1
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Essien SK, Zucker-Levin A. Comorbidity and risk factors of subsequent lower extremity amputation in patients diagnosed with diabetes in Saskatchewan, Canada. Chronic Illn 2023; 19:779-790. [PMID: 36366747 PMCID: PMC10655619 DOI: 10.1177/17423953221137891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/14/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Subsequent limb amputation (SLA) may be necessary due to disease progression, infection, or to aid prosthesis fit. SLA in Saskatchewan has increased 3.2% from 2006 to 2019 with minor SLA increasing 9.6% during that period. Diabetes affects a large proportion of patients who require SLA; however, the impact of additional comorbidities is not clear. METHODS First-episode subsequent lower extremity limb amputation (SLEA) cases with the presence/absence of diabetes, other comorbidities, and demographic characteristics from 2006-2019 were retrieved from Saskatchewan's Discharge Abstract Database. Logistic regression was performed to examine the magnitude of the odds of SLEA. RESULTS Among the 956 first-episode SLEA patients investigated, 78.8% were diagnosed with diabetes. Of these, 76.1% were male and 83.0% were aged 50 + years. Three comorbidities: renal failure (AOR = 1.9, 95% Cl 1.1 - 3.0), hypertension (AOR = 3.0, 95% Cl 2.0 - 4.5), and congestive heart failure (AOR = 2.0, 95% CI 1.2 - 3.2), conferred the highest odds of SLEA. The odds of SLEA is greatest for those aged 50-69 years, males, Registered Indians, and associated with a prolonged hospital stay. DISCUSSION These data are important as they may help medical providers identify patients at the highest risk of SLEA and target interventions to optimize outcomes.
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Affiliation(s)
- Samuel Kwaku Essien
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
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2
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Hanwright PJ, Suresh V, Shores JT, Souza JM, Tuffaha SH. Current Concepts in Lower Extremity Amputation: A Primer for Plastic Surgeons. Plast Reconstr Surg 2023; 152:724e-736e. [PMID: 37768220 DOI: 10.1097/prs.0000000000010664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the goals of lower extremity reconstruction and identify clinical scenarios favoring amputation. 2. Understand lower extremity amputation physiology and biomechanics. 3. Review soft-tissue considerations to achieve durable coverage. 4. Appreciate the evolving management of transected nerves. 5. Highlight emerging applications of osseointegration and strategies to improve myoelectric prosthetic control. SUMMARY Plastic surgeons are well versed in lower extremity reconstruction for traumatic, oncologic, and ischemic causes. Limb amputation is an increasingly sophisticated component of the reconstructive algorithm and is indicated when the residual limb is predicted to be more functional than a salvaged limb. Although plastic surgeons have traditionally focused on limb salvage, they play an increasingly vital role in optimizing outcomes from amputation. This warrants a review of core concepts and an update on emerging reconstructive techniques in amputee care.
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Affiliation(s)
- Philip J Hanwright
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Visakha Suresh
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Jaimie T Shores
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Jason M Souza
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center
| | - Sami H Tuffaha
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
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3
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Pidgeon TS, Hollins AW, Mithani SK, Klifto CS. Dermal Regenerative Templates in Orthopaedic Surgery. J Am Acad Orthop Surg 2023; 31:326-333. [PMID: 36812411 DOI: 10.5435/jaaos-d-22-01089] [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] [Received: 11/16/2022] [Accepted: 01/19/2023] [Indexed: 02/24/2023] Open
Abstract
Management of soft-tissue injuries is a critical principle in the treatment of orthopaedic trauma. Understanding the options for soft-tissue reconstruction is vital for successful patient outcomes. Application of dermal regenerative templates (DRTs) in traumatic wounds has created a new rung in the reconstructive ladder bridging the gap between skin graft and flap coverage. There are multiple DRT products with specific clinical indications and mechanisms of action. This review outlines the up-to-date specifications and uses of DRT in commonly seen orthopaedic injuries.
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Affiliation(s)
- Tyler S Pidgeon
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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4
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Veale RWF, Kollmetz T, Taghavi N, Duston-Fursman CG, Beeson MT, Asefi D, Chittock HD, Vikranth AS, Dowling SG, Dempsey SG, Rose HJ, Mason ITT, May BCH. Influence of advanced wound matrices on observed vacuum pressure during simulated negative pressure wound therapy. J Mech Behav Biomed Mater 2023; 138:105620. [PMID: 36543083 DOI: 10.1016/j.jmbbm.2022.105620] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/24/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
Biomaterials and negative pressure wound therapy (NPWT) are treatment modalities regularly used together to accelerate soft-tissue regeneration. This study evaluated the impact of the design and composition of commercially available collagen-based matrices on the observed vacuum pressure delivered under NPWT using a custom test apparatus. Specifically, testing compared the effect of the commercial products; ovine forestomach matrix (OFM), collagen/oxidized regenerated cellulose (collagen/ORC) and a collagen-based dressing (CWD) on the observed vacuum pressure. OFM resulted in an ∼50% reduction in the observed target vacuum pressure at 75 mmHg and 125 mmHg, however, this effect was mitigated to a ∼0% reduction when fenestrations were introduced into the matrix. Both collagen/ORC and CWD reduced the observed vacuum pressure at 125 mmHg (∼15% and ∼50%, respectively), and this was more dramatic when a lower vacuum pressure of 75 mmHg was delivered (∼20% and ∼75%, respectively). The reduced performance of the reconstituted collagen products is thought to result from the gelling properties of these products that may cause occlusion of the delivered vacuum to the wound bed. These findings highlight the importance of in vitro testing to establish the impact of adjunctive therapies on NPWT, where effective delivery of vacuum pressure is paramount to the efficacy of this therapy.
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Affiliation(s)
- Robert W F Veale
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Tarek Kollmetz
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Navid Taghavi
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | | | - Matthew T Beeson
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Dorrin Asefi
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Henry D Chittock
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | | | - Shane G Dowling
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Sandi G Dempsey
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Hamish J Rose
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Isaac T T Mason
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand
| | - Barnaby C H May
- Aroa Biosurgery Limited, Airport Oaks, Auckland, 2022, New Zealand.
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5
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May BL, Googe B, Durr S, Googe A, Arnold P, Hoppe I, McIntyre B. Utility of a Continuous External Tissue Expander in Complex Pediatric Wound Reconstruction. EPLASTY 2022; 22:e10. [PMID: 35611153 PMCID: PMC9108423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Soft tissue reconstruction following traumatic injury can be devastating. Reconstructive treatment modalities can prove to be complex. DermaClose (Synovis Micro Companies Alliance, Inc) is a relatively novel wound closure device that has gained popularity for continuous external tissue expansion (CETE). METHODS A single-institution case series of 3 traumatic pediatric soft tissue injuries in which DermaClose was used for soft tissue reconstruction as an alternative to free tissue transfer was presented. A review of the literature to identify similar reported cases was also conducted. RESULTS The authors report their success with the use of this continuous external tissue expander in the management of pediatric soft tissue injuries. Open tibial fractures were sustained by 2 patients, and 1 patient suffered an avulsion injury to the scalp; sequential DermaClose application was successfully utilized to achieve wound closure in all cases. CONCLUSIONS The minimal amount of data currently available in the literature that document the use of this continuous external tissue expander in pediatric patients suggest that its safety and efficacy are inadequately investigated in this population. The cases included in this report suggest DermaClose may be an alternative to traditional methods for complex soft tissue closure in pediatric patients. For larger wounds, repeat applications with sequential closure should be expected and is described in an algorithm within this report.
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Affiliation(s)
- Bobby L. May
- Duke University Hospital, Durham, North Carolina
| | - Ben Googe
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, Jackson, Mississippi
| | - Somer Durr
- University of Mississippi School of Medicine, Jackson, Mississippi
| | - Amber Googe
- University of Mississippi Medical Center, Division of Pediatrics, Grenada, Mississippi
| | - Peter Arnold
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, Jackson, Mississippi
| | - Ian Hoppe
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, Jackson, Mississippi
| | - Ben McIntyre
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, Jackson, Mississippi
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6
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Chan PYW, Colon AF, Clune J, Shah A. External Tissue Expansion in Complex Extremity Reconstruction. J Hand Surg Am 2021; 46:1094-1103. [PMID: 34688502 DOI: 10.1016/j.jhsa.2021.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/30/2021] [Accepted: 07/23/2021] [Indexed: 02/02/2023]
Abstract
Skin grafting and flap-based reconstruction have been the conventional treatments for complex extremity wounds. However, these methods can be associated with relatively high complication rates and involve increasing levels of complexity. External tissue expansion has recently emerged as an attractive alternative to its conventional counterparts. It is a technically simple and low-morbidity technique for complex wound reconstruction. This article provides a review of internal and external tissue expansion with a focus on the evolution, indications, and recent successes of external expansion for soft tissue coverage.
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Affiliation(s)
- Peter Y W Chan
- The Center for Hand and Upper Extremity Surgery, Institute for Advanced Reconstruction, Shrewsbury, NJ
| | - Anthony F Colon
- Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - James Clune
- Division of Plastic Surgery, Yale University School of Medicine, New Haven, CT
| | - Ajul Shah
- The Center for Hand and Upper Extremity Surgery, Institute for Advanced Reconstruction, Shrewsbury, NJ.
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7
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MacKay BJ, Dardano AN, Klapper AM, Parekh SG, Soliman MQ, Valerio IL. Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review. Adv Wound Care (New Rochelle) 2020; 9:525-538. [PMID: 32941124 PMCID: PMC7522632 DOI: 10.1089/wound.2019.1112] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Significance: Continuous external tissue expansion (CETE) is a versatile tool in soft tissue injury management, and could be an addition to the traditional reconstructive ladder. Recent Advances: This critical review discusses the principles and application of CETE, covering a company-sponsored consensus meeting on this emerging technology and highlighting the DermaClose® (Synovis Micro Companies Alliance, Inc., Birmingham, AL) device's unique approach to soft tissue injury management. There is clinical evidence to support the use of CETE in the management of a number of wound types, including fasciotomy, trauma, amputation, and flap donor sites. The device can be applied to open wounds, potentially avoiding the need for a skin graft or other more complex or invasive reconstruction options. DermaClose applies constant tension without restricting blood flow and does not require repeated tightening. Critical Issues: CETE is becoming more widely used by surgeons of different specialties, and numerous reports describing its efficacy and safety in wound management have been published. Surgeons using CETE must follow the correct technique and select patients carefully to achieve optimal outcomes. However, there is no single source of information or consensus recommendations regarding CETE application. Future Directions: Prospective evidence on the efficacy and safety of CETE in clinical practice is required to communicate the best techniques and share important experiences. This will help to solidify its place in the reconstructive ladder as a valuable additional option for surgeons.
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Affiliation(s)
- Brendan J. MacKay
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
- Department of Orthopaedic Surgery, University Medical Center, Lubbock, Texas
| | - Anthony N. Dardano
- Department of Plastic and Reconstructive Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Andrew M. Klapper
- Department of Plastic and Reconstructive Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Selene G. Parekh
- Department of Orthopaedic Surgery, North Carolina Orthopaedic Clinic, Durham, North Carolina
- Fuqua Business School, Duke University, Durham, North Carolina
| | - Mohsin Q. Soliman
- Overland Park General and Bariatric Surgery, HCA Physician Services, Overland Park, Kansas
| | - Ian L. Valerio
- Department of Plastic and Reconstructive Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
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8
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Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. J Trauma Acute Care Surg 2020; 88:e53-e76. [PMID: 32150031 DOI: 10.1097/ta.0000000000002407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE Systematic review of predominantly level II studies, level II.
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9
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Metoyer GT, Anderson SR, Horne BR, Mancho SN, Wimalawansa SM. Preserving the Knee in the Setting of High Segmental Tibial Bone and Massive Soft-Tissue Loss Using Vascularized Distal Tibial Bone Docking and a Foot Fillet Flap: A Case Report. JBJS Case Connect 2020; 10:e0496. [PMID: 32649142 DOI: 10.2106/jbjs.cc.19.00496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We discuss our reconstructive approach to avoid an above-knee amputation in a 33-year-old man presenting after lower extremity crush injury. We used a vascularized tibial bone flap and a foot fillet flap to restore length and joint functionality to the residual limb. The patient ambulates with good prosthetic fit on durable heel pad skin and 100° active knee motion. CONCLUSION This pairing of intramedullary nail with vascularized bone flap and fillet flap to address soft-tissue coverage and retain limb length is a useful tool in traumatic lower extremity injury management, providing an alternative technique for tibial bone graft stabilization with robust, sensate tissue coverage.
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Affiliation(s)
- Garyn T Metoyer
- 1Wright State University, Boonshoft School of Medicine, Dayton, Ohio 2Department of Orthopedic and Plastic Surgery, Wright State University, Boonshoft School of Medicine, Dayton, Ohio
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10
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Black CK, Ormiston LD, Fan KL, Kotha VS, Attinger C, Evans KK. Amputations versus Salvage: Reconciling the Differences. J Reconstr Microsurg 2019; 37:32-41. [PMID: 31499559 DOI: 10.1055/s-0039-1696733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. METHODS In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. RESULTS The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. CONCLUSION Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.
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Affiliation(s)
- Cara K Black
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Laurel D Ormiston
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Kenneth L Fan
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Vikas S Kotha
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Christopher Attinger
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Karen Kim Evans
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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11
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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12
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Alnaif N, Lee J, Azzi AJ, Aldekhayel S, Zadeh T. Preservation of lower extremity spare parts using the University of Wisconsin solution. SAGE Open Med Case Rep 2019; 7:2050313X18823438. [PMID: 30728972 PMCID: PMC6350014 DOI: 10.1177/2050313x18823438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/17/2018] [Indexed: 11/16/2022] Open
Abstract
The management of a mangled limb is a challenging endeavor. With the advancement in microsurgery, spare parts surgery (fillet flaps) has gained recent interest. In the context of lower extremity amputation secondary to trauma, viable spare parts can provide stump soft tissue coverage, potentially preserving critical length and obviating above-knee amputations. Commonly, spare parts surgery is performed in the acute setting but tissue preservation is sometimes necessary. The authors report their experience preserving a fillet flap of a mangled lower extremity for 48 h using the University of Wisconsin solution. A sole fillet flap and a split-thickness skin graft were harvested and preserved from the amputated lower extremity (based on the posterior tibial artery and vein). Stump coverage was achieved by anastomosing the fillet flap to the proximal posterior tibial artery and vein. This solution has not been previously described for preservation of fillet flaps.
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Affiliation(s)
- Nayif Alnaif
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - James Lee
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Alain Joe Azzi
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Salah Aldekhayel
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Teanoosh Zadeh
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
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13
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Zhao JY, Bass KD. Skeletal muscle regeneration by extracellular matrix biological scaffold: a case report. J Wound Care 2018; 27:S11-S14. [DOI: 10.12968/jowc.2018.27.sup9.s11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jane Y. Zhao
- University at Buffalo, State University of New York, Buffalo, NY
| | - Kathryn D. Bass
- University at Buffalo, State University of New York, Buffalo, NY; John R. Oishei Children's Hospital, Buffalo, NY
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Abstract
In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.
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15
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Extracellular Matrix Applications in the Treatment of Open Fractures With Complex Wounds and Large Soft Tissue Defects. J Orthop Trauma 2018; 32:e76-e80. [PMID: 29240612 DOI: 10.1097/bot.0000000000001034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Use of biologic scaffolds such as extracellular matrix (ECM) is a promising trend in the treatment of complex wounds in orthopedic trauma patients. In this clinical series we describe the technique of the successful application of porcine urinary bladder ECM products in the treatment of open fractures of the extremities with complex wounds and large soft tissue defects. The clinical outcomes demonstrated that even in challenging cases where local flap coverage of bone or neurovascular structures is not possible, sequential xenograft implantation allowed us to achieve a stable soft tissue envelope. Different forms of ECM products are easy to apply in the presence of orthopedic hardware. In certain wounds, complete closure can be achieved even without subsequent skin grafting. We recommend relatively earlier application of xenograft.
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Ramu EM, Houdek MT, Isaac CE, Dickie CI, Ferguson PC, Wunder JS. Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes. SICOT J 2017; 3:20. [PMID: 28287387 PMCID: PMC5347369 DOI: 10.1051/sicotj/2017010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022] Open
Abstract
Soft-tissue sarcomas (STS) are a rare group of malignant tumors which can affect any age group. For the majority of patients who present with a localized STS, treatment involves a multidisciplinary team decision-making approach ultimately relying on surgical resection with or without adjuvant radiation for successful limb salvage. The goals of treatment are to provide the patient with a functional extremity without local tumor relapse. The purpose of this article is to review the treatment of extremity STS, with a focus on staging, treatment options, and outcomes.
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Affiliation(s)
- Eyal M Ramu
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Matthew T Houdek
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Christian E Isaac
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Colleen I Dickie
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Peter C Ferguson
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Jay S Wunder
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
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Complications in Tibial Pilon Fractures: Avoiding Errors in Judgment. TECHNIQUES IN FOOT AND ANKLE SURGERY 2016. [DOI: 10.1097/btf.0000000000000131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mishra R, Bishop T, Valerio IL, Fisher JP, Dean D. The potential impact of bone tissue engineering in the clinic. Regen Med 2016; 11:571-87. [PMID: 27549369 DOI: 10.2217/rme-2016-0042] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Bone tissue engineering (BTE) intends to restore structural support for movement and mineral homeostasis, and assist in hematopoiesis and the protective functions of bone in traumatic, degenerative, cancer, or congenital malformation. While much effort has been put into BTE, very little of this research has been translated to the clinic. In this review, we discuss current regenerative medicine and restorative strategies that utilize tissue engineering approaches to address bone defects within a clinical setting. These approaches involve the primary components of tissue engineering: cells, growth factors and biomaterials discussed briefly in light of their clinical relevance. This review also presents upcoming advanced approaches for BTE applications and suggests a probable workpath for translation from the laboratory to the clinic.
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Affiliation(s)
- Ruchi Mishra
- Department of Plastic Surgery, The Ohio State University, Columbus, OH, USA
| | - Tyler Bishop
- Department of Plastic Surgery, The Ohio State University, Columbus, OH, USA
| | - Ian L Valerio
- Department of Plastic Surgery, The Ohio State University, Columbus, OH, USA
| | - John P Fisher
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, USA
| | - David Dean
- Department of Plastic Surgery, The Ohio State University, Columbus, OH, USA
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Connolly M, Ibrahim ZR, Johnson ON. Changing paradigms in lower extremity reconstruction in war-related injuries. Mil Med Res 2016; 3:9. [PMID: 27042328 PMCID: PMC4818384 DOI: 10.1186/s40779-016-0080-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 03/21/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Ballistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage. METHODS A literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications. RESULTS Extremity injuries account for over 60 % of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage. CONCLUSION Lower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.
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Affiliation(s)
- Margaret Connolly
- Department of Surgery, University of Maryland Medical Center, 22 S Greene St., Baltimore, MD 21201 USA
| | - Zuhaib R Ibrahim
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, 601 N Caroline St., Baltimore, MD 21287 USA
| | - Owen N Johnson
- Johns Hopkins University School of Medicine, 601 N Caroline St., Baltimore, MD 21287 USA
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Radtke C, Panzica M, Dastagir K, Krettek C, Vogt PM. Soft Tissue Coverage of the Lower Limb following Oncological Surgery. Front Oncol 2016; 5:303. [PMID: 26793620 PMCID: PMC4711341 DOI: 10.3389/fonc.2015.00303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 12/17/2015] [Indexed: 11/13/2022] Open
Abstract
The treatment of lower limb tumors has been shifted by advancements in adjuvant treatment protocols and microsurgical reconstruction from limb amputation to limb salvage. Standard approaches include oncological surgery by a multidisciplinary team in terms of limb sparing followed by soft tissue reconstruction and adjuvant therapy when indicated. For the development of a comprehensive surgical plan, the identity of the tumor should first be determined by histology after biopsy. Then the surgical goal and comprehensive treatment concept should be developed by a multidisciplinary tumor board and combined with soft tissue reconstruction. In this article, plastic surgical reconstruction options for soft coverage of the lower extremity following oncological surgery will be described along with the five clinical cases.
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Affiliation(s)
- Christine Radtke
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School , Hannover , Germany
| | - Martin Panzica
- Department of Trauma Surgery, Hannover Medical School , Hannover , Germany
| | - Khaled Dastagir
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School , Hannover , Germany
| | - Christian Krettek
- Department of Trauma Surgery, Hannover Medical School , Hannover , Germany
| | - Peter M Vogt
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School , Hannover , Germany
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Abstract
OBJECTIVES Trauma-related hemipelvectomy is a rare and often fatal injury that poses a number of challenges to the treating surgeon. Our objective was to identify patient and injury characteristics that have proven difficult to treat, and to describe management techniques. DESIGN Retrospective review. SETTING Level II trauma center. PATIENTS Thirteen consecutive patients who underwent 14 combat-related hemipelvectomies between 2001 and 2013. INTERVENTION We reviewed our prospective trauma registry, along with the patients' medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS Injury severity scores, required surgical procedures, ambulatory status, and bowel and bladder function. RESULTS Hemipelvectomy was indicated for insufficient soft tissue coverage, complicated by life-threatening local infection and/or a dysvascular hemipelvis. Five patients underwent resection for angioinvasive fungal infections. All patients sustained a genitourinary injury, with 7 requiring suprapubic catheters and all undergoing diverting colostomy. After a median of 2 years of follow-up, 2 patients had normal urinary continence and 3 regained fecal continence. The surviving patients required a mean of 44 operations. One patient returned to community ambulation. CONCLUSIONS This is the largest published series of trauma-related hemipelvectomies. Our lessons learned may benefit civilian surgeons who are confronted with high-energy open injuries to the pelvic girdle. Although the decision to perform hemipelvectomy should not be taken lightly, this procedure can be lifesaving and should be performed in a timely fashion when indicated. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Gordon W, Kuhn K, Staeheli G, Dromsky D. Challenges in definitive fracture management of blast injuries. Curr Rev Musculoskelet Med 2015; 8:290-7. [PMID: 26104316 PMCID: PMC4596208 DOI: 10.1007/s12178-015-9286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The United States military remains engaged in the longest armed conflict in this nation's history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.
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Affiliation(s)
- Wade Gordon
- />Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Kevin Kuhn
- />Naval Medical Center San Diego, San Diego, CA USA
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Bauer JM, Callan AK, Jahangir AA. Length-Preserving Intramedullary Femoral Fixation for Traumatic Leg Amputation. JBJS Case Connect 2015; 5:e38. [PMID: 29252607 DOI: 10.2106/jbjs.cc.n.00169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present the case of a twenty-one-year-old woman with a traumatic left leg amputation, substantial proximal skin degloving, and an ipsilateral femoral fracture treated with revision amputation distal to the fracture site and retrograde femoral nailing through the amputation site. CONCLUSION A short retrograde femoral nail is a surgical option to fix a femoral shaft fracture proximal to a traumatic amputation in order to preserve limb length for effective prosthetic fit and ambulation.
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Affiliation(s)
- Jennifer M Bauer
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
| | - Alexandra K Callan
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
| | - Alex A Jahangir
- Vanderbilt Orthopaedic Institute, Medical Center East, South Tower, Suite 4200, 1215 21st Avenue South, Nashville, TN 37232-8774
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