Total Hip Arthroplasty in Human Immunodeficiency Virus Positive Patients: A Systematic Review of Outcomes

BACKGROUND

Total hip arthroplasty (THA) has become a common intervention for human immunodeficiency virus (HIV)-positive patients who have osteonecrosis of the femoral head. This paper provides a systematic review to assess survivorships, patient-reported outcomes (PROMs), infection rates, other complications, and immune competence for patients who had THAs who did and did not have HIV.

METHODS

A comprehensive and systematic review of published studies investigating the outcomes of THA in HIV-positive patients (osteonecrosis and non-osteonecrosis patients) was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 10 studies with 9,534 HIV-positive patients fulfilled the inclusion and exclusion criteria. Manuscript quality was assessed on 2 scales: the Coleman Methodology Score and the level of evidence derived from Center for Evidence-Based Medicine criteria. Data were extracted from studies in the 5 key areas of interest: survivorships, PROMs, infection rates, complications, and clusters of differentiation-4 (CD4+) counts and viral loads.

RESULTS

Implant survivorship was between 95% and 100%. Postoperative Harris Hip Scores were significantly improved from preoperative values in HIV-positive patients. Postoperative PROMs and infections did not appear to be different between HIV-positive and HIV-negative patients. Many of the cohort studies demonstrate comparable complication rates to matched controls. Where described (7 reports), mean CD4+ counts ranged from 425 to 646 cells/mm3, with low viral loads (3 reports) and variations not found to influence outcomes.

CONCLUSIONS

THA is an effective treatment for HIV-positive patients, many of whom suffer from osteonecrosis of the femoral head. The results demonstrate excellent implant survivorship, improved quality of life, and a low risk of infections and complications.

Angle of progression measured using transperineal ultrasound for prediction of uncomplicated operative vaginal delivery: systematic review and meta-analysis

OBJECTIVE

To determine whether intrapartum transperineal ultrasound measurement of the angle of progression (AoP) during the second stage of labor can predict uncomplicated operative vaginal delivery (OVD) using vacuum or forceps extraction.

METHODS

A systematic search in PubMed, EMBASE, Scopus, Web of Science and Google Scholar was performed from inception to February 2021. Studies assessing the predictive accuracy of AoP, measured using intrapartum transperineal ultrasound, for uncomplicated OVD, defined as successful vaginal delivery within three pulls using forceps or no more than two detachments of the vacuum extractor cup, were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Summary receiver-operating-characteristics (ROC) curves, pooled sensitivity and specificity, area under the ROC curve (AUC) and summary likelihood ratios (LRs) were calculated.

RESULTS

Seven studies reporting on a total of 782 patients undergoing OVD were included in this systematic review and meta-analysis. Second-stage AoP measured during maternal rest had a pooled sensitivity of 80% (95% CI, 59-92%) and specificity of 89% (95% CI, 76-95%), with a LR+ of 7.3 (95% CI, 3.1-15.8) for uncomplicated OVD. AoP measured during active pushing had a sensitivity of 91% (95% CI, 85-94%) and specificity of 83% (95% CI, 69-92%), with a LR+ of 5.4 (95% CI, 2.7-10.6) for uncomplicated OVD. The performance of AoP measured at rest was particularly high in nulliparous women, with a sensitivity of 87% (95% CI, 75-94%) and specificity of 90% (95% CI, 82-94%) for uncomplicated OVD.

CONCLUSION

AoP may be a reliable predictor for uncomplicated OVD when measured during the second stage of labor, especially in nulliparous women. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Increased Arthrodesis Rates in Charcot Neuroarthropathy Utilizing Distal Tibial Distraction Osteogenesis Principles

Charcot neuroarthropathy of the hindfoot and ankle poses substantial challenges due to deformity, segmental bone loss, chronic infection, and difficulty with bracing. Hindfoot or ankle arthrodesis is often employed at high rates of complications and nonunion. This study reports 15 consecutive patients with Charcot neuroarthropathy who underwent tibiotalocalcaneal or tibiocalcaneal fusion with simultaneous distal tibial distraction osteogenesis with a mean follow-up period of 20.2 ± 5.66 months. Arthrodesis rate was 93.3% (14 patients) with mean time to fusion of 4.75 ± 3.4 months. One hypertrophic nonunion occurred at the arthrodesis site. Complete consolidation of 4 cortices was achieved at the distraction site in 93.3% of patients (14 patients) with a mean duration to consolidation of 9.8 ± 3.3 months. One patient experienced hypertrophic nonunion at the regeneration site. The authors report a technique to enhance arthrodesis rates in Charcot neuroarthropathy by combining distal tibial distraction osteogenesis with simultaneous tibiotalocalcaneal or tibiocalcaneal arthrodesis for hindfoot fusion and salvage. Distraction osteogenesis supports enhanced vascularity to the arthrodesis site.Level of Clinical Evidence: Level 4.

Cardiopulmonary transit time: A novel PET imaging biomarker of in vivo physiology for risk stratification of heart transplant recipients

BACKGROUND

Myocardial blood flow (MBF) can be quantified using dynamic PET studies. These studies also inherently contain tomographic images of early bolus displacement, which can provide cardiopulmonary transit times (CPTT) as measure of cardiopulmonary physiology. The aim of this study was to assess the incremental prognostic value of CPTT in heart transplant (OHT) recipients.

METHODS

94 patients (age 56 ± 16 years, 78% male) undergoing dynamic 13N-ammonia stress/rest studies were included, of which 68 underwent right-heart catherization. A recently validated cardiac allograft vasculopathy (CAV) score based on PET measures of regional perfusion, peak MBF and left-ventricular (LV) ejection fraction (LVEF) was used to identify patients with no, mild or moderate-severe CAV. Time-activity curves of the LV and right ventricular (RV) cavities were obtained and used to calculate the difference between the LV and RV bolus midpoint times, which represents the CPTT and is expressed in heartbeats. Patients were followed for a median of 2.5 years for the occurrence of major adverse cardiac events (MACE), including cardiovascular death, hospitalization for heart failure or acute coronary syndrome, or re-transplantation.

RESULTS

CPTT was significantly correlated with cardiac filling pressures (r = .434, P = .0002 and r = .439, P = .0002 for right atrial and pulmonary wedge pressure), cardiac output (r = - .315, P = .01) and LVEF (r = - .513, P < .0001). CPTT was prolonged in patients with MACE (19.4 ± 6.0 vs 14.5 ± 3.0 heartbeats, P < .001, N = 15) with CPTT ≥ 17.75 beats showing optimal discriminatory value in ROC analysis. CPTT ≥ 17.75 heartbeats was associated with a 10.1-fold increased risk (P < .001) of MACE and a 7.3-fold increased risk (P < .001) after adjusting for PET-CAV, age, sex and time since transplant.

CONCLUSION

Measurements of cardiopulmonary transit time provide incremental risk stratification in OHT recipients and enhance the value of multiparametric dynamic PET imaging, particularly in identifying high-risk patients.

AB0624 Patients with vasculitis have a high prevalence of coronary microvascular dysfunction

Background

Vasculitides are a heterogenous group of diseases characterized by intense vessel wall inflammation, endothelial injury, and systemic inflammation. Several vasculitides are associated with high risk of cardiovascular (CV) disease, an important source of morbidity and mortality in this population. This excess CV risk is attributed both to a high burden of traditional risk factors and to inflammation, but this remains poorly studied. Indeed, inflammation is a known risk factor for CV disease and implicated in coronary microvascular dysfunction (CMD) which may precede obstructive coronary artery disease (CAD).

Objectives

We sought to assess whether vasculitis is associated with CMD in the absence of obstructive CAD.

Methods

We retrospectively identified subjects with systemic vasculitis who underwent symptom prompted rest/stress myocardial perfusion PET. Patients with an abnormal myocardial perfusion study (summed stress score ≥3) or LVEF<40% were excluded. Controls were identified from the same population and matched on age, gender and cardiovascular risk factors (CAD, hypertension, dyslipidemia, diabetes mellitus, and obesity). Coronary flow reserve (CFR), was calculated as the ratio of myocardial blood flow (ml/min/g) at peak stress compared to rest. CMD was defined as CFR <2.

Results

We studied 26 vasculitis cases and 66 matched controls. The most common vasculitides were giant cell arteritis (38%), ANCA-associated vasculitis (31%), and Takayasu’s arteritis (12%). Median (IQR) time between diagnosis and PET was 6.5 (2.9, 14.2) years. Seven (27%) cases had active vascultis at the time of PET. Cases and controls were well-matched on age, sex, and CV risk factors (Table 1). Despite a similar prevalence of CV risk factors, coronary flow reserve (reflected by CMD) was abnormal in 38% of vasculitis cases compared to 15% of controls (p=0.004). The mean [SD] CFR was 19% lower in vasculitis cases vs controls (2.11 [0.5] versus 2.6 [0.7], p=0.003).

Table 1.

The presence of coronary microvasculature dysfunction in patients with systemic vasculitis without obstructive coronary artery disease

Cohort characteristicsVasculitis (n=26)Control (n=66)P-valueAge at PET, years62 (18)61 (17)0.24Time from Vasculitis Diagnosis to PET, years (median, IQR)6.5 (2.9, 14.2)n/aFemale, n (%)18 (72%)43 (65%)0.99Vasculitis CharacteristicsLarge Vessel (e.g., giant cell arteritis, Takayasu’s), n(%)13 (50%)n/an/aMedium Vessel (e.g., polyarteritis nodosa, Kawasaki’s arteritis), n(%)2 (8%)n/an/aSmall Vessel (e.g., ANCA-associated vasculitis, Henoch-Schonlein Purpura), n(%)11 (42%)n/an/aCardiovascular Risk FactorsAt DiagnosisAt PETAt PETHypertension, n (%)12 (46%)20 (71%)47 (80%)0.47Obesity, n (%)3 (12%)2 (32%)2 (32%)0.84Diabetes, n (%)3 (12%)5 (20%)13 (20%)0.99Dyslipidemia, n (%)4 (15%)15 (58%)40 (61%)0.99Known CAD, n (%)0 (0%)1 (4%)1 (2%)0.48Imaging FindingsRest myocardial blood flow, ml/min/g1.0 (0.3)1.0 (0.3)0.8Stress myocardial blood flow, ml/min/g2.1 (0.6)2.6 (1.0)0.008Coronary Flow Reserve, ml/min/g*2.1 (0.5)2.6 (0.7)0.003Coronary Microvasculature Dysfunction** (CMD), n (%)10 (38%)11 (15%)0.004

Conclusion

Patients with systemic vasculitis, even in the absence of obstructive CAD, have a high prevalence of CMD compared with non-vasculitis patients. These differences were observed despite matching cases and controls on traditional CV risk factors, highlighting the importance of other factors, such as inflammation and vasculitis treatments on CMD and CV disease in this population. CMD is a known independent risk factor for CV mortality. Future prospective studies are needed to understand the relationship between vasculitis, systemic inflammation, and CMD.

Disclosure of Interests

None declared

A Functional Chopart's Amputation With Tendon Transfers

Generally, forefoot osteomyelitis is treated with a reliable level of amputation such as at the transmetatarsal level. However, when osteomyelitis extends proximal to the midfoot and presents with significant peripheral arterial disease, it is generally thought that the next best functional level of amputation is a transtibial amputation. This is mostly in part due to the high failure rate of Chopart's amputations which can be attributed to poor biomechanical and tendon balancing. We present a new technique of tendon balancing with a Chopart's amputation that results in optimized ambulatory function, durable soft tissue envelope of amputation, and successful limb salvage.

Reconstruction of COVID-19-Related Compartment Syndrome With Massive Soft Tissue Necrosis

INTRODUCTION

The COVID-19 virus is caused by the new coronavirus, SARS-CoV-2. COVID-19 has drastically changed the medical landscape. Although predominantly impacting the respiratory system, COVID-19 has several non-respiratory symptoms associated with its presentation and course. Among these are gastrointestinal symptoms and thromboembolic events with stroke. Increasingly recognized, but often overlooked, are the coagulopathy phenomena occurring with COVID-19. The severe respiratory symptoms are the primary focus of clinical management. However, close inspection of patients demonstrates that patients often exhibit both thromboembolic and bleeding events, ranging from simple skin lesions to overt emergencies.

CASE REPORT

The author presents a case of COVID-19-associated coagulopathy resulting in compartment syndrome of the arm with volar forearm necrosis, requiring flap reconstruction and tendon transfer to salvage the upper extremity.

CONCLUSIONS

Massive rhabdomyolysis resulted in acute tubular necrosis with renal failure requiring hemodialysis. The timing of reconstruction of the sequelae of compartment syndrome in an acutely ill patient is challenging, but optimal timing can result in a successful outcome.

The Free Fibula Flap for Lower Extremity Reconstruction

Reconstruction of critical size bone defects in the lower extremity poses a significant risk to not only limb malfunction but also amputation. The reconstructive goal of free bone flaps is to provide vascularized bone that restores length and stability. This applies to the native limb and also in amputations when a vascularized length of bone is required to maintain level of amputation. Multiple anatomic regions of the lower extremity may be successfully reconstructed with the fibula free flap.

A Novel Limb Salvage Technique of External Fixation Protection of Lower Extremity Plastic Reconstructions with Immediate Postoperative Ambulation (Bibbo Flap and Frame Technique)

Non-weight bearing is mandatory after soft tissue reconstructions of the weight-bearing and the high-pressure areas in the lower extremity. The most common method of patient mobilization after surgical reconstruction of chronic foot and ankle wounds has been to place patients non-weight bearing with crutches, walkers, or a wheelchair. Often patients are older, have more complex medical comorbidities, are deconditioned, and simply cannot comply with the prescribed weight-bearing status with these methods, which leads to deconditioning, depression, or noncompliance. Noncompliance quickly leads to failure of the reconstructive effort and the serious threat of limb loss.

Coronary vasomotor dysfunction is associated with worse outcomes in patients with inflammatory disease

Background

Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and psoriasis (PsO) are common inflammatory conditions with excess cardiovascular (CV) risk compared to the general population. This excess CV risk is associated with traditional risk factors, glucocorticoid treatment, and systemic inflammation. Systemic inflammation perturbs endothelial function and has been linked to coronary vasomotor dysfunction. It is not clear if coronary vasomotor dysfunction would be associated with worse clinical outcomes in systemic autoimmune inflammatory conditions.

Purpose

We tested the hypothesis that impaired coronary flow reserve (CFR), which in the absence of flow-limiting obstructive coronary artery disease (CAD) reflects vasomotor dysfunction, among patients with SLE, RA, and PsO is associated with worse clinical outcomes.

Methods

We included patients with RA, SLE, and PsO who underwent clinically indicated rest/stress myocardial perfusion positron emission tomography (PET) at a large academic medical center from 2006 to 2019. Patients with an abnormal myocardial perfusion study (summed stress score &gt;3) or left ventricular ejection fraction &lt;40% were excluded. CFR was calculated as the ratio of myocardial blood flow (MBF, ml/min/g) at peak stress compared to the MBF at rest and adjusted for baseline heart rate and blood pressure.

Results

Among the 175 patients (median age 65.1 years, 80% female) in the cohort, 24% had SLE, 35% PsO, and 41% RA. There was no difference in mean CFR between patients with RA, SLE, or PsO. Over a median follow-up of 8.5 years after PET, there were 47 deaths. Patients in the lowest and middle tertile (CFR &lt;2.18) had a higher all-cause mortality when compared with the highest (Figure 1), and this association remained significant after adjusting for age and a composite clinical score incorporating sex, symptoms, and CV risk factors (lowest vs. highest tertile: HR 2.8; 95% confidence interval 1.2–6.5; p=0.01). CV risk factors such as diabetes, hypertension, obesity, tobacco use, and a family history of CAD were not significantly different across CFR tertiles, suggesting that inflammatory-disease specific risk factors may contribute to coronary vasomotor dysfunction.

Conclusions

In patients with systemic inflammatory disease, coronary vasomotor dysfunction was associated with worse outcomes independent of traditional CV risk factors and may have utility as a marker of CV risk among patients with inflammatory disease.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): 1. 5T32HL094301-02 NIH T32 Training Grant, “Noninvasive Cardiovascular Imaging Research Training Program”

Medial Plantar Artery Flap for Wound Coverage of the Weight-Bearing Surface of the Heel

Covering soft tissue defects of the heel is particularly challenging because of the highly specialized functional units unique to the plantar fat pad and the shear and compressive forces experienced in this area. The medial plantar artery fasciocutaneous flap provides the unique ability to restore both sensation and the functional units to the plantar heel by taking tissue similar to that which was lost and relocating it from a non-weight-bearing portion of the foot, while maintaining minimal host morbidity. This provides a lasting solution and may prevent future ulcerations from occurring.

The Gastrocnemius Flap for Lower Extremity Reconstruction

The gastrocnemius flap is a versatile flap when muscle, or, muscle and skin is desired for coverage of bone of the proximal one-third of the leg, and about the knee. Both the medial and lateral heads, or both combined, may be used as flaps. Typically, the reach of only the muscle will restrict reach to just below the knee. Release off the medial femoral condyle permits increased reach, and a bit more is obtained by scoring the deep fascia and gently slow expansion of the muscle.

P361 Assessment of accuracy and reproducibility of coronary flow reserve measured by SPECT in patients with known or suspected coronary artery disease

Funding Acknowledgements

Spectrum Dynamics

Background

Traditional relative assessment of regional myocardial perfusion by single photon emission computed tomography (SPECT) has limited ability to identify multivessel coronary artery disease, as well as diffuse atherosclerosis and coronary microvascular dysfunction. Current gamma cameras with cadmium-zinc-telluride (CZT) detectors have higher temporal resolution and sensitivity and allow the acquisition of multi-frame images and quantification of absolute myocardial blood flow (MBF) and coronary flow reserve (CFR

Purpose

The aim of this study was to assess the accuracy and reproducibility of quantitative measurements of MBF and CFR obtained with a CZT SPECT system compared to PET in a cohort of patients with known or suspected coronary artery disease.

Methods

Accuracy was assessed in 22 patients who underwent dynamic rest/stress 99mTc-sestamibi-SPECT and 13N-ammonia PET myocardial perfusion imaging within two weeks of each other. Fourteen patients comprised the reproducibility cohort and underwent two dynamic 99mTc-sestamibi SPECT scans within two weeks. A rest/pharmacological stress single-day SPECT protocol was performed, using a 1:3 dose ratio. SPECT image reconstruction was performed using a spline-fitting method and SPECT MBF was quantified using a net retention kinetic model in commercially available software. Rest MBF and CFR were adjusted for heart-rate pressure product.

Results

Global MBF at rest and stress showed a good correlation between SPECT and PET (r = 0.814, p &lt; 0.001). For global rest MBF the mean difference between the two techniques was -0.25 ± 0.24 ml/min/g, while for stress MBF mean difference was -0.21 ± 0.40 ml/min/g. We also observed a significant correlation between global SPECT and PET CFR measurements (r = 0.745, p &lt; 0.001), with no significant difference between the two (mean difference: 0.16 ± 0.50). Regarding the reproducibility cohort, the correlation between global CFR measured by two SPECT scans was also significant (r = 0.616, p = 0.019), with a mean difference of 0.14 ±0.51. The mean difference between scans for rest MBF (-0.05 ± 0.19) and stress MBF (0.01 ± 0.42) were also not significant.

Conclusion

MBF and CFR quantification is feasible using a CZT gamma camera and provides accurate and reproducible results that correlate with 13N-ammonia PET. This may be of special relevance in sites where PET is not available, enabling MBF and CFR quantification with CZT SPECT cameras.

Abstract P361 Figure.

Superficial Peroneal Nerve to Deep Peroneal Nerve Transfer With Allograft Conduit for Neuroma in Continuity

The anterior approach to the ankle for surgery can result in injury to the superficial peroneal nerve, resulting in a painful neuroma and significant patient morbidity. A paucity of data is available evaluating the role of the superficial peroneal nerve to deep peroneal nerve transfer as a method of treatment of neuromas in continuity after ankle arthrodesis. We describe 11 patients who underwent nerve transfer with nerve allograft and conduit repair to treat recalcitrant painful neuromas after ankle arthrodesis. At a mean follow-up period of 31 months, the mean visual analog pain scale score had improved from 7.9 preoperatively to 2.45 postoperatively (p < .0001). These data suggest that nerve transfer with a nerve allograft can provide significant clinical improvement for painful neuromas of the peripheral nerves at the ankle.

The Lisfranc Amputation: A More Reliable Level of Amputation With Proper Intraoperative Tendon Balancing

Traditional transmetatarsal amputations are a reliable level of amputation. However, amputations at the Lisfranc level have met with limited success owing to improper biomechanics resulting from tendon imbalance, ultimately leading to foot deformity positions and an unstable soft tissue envelope with ensuing skin breakdown, infection, and below-the-knee amputation. We describe proper tendon rebalancing that results in improved biomechanics and a more reliable and stable amputation at the more proximal Lisfranc level.

A Practical Guide to the Use of the Anterolateral Thigh Flap

Introduction

The anterolateral thigh (ALT) flap allows for healthy, reliable, vascularized, soft-tissue coverage of extremity or axial defects of traumatic or acquired deformities.

Indications & Contraindications

Step 1 Positioning and Markings

Place the patient in the supine position, which allows for flap harvest and typically does not require any position changes (Fig. 1), and then mark the septum between the vastus lateralis and rectus femoris, which facilitates harvest of this flap (Video 1).

Step 2 Perforator Dissection

Dissect this flap, which is relatively straightforward and rapid after identifying the perforating vessels (Video 2, Fig. 4).

Step 3 Pedicle Dissection

Trace the course of the descending branch of the lateral femoral circumflex proximally and determine the maximum pedicle length and vessel diameter for microvascular anastomoses (Figs. 5 and 6).

Step 4 Flap Harvest and Recipient Vessels

Confirm the dimensions of the flap prior to final harvest of the flap, and pay special attention to the recipient arterial inflow and venous outflow to ensure success.

Step 5 Microvascular Anastomoses

When performing this flap as a microvascular free flap, identify and prepare suitable vessels for tissue transfer (Fig. 13).

Step 6 Flap Inset

Pay special attention to the flap inset to ensure that there is no mechanical obstruction to the pedicle and that the inset allows for the anticipated postoperative edema (Figs. 14 and 15).

Step 7 Donor Site Closure

Close the donor site for this flap, which is well tolerated and easily concealed (Fig. 16).

Step 8 Flap Monitoring and Postoperative Care

Postoperative monitoring is critical to identify any potential vascular compromise early and maximize successful outcomes⁴.

Results

The ALT is a highly successful and reliable flap that has become a workhorse of reconstructive microsurgery⁵.

Pitfalls & Challenges

Nerve Transfer With Entubulated Nerve Allograft Transfers to Treat Recalcitrant Lower Extremity Neuromas

Neuroma formation in the lower extremity can be debilitating to patients, especially when the neuromas are recurrent. The results of an advanced nerve reconstruction technique consisting of nerve transfer combined with nerve allograft and entubulation was evaluated in 4 patients with severe, debilitating, lower extremity neuromas. At a mean follow-up period of 26 months, the mean visual analog scale had improved from 9.5 preoperatively to 1.25 postoperatively (p < .05). These data suggest that techniques using a nerve allograft with a nerve conduit could be of great assistance in successfully managing debilitating neuromas of the lower extremity. Thus, further in-depth evaluation of these techniques is warranted.

Role of Recombinant Human Bone Morphogenetic Protein-2 on Hindfoot Arthrodesis

Despite advances in understanding bone healing physiology and surgical techniques, delayed union and nonunion still occur after the treatment of hindfoot arthrodesis. There is increasing appeal of bone morphogenetic proteins (BMPs) owing to the innate osteoinductive abilities of BMPs. Effective treatment with BMPs has been shown in animal studies. Human clinical studies have also shown success. The only study investigating the use of recombinant human BMP (rhBMP)-2 in hindfoot arthrodesis found a significant increase in fusion rate. Treatment cost effective. Complications from their use remain low. rhBMP-2 is a safe and effective bone-healing adjunct in hindfoot arthrodesis surgery.

Maintaining Levels of Lower Extremity Amputations

Patients who have undergone a lower extremity amputation may develop an unstable soft tissue envelope of the amputation stump. This envelope may result in pain that prohibits prosthetic use or may become chronically infected. Providing stable soft tissue coverage at the amputation site may provide relief from pain and cure of infection. Additionally, a stable amputation soft tissue envelope may assist with the ability of that patient to maintain his or her existing level of ambulation, overall sense of wellness, and ability to maintain social integration. Salvage of a lower extremity amputation level may significantly improve a patient's overall quality of life. Attempts to salvage an amputation level that is plagued by unstable wounds, pain, or infection are warranted in those patients who have the physiologic reserves to undergo salvage of their amputation level. This article presents an approach to the salvage of lower extremity amputations utilizing both local tissue rearrangements and free tissue transfer techniques.

Reconstruction of the Pediatric Lateral Malleolus and Physis by Free Microvascular Transfer of the Proximal Fibular Physis

Traumatic injury to the pediatric growth plate can result in growth disturbances, late angular deformity, and limb length inequalities. Complete traumatic loss the entire growth plate complex (physis, epiphysis, and distal metaphysis) of the ankle can lead to severe joint instability and loss of function. In the growing child, physeal preservation is paramount; however, the reconstructive options are limited. We report a case of post-traumatic loss of the distal fibular physis resulting in severe ankle valgus in a pediatric patient after a Gustilo grade 3B open injury. Ankle valgus secondary to post-traumatic necrosis of the lateral ankle physeal complex was successfully managed by microvascular free transfer of the ipsilateral proximal fibula physis. The 24-month follow-up examination demonstrated continued growth of the free vascularized physeal graft and a stable ankle. The donor site had healed without incident. The patient was able to return to age-appropriate play, sports, and social integration.

Reconstruction of the Pediatric Lateral Malleolus and Physis by Free Microvascular Transfer of the Proximal Fibular Physis

Traumatic injury to the pediatric growth plate can result in growth disturbances, late angular deformity, and limb length inequalities. Complete traumatic loss the entire growth plate complex (physis, epiphysis, and distal metaphysis) of the ankle can lead to severe joint instability and loss of function. In the growing child, physeal preservation is paramount; however, the reconstructive options are limited. We report a case of post-traumatic loss of the distal fibular physis resulting in severe ankle valgus in a pediatric patient after a Gustilo grade 3B open injury. Ankle valgus secondary to post-traumatic necrosis of the lateral ankle physeal complex was successfully managed by microvascular free transfer of the ipsilateral proximal fibula physis. The 24-month follow-up examination demonstrated continued growth of the free vascularized physeal graft and a stable ankle. The donor site had healed without incident. The patient was able to return to age-appropriate play, sports, and social integration.

Bone morphogenetic proteins: indications and uses

The BMPs are a group of growth factors that have varied roles in the development and maintenance of many organ systems. Several of the BMPs have osteogenic potential, and exert their effects via complex and highly regulated pathways. At present, only rhBMP-2 and rhBMP-7 are available for clinical use, but only rhBMP-2 is readily available, and from a practical standpoint is considered the only commercially available BMP. Only a few studies exist on BMP use in foot and ankle surgery, but these have shown promising results with low complication rates. BMP is an adjuvant to bone healing,and does not substitute for structural bone needs. In addition, rhBMP-2 outside spinal fusions is considered to be US Food and Drug Administration off-label, and should be used only in patients who are at high risk for bone healing problems.

Low Wound Complication Rates for the Lateral Extensile Approach for Calcaneal ORIF When the Lateral Calcaneal Artery Is Patent

BACKGROUND

Historically, the lateral extensile approach for calcaneal fracture osteosynthesis has had relatively high rates of wound healing problems. The vascular territory (angiosome) of the lateral foot is now known to be dependent upon the lateral calcaneal branch of the peroneal artery (LCBP artery). We postulated that patency of the LCBP artery may have a profound positive impact on incisional wound healing for calcaneal open reduction and internal fixation (ORIF).

METHODS

Ninety consecutive calcaneal fractures that met operative criteria were preoperatively evaluated for the presence of a Doppler signal in the LCBP artery and were followed for the development of wound healing problems.

RESULTS

Among these 90 fractures, 85 had a positive preoperative Doppler signal along the course of the LCBP artery (94%) and 5 had no Doppler signal (6%). All patients underwent ORIF via a lateral extensile approach. Overall, incisional wound healing problems occurred in 6 of 90 calcaneal incisions (6.5%). All 5 feet that exhibited an absent Doppler signal in the LCPB artery developed an incisional wound healing complication (5/6, approximately 83%): 2 large apical wounds and 3 major dehiscence/slough. However, among the 84 feet that possessed a positive preoperative Doppler signal in the LCBP artery, there was only 1 (1/84, approximately 1%) incisional wound healing problem (P < .0001, Fischer's exact test). Smokers with a positive Doppler signal in the LCBP artery did not develop a wound healing complication.

CONCLUSIONS

This study suggests a strong link to low incisional wound healing complications for the lateral extensile approach to the calcaneus when a preoperative Doppler signal is present in the LCBP artery. We believe this simple examination should be routinely performed prior to calcaneal ORIF.

LEVEL OF EVIDENCE

Level III, comparative case series.

Successful salvage of complicated calcaneal blastomycosis in disseminated disease with staged surgical reconstruction and local-systemic antifungal therapy

Disseminated blastomycosis can be a devastating disease, affecting multiple organ systems, including the musculoskeletal system. Osteomyelitis from disseminated disease can be difficult to eradicate but is particularly important to successfully manage in the load-bearing bones of the lower extremity. We present a staged protocol for salvage of blastomycotic calcaneal osteomyelitis in the presence of disseminated disease.

Reverse sural flap with bifocal Ilizarov technique for tibial osteomyelitis with bone and soft tissue defects

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk patients. We describe a case of methicillin-resistant Staphylococcus aureus tibial osteomyelitis with intercalary bone loss successfully managed with bifocal Ilizarov compression osteogenesis at the bone resection site and proximal distraction osteogenesis, accompanied by a reverse sural fasciocutaneous flap performed with a delayed technique. When free tissue transfer is not a reconstructive option owing to medical comorbidities or patient refusal, the reverse sural flap combined with bifocal Ilizarov compression and distraction osteogenesis can provide a reconstructive option to achieve limb salvage for these challenging cases.

Modification of the Syme amputation to prevent postoperative heel pad migration

The Syme amputation (ankle disarticulation level amputation) can be a valuable procedure for properly selected patients but might be underused owing to the problem of postoperative migration of the heel pad cushion. The present report presents a modification of the Syme amputation technique to prevent postoperative heel pad migration. The technique was performed in 12 patients, most of whom were male patients with diabetic foot infections. At an average follow-up of 7 years, the soft tissue cushion remained in a stable position, without ulceration. Also, patient satisfaction was high with the Syme level of amputation using the modified technique.

Temporary cementation in total ankle arthroplasty

Total ankle arthroplasty can be technically demanding in patients with poor bone quality. In bone fragile patients, the use of a temporary cementation technique ("biocementation") can assist in providing a stable, secure implant interface with native bone that is of poor quality. I report the short-term results of 9 ankles (7 consecutive patients) undergoing total ankle replacement with temporary cementation using a slowly resorbable injectable bone graft substitute composed of 75% calcium sulfate and 25% calcium phosphate.

Flap infection associated with medicinal leeches in reconstructive surgery: two new drug-resistant organisms

The use of medicinal leeches in reconstructive surgery has proven value for the salvage of flaps with venous congestion but is associated with a risk of leech-acquired infection. The most common leech-associated organism is Aeromonas hydrophila, which antibiotic prophylaxis is typically directed against. The authors describe two new multidrug-resistant organisms acquired from medicinal leech therapy that resulted in flap infection. The evaluation of suspected leech-borne infection and management protocol for this leech-acquired resistant multi-organism infection is presented.

The reverse peroneus brevis muscle flap for ankle wound coverage

Coverage of lower extremity wounds, especially those in the ankle region, presents a challenge to the foot and ankle surgeon. The present case illustrates a surgical technique for the use of the reverse (distally based) peroneus brevis muscle flap for coverage of a postoperative ankle wound with exposed bone. The reverse peroneus brevis muscle flap provides an option for wound coverage in the ankle region in limb salvage cases in medically frail patients.

Posterior approach for total ankle arthroplasty

Total ankle arthroplasty is a technically challenging reconstruction, with soft tissue complications posing potential significant morbidity, especially when the anterior ankle soft tissue envelope is not pristine. Alternate approaches to the ankle for arthroplasty may need to be sought in unique cases. The author describes a posterior surgical approach for total ankle arthroplasty.

A modified anterior approach to the ankle

The anterior approach to the ankle is frequently used in fracture fixation, ankle arthroplasty, and various tendon reconstructive procedures. However, wound complications and trauma may lead to scarring and a suboptimal anterior ankle soft tissue envelope for healing. The author presents a modified approach to the anterior ankle in cases where scarring and soft tissue injury preclude a direct anterior incision.

Plantar heel reconstruction with a sensate plantar medial artery musculocutaneous pedicled island flap after wide excision of melanoma

Reconstruction of soft tissue defects in the plantar heel pad presents a surgical challenge that requires replacing the lost tissue with another tissue having similarly unique physical characteristics. This case report describes a reconstruction of the plantar heel pad after wide excision of a heel melanoma, using a sensate plantar medial artery musculocutaneous pedicled island flap.

Reduction calcaneoplasty and local muscle rotation flap as a salvage option for calcaneal osteomyelitis with soft tissue defect

Plantar heel wounds with infection remain a surgical challenge. Reduction calcaneoplasty combined with local muscle flap is an alternative technique to achieve limb salvage when standard wound therapy fails to resolve complex wounds of the plantar heel complicated by osteomyelitis of the calcaneus.

Tumoral calcinosis of the foot: a radiologic case study

Tumoral calcinosis is a disorder characterized by deposits of calcium phosphate in the subcutaneous tissues near large joints. While often resembling a neoplasm, the soft tissue deposits of tumoral calcinosis are benign in nature. The deposits can, however, cause significant morbidity to patients due to tissue pressure or impingement. The focus of this case report will include the presentation, radiographic examinations, clinical course, and treatment of a 90-year-old female patient presenting for evaluation of a painful plantar right foot soft tissue mass associated with chronic renal failure and secondary hyperparathyroidism.

Combined total ankle replacement and modified bridle tendon transfer for end-stage ankle joint arthrosis with paralytic dropfoot: report of an unusual case

In recent years, total ankle replacement has become a reasonable option for many patients with end-stage ankle arthrosis. In order to be successful, total ankle replacement requires a relatively balanced alignment of the foot in relation to the leg. Such alignment is traditionally achieved surgically by means of stabilization of the hindfoot in conjunction with relocation osteotomy of the calcaneus and/or tibia. In this report, we describe the unconventional combination of total ankle replacement in an adult patient with concomitant paralysis that was addressed by means of tendon transfer.

Review of vascular leiomyosarcoma and report of a case localized to the greater saphenous vein of the ankle

Smooth muscle sarcomas involving blood vessels, leiomyosarcomas, are rare, making up less than 2% of all leiomyosarcomas. Leiomyosarcoma of the saphenous vein is even more uncommon, with nearly all cases reported occurring in the thigh. This article reviews leiomyosarcoma of blood vessels and reports on a 62-year-old woman with an extremely rare case of a leiomyosarcoma of the distal portion of the greater saphenous at the ankle.

Platelet-rich plasma concentrate to augment bone fusion

Within the foot and ankle literature, there exists only a handful of basic science and clinical articles reporting on the efficacy and clinical utility of platelet-rich plasma (PRP). This article discusses the concept and basic science of PRP, and clinical applications of PRP for the augmentation of bone healing in foot and ankle surgery. The authors also provide a classification system that assesses relative risks for poor bone healing and the need for orthobiologic augmentation.

Lower extremity manifestations and treatment of heparin-induced thrombocytopenia syndromes: a cohort study

Heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) syndromes are the result of an adverse reaction to heparin that results in a spectrum of laboratory and end-organ manifestations secondary to thrombosis of both arterial and venous small and large vessels. HITT most often manifests in the extremities as acral ischemia and necrosis, with a spectrum of severity. The lower extremity surgical patient is at risk for deep venous thrombosis, and when exposed to heparin products, is also at risk for the development of a heparin-induced thrombocytopenic syndrome. This article reports on a cohort of patients from a tertiary referral lower extremity reconstruction practice with the HIT/HITT syndromes, with an analysis of the frequency, medical characteristics, clinical settings, lower extremity manifestations, management, and outcomes of patients with HIT/HITT.).

Complications of digital and lesser metatarsal surgery

Complications associated with digital and lesser metatarsal surgical procedures have been well documented in the literature. These complications may stem from systemic medical, structural, biologic, biomechanical, or iatrogenic causes. The surgeon must be cognizant of all potential complications, including ways to prevent them from occurring and how to manage them when they do occur. This article discusses preventative measures through the preoperative evaluation of the patient, and examines the subsets of complications that may occur after lesser ray surgery that pose a particular management challenge, as well as special complications specific to particular operative techniques.

Metatarsal giant cell tumor in adolescents

Level of Evidence: V, Expert Opinion

Ilizarov wound closure method for traumatic soft tissue defects

Level of Evidence: V, Expert Opinion

VERSAJET hydrosurgery technique for the preparation of full thickness skin grafts and the creation of retrograde split thickness skin grafts

Full- and split-thickness skin grafts continue to serve a vital role in lower extremity wound coverage, and meticulous preparation of the recipient site is vital to incorporation of the transplanted skin. A technique for the rapid, controlled preparation of full-thickness skin grafts and creation of thick-split thickness skin grafts from full-thickness donor tissue, using a high-pressure stream of saline solution, is described.

Prevention and management of complications arising from external fixation pin sites

The use of external fixation devices to assist in the management of lower extremity trauma and reconstruction continues to rise. Despite the distinct advantages of external fixation, complications from external fixators continue to exist. The complicated external fixator-associated pin site may be a potential source of significant morbidity, especially in the at-risk patient, which may lead to soft tissue healing problems and infections, as well as osteomyelitis. This article describes both simple as well as more complex techniques that the authors use in the prevention and management of complications arising from external fixator pin sites, and solutions to the difficult task of incorporating external fixator wires into negative-pressure dressings.

The porcine small intestinal submucosa (SIS) patch in foot and ankle reconstruction

We undertook a retrospective cohort study of 54 patients who underwent foot and ankle soft tissue reconstructive surgery augmented with a porcine small intestinal submucosal (SIS) patch. The mean patient age was 44 (range 17 to 68) years, there were 21 (38.89%) males in the cohort, and the mean follow-up duration was 1080 (range 365 to 1943) days. Clinical outcomes were considered excellent in 46 (85.19%) patients, good/fair in 3 (5.56%) patients, and poor in 5 (9.26%) patients; and no adverse events attributable to the xenograft were observed. Direct SIS patch failure, resulting in stretching of the repair, re-tear, or tendon stenosis, occurred in 3 (5.56%) patients, and delayed incision healing occurred in 6 (11.11%) patients. Based on our observations, we concluded that the porcine SIS xenograft, when used to augment cellular and vascular in-growth, is a viable adjunct to musculoskeletal reconstructions of the foot and ankle.