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Thomas B, Hackenberg RK, Krasniqi D, Eisa A, Böcker A, Gazyakan E, Bigdeli AK, Kneser U, Harhaus-Wähner L. [Modern concepts of interdisciplinary extremity reconstruction in open fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:469-480. [PMID: 38739196 DOI: 10.1007/s00113-024-01437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/14/2024]
Abstract
The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland.
| | - Roslind K Hackenberg
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Demir Krasniqi
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amr Eisa
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Arne Böcker
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Emre Gazyakan
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amir K Bigdeli
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Ulrich Kneser
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Leila Harhaus-Wähner
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
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Shen Z, Chen S, Duan Y, Yu J, Pan D, Dong J, Wang S, Li Q, Xiao Y, Yuan X. Application of Adjustable Skin Stretchers in Repairing Wound-Related Defects. Clin Cosmet Investig Dermatol 2023; 16:2409-2417. [PMID: 37694193 PMCID: PMC10492556 DOI: 10.2147/ccid.s411870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/18/2023] [Indexed: 09/12/2023]
Abstract
Objective To explore the application value of adjustable skin stretchers for repairing skin wound defects. Methods Twenty patients with skin defects were included in this study. The largest defect was measured to be 45.4 cm × 13.3 cm (length × width) and the smallest one was 4.4 cm × 3.2 cm (length × width). All patients were subjected to adjustable skin stretchers and the short- and long-term clinical efficacy was evaluated. Results The wounds of all enrolled patients were healed completely except for one patient with a dorsal foot infection (the patient requested to return to the local county hospital for further treatment), with a total satisfaction of 100%. Postoperative 3-month follow-up showed scar formation, a little local hyperpigmentation, normal skin elasticity, and intact organs of involved cases, thus signifying the significant impact of adjacent joint activities. Conclusion Adjustable skin stretchers can accurately control the tension on wound margins, breaking the limitation of previous stretchers to provide objective quantitative indicators for clinical application. These stretchers are characterized by high use-value and are worth promoting.
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Affiliation(s)
- Zhimin Shen
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Shiping Chen
- Department of Orthopedics, The No.1 People’s Hospital of Qingzhen, Qingzhen City, People’s Republic of China
| | - Yiqiang Duan
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Juan Yu
- The Affiliated Stomatological Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Dayang Pan
- The 4th People’s Hospital of Guiyang, Guiyang City, People’s Republic of China
| | - Jiaxin Dong
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Shanglong Wang
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Qizhe Li
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Yinlong Xiao
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
| | - Xun Yuan
- Department of Orthopedics, The Affiliated Hospital of Guizhou Medical University, Guiyang City, People’s Republic of China
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Levin SR, Burke PA, Brahmbhatt TS, Siracuse JJ, Slama J, Roh DS. Assessment of Risk Factors Correlated with Outcomes of Traumatic Lower Extremity Soft Tissue Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4961. [PMID: 37124392 PMCID: PMC10132714 DOI: 10.1097/gox.0000000000004961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Abstract
Identifying risk factors for traumatic lower extremity reconstruction outcomes has been limited by sample size. We evaluated patient and procedural characteristics associated with reconstruction outcomes using data from almost four million patients. Methods The National Trauma Data Bank (2015-2018) was queried for lower extremity reconstructions. Univariable and multivariable analyses determined associations with inpatient outcomes. Results There were 4675 patients with lower extremity reconstructions: local flaps (77%), free flaps (19.2%), or both (3.8%). Flaps were most commonly local fasciocutaneous (55.1%). Major injuries in reconstructed extremities were fractures (56.2%), vascular injuries (11.8%), and mangled limbs (2.9%). Ipsilateral procedures prereconstruction included vascular interventions (6%), amputations (5.6%), and fasciotomies (4.3%). Postoperative surgical site infection and amputation occurred in 2% and 2.6%, respectively. Among survivors (99%), mean total length of stay (LOS) was 23.2 ± 21.1 days and 46.8% were discharged to rehab. On multivariable analysis, vascular interventions prereconstruction were associated with increased infection [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.05-3.79, P = 0.04], amputation (OR 4.38, 95% CI 2.56-7.47, P < 0.001), prolonged LOS (OR 1.59, 95% CI 1.14-2.22, P = 0.01), and discharge to rehab (OR 1.49, 95% CI 1.07-2.07, P = 0.02). Free flaps were associated with prolonged LOS (OR 2.08, 95% CI 1.74-2.49, P < 0.001). Conclusions Prereconstruction vascular interventions were associated with higher incidences of adverse outcomes. Free flaps correlated with longer LOS, but otherwise similar outcomes. Investigating reasons for increased complication and healthcare utilization likelihood among these subgroups is warranted.
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Affiliation(s)
- Scott R. Levin
- From the Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Peter A. Burke
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Tejal S. Brahmbhatt
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J. Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jaromir Slama
- From the Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Daniel S. Roh
- From the Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
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Besmens IS, Zoller FE, Guidi M, Giovanoli P, Calcagni M. How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis. J Plast Surg Hand Surg 2023; 57:505-532. [PMID: 36779747 DOI: 10.1080/2000656x.2023.2168274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.
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Affiliation(s)
- Inga S Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Florence E Zoller
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marco Guidi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Othman S, Stranix JT, Piwnica-Worms W, Bauder A, Azoury SC, Elfanagely O, Klifto KM, Levin LS, Kovach SJ. Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure. Microsurgery 2023; 43:5-12. [PMID: 34228378 DOI: 10.1002/micr.30785] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/12/2021] [Accepted: 06/25/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.
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Affiliation(s)
- Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - John T Stranix
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - William Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Andrew Bauder
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Omar Elfanagely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kevin M Klifto
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Wong A, Burke CE, Bangura A, O'Hara NN, Mundy L, O'Toole RV, Pensy RA. What Outcomes Are Most Important to Patients Following a Lower Extremity Limb-threatening Injury? Ann Surg 2023; 277:21-27. [PMID: 35797182 DOI: 10.1097/sla.0000000000005470] [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: 11/26/2022]
Abstract
OBJECTIVE To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury. BACKGROUND The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences. METHODS Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score. RESULTS A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation. CONCLUSIONS Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.
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Affiliation(s)
- Alison Wong
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Reconstruction Options for Lower Extremity Traumatic Wounds. J Am Acad Orthop Surg 2022; 30:735-746. [PMID: 36067459 DOI: 10.5435/jaaos-d-21-01081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/15/2022] [Indexed: 02/01/2023] Open
Abstract
The senior author first coined the "orthoplastic" approach to traumatic lower extremity reconstruction, by which multidisciplinary surgeons and specialists work together for optimal patient success. The goals of lower extremity salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Composite traumatic defects require an organized approach, and the reconstructive ladder is used for strategies of varying complexity for repair of soft-tissue wounds. The lower rungs of the ladder include simpler reconstructive options such as the use of skin grafts and local flaps, and the higher rungs represent complex techniques such as free tissue transfer. Although there is no notable difference between muscle and fasciocutaneous/perforator flaps in reconstructive outcomes, there has been a trend toward perforator flaps to minimize donor site morbidity.
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Levin LS. CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes. Clin Orthop Relat Res 2021; 479:2397-2399. [PMID: 34570743 PMCID: PMC8509994 DOI: 10.1097/corr.0000000000001994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 01/31/2023]
Affiliation(s)
- L Scott Levin
- Chair, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- USA, MC, Retired
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Short- and Long-Term Outcomes following Severe Traumatic Lower Extremity Reconstruction: The Value of an Orthoplastic Limb Salvage Center to Racially Underserved Communities. Plast Reconstr Surg 2021; 148:646-654. [PMID: 34432698 DOI: 10.1097/prs.0000000000008277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have demonstrated that nonwhite race and disadvantaged socioeconomic status negatively impact outcomes following lower extremity reconstruction. The authors sought to characterize differences in outcomes between racial groups in patients necessitating traumatic lower extremity reconstruction at an orthoplastic limb salvage center. METHODS A retrospective review between 2002 and 2019 was conducted of patients who underwent free flap lower extremity reconstruction at an orthoplastic limb salvage center. Patient demographics were identified, and permanent addresses were used to collect census data. Short-term complications and long-term functional status were recorded. RESULTS One hundred seventy-three patients underwent lower extremity reconstruction and met inclusion criteria. Among all three groups, African American patients were more likely to be single (80 percent African American versus 49 percent Caucasian and 29.4 percent other; p < 0.05) and had significantly lower rates of private insurance compared with Caucasian patients (25 percent versus 56.7 percent; p < 0.05). African American patients demonstrated no significant differences in total flap failure (4.9 percent versus 8 percent and 5.6 percent; p = 0.794), reoperations (10 percent versus 5.8 percent and 16.7 percent; p = 0.259), and number of readmissions (2.4 versus 2.0 and 2.1; p = 0.624). Chronic pain management (53.3 percent versus 44.2 percent and 50 percent; p = 0.82), full weight-bearing status (84.2 percent versus 92.7 percent and 100 percent; p = 0.507), and ambulation status (92.7 percent versus 100 percent and 100 percent; p = 0.352) were similar among groups. CONCLUSIONS Outcomes are equivalent between racial groups presenting to an orthoplastic limb salvage center for lower extremity reconstruction. The postoperative rehabilitation strategies, follow-up, and overall support that an orthoplastic limb salvage center ensures may lessen the impact of socioeconomic disparities in traumatic lower extremity reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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The Value of an Orthoplastic Approach to Management of Lower Extremity Trauma: Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3494. [PMID: 33968555 PMCID: PMC8099387 DOI: 10.1097/gox.0000000000003494] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/26/2021] [Indexed: 12/29/2022]
Abstract
Background: Management of traumatic lower extremity injuries requires a skill set of orthopedic surgery and plastic surgery to optimize the return of form and function. A systematic review and meta-analysis was performed comparing demographics, injuries, and surgical outcomes of patients sustaining lower extremity traumatic injuries receiving either orthoplastic management or nonorthoplastic management. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and GRADE certainty evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were systematically and independently searched. Nine studies published from 2013 through 2019 compared 1663 orthoplastic managed patients to 692 nonorthoplastic managed patients with traumatic lower extremity injuries. Results: Orthoplastic management, compared to nonorthoplastic management likely decreases time to bone fixation [standard mean differences: −0.35, 95% confidence interval (CI): −0.46 to −0.25, P < 0.0001; participants = 1777; studies = 3; I2 = 0%; moderate certainty evidence], use of negative pressure wound therapy [risk ratios (RR): 0.03, 95% CI: 0.00–0.24, P = 0.0007; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence] with reliance on healing by secondary intention (RR: 0.02, 95% CI: 0.00–0.10, P < 0.0001; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence), and risk of wound/osteomyelitis infections (RR: 0.37, 95% CI: 0.23–0.61, P < 0.0001; participants = 224; studies = 3; I2 = 0%; moderate certainty evidence). Orthoplastic management likely results in more free flaps compared to nonorthoplastic management (RR: 3.46, 95% CI: 1.28–9.33, P = 0.01; participants = 592; studies = 5; I2 = 75%; moderate certainty evidence). Conclusion: Orthoplastic management of traumatic lower extremity injuries provides a synergistic model to optimize and expedite definitive skeletal fixation and free flap-based soft-tissue coverage for return of extremity form and function.
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