Early outcomes of limb salvage surgery with mega-prosthesis:A single center experience

Objective:To determine the early outcomes of limb salvage surgery with mega prosthesis.Methods:This retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre(SKMCH&RC)from 1st January 2017 till 31st January 2020.Data like demographics,histopathology,functional and survival outcomes were retrieved from the Hospital Information System.Musculoskeletal Tumor Society(MSTS)score was used to evaluate the functional outcomes after the surgery.For survival analyses,Kaplan-Meier curve was applied.Prosthesis joint infection,amputation rate,metastasis,mortality rate,and recurrence were also recorded.Results:This study included 43 patients who underwent limb salvage surgery with endoprosthesis reconstruction at SKMCH&RC.The mean age at the time of diagnosis was(26.5±15.8)years.Patients with distal femoral replacement had the highest MSTS scores(81.45±9.70)while those with proximal humerus replacement has the lowest MSTS scores(56.8±11.2).There was a strong association between site of tumor and MSTS(F=3.30,P=0.017).We also found a correlation between surgical site infection and MSTS scores(r=0.484,P=0.001).Patients with recurrence also had significantly lower MSTS scores(P<0.05).The cumulative survival rate at the end of two-year follow-up was(71.4±17.1)%in proximal femur tumor patients,(88.0±7.8)%in distal femur tumor patients,and(50.0±3.5)%in proximal humerus tumor patients.Besides,patients with Ewing sarcoma had the highest survival rate(97.5±11.0)%while patients with chondrosarcoma had the lowest survival rate(77.8±13.9)%.Conclusions:Limb salvage surgery with mega-prosthesis can be performed with satisfactory functional and survival outcomes,but further studies are needed to compare it with other limb salvage methods.This study can be used as a reference for future studies.

Limb Salvage Using Human Placental Allografts: Adding to the Reconstructive Ladder Paradigm

Human placental allografts are the latest treatment modalities for diabetic ulcers, chronic wounds, limbs, and tendons for healing cascade and promoting granulation tissue coverage. Purion® processed dehydrated human amnion/chorion membrane allografts (dHACM), decellularized human collagen matrix (dHCM), dehydrated umbilical cord (dHUC) and micronized dehydrated human amnion/chorion membrane allografts (mdHACM) have been the newest modality used to salvage injured human extremities with tendon and bone exposure. A 53-year-old male was assaulted and sustained second and third degree burns to both legs. The left extremity had a 9.5% total body surface area (%TBSA) burned. The right extremity had a 5.5% TBSA and three exposed tendons (Achilles/flexor digitorum longus/tibialis anterior), muscles, talar and tibial bones. Bilateral extremity pedal pulses were present, and all toes had less than two second capillary refill. Sensation, motor, and strength were normal. During the 48-day-hospital stay, the patient had eight operations: tangential excisional debridements of necrotic tissue with weekly wound dressing applications of dHACM and dHCM, on both legs. In addition, dHUC was applied over the exposed tendons on weeks 2 - 5. The exposed tendons were injected with mdHACM on weeks 4 and 5. Negative pressure wound therapy was applied at 125 mmHg for fourteen days over the wound surfaces covered with a nonadherent dressing, 3% bismuth tribromophenate petrolatum dressing with a glycerol-hydroxyethyl cellulose lubricant. At discharge for rehabilitation, 90% of the split-thickness-skin-graft (STSG) was viable over the right ankle joint, tendons and bone. Use of human placental allografts prevented the need for myocutaneous flap coverage or amputation of the right foot.

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Aim:Free tissue transfer is essential for extremity reconstruction following traumatic injuries,oncologic resection,and diabetic complications.However,given the circumferential shape of the arm and leg,a small amount of ongoing edema can prevent a tension-free closure.Additionally,intraoperative thrombosis,vascular disease can lead to proximal exposure of the pedicle or vein grafts.This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle,in comparison with a matched cohort with a tension-free primary closure.Methods:A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution.Flaps that utilized skin grafting for closure were compared to those closed primarily.Adjunct operative procedures,demographics,and complications were evaluated.Results:A total of 71 patients fulfilled the inclusion criteria.The 11 flaps in 10 patients underwent skin grafting over the pedicle.The two cohorts were comparable in age,gender,BMI,and co-morbidities,excluding renal disease which was present in 40%(n=4)of skin grafted group compared to 6.5%(n=4)in the primary closure group.Flap area,operative time,and anastomosis technique were comparable between the two groups.There was no significant difference in the rates of post-operative complications including partial flap loss,complete flap loss,infection.Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group. ;Conclusion:As per the principal,a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle.However,with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.

Patient survival and limb salvage after shark attack with major vascular injury:A case report

Shark attacks are rare unique pathological processes.Some of them represent devastating injuries with a high morbidity and significant mortality.Related published articles are limited.The increased human interaction within the environment of sharks is the cause of rising incidence of such attacks.This study reported a case of level 4 shark injuries(shark-induced trauma scale)in a 33-year-old male patient,who presented with an extensive injury of the right lower limb with the characteristic features of shark bite.At admission the patient was in a state of shock with profuse bleeding that was controlled by tourniquet.The patient was resuscitated according to the advanced trauma life support.Clinical examination showed hard signs of vascular injury with absent pedal pulse,associated neurological deficits and severance at the knee joint.Prompt vascular intervention after resuscitation was performed to manage the major vascular injuries,together with proper washout and debridement of all the necrotic tissues under strong antibiotic coverage to prevent infection.After that,the patient underwent sequenced plastic,orthopedic,and neurological interventions.Strict follow-up was conducted,which showed that the patient was saved and achieved a functioning limb.This study aims to highlight the management of level 4 shark injuries,which are considered serious and challenging with a high fatality rate and a great risk of amputation due to the associated major vascular injuries.Immediate well organized management plan is crucial.Prompt resuscitation and surgical intervention by a highly-skilled medical team are required to improve the chance of patient survival and limb salvage.

Limb salvage surgery in a patient with macrodystrophia lipomatosa involving an entire upper extremity

Macrodystrophia lipomatosa is a rare form of congenital localized gigantism, which is characterized by slowly progressive overgrowth of the mesenchymal elements, especially the fibroadipose tissue, in a limb. Frequently, multiple contiguous digits are involved on the lateral side of the hand or the medial side of the foot. Overabundance of the fibroadipose tissue and osseous overgrowth are most remarkable at the distal ends of the extremity.

Preliminary evidence using negative pressure wound therapy to achieve limb salvage for the ischemic diabetic foot

Aim:Negative pressure wound therapy(NPWT)in diabetic foot ulcers(DFU)has been discussed in several studies,but without a focus on peripheral arterial disease(PAD),which is a common comorbidity.This study aims to investigate the feasibility of NPWT in the treatment of DFU with PAD in regards to limb salvage and the clinical course.Methods:The authors retrospectively collected patients with DFU and PAD diagnosed with either Doppler ultrasound or angiography as the PAD study group.Patients with DFU but no PAD were enrolled as the non-PAD comparison group.NPWT was applied to both PAD and non-PAD subjects.Results:There were 10 patients in the PAD group and 3 patients in the non-PAD group.In the PAD group,there was a 70%limb salvage rate with 14.70(±10.33)treatment days.The non-PAD comparison group had a higher limb salvage rate(100%vs.70%,respectively),but a longer treatment time(30.00 vs.14.70 days,P<0.05,respectively)when compared to the PAD group.The 3 patients in the PAD group who failed limb salvage all had issues related to uncontrolled infection.Conclusion:NPWT is a feasible adjuvant therapy for DFU in patients with PAD,with a 70%limb salvage rate.Prolonged treatment time was due to the initial severity of the subjects with multiple comorbidities.The main reason for limb loss was intractable infection.

Indication and surgical approach for reconstruction with endoprosthesis in bone-associated soft tissue sarcomas:Appropriate case management is vital

It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas(STS)have unique features in terms of indication,surgical approach and follow-up,in terms of the management of these cases.Some STS are associated with bone and major neurovascular structures.Bone-associated STS are generally relatively large and relatively deep-seated.Additionally,the tendency for metastasis is high.In some cases,the decision about which structures to resect is difficult.These cases are often accompanied by poor oncological and surgical outcomes.Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field.The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery.Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.

Expandable endoprostheses in skeletally immature patients:Where we are

Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality.Until the early 1990s,the treatment options for these patients were rotationplasty or amputation.Multimodal approaches that combine imaging,chemotherapy,and surgical techniques have enabled the development of limb-preserving methods with satisfactory results.In order to overcome inequality problems,expandable prostheses have been developed in the 1980s.Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative.Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures,but the complication rate remains high.Therefore,although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children,they are still a suitable interim choice until full adulthood is achieved.Due to reported high complication rates,the procedures require significant experience and are recommended for use only in specialized cancer centers.

Delayed Management of Popliteal Artery Injury Following Knee Dislocation—A Case Report

Knee dislocations frequently involve vascular injuries that demand early diagnosis and timely intervention. Time of ischemia is pivotal in determining the outcome for the limb, delays in treatment beyond 8 hours significantly increase the risk of limb loss. Unfortunately, this critical window is often missed in resource-limited settings. Here we report a 25-year-old female sustained a left knee injury after falling into a trench. She was diagnosed with an open knee dislocation accompanied by a popliteal artery injury. However, revascularization was delayed for 18 hours due to limited resources, including the unavailability of a thrombectomy catheter. Postoperatively, the patient received anticoagulation therapy with serial limb assessments and after 3 weeks the laceration healed and the limb was still viable. Knee dislocations frequently result in vascular injury (popliteal artery most common), making prompt diagnosis and intervention essential for limb preservation. In settings with limited resources, like ours, delayed presentation and transfer to specialized centers contribute to prolonged ischemic times. Nonetheless, viable limbs should be revascularized in stable patients, even with prolonged ischemia. This case highlights the importance of limb revascularization despite delay. Efforts should be made to improve prompt diagnosis, timely referral, and availability of necessary equipment for vascular repair to optimize outcomes in similar cases.

Outcome of application of primary versus secondary Illizarov＇s fixator in open tibial shaft fractures

BACKGROUND: The present study aimed to compare outcome of primary and secondary Illizarov's fi xator application as a treatment method for type III open tibial fractures in terms of nonunion and wound infection.METHODS: This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary(n=28) and secondary(n=20).RESULTS: In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were signifi cantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group.CONCLUSION: Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fi xation, mostly due to a signifi cantly less number of patients with a bone defect in the primary group.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily.Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage,duration of limb ischemia,patient’s medical status and presence of associated injuries.The management of these injuries is challenging and requires a specific algorithm of action,because they are usually characterized by increased morbidity,amputation rate,infection,neurological and functional deficits,and they could be life threatening.Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma,the high index of suspicion,imaging control,and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases.Even after a successful initial treatment of a combined trauma pattern,long-term follow-up is crucial to prevent and detect early possible complications.The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities,from an orthopedic point of view.

Adipose-derived stem cell/FGF19-loaded microfluidic hydrogel microspheres for synergistic restoration of critical ischemic limb

The efficacy of stem cell therapy is substantially compromised due to low cell survival rate and poor local retention post-delivery. These issues drastically limit the application of stem cells for ischemic limb therapy, which requires effective blood perfusion and skeletal muscle regeneration. Herein, based on microfluidic technology, an integrated stem cell and cytokine co-delivery system designed for functional ischemic limb salvage was constructed by first incorporating the myogenic cytokine, fibroblast growth factor 19 (FGF19), into microspheres composed of methacrylate gelatin (GelMA). Then adipose-derived stem cells (ADSCs) were highly absorbed into the porous structure of the microspheres, overcoming the insufficient loading efficiency and activities by conventional encapsulation strategy. The fabricated ADSCs/FGF19@μsphere system demonstrated a uniform size of about 180 μm and a highly porous structure with pore sizes between 20 and 40 μm. The resultant system allowed high doses of ADSCs to be precisely engrafted in the lesion and to survive, and achieved sustained FGF19 release in the ischemic region to facilitate myoblast recruitment and differentiation and myofibrils growth. Furthermore, the combination of ADSCs and FGF19 exhibited a positive synergistic effect which substantially improved the therapeutic benefit of angiogenesis and myogenesis, both in vitro and in vivo. In summary, a stem cell and cytokine co-delivery system with the properties of easy preparation and minimal invasiveness was designed to ensure highly efficient cell delivery, sustained cytokine release, and ultimately realizes effective treatment of ischemic limb regeneration.

Advances in microsurgery for upper and lower extremity reconstruction and limb preservation

In the recent decades,microsurgical reconstruction has evolved from simple survival of the affected extremity to the improvement of functional and aesthetic outcome.This review retraces the main contributions to the advances of microsurgery for reconstruction of upper and lower extremities and limb preservation.In the upper extremity,it is important to restore fine motility,together with allowing prompt mobilization.In the lower limb,care must be taken in the reconstruction of weight-bearing areas and the aim must be proper ambulation and shoe wearing.Local perforator flaps can be considered for medium size defects.They provide thin coverage and can be performed in short operating time.Their use,though,is often limited by tissue availability.Free flaps allow to overcome this problem and,thanks to the recent development in the study of perforator vessels,the microsurgeon can choose the flap with the most appropriate characteristics.Chimeric flaps can accomplish simultaneous reconstruction of different tissue components and large bone defects often require vascularized bone reconstruction.When dealing with limb preservation it is very important to consider residual functionality.Functioning muscle transfer and targeted muscle re-innervation can be performed in these cases.A useful reconstructive tool in severely damaged limbs with limited blood supply is the use of cross-leg free flaps.In conclusion,extremity reconstruction and limb preservation are reaching new heights thanks,not only to the work of plastic surgeons,but also to the new developments in other fields of study such as oncology,traumatology,radiology and medical engineering.

Limb preservation with suprafascial and thin perforator flaps: salvaging osteomyelitis, Charcot collapse and critical limb ischemia

AIM: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine patient and flap related outcomes in advanced lower extremity disease. Methods: The authors conducted a retrospective review of fasciocutaneous free flaps of variable thickness for lower extremity salvage. Osteomyelitis and non-osteomyelitis patients were compared according to our primary outcome measures: functional ambulation, bone healing and complications to flap and patient. Subgroups with critical limb ischemia, Charcot collapse and diabetic foot were analyzed separately. Results: Fifty-nine patients underwent free flap reconstruction: osteomyelitis (n = 20, 34%), Charcot collapse (n = 22, 37%), and/or critical limb ischemia (n = 12, 20%). All patients underwent anterolateral thigh flaps tailored for defect-specific thicknesses: 17 superthin, 25 suprafascial, 17 subfascial. There were no significant differences between groups in terms of partial and complete flap loss (P = 1.000 and P = 0.108). Ninety-one percent of patients were ambulatory at follow up. Eighty-tive percent of individuals with osteomyelitis cleared their infection demonstrating radiographic bone healing. Two patients developed recalcitrant deep space infections ultimately requiring amputation. Subgroup analysis did not show any differences in flap related complications within the diabetic Charcot population. In multivariate regression, preoperative revascularization was independently associated with failure of limb salvage. ;Conclusion: Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limbischemia, osteomyelitis, and the Charcot foot - expanding their role in the armamentarium for lower extremity care.

Traumatic soft tissue defects:a perspective review on reconstruction and communication priorities from the orthopaedic trauma surgeon as a partner in care

Communication and coordination between orthopedic and plastic surgeons improve outcomes in severe extremity trauma.The“orthoplastics”approach to limb salvage incorporates priorities and skillsets from both fields.Prevention of infection,coordinated skeletal and soft tissue reconstruction,and communication during recovery and rehabilitation are key priorities.The purpose of this review is to describe the orthopedic trauma surgeon’s perspectives on lower extremity reconstruction,including initial management,techniques and timing for provisional and definitive skeletal reconstruction,and considerations for rehabilitation and orthotic use to optimize functional outcomes.

Review of soft tissue coverage options in distraction osteogenesis of the extremity

Aim:To review the choices of soft tissue coverage in distraction osteogenesis of the extremity.Methods:A PubMed literature search yielded 14 articles included for systematic review.Data were extracted from each article if available(sample size,patient age,surgical indications,type of flap,use of additional modalities,method of bone osteogenesis,postoperative events,follow-up,satisfaction,weight-bearing status,and success rate).Unpaired t-tests were performed to compare complication rates.A retrospective review of three cases was also conducted.Results:Fourteen articles discussed 145 patients with a mean age of 33.4 years and 146 extremity injuries followed over 3.3 years on average.Indications included chronic osteomyelitis or nonunion(58.2%)and acute trauma(41.8%).Average time from injury was 1.1 years.Ilizarov frame was used in 12 articles.Free flaps(88.0%)or rotational flaps(12.0%)were used,with muscle flaps(96.7%)being most common.Most extremities received free latissimus dorsi or rectus abdominis flaps.Bone grafts and antibiotic beads were often used in conjunction.Although complications and reoperations were not uncommon(up to 30%),98.8%of patients on average were ultimately weight bearing and all articles reported>91%success rate.Additionally,the rates of any complication were not statistically different between"fix and flap"protocol and flap or frame first.Lastly,a three-patient case series is presented.Conclusion:Bone transport with soft tissue reconstruction remains an excellent choice for patients with large bony defects or who are unable to undergo autologous bone grafting.Not one surgical approach to limb salvage is superior,and decision should be made on a case by case basis between the surgeon and the patient.

The evolution of lower extremity reconstruction

Reconstruction of the lower extremity is a complex task that has evolved greatly in both technique and indication over the past century.Early advances in treating traumatic lower extremity injuries focused on primary amputation to avoid the high mortality of infection.The introduction of antibiotics improved surgical debridement and local reconstructive options,enhancing the viability of lower extremities with simple and proximal defects.With the advent of microvascular surgery,free tissue transfer techniques provided a means to reconstruct more distal and complex problems.As these surgical techniques have continued to evolve,so too have indications for reconstruction,patient management and post-operative care-now with a greater emphasis on patient quality of life and limb function.The purpose of this article is to outline the evolution of lower extremity reconstruction,and how the standard of practice has changed over time.

Ethical challenges in vascularized composite allotransplantation of the lower extremity:lessons learned from hand transplantation and implications for the future

Vascularized composite allotransplantation(VCA)is a novel surgical practice that involves the transplantation of multiple tissue types as a functional unit without the primary purpose of extending life.While VCA of the upper extremity is becoming increasingly accepted and performed,VCA of the lower extremity remains largely unexplored despite its acknowledged potential value.There are inherent ethical concerns surrounding VCA that are dominated by a conflict between the principles of beneficence and maleficence.The primary question is whether the quality-of-life benefits to the patient outweigh the risks associated with long-term immunosuppression for a non-lifesaving procedure.In addition,the ethical conversation involves concerns regarding informed consent,donor autonomy,patient privacy and public disclosure,patient selection,and unique considerations in the pediatric patient.Lower extremity VCA has additional ethical issues compared to upper extremity VCA,as current lower limb prostheses provide excellent,near baseline function that upper limb constructs have not yet been able to achieve.In this review,we discuss the ethical challenges of lower extremity VCA using available evidence for the upper extremity.We also compare ethical considerations of VCA of the extremity with other surgical alternatives to limb loss-namely,limb salvage and replantation-and address how the conversation may be altered with further advancements in immunosuppression and prosthetic technology.