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Meyer A, Rother U, Thamm OC. [Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery]. Zentralbl Chir 2024; 149:468-474. [PMID: 37956972 DOI: 10.1055/a-2183-1770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.
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Affiliation(s)
- Alexander Meyer
- Klinik für Gefäßchirurgie, HELIOS Klinikum Berlin-Buch, Berlin, Deutschland
- MSB Medical School Berlin, Berlin, Deutschland
| | - Ulrich Rother
- Gefäßchirurgische Abteilung, Universitätsklinikum Erlangen, Erlangen, Deutschland
- Friedrich-Alexander-Universität, Erlangen, Deutschland
| | - Oliver C Thamm
- Klinik für Plastische und Ästhetische Chirurgie, HELIOS Klinikum Berlin-Buch, Berlin, Deutschland
- Universität Witten-Herdecke, Witten, Deutschland
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2
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Matsuda N, Seo D, Suzuki R, Dannoura Y, Horiuchi K. Free Flap Limb Salvage and Ulcer Recurrence in Chronic Limb-threatening Ischemia. INT J LOW EXTR WOUND 2024:15347346241287335. [PMID: 39328168 DOI: 10.1177/15347346241287335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
Free flap transfer is a well-established treatment for foot reconstruction in patients with chronic limb-threatening ischemia (CLTI) and can achieve prolonged amputation-free survival. However, reports on ulcer recurrence after free flap transfer are scarce, with most focusing on trauma patients. Therefore, we retrospectively reviewed patients with CLTI who underwent free flap reconstruction at our institution over a 17-year period. Patient characteristics, ulcer recurrence rates, activity level, and variables associated with ulcer recurrence were investigated in patients who met the following criteria: successful reconstructive surgery, complete wound healing, and at least 1 year of follow-up. Free flap foot reconstruction was performed in 42 patients (92.9% male, 7.1% female; mean age 57.1 years, range 37-81 years). Among them, 39 patients (92.9%) had diabetes mellitus, 15 (35.7%) had critical limb ischemia, and 15 (35.7%) had end-stage renal disease/hemodialysis. Mean postoperative follow-up was 60.5 (range 12.0-208.0) months. The 5-year primary ulcer recurrence-free survival rate was 48.7%. High activity level and selection of the posterior tibial artery as the recipient artery were significantly associated with ulcer recurrence [hazard ratio, 3.59 and 9.81; P = .046 and P < .001, respectively]. Activity levels were not significantly different before and 1 year after surgery. In conclusion, survival analysis revealed that ulcer recurrence is most likely to occur within the first 2 years after surgery. Although recurrence occurred in approximately half of the patients, most patients maintained activity levels comparable to their preoperative levels.
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Affiliation(s)
- Norifumi Matsuda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Plastic and Reconstructive Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Dongkyung Seo
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Plastic and Reconstructive Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Riho Suzuki
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Sapporo, Japan
- Limb Salvage Center, Sapporo City General Hospital, Sapporo, Japan
| | - Yutaka Dannoura
- Department of Cardiovascular Medicine, Sapporo City General Hospital, Sapporo, Japan
- Limb Salvage Center, Sapporo City General Hospital, Sapporo, Japan
| | - Katsumi Horiuchi
- Department of Plastic and Reconstructive Surgery, Sapporo City General Hospital, Sapporo, Japan
- Limb Salvage Center, Sapporo City General Hospital, Sapporo, Japan
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3
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Huffman SS, Bovill JD, Li K, Spoer DL, Berger LE, Bekeny JC, Akbari CM, Fan KL, Evans KK. Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction. J Reconstr Microsurg 2024; 40:384-391. [PMID: 37751882 DOI: 10.1055/a-2181-7149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO. METHODS Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status. RESULTS A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups. CONCLUSION This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.
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Affiliation(s)
- Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Georgetown University School of Medicine, Washington, District of Columbia
| | - John D Bovill
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Karen Li
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Goodall RJ, Borsky KL, Harrison CJ, Mavromatidou G, Shirley RA, Ellard DR, Rodrigues JN, Chan JK. A Qualitative Study of Patients' Lived Experiences of Free Tissue Transfer for Diabetic Foot Disease. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5842. [PMID: 38798930 PMCID: PMC11124632 DOI: 10.1097/gox.0000000000005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 04/04/2024] [Indexed: 05/29/2024]
Abstract
Background Free tissue transfer (FTT) for reconstruction of diabetic foot disease (DFD) is an emerging field to preserve the lower limb within this patient group. The design of future quantitative research and clinical services in this area must consider the needs, expectations and concerns of patients. This qualitative study explores patient experiences of FTT for reconstruction of DFD. Methods Semistructured interviews were conducted to explore patients' lived experiences of FTT for DFD. A purposive sampling strategy identified six patients who underwent FTT for recalcitrant DFD between September 2019 and December 2021 in a single center in the United Kingdom. Results Three experiential themes emerged. Theme 1: "negative lived experiences of living with DFD" included frustration with the chronic management of nonhealing ulcers and fear regarding limb amputation. Theme 2: "surgery related concerns" included fears of reconstructive failure and subsequent amputation, as well as foot cosmesis and donor-site morbidity. Theme 3: "positive lived experiences following reconstruction" included the positive impact the reconstruction had on their overall life and diabetic control. All patients would repeat the process to obtain their current results. Conclusions This qualitative study provides first-hand insight into the lived experience of FTT for DFD, exploring both the negative and positive experiences and reasons for these. We found that FTT for DFD can be positively life-changing for affected individuals.
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Affiliation(s)
- Richard J Goodall
- From the Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Kim L Borsky
- From the Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
- Department of Plastic Surgery, Salisbury District Hospital, Salisbury, United Kingdom
| | - Conrad J Harrison
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Galini Mavromatidou
- From the Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
| | - Rebecca A Shirley
- From the Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
| | - David R Ellard
- Warwick Clinical Trials Unit, University of Warwick, Warwick, United Kingdom
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
| | - Jeremy N Rodrigues
- From the Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Warwick, United Kingdom
| | - James Kk Chan
- From the Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Warwick, United Kingdom
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Yang CC, Wu MS, Hsu H. Management of diabetic foot ulcers using topical probiotics in a soybean-based concentrate: a multicentre study. J Wound Care 2023; 32:S16-S21. [PMID: 38063295 DOI: 10.12968/jowc.2023.32.sup12.s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Diabetic foot ulcer (DFU) is a common complication in people with diabetes. Standard management includes strict glycaemic management, control of the infection, revascularisation, debridement, mechanical offloading and foot care education. This study aimed to evaluate the efficacy of using topical probiotics in a soybean-based concentrate in the management of DFUs. METHOD A retrospective, multicentre evaluation of patients with diabetes with non-infected DFUs between October 2020 and October 2021, and who were treated with twice daily topical application of probiotics in a soybean-based concentrate as an adjunct to standard wound care. RESULTS A total of 22 patients were enrolled into this study, including 16 males and six females, with a mean age of 61 years (range: 31-89 years). Defect size ranged from 1-33.5cm2 (mean: 7.2cm2). The mean number of days until complete healing was 51 (range: 21-112 days). Of the patients, 83% showed complete healing at the end of 16 weeks, 72% showed complete healing at 12 weeks, 56% at eight weeks, and 22% at four weeks. The wounds showed an average decrease in size of 0.59cm2 (9%) per week, calculated using generalised estimating equation. CONCLUSION This findings of this study provide a new perspective on the therapeutic potential of probiotics as an effective form of management in patients with small, hard-to-heal (chronic) DFUs.
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Affiliation(s)
- Chao-Chih Yang
- Attending Plastic Surgeon and Chief of Division of Plastic Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan
| | - Megn-Si Wu
- Attending Plastic Surgeon, Lecturer, Division of Plastic Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
| | - Honda Hsu
- School of Medicine, Tzu Chi University, Hualien, 97004, Taiwan
- Attending Plastic Surgeon, Associate Professor, Division of Plastic Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
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Shimbo K, Kawamoto H, Koshima I. Combined Revascularization and Free Flap Reconstruction for Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2023; 39:581-588. [PMID: 36577499 DOI: 10.1055/a-2003-9004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Combined revascularization and free flap reconstruction is one treatment method for chronic limb-threatening ischemia (CLTI) with complex wounds. The purpose of this systematic review and meta-analysis was to investigate the characteristics of this combined procedure and to assess postoperative outcomes. METHODS A systematic search was performed across PubMed, Scopus, and the Web of Science for studies between January 2000 and February 2022. A random-effects meta-analysis for postoperative outcome was conducted. RESULTS Fifteen articles encompassing 1,176 patients with 1,194 free flaps were ultimately included in the qualitative and quantitative assessment. Our meta-analysis showed the following complication rates for short-term postoperative outcomes: 37% (95% confidence interval [CI], 18-53%; I 2 = 74%) for reoperation, 13% (95% CI, 2-24%; I 2 = 0%) for vascular thrombosis, 9% (95% CI, 0-17%; I 2 = 0%) for total flap failure, 8% (95% CI, 0-17%; I 2 = 0%) for partial flap failure, 4% (95% CI, 0-10%; I 2 = 0%) for amputation, and 3% (95% CI, 0-9%; I 2 = 0%) for 30-day mortality. The 1-, 3-, and 5-year limb salvage rates were 86% (95% CI, 78-92%), 81% (95% CI, 68-88%), and 71% (95% CI, 53-83%), respectively. The 1-, 3-, and 5-year patient survival rates were 93% (95% CI, 90-96%), 92% (95% CI, 77-97%), and 75% (95% CI, 50-88%), respectively. CONCLUSION Combined revascularization and free flap reconstruction for CLTI with complex wounds was clearly effective for the long-term outcomes. However, this combined procedure should be considered on the assumption that the reoperation rate is high and that flap-related complications rate may be higher than lower extremity reconstruction of other etiologies.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
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Use of Recanalized Vessels for Diabetic Foot Reconstruction: Pushing the Boundaries of Reconstruction in a Vasculopathic Lower Extremity. Plast Reconstr Surg 2023; 151:485e-494e. [PMID: 36730343 DOI: 10.1097/prs.0000000000009935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Free flap after lower extremity revascularization may enable limb salvage in defects after critical limb ischemia. This study examined the outcomes of reconstruction of ischemic diabetic foot according to the severity of the vessel occlusion and assessed whether recanalized vessels may serve as a reliable recipient vessel. METHODS A total of 62 patients who underwent diabetic foot reconstruction with free flaps after successful percutaneous transluminal angioplasty (PTA) from February of 2010 to February of 2016 were identified and divided into three groups: group 1, nonoccluded vessels as recipient ( n = 11); group 2, recanalized artery after PTA for partially occluded artery ( n = 30); and group 3, recanalized artery after PTA for completely occluded artery ( n = 21). RESULTS Flap survival was statistically higher in group 2 (90%) compared with group 3 (67%) ( P < 0.05). Subsequent major amputation was significantly lower in groups 1 and 2 [0/7 and 1/30 (3.3%)] compared with group 3 [5/21 (23.8%)] ( P < 0.05). The patient survival and limb salvage rate was 90.9% at 1 and 3 years in group 1, 89.8% at 1 year and 86.3% at 3 and 5 years in group 2, and 76.2% at 1, 3, and 5 years in group 3. This difference was not statistically significant ( P = 0.485). CONCLUSIONS The use of recanalized vessels after PTA can be safe for partially occluded arteries but requires caution for completely occluded arteries. Using completely occluded vessels after PTA can be attempted when other options are not available and achieves a 76% chance of limb salvage. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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8
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Hung CT, Hsu H. Microsurgical complication associated with vaccine-induced immune thrombotic thrombocytopenia (VITT): A case report. Medicine (Baltimore) 2023; 102:e33013. [PMID: 36800613 PMCID: PMC9936026 DOI: 10.1097/md.0000000000033013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
RATIONALE The use of ChAdOx1 nCoV-19 (Astra Zeneca) vaccine has proven beneficial, but in a limited number of the general population, it was found to be associated with vaccine-induced immune thrombotic thrombocytopenia (VITT). However, there have been no reports of this complication occurring in a microsurgical free tissue transfer. PATIENT CONCERNS A 49-year-old man developed an acute myocardial infarction 3 weeks after receiving his first dose of ChAdOx1 nCoV-19 in June 2021. Three months later, he presented with right third toe wet gangrene with extension into the plantar foot nine days after receiving his second dose of ChAdOx1 nCoV-19 vaccine. DIAGNOSIS Based on recent exposure to vaccination, the timing of inoculation before the development of his symptoms, and serology tests (platelet, D-dimer, and anti-PF4 antibodies), the patient was diagnosed with VITT. INTERVENTIONS Fasciectomy and sequestrectomy were performed for wound bed preparation. Limb salvage was done using free vastus lateralis muscle flap and skin graft for reconstruction. OUTCOME The flap was complicated by persistent microthrombi leading to superficial necrosis without vascular pedicle compromise. Repeated debridement of the superficial necrosis was done. Three months after the development of VITT, no further new superficial necrosis was seen. A well-contoured flap was seen 5 months after the initial surgery. LESSONS We believe this is the first case describing microthrombi in the free flap due to VITT after microsurgical reconstruction. Patients and surgeons should be advised of this possible risk when contemplating microsurgery once VITT has developed after ChAdOx1 nCoV-19 administration.
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Affiliation(s)
- Chen-Ting Hung
- Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Honda Hsu
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- * Correspondence: Honda Hsu, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan (e-mail: )
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Ishikawa S, Arai K, Kurihara T, Sato T, Ichioka S. Endovascular therapy and free flap transfer in chronic limb-threatening ischemia. J Plast Surg Hand Surg 2023; 57:422-426. [PMID: 36433928 DOI: 10.1080/2000656x.2022.2149541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although revascularization has evolved, treating foot gangrene with chronic limb-threatening ischemia remains challenging. There have been many reports on bypass surgery and free flap transfer. Meanwhile, few studies have reported on endovascular therapy and free flap transfer, with high flap survival rates and high wound complication rates. Wound complications are a serious problem that can lead to limb amputation, but previous studies have failed to identify risk factors for wound complications. In this study, we evaluated the results of endovascular therapy and free flap transfer for chronic limb-threatening ischemia and analyzed risk factors for wound complications. A total of 31 legs from 28 patients who underwent endovascular therapy and free flap transfer for lower limb salvage between August 2016 and April 2020 were retrospectively reviewed. The primary endpoints were flap survival and limb salvage rates and wound complication rates. In addition, we performed a statistical analysis of risk factors for wound complications. The flap survival rate was 100%, with partial necrosis in 6% of the patients. The limb salvage rate was 100%. The wound complication rate was 45%. The multivariate analysis showed end-stage renal failure on dialysis as a significant risk factor for wound complications (odds ratio = 133, 95% confidence interval = 2.74-6430, p = 0.014). Endovascular therapy and free flap transfer in chronic limb-threatening ischemia achieved high flap survival rate and limb salvage, but had a high incidence of wound complications. We identified end-stage renal failure on dialysis was a significant risk factor for wound complications.
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Affiliation(s)
- Shoichi Ishikawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Saitama Medical University, Saitama, Japan
| | - Kiyohito Arai
- Department of Cardiology, Saiseikai Kurihashi Hospital, Saitama, Japan
| | - Takeshi Kurihara
- Department of Plastic, Reconstructive and Aesthetic Surgery, Saitama Medical University, Saitama, Japan
| | - Tomoya Sato
- Department of Plastic, Reconstructive and Aesthetic Surgery, Saitama Medical University, Saitama, Japan
| | - Shigeru Ichioka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Saitama Medical University, Saitama, Japan
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10
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Umemoto K, Otsuka S, Mizuno D, Nanizawa E, Fukushige K, Hatayama N, Naito M. Nerve branches to the anterior tibial artery: clinical application. Clin Anat 2022; 35:1051-1057. [PMID: 35366025 DOI: 10.1002/ca.23868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/01/2022] [Accepted: 03/24/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Arteries receive vascular branches (VBs) from peripheral nerves. VBs are thought to be involved in arterial constriction. Although the anterior tibial artery (ATA) receives VBs, information on their branching patterns and distribution areas remains limited. The aim of this study was to investigate the anatomical structures of the VBs reaching the ATA. MATERIALS AND METHODS Forty cadaver limbs were examined to assess the branching patterns and distribution areas of the VBs reaching the ATA. RESULTS The VBs reaching the ATA ramified from the deep fibular nerve (DFN), and the ATA received two or three VBs in each limb. The following mean distances from the head of fibula to the points at which the VBs reached the ATA were measured: all the VBs, 1st VB, 2nd VB and 3rd VB. The measurements were 51.5 ± 23.2 mm, 33.3 ± 3.7 mm, 53.3 ± 18.6 mm, and 72.2 ± 24.5 mm, respectively. In all limbs, the DFN and the ATA converged after the DFN branched into the 1st VB. The 2nd VB in 38 of 40 limbs and the 3rd VB in 20 of 32 limbs were distributed in the ATA proximal to the convergence point of the ATA and the DFN. CONCLUSIONS These findings revealed that all VBs reaching the ATA ramified from the DFN in all limbs. The ATA received two or three VBs, and all the 1st VBs distributed to the ATA proximal to the convergence point. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- K Umemoto
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - S Otsuka
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - D Mizuno
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - E Nanizawa
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - K Fukushige
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - N Hatayama
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - M Naito
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
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11
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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12
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Kim KG, Tirrell AR, Dekker PK, Haffner Z, Attinger CE, Fan KL, Evans KK. The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis. J Reconstr Microsurg 2021; 37:764-773. [PMID: 33853126 DOI: 10.1055/s-0041-1726398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades. METHODS PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test. RESULTS The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p < 0.001). Functional outcomes were more commonly reported between 1990 and 2012 (78.0 vs. 47.5%, p = 0.003); similarly, ambulatory status was reported more often in the previous review (70.0 vs. 40.0%, p = 0.004). This study solely examined the rate at which PCO were reported in the literature; the individual importance and effect on medical outcomes of each PCO was not evaluated. CONCLUSION Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.
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Affiliation(s)
- Kevin G Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Abigail R Tirrell
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Paige K Dekker
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Zoe Haffner
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
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Hahn HM, Lee DH, Lee IJ. Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases. J Plast Reconstr Aesthet Surg 2020; 74:1544-1552. [PMID: 33454224 DOI: 10.1016/j.bjps.2020.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/18/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia. METHODS Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected. RESULTS Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications. CONCLUSION The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.
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Affiliation(s)
- Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea.
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Stoberock K, Kaschwich M, Nicolay SS, Mahmoud N, Heidemann F, Rieß HC, Debus ES, Behrendt CA. The interrelationship between diabetes mellitus and peripheral arterial disease - a systematic review. VASA 2020; 50:323-330. [PMID: 33175668 DOI: 10.1024/0301-1526/a000925] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This systematic review examined the interrelationship between concomitant diabetes mellitus (DM) and peripheral arterial disease (PAD). The objective was to determine differences in the prevalence as well as in the outcomes in diabetic vs. non-diabetic PAD patients. The current review followed a study protocol that was published online in German in 2017. The search included societal practice guidelines, consensus statements, systematic reviews, meta-analyses, and observational studies published from 2007 to 2020 reporting symptomatic PAD and concomitant DM in patients undergoing invasive open-surgical and endovascular revascularizations. German and English literature has been considered. Eligibility criteria were verified by three independent reviewers. Disagreement was resolved by discussion involving a fourth reviewer. 580 articles were identified. After exclusion of non-eligible studies, 61 papers from 30 countries remained, respectively 850,072 patients. The included studies showed that PAD prevalence differed between diabetic vs. non-diabetic populations (20-50% vs. 10-26%), and further by age, gender, ethnicity, duration of existing diabetes, and geographic region. The included studies revealed worse outcomes regarding perioperative complications, amputation rate, and mortality rate in diabetic patients when compared to non-diabetic patients. In both groups, the amputation rates decreased during the research period. This review emphasizes an interrelationship between PAD and DM. To improve the outcomes, early detection of PAD in diabetic patients, and vice versa, should be recommended. The results of this systematic review may help to update societal practice guidelines.
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Affiliation(s)
- Konstanze Stoberock
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Kaschwich
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shiva Sophia Nicolay
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nazeh Mahmoud
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik C Rieß
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Haug V, Kadakia N, Panayi AC, Kauke M, Hundeshagen G, Diehm Y, Fischer S, Hirche C, Kneser U, Pomahac B. Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients. J Plast Reconstr Aesthet Surg 2020; 74:1031-1040. [PMID: 33436337 DOI: 10.1016/j.bjps.2020.10.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/06/2020] [Accepted: 10/20/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage. METHODS By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. RESULTS We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001). CONCLUSION Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.
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Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Nikita Kadakia
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA
| | - Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Yannick Diehm
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA.
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16
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Houlind K. Surgical revascularization and reconstruction procedures in diabetic foot ulceration. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3256. [PMID: 31840931 DOI: 10.1002/dmrr.3256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/25/2019] [Indexed: 11/08/2022]
Abstract
This article summarizes surgical procedures for preservation of the foot in diabetic patients with peripheral artery disease. Distal bypass surgery performed to perigeniculate arteries and to an isolated 'blind' popliteal segment with visible collaterals can be performed with limb salvage rates close to what can be achieved with standard bypass to crural arteries. This is also the case when performing bypass to the dorsalis pedis artery. Bypass to the medial or lateral plantar artery or to the lateral tarsal artery is associated with a relatively high rate of early occlusion, but in the patients who have persistently open grafts, limb salvage is common. The use of an arteriovenous fistula as an adjunct to distal bypass surgery does not improve prognosis. Venous arterialization, either creating retrograde perfusion of the superficial or of the deep veins of the foot has been successful in several cases although it is difficult to predict which patients will benefit. Reconstructive surgery is often performed in a multidisciplinary team including plastic surgeons. In patients with need of more extensive cover of defects, the transplant of muscular or fasciocutaneous free flaps has provided good results in the few centres that have applied this technique. This procedure can be combined with a revascularization in the same session or at a later stage. A majority of the described techniques can be implemented in most vascular centres and they should be considered in complicated cases when standard methods of revascularization and reconstruction do not suffice.
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Affiliation(s)
- Kim Houlind
- Kolding Hospital, University Hospitals of Southern Denmark, Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark
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17
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Liu C, You JX, Chen YX, Zhu WF, Wang Y, Lv PP, Zhao F, Li HY, Li L. Effect of Induced Membrane Formation Followed by Polymethylmethacrylate Implantation on Diabetic Foot Ulcer Healing When Revascularization Is Not Feasible. J Diabetes Res 2019; 2019:2429136. [PMID: 31828156 PMCID: PMC6885796 DOI: 10.1155/2019/2429136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/22/2019] [Indexed: 01/04/2023] Open
Abstract
No study has investigated the role of induced membrane (IM) formation in treating diabetic foot ulcer (DFU). This retrospective study was aimed (1) at evaluating the potential role of a two-staged surgical approach, comprising polymethylmethacrylate (PMMA) implantation and IM formation, in the treatment of DFU and (2) at comparing the results of those with routine wound debridement in patients with DFUs and nonrevascularized peripheral arterial disease (PAD). Fifty patients with infected DFUs who were not candidates for vascular interventions were enrolled between February 2016 and April 2018 and assigned to the PMMA group (n = 28) and conventional group (n = 22). The healing rate, major amputation rate, duration of healing, frequency of debridement procedures, patient survival rate, and reulceration of DFUs were determined. The Mann-Whitney U test, independent sample t-test, and χ 2 or Fisher exact test were used in statistical analysis. Overall clinical outcomes were statistically different between the groups (Z = -2.495, P = 0.013). In the PMMA group, 16 patients (57.1%) with intact IM formation achieved ulceration healing at 13.1 ± 3.7 weeks with a mean number of debridements of 1.3 ± 0.4, which were significantly different compared to those values in 5 patients of the conventional group (22.7%, P = 0.014; healing duration: 26.4 ± 7.8 weeks, P = 0.016; mean number of debridements: 3.6 ± 0.5, P ≤ 0.001). At a mean 16.8 ± 4.3-month follow-up, patient survival rates were 92.9% and 68.2% in the PMMA and conventional groups, respectively (P = 0.032). The major amputation rate and reulceration of DFUs were similar between the groups. The two-staged surgical approach is an available, effective modality for improving healing of DFUs. This study provides preliminary information of IM formation followed by PMMA implantation in the management of DFUs in PAD when revascularization is not feasible.
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Affiliation(s)
- Chao Liu
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Jia-Xing You
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Yi-Xin Chen
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Wei-Fen Zhu
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Ying Wang
- Wound and Ostomy Care Clinic, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Pan-Pan Lv
- Department of Ultrasound, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Feng Zhao
- Department of Clinical Laboratory, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Hong-Ye Li
- Department of Orthopedics, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
| | - Lin Li
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, #3 E. Qingchun Rd, Hangzhou 310016, China
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Lejay A, Chakfé N. Together We are Stronger. Eur J Vasc Endovasc Surg 2018; 57:537. [PMID: 30591256 DOI: 10.1016/j.ejvs.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France.
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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