Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

Introduction Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes. Materials and methods A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. Primary outcomes: limb salvage rate and infection eradication. Secondary outcomes: patient functional outcomes and satisfaction. Results Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6–600) and 5.4 cm (1–23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were “very satisfied” with the treatment outcome. Conclusion A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.

Vascular Care Services during the Covid-19 Pandemic in a South Asian Country: Implications for Limb Salvage

Objective: Covid-19 continues its negative impact on limb salvage in patients with limb ischemia and vascular trauma. Bangladesh fought the 1st and 2nd waves of the Covid-19 pandemic during April through August, 2020 and in April-May, 2021, respectively. Infections have been rising once again since early June 2021 to reach a positivity rate over 30%. With limited resources, vascular surgical care during the pandemic has been an unprecedented challenge for a developing country like Bangladesh. As a small vascular community, we have adopted a strategy focused on conserving essential resources including manpower while delivering essential vascular care. The present study evaluates the effectiveness of our pandemic-time guideline-based working strategy with a focus on limb salvage. Methods: Essential vascular services were provided by customized teams throughout the Covid-19 pandemic at two referral centers according to our working guidelines. Data were analyzed and key limb salvage outcomes compared between the two pandemic waves by chi-square test. Results: A total of 1792 vascular surgical cases were addressed during the pandemic- over 90% of which involved limb or life-saving procedures. Overall mortality was 0.6% and overall limb salvage rate for acute and Chronic Limb Threatening Ischemia (CLTI) were 95.3% and 76.8%, respectively. Limb salvage rate for CLTI was significantly higher in the 2nd wave compared with the 1st (P<0.05). Rate of Covid-19 infection among vascular workforce was about 20%. Conclusion: Emergency-focused altered working guideline has produced satisfactory results in terms of continuing emergency vascular services, improving limb salvage and safeguarding vascular workforce during Covid-19 pandemic in a developing country. Conservation of resources including manpower remains relevant in the context of a highly probable 3rd wave of infection.

Limb Salvage in Early Versus Delayed Revascularization of Acute Lower Limb Ischemia

Aim: To compare the limb salvage rate in early versus late presenting patients of Rutherford class IIB acute lower extremity ischemia undergoing revascularization. Study Design: Comparative/observational study Place and duration of study: Department of Surgery, CMH Peshawar from January 2019 to March 2021 Methodology: Twenty eight patients of both genders with ages 20 to 70 years presented with Rutherford class IIB acute lower limb ischemia were enrolled in this study. Patients were divided into two groups. Group I (presented after 6 hours of onset of symptoms) consisted of 20 patients and group II (presented within 6 hours of onset of symptoms) consisted of 8 patients. All the patients underwent femoral embolectomy. Limb salvage rate between both groups was examined at postoperative 3rd month. Data was analyzed by SPSS 24.0. P-value <0.05 was taken as significant. Results: There were 16(80%) male and 4(20%) females with mean age 50.52±11.74 years in group I, in group II 6(75%) were male and 2(25%) were females with mean age 50.08±10.94 years. No significant difference was observed between both groups regarding age and gender with p-value >0.05. In group I, limb salvage found in 19(95%) patients while in group II limb salvage found in 5(62.5%) patients, a significant difference was observed regarding limb salvage rate between both groups (p-value <0.05). Mortality rate was high in group II (delayed presentation) as compared to group I (12.5% Vs 0%) with p-value <0.05. Conclusion: The limb salvage rate was high in early presenting patients than late presenting patients with a significant difference. 30 days mortality rate and amputation rate were significantly high in delayed presentation as compared to early presented cases. Keywords: Acute lower limb ischemia, revascularization, limb salvage

Can concomitant above-knee femoropopliteal bypass with artificial graft affect the outcome of femorofemoral bypass with artificial graft?

Objectives Few have studied the effect of concomitant femoropopliteal (FEM-POP) bypass surgery on the outcome of femorofemoral (FEM-FEM) bypass in patients with peripheral arterial disease (PAD). This study was aimed to analyze the risk relationship of concomitant FEM-POP bypass on the patency of FEM-FEM bypass. Methods From March 2009 to April 2020, a total of 27 patients who underwent FEM-FEM bypass surgery using polytetrafluoroethylene grafts were retrospectively analyzed according to concomitant FEM-POP bypass surgery. The mean follow-up duration was 38.20 ± 34.56 months. Results The overall primary patency of the FEM-FEM bypass grafts in all 27 patients was 83.7, 78.5, and 72.0 at one, two, and 3 years, respectively. The overall limb salvage rate was 100, 94.1, and 86.9 at one, two, 3 years, respectively. Among them, ten patients underwent FEM-FEM bypass only (group 1). The other 17 patients needed a concomitant FEM-POP bypass and these patients were classified into three groups (group 2, ipsilateral FEM-POP, n = 5; group 3, crossover FEM-POP, n = 6; and group 4, bilateral FEM-POP, n = 6) The comparison of the primary patency of group 1 with the concomitant FEM-POP groups (sum of groups 2, 3, and 4, that is, group 5, n = 17) revealed a statistically significant improved patency for FEM-FEM bypasses not requiring concomitant infra-inguinal bypass ( p = .036). Among the concomitant FEM-POP groups, group 2 had the lowest primary patency of the FEM-FEM bypass significantly ( p = 0.07). The limb salvage rate of group 4 was significantly low. Conclusions A concomitant FEM-POP bypass influenced the outcome of FEM-FEM bypass surgery. In conclusion, compromised infra-inguinal runoff at either extremity requiring concomitant FEM-POP bypass significantly worsens long-term FEM-FEM bypass patency. In addition, a concomitant bilateral FEM-POP bypass is a risk factor affecting the limb salvage rate in FEM-FEM bypass.

Technical Success and Mid-Term Outcomes of Endovascular Revascularization of Tibio-Peroneal Trunk Lesions

Tibio-peroneal trunk (TPT) lesions are usually categorized as ‘complex’ in anatomical classifications, which leads to the perception that endovascular therapy (EVT) will be challenging and the outcome most likely poor. This multicenter, retrospective cohort study investigates the efficacy of the EVT of TPT lesions in patients with chronic limb threatening ischemia (CLTI) or an infrapopliteal bypass at risk. The primary endpoint was limb-salvage. The secondary outcomes were technical success, freedom from clinically driven target lesion revascularization (CD-TLR), overall survival, and amputation-free survival. A total of 107 TPT lesions were treated in 101 patients. At 3 years, the limb-salvage rate was 76.4% (95% CI 66.0–86.8%). Technical success was achieved in 96.3% of cases. The freedom from CD-TLR, amputation-free survival, and overall survival at 3 years were 53.0% (95% CI 38.1–67.9%), 33.6% (95% CI 23.0–44.2%), and 47.7% (95% CI 36.1–59.3%), respectively. Reintervention significantly increased the hazard ratio for amputation by 7.65 (95% CI 2.50–23.44, p < 0.001). Our results show that the EVT of both isolated and complex TPT lesions is associated with high technical success and acceptable limb-salvage rates, with reintervention being a major risk factor for amputation. Moreover, mid-term mortality rate was relatively high. In future revisions of the anatomical grading scales, the classification of TPT lesions as highly complex should be reconsidered.

Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients

Background Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. Methods Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. Results Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9–20 days). Patients were followed-up for a median of 344 days (range: 142–594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. Conclusion TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.

Penetrating Popliteal Vascular Injury: Surgical Management and Early Outcome During Current War in Taiz –Yemen

Background: Popliteal vascular injury remains a challenging entity, and carries the greatest risk of limb loss among lower extremity vascular injuries. We aim to review our experience with complex penetrating popliteal vascular injuries, thereby focusing on therapeutic challenges, and early outcomes.Methods: From September 2015 to December 2019, we managed total of 728 penetrating vascular injuries with 163 popliteal vascular injuries presented to Authority of Althawra hospital in Taiz. Of 125 patients, 103 patients were fulfilling the inclusion criteria. Variables were retrospectively collected included patient demographics, mechanism and type of injuries, limb ischemia time, type of vascular reconstruction, associated complications, limb salvage, and mortality.Results: 157 vascular reconstructions were performed for 103 patients with penetrating popliteal vascular injuries, the majority 94 (91.3%) were male. Mean age was 27.3 ± 12.3 years. Popliteal vascular injuries were the second most common accounting for 35% of lower extremity vascular injuries and 22.4% of the total vascular injuries. Nearly half 54 (52.4%) of patients sustained complex popliteal vascular injuries (arterial and venous injuries), 31 (30.1%) isolated arterial injuries, and 18 (17.5%) isolated venous injuries. Management of vascular injury was repaired by interposition graft in 68 (66%), end-to-end anastomosis in 16 (15.5%), and venous patch in 1(1%). Venous injury was repaired in 53 (51.4%) and ligated in 18 (17.5%). Less than 6 hours from injury to completed revascularization was achieved in 58 (56.3%) patients. The overall fasciotomy was 28 (27.2%) which significantly increased length of hospital stays (17 days vs 7 days, P= 0.0003). The overall limb-salvage rate in our study was 94.2%. During the study period, the most common complication was 14 (13.6%) wound infection, 14 (13.6%) graft thrombosis, 6 (5.8%) bleeding, 4 (3.9%) graft infection. Early limb loss occurred in 6 (5.8%) and the mortality rate was (1.9%).Conclusions: Wartime penetrating popliteal vascular injury is a real challenge. However, team approach and promptly vascular repair found to associate with a remarkable limb salvage rate of 94.2%. We advocate repair of arterial injury with vein graft as the treatment of choice whenever possible.

Comparison of Percutaneous Transluminal Angiography With or Without Catheter-Directed Thrombolysis for Chronic Femoropopliteal Occlusive Disease

Background: Catheter-directed thrombolysis (CDT) is seldom used for chronic femoropopliteal occlusive disease. Methods: Patients with chronic femoropopliteal occlusive disease enrolled between January, 2011 and April, 2017. Hospitalization expense, limb salvage rate and survival rate were calculated. Results: Twenty-nine patients were treated with CDT (CDT group) and 31 patients without CDT (Non-CDT group).The mean hospitalization expense (5.2 ± 0.5), balloon catheter (1.0 ± 0.2) and stents number (0.8 ± 0.2) in CDT group were significantly less compared to Non-CDT group ( P < 0.05). The short-term and long-term effect scales showed similar in both groups. The incidences of perioperative complications (10.3% vs. 19.4%), primary patency and second patency rate, limb salvage rate (14.8% vs. 16.1%) and survival rate were also similar ( P > 0.05). Six patients died in each group and only 2 disease related deaths were found in Non-CDT group. Conclusion: CDT is a safe and economic strategy for patients with chronic femoropopliteal occlusive disease, and should be served as blanket treatment for every patient without thrombolytic contradictions or a remedy for failure PTA to achieve a comparable clinical effect.

Long term clinical outcome after self-expandable nitinol stent implantation for femoropopliteal occlusive disease in hemodialysis patients

Background Endovascular therapy (EVT) using self-expandable bare nitinol stent (BNS) has been commonly accepted in patients with symptomatic femoropopliteal (FP) occlusive disease. However, poor clinical outcomes in hemodialysis (HD) patients are major problems. We investigated the impact of HD on clinical outcome after EVT in patients with FP disease. Methods A total of 427 consecutive HD patients undergoing successful EVT with BNS for FP disease were enrolled with 157 non-HD patients as a control group. They were followed-up for 5 years. We collected data on target lesion revascularization (TLR) rate, and limb salvage rate as well as survival rate. Propensity-score matching analysis was performed to investigate the true impact of HD on the outcome. Results Critical limb ischemia was observed in 44.0% of overall population (43.0% in HD group vs. 46.8% in non-HD group, p=0.42). Rates of diabetes (67.1% vs. 58.1%, p=0.045) and coronary artery disease (73.5% vs. 58.3%, p=0.0008) were higher, while age (70±10 years old vs. 76±10 years old, p&lt;0.0001) and TASC2 C/D lesion (27.9% vs. 44.6%, p=0.0002) were lower in HD group compared to non-HD group. Pre-procedural C-reactive protein level (0.4mg/l vs. 0.3mg/l, p=0.045) was higher and serum albumin level (3.6g/dl vs. 3.8g/dl, p=0.0045) was lower in HD group than those in non-HD group. The freedom rate from TLR at 5 years was significantly lower in HD group than in non-HD group [47.2% vs. 65.2%, hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.23–2.64, p=0.0017]. The limb salvage rate was comparable between the groups (93.3% vs. 97.1%, HR 1.57, 95% CI 0.58–5.47, p=0.41), while the survival rate was significantly lower in HD group compared to non-HD group (60.6% vs. 86.0%, HR 2.53, 95% CI 1.56–4.36, p=0.0002). After propensity-score analysis, 250 patients (125 in each group) were matched without any difference of clinical characteristics in both groups. In the matched cohort, the freedom rate from TLR was still lower in HD group compared to non-HD group (46.7% vs. 66.6%, HR 2.25, 95% CI 1.35–3.87, p=0.0019). The adjusted limb salvage rate was consistently similar between the groups (95.4% vs. 97.3%, HR 1.10, 95% CI 0.20–5.94, p=0.91). Also, the adjusted survival rate was lower in HD group than in non-HD group (47.6% vs. 89.9%, HR 3.60, 95% CI 1.89–7.44, p&lt;0.0001). Conclusion The freedom rate from TLR at 5 years after BNS implantation for FP disease were significantly lower in HD group than in non-HD group, though the limb salvage rate was similar between the groups. The survival rate was consistently lower in HD group compared to non-HD group. HD status had a great impact on TLR and mortality after EVT with BNS in patients with FP disease. Funding Acknowledgement Type of funding source: None

Complication Rates in Ankle and Hindfoot Charcot Arthropathy Treated with Arthrodesis

Category: Diabetes; Ankle; Hindfoot; Other Introduction/Purpose: Charcot arthropathy of the ankle and hindfoot is a progressive and destructive process that can lead to instability and ulceration resulting in significant morbidity. When indicated, the surgical goals are to restore a stable plantigrade foot, reduce the risk of ulceration, and improve function to independent ambulation. Techniques for reconstruction of the neuropathic ankle/hindfoot include external and/or internal fixation. Current literature involving small series of surgical patients has shown a high rate of limb salvage and low complication rate. Our experience has been less promising, although we believe it remains a viable option. It is our goal to report the outcomes of Charcot patients undergoing corrective ankle and hindfoot reconstruction. Methods: We retrospectively reviewed 377 patients undergoing hindfoot and ankle arthrodesis at our institution from 2006- 2017. 77 patients were identified that underwent arthrodesis for Charcot arthropathy, 51 of which met inclusion and exclusion criteria with a minimum one year follow up. 42 had internal fixation as their primary procedure (plate or nail) and 9 patients underwent external fixation with a multi-planar external fixator. Median follow up time was 4 years (IQR 2.97 years). Preoperatively, basic demographic variables, etiology of neuropathy, ulcer status, radiographic measurements, Brodsky classification, and presence of a viable talus were collected and analyzed. Postoperatively, we collected complications including infection, hardware failure, ulceration, recurrent deformity, and nonunion. Reoperation numbers and indications for reoperation were also collected. The primary outcome measure was limb salvage at final follow up. Secondary outcome measures were ambulatory and footwear/bracing status. Results: 11 patients (20%) underwent amputation at final follow up and 26 (47.3%) achieved radiographic union, both of which did not vary by fixation type (p=0.67 and p=0.88). The primary reasons for amputation were persistent infection and non-union. 74.5% of patients developed a post-operative complication and 58.2% had at least one reoperation. 25.5% of patients developed a post- operative infection. Patients with a pre-operative ulceration were more likely to undergo external fixation (p=0.02), but amputation rates did not differ between groups (p>0.99). There was a trend toward increased risk of post-operative infection in the ulceration group (p=0.07). A pre-operative Meary’s angle >25° was more likely to undergo amputation (p=0.04) and less likely to achieve radiographic union (p=0.05). 75.9% of patients were ambulatory at final follow up. Conclusion: Our rates of amputation (20%), post-operative infection (25%), complications (74.5%) and non-union (52%) are higher than previously described. Previous literature has described a near 100% limb salvage rate, but in our report on a large series of Charcot patients undergoing hindfoot/ankle arthrodesis we describe an 80% limb salvage rate. Pre-operative Meary’s angle >25° was predictive of treatment failure.