establishment of data safe teleconsultation facility and its widespread advertisement is needed to encourage patients to seek consult.

scholarly journals Impact of COVID-19 pandemic on non-COVID patient’s management in urology: a public hospital experience in Mumbai

2021 ◽  
Vol 27 (1) ◽  
Author(s):  
Nikhilesh A. Jibhakate ◽  
Sujata K. Patwardhan ◽  
Ajit S. Sawant ◽  
Hemant R. Pathak ◽  
Bhushan P. Patil ◽  
...  
Keyword(s):  
Tertiary Care ◽  
Stone Disease ◽  
Outpatient Clinics ◽  
Percentage Decrease ◽  
Emergency Procedures ◽  
Number Of Patients ◽  
Long Term Impact ◽  
Tertiary Care Hospitals ◽  
The Impact ◽  
Near Future

Abstract Background To evaluate the impact of COVID-19 lockdown on non-COVID urological patient’s management in tertiary care urology centres. Methods This is an observational study in which data of patients visiting the urology department of all the MCGM run tertiary care hospitals were recorded for the duration of 1 April 2020 to 31 July 2020 and were compared to data of pre-COVID-19 period of similar duration. Results There was a decrease of 93.86% in indoor admissions of urology patients during the COVID-19 lockdown. Indoor admissions for stone disease, haematuria, malignancy accounted for 53.65%, 15.85%, 9.75%, respectively. Elective surgeries had the highest percentage decrease followed by emergency and semi-emergency procedures. There was a reduction of more than 80% in patients attending outpatient clinics. Stone disease and its consequences were the main reasons for visiting outdoor clinics (39%). A substantial number of patients presented with flank and abdominal pain (14.8%) and benign enlargement of the prostate (10.23%). Malignancy accounted for a very small number of patients visiting outdoor clinics (1.58%). Conclusions COVID-19 pandemic has a profound impact on patient care and education in Urology. There was more than ninety percent reduction in indoor admissions, operative procedures, and outpatient clinics attendance. Once the pandemic is controlled, there will be a large number of patients seeking consultation and management for urological conditions and we should be prepared for it. Surgical training of urology residents needs to be compensated in near future. Long-term impact on urological patient outcome remains to be defined.

Abstract 14747: Dwindling Trends of Cardiology Admissions Amidst Covid-19 Pandemic in a Tertiary Care Center of Pakistan

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jamshed Ali ◽  
Osman Faheem ◽  
Pirbhat Shams ◽  
ghufran adnan ◽  
Maria Khan
Keyword(s):  
Care Center ◽  
Tertiary Care ◽  
Electronic Record ◽  
Medical Attention ◽  
Care Hospital ◽  
Record System ◽  
Admission Rates ◽  
Cardiovascular Morbidity And Mortality ◽  
Number Of Patients ◽  
The Impact

Introduction: Social containment measures have been adopted globally to control COVID-19 outbreak. Reduction in hospital visits and inpatient admission rates have become cause for concern. Through this study we aimed to analyze the impact of SARS-CoV-2 virus Outbreak on cardiology inpatient admissions at a tertiary care hospital in Pakistan. Hypothesis: COVID-19 pandemic has resulted in significant decline in cardiology admissions. Methods: We conducted a retrospective study at our center. Admission log was accessed via electronic record system. Comparison was made for same months of 2019 and 2020 with regard to cardiology inpatient admissions. Results: A total of 239 patients were admitted to cardiology services in 2019 period and 106 in 2020 period with resultant reduction of 55.6%. Number of patients admitted to the coronary care unit were 179 and 78 respectively where as the numbers declined to 28 from 60 for cardiac step down. Reduction for admission numbered to 52.4% for males and 38.89% for females. 9.3% patients left against medical advice in 2019 and 3.4% in 2020. Conclusions: Our study concludes that numbers of cardiology admissions have dwindled. Possible explanation for this can be implementation of social containment and fear of acquiring infection. This has raised a question of whether a significant number of cardiovascular morbidity and mortality has occurred without seeking medical attention and has went unrecorded during the pandemic. This calls for stringent diagnostic measures in future to diagnose previously unrecorded burden.

CLINICAL PROFILE OF OUTPATIENTS ATTENDING DERMATOLOGY DEPARTMENT DURING COVID-19 LOCKDOWN RELAXATION PERIOD IN A TERTIARY CARE CENTRE IN SOUTH INDIA – A CROSS-SECTIONAL ANALYTICAL STUDY

2021 ◽  
pp. 13-16
Author(s):  
Afthab Jameela Wahab ◽  
Pavithra Gunasekaran ◽  
P. Mohan ◽  
V. Sudha ◽  
L. Balamurugan ◽  
...  
Keyword(s):  
South India ◽  
Tertiary Care ◽  
Care Centre ◽  
Tertiary Care Centre ◽  
Dermatology Department ◽  
Cutaneous Manifestations ◽  
Relaxation Period ◽  
Number Of Patients ◽  
Outpatient Practice ◽  
The Impact

Background - The cutaneous manifestations of the novel coronavirus have been well documented. However, there are few studies that relate to the clinical prole of regular dermatology outpatients seeking treatment during the lockdown relaxation period braving the pandemic. With the Aim - view to determine the changes seen in dermatology outpatient practice, this study analysed the clinical prole of new patients attending the Dermatology Outpatient Department (OPD) during the COVID-19 lockdown relaxation period in a tertiary care centre in a metropolitan suburb in South India. New dermatology outpatients during the months of May, June, July and August Method - 2020 were included in the study. Outpatient data for this period was analysed and compared with corresponding data for the same period in the previous two years. There was a Result – decrease in the OP census, number of patients in the extremes of life as well as those with asymptomatic dermatoses. There was an increase in the number of patients with infections, particularly dermatophytosis. There was also a noteworthy absence of dermatological emergencies. Conclusion - In essence, our study shows the impact of COVID-19 pandemic on the routine dermatology outpatient services with signicant changes in the clinical prole of outpatient practice following lockdown relaxation.

scholarly journals P73 Trends in ultrasound guided musculoskeletal injections at one tertiary care centre over 6 years

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Kunal Lall ◽  
Vivian Ejindu ◽  
Patrick D. W Kiely
Keyword(s):  
Soft Tissue ◽  
Time Pressure ◽  
Waiting Times ◽  
Tertiary Care ◽  
Fold Increase ◽  
Ultrasound Guided ◽  
Tertiary Care Centre ◽  
The Impact ◽  
Effective Service

Abstract Background Ultrasound (US) has brought many benefits into rheumatologic practice, delivery of targeted injections into joints, bursae and other structures. Whilst many joints may be accurately injected in clinic, guided by clinical landmarks, US permits injections into anatomically less accessible sites. We have assessed trends in the number and type of requests for US guided joint or soft tissue injections from the rheumatology department over the last 6 years, and the impact on waiting times. Methods Details of all requests for US guided joint or soft tissue injections were obtained from the St George’s PACS system from 1 January 2013 - 31 December 2018. Review of patient records was conducted to determine whether the referral was routine or urgent, the waiting time between referral and appointment, the joint or structure to be injected, and whether an injection into the requested site was actually performed. Results Table 1 shows the total number of out-patient attendances in rheumatology per year from 2013 - 2018, the number of referrals for US-guided injection, the proportion requested urgently and waiting times for routine and urgent cases. Over 6 years requests for US guided injections have risen 2.3-fold, from &lt;1% to nearly 2% of all out-patient attendances. Of 1834 requests, no injections were given in 420 instances (23%), due to patient preference or lack of indication at time of US. In 2018 of all joint or tendon/bursa injections initiated in rheumatology, 260 (38%) were given in routine clinic time without delay, and 420 (62%) were requested by US with a delay of over 2 months. Conclusion Over 6 years a 33% increase in out-patient clinic workload has been accompanied by a disproportionate 2.3-fold increase in requests for US guided injections, representing &gt;50% of injections initiated by the service. One explanation may be time pressure in clinic. This trend has not been matched by increased radiology capacity, with urgent requests now waiting &gt;6 weeks. This has implications for quality of care, staffing and effective service delivery. The trend to fewer injections in clinic will continue if clinicians become increasingly reliant on radiology colleagues. Disclosures K. Lall None. V. Ejindu None. P.D.W. Kiely None.

scholarly journals Impact on Utilization and Shift in Treatment Needs Post-COVID Lockdown of Pediatric Dentistry in a Tertiary Care Hospital

2021 ◽  
Vol 2 ◽  
Author(s):  
Bhojraj Nandlal ◽  
Birti Singh ◽  
Arun Gopi
Keyword(s):  
Linear Regression Analysis ◽  
Tertiary Care ◽  
Pediatric Dentistry ◽  
Care Hospital ◽  
Dental Disease ◽  
Care Seeking ◽  
Treatment Needs ◽  
Dental Services ◽  
Number Of Patients ◽  
The Impact

Background: The COVID-19 pandemic has brought all treatments other than emergencies to a halt. Dental disease, being a multifactorial microbial disease, is capable of progressing to pulpits and its sequelae. The purpose of this study is to predict the impact of utilization of dental services and the progression of treatment needs in children during the lockdown and partial lockdown.Methods: Outpatient department data from the year 2017–2019 from the Department of Pediatric and Preventive Dentistry, JSS Dental College was collected. A table of treatments provided was prepared. Utilization of services as care-seeking rates at 10, 25, and 50% were assumed and modeled corresponding to each stage of the lockdown using linear regression analysis. Dental caries progression was calculated as shifts in treatment needs from permanent restorations to temporary restorations, pulpectomies, or extraction, assuming a 10% progress to each sequela.Results: The p-values for 10, 25, and 50% care-seeking rates were 0.021, &lt;0.001, and &lt;0.001, respectively.Conclusion: The number and severity of cases were predicted to have increased. However, after removal of lockdown, it was noted that the number of patients seeking care was significantly less. The advancement in progression of dental disease further adds to the burden of society and caregivers.

Impact of NICE guidelines on the survival of patients with soft-tissue sarcomas

2021 ◽  
Vol 103-B (3) ◽  
pp. 569-577
Author(s):  
Tomohiro Fujiwara ◽  
Robert J. Grimer ◽  
Scott Evans ◽  
Manuel Ricardo Medellin Rincon ◽  
Yusuke Tsuda ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Soft Tissue Sarcomas ◽  
High Grade ◽  
Nice Guidelines ◽  
Number Of Patients ◽  
Mean Size ◽  
The Mean ◽  
The Uk ◽  
The Impact ◽  
Grade Tumour

Aims Urgent referral to a specialist centre for patients with a soft-tissue sarcoma (STS) has been recommended by the National Institute for Health and Care Excellence (NICE) in the UK since 2006. However, the impact of this recommendation on the prognosis for these patients remains unclear. We aimed to determine the impact of the NICE guidelines on the disease-specific survival (DSS) of patients with an STS. Methods A total of 2,427 patients with an STS referred to a supraregional centre in the ten-year periods before (n = 1,386) and after (n = 1,041) the issue of the NICE guidelines were evaluated. Results The mean size of the tumour was significantly smaller at the time of diagnosis (10.3 cm (SD 6.5) vs 9.1 cm (SD 6.2); p < 0.001) and the number of patients who had undergone an inadvertent excision significantly decreased (28% (n = 389) vs 20% (n = 204); p < 0.001) following the introduction of the NICE guidelines. The five-year DSS was 63% in the pre-NICE and 71% in post-NICE groups (p < 0.001). The improved survival was more significant for those with a high-grade tumour (pre-NICE, 48%; post-NICE, 68%; p < 0.001). In those with a high-grade tumour, the mean size of the tumour (11.6 cm (SD 6.2) vs 9.6 cm (SD 5.8); p < 0.001) and the number of patients with metastasis at the time of diagnosis (15% (n = 124 vs 10% (n = 80); p = 0.007) significantly decreased in the post-NICE group. Conclusion An improvement in survival was seen after the introduction of the NICE guidelines, especially in patients with a high-grade STS. More patients were referred at an earlier stage, indicating a clearer pathway after the issue of national policy for the management of STSs in the UK. Cite this article: Bone Joint J 2021;103-B(3):569–577.

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