Foot Wounds and the Reconstructive Ladder

When to ditch the ladder and take the elevator: The Anderson SArcoma Risk of Complications (A-SARC) score to guide reconstructive decision-making in extremity soft tissue sarcoma patients

BACKGROUND

The reconstructive ladder relies mostly on defect size and depth to determine reconstructive technique, however, in actuality, many more variables ultimately inform reconstructive decision making, especially regarding extremity soft tissue sarcoma (eSTS) defects. The purpose of this study was to describe eSTS patients who will most optimally benefit from an advanced method of reconstruction (defined as a pedicled regional flap or free flap) and to create a simple risk assessment scale that can be employed in clinical practice.

STUDY DESIGN

A single-institution retrospective cohort study examined patients undergoing resection of soft tissue sarcoma affecting the upper or lower extremities between 2016 and 2021. We categorized patients who required a pedicled or free flap as having had advanced reconstruction, and all other techniques were considered simple reconstruction. A regression was used to create a risk scale to guide reconstructive decision-making.

RESULTS

The following variables were identified as independent predictors of complications and used to create our risk scale: lower extremity tumor location, preoperative radiotherapy, tumor bed excision, male sex, hypertension, and tumor volume. Intermediate and high-risk patients reconstructed using simple techniques had significantly greater overall complication rates compared to those reconstructed with advanced techniques. Major complications were significantly greater in low-risk patients reconstructed with advanced techniques.

CONCLUSIONS

To minimize postoperative wound complications, low-risk patients should receive simple methods of reconstruction, whereas high-risk patients should be reconstructed using advanced techniques.

Unique Challenges in Diabetic Foot Science

In the past 30 years, there has been a rapid influx of information pertaining to the diabetic foot (DF) coming from numerous directions and sources. This article discusses the current state of the DF literature and challenges it presents to clinicians with its associated increase in knowledge on their derivations, complications, and interventions. Further, we attempt to provide tips on how to navigate and criticize the current literature to encourage and maximize positive outcomes in this challenging patient population.

"Spare Parts" for Foot Wound Reconstruction: A Report of 2 Cases

Soft tissue reconstruction of the foot can be a complex task to undertake when presented with challenging wounds. The foot comprises thick, glabrous skin with its own unique soft tissue anatomy that is suited to withstand its necessary functional demands. "Spare parts" reconstruction provides an option for closure of complicated skin wounds encompassing areas of large, unsalvageable defects. This report presents the cases of 2 patients who underwent successful care at our institution. Each patient's approach was individualized based on the etiology and presentation of the wound while any comorbid conditions were taken into consideration. The purpose of these case reports is to highlight 2 examples involving spare parts foot reconstruction of complicated defects, both of which decreased donor morbidity and lessened the degree of amputation.

Practical Review of the Current Management of Frostbite Injuries

Frostbite is an injury that occurs when the skin and tissues are exposed to temperatures below their freezing point. This type of injury can lead to various complications such as functional loss, chronic pain, and psychological trauma. As such, understanding frostbite management is crucial for optimal patient care. A scoping review was conducted in February 2022 using PubMed, EMBASE, referenced articles and snowballing to identify relevant published articled using the terms "frostbite" and "management" and "surgery. Articles related to pathophysiology, classifications, radiography, complications, and medical and surgical management were included to formulate recommendations for practical management. Two hundred fifty-one articles were identified and 54 met inclusion criteria. Rapid rewarming in warm water (40-42 °C) remains the standard of care. Thrombolytic therapy has been shown in numerous studies to improve tissue salvage. Radiographic imaging has become crucial in the evaluation and management in frostbite injury. Current literature recommends delayed surgery with soft tissue debridement and bone scan-guided amputations. Surgical intervention including debridement, selective blister drainage, fasciotomies, surgical salvage, skin grafts' and flaps are often necessary in these patients towards optimizing form and function. The true prevalence and incidence of frostbite injury is unknown. A centralized national database will improve our understanding of the diagnostic and management modalities used in frostbite care. Plastic surgeons have a critical role in the management of frostbite care and must work with an interdisciplinary team to identify the best treatment route for optimal patient care.