Partial or Total Calcanectomy as an Alternative to Below-the-Knee Amputation for Limb Salvage

2012 ◽  
Vol 102 (5) ◽  
pp. 396-405 ◽  
Author(s):  
Valerie L. Schade
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Limb Salvage ◽  
Free Tissue Transfer ◽  
Definitive Treatment ◽  
Ambulatory Status ◽  
Below The Knee ◽  
Major Complications ◽  
Ambulatory Patients

Background: Below-the-knee amputations are regarded as definitive treatment for calcaneal osteomyelitis. They may be less than desirable in patients with a viable midfoot and forefoot. Partial and total calcanectomies have been reported as an alternative for limb salvage. However, the durability of the residual limb is questionable. Methods: A systematic review was undertaken to identify material relating to the potential for limb salvage with partial or total calcanectomy in ambulatory patients with calcaneal osteomyelitis. Studies eligible for inclusion consecutively enrolled ambulatory patients older than 18 years who underwent partial or total calcanectomy without adjunctive free tissue transfer for the treatment of calcaneal osteomyelitis and had a mean follow-up of 12 months or longer. Results: Sixteen studies involving 100 patients (76 partial and 28 total calcanectomies) met all of the inclusion criteria. Weighted mean follow-up was 33 months. Minor complications with subsequent healing occurred in less than 24% of patients. Most major complications were related to residual soft-tissue infection and osteomyelitis. Approximately 10% of patients required a major lower-extremity amputation. Major complications and major lower-extremity amputations occurred more frequently after total calcanectomy and in patients with a diagnosis of diabetes. Eighty-five percent of patients maintained or improved their ambulatory status postoperatively. Only 3% of patients decreased their ambulatory status postoperatively, becoming unlimited household ambulators. Conclusions: This systematic review provides evidence that partial or total calcanectomy is a viable option for limb salvage in ambulatory patients with calcaneal osteomyelitis. (J Am Podiatr Med Assoc 102(5): 396–405, 2012)

scholarly journals Outcomes of Primary Tibiotalocalcaneal Nailing for Complicated Diabetic Ankle Fractures

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0016
Author(s):  
M Pierce Ebaugh ◽  
Benjamin Umbel ◽  
Benjamin Taylor ◽  
David Goss
Keyword(s):  
Hospital Stay ◽  
Limb Salvage ◽  
Weight Bearing ◽  
Ankle Fractures ◽  
Definitive Treatment ◽  
Diabetic Patients ◽  
Charcot Arthropathy ◽  
Early Weight Bearing ◽  
Ambulatory Status

Category: Trauma, Ankle, Ankle Arthritis Introduction/Purpose: Ankle fractures in complicated diabetic patients (i.e. presence of neuropathy, nephropathy, or peripheral vascular disease) have significantly increased rates of complications with markedly worse functional outcomes. Current management advocates for operative intervention due to high rates of fracture reduction loss and Charcot arthropathy in those treated nonoperatively. Tibiotalocalcaneal (TTC) nails have been reported in the literature as a salvage option when initial ankle stabilization has failed. We hypothesize that the minimally invasive, robust construct that primary TTC fixation with an intramedullary nail offers will result in high rates of limb salvage, acceptable rates of complications, and nominal loss of function. Thus, the purpose of this study was to evaluate the outcomes of primary TTC intramedullary nailing for definitive treatment of neuropathic ankle fractures. Methods: This was an IRB approved retrospective study of 27 complicated diabetic patients who underwent TTC nailing of their ankle fracture as a primary treatment without formal joint preparation. The study was undertaken at an urban Level 1 trauma center. Complicated diabetes was defined as having one or more of the following formal diagnoses: neuropathy (20 patients), nephropathy (4), PVD (3). Mean clinical follow up was 888 days (range 21-2843 days). Patients were screened for associated risk factors such as open fracture, neuropathy, nicotine and alcohol abuse, obesity and elevated Hba1c. Data was also collected on surgical complications such as superficial and deep infection, wound dehiscence, amputation, revision fixation, hardware failure, malunion, nonunion. Outcomes were measured in length of hospital stay, loss of ambulatory level, and time to death. Results: The mean age was 66 (32-92) years with an average BMI of 38 (21-68). Six of 27 fractures were open and 20 of 27 patients were neuropathic. Mean hemoglobin A1C was 7.4 (5.5-13). Average hospital stay was 6 days (0-22). The average patient was fully weight bearing at 6 weeks (1-17). Two patients underwent removal of hardware, due to pain and proximal screw failure respectively. One patient required formal arthrodesis. There were no malunions, symptomatic nonunions, or instances of Charcot arthropathy. Two patients underwent repeat debridement for infection, resulting in antibiotic nail placement and above knee amputation respectively. A total of eight patients had died by final follow up (mean 1048 days) from index procedure. Overall, mean ambulatory status was maintained. Conclusion: Primary tibiotalocalcaneal nailing is a viable alternative to previously described methods of fixation of complicated diabetic ankle fractures. With high limb salvage rates, early weight bearing, maintained ambulatory status and low rates of return to the operating room, our technique can be considered an applicable approach to increase overall survivability of threatened limbs and lives with acceptably low complications.

scholarly journals Limb Salvage and Functional Outcomes following Free Tissue Transfer for the Treatment of Recalcitrant Diabetic Foot Ulcers

2018 ◽  
Vol 35 (02) ◽  
pp. 117-123 ◽  
Author(s):  
Jocelyn Lu ◽  
Michael DeFazio ◽  
Chrisovalantis Lakhiani ◽  
Michel Abboud ◽  
Morgan Penzler ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Limb Salvage ◽  
Diabetic Foot ◽  
Functional Outcomes ◽  
Free Tissue Transfer ◽  
Major Amputation ◽  
Foot Ulcers ◽  
Diabetic Foot Ulcers ◽  
Flap Survival ◽  
Foot Reconstruction

Background Recent evidence documenting high success rates following microvascular diabetic foot reconstruction has led to a paradigm shift in favor of more aggressive limb preservation. The primary aim of this study was to examine reconstructive and functional outcomes in patients who underwent free tissue transfer (FTT) for recalcitrant diabetic foot ulcers (DFUs) at our tertiary referral center for advanced limb salvage. Methods Between June 2013 and June 2016, 29 patients underwent lower extremity FTT for diabetic foot reconstruction by the senior author (K.K.E.). In all cases, microsurgical reconstruction was offered as an alternative to major amputation for the management of recalcitrant DFUs. Overall rates of flap survival, limb salvage, and postoperative ambulation were evaluated. The lower extremity functional scale (LEFS) score was used to assess functional outcomes after surgery. Results Overall rates of flap success and lower limb salvage were 93 and 79%, respectively. Flap failure occurred in two patients with delayed microvascular compromise. Seven patients in this series ultimately required below-knee amputation secondary to recalcitrant infection (n = 5), intractable pain (n = 1), and limb ischemia (n = 1). The average interval between FTT and major amputation was 8 months (r, 0.2–15 months). Postoperative ambulation was confirmed in 25 patients (86%) after a mean final follow-up of 25 months (r, 10–48 months). The average LEFS score for all patients was 46 out of 80 points (r, 12–80 points), indicating the ability to ambulate in the community with some limitations. Conclusion FTT for the management of recalcitrant DFUs is associated with high rates of reconstructive success and postoperative ambulation. However, several patients will eventually require major amputation for reasons unrelated to ultimate flap survival. These data should be used to counsel patients regarding the risks, functional implications, and prognosis of microvascular diabetic foot reconstruction.

The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

2020 ◽  
Vol 36 (09) ◽  
pp. 634-644
Author(s):  
Carol E. Soteropulos ◽  
Nikita O. Shulzhenko ◽  
Harry S. Nayar ◽  
Samuel O. Poore
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Complication Rate ◽  
Perforator Flap ◽  
Free Tissue Transfer ◽  
Cochrane Central Register ◽  
Fasciocutaneous Flaps ◽  
Tissue Transfer ◽  
Individual Participant ◽  
The Impact

Abstract Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity. Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used. Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01). Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

The Role of Revascularization in Transmetatarsal Amputations

2001 ◽  
Vol 91 (10) ◽  
pp. 533-535 ◽  
Author(s):  
Javier La Fontaine ◽  
Alex Reyzelman ◽  
Gary Rothenberg ◽  
Khalid Husain ◽  
Lawrence B. Harkless
Keyword(s):  
Lower Extremity ◽  
Diabetes Duration ◽  
Amputation Level ◽  
Knee Amputation ◽  
Below The Knee ◽  
Transmetatarsal Amputation ◽  
The Mean ◽  
Lower Extremity Revascularization

Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (± 13.2) years and 16.6 (± 8.9) years, respectively. The follow-up period averaged 42.1 (± 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level. (J Am Podiatr Med Assoc 91(10): 533-535, 2001)

Major lower extremity amputations in a developing country: 10-Year experience at a tertiary medical center

Vascular ◽  
2020 ◽  
pp. 170853812096508
Author(s):  
Mohamad A Chahrour ◽  
Mouafak Homsi ◽  
Mohammad R Wehbe ◽  
Caroline Hmedeh ◽  
Jamal J Hoballah ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Developing Country ◽  
Positive Impact ◽  
Medical Center ◽  
Perioperative Complications ◽  
Care Center ◽  
Major Amputation ◽  
Ambulatory Status ◽  
Rehabilitation Centers

Background Lower extremity amputation (LEA) is a major surgical procedure with a high risk of significant morbidity and mortality. The objective of this study was to describe mortality and functionality outcomes following this procedure in a developing country. Methods This is a retrospective study of all patients undergoing LEA for non-traumatic etiology between 2007 and 2017. Medical records were used to retrieve demographics, comorbidities, and perioperative complications of identified patients. Patients were contacted to follow-up on their medical, postoperative care, and ambulatory status. Mortality and postoperative functionality rates were analyzed. Results The study included 78 patients. Median follow-up duration was 24 months. Hypertension (81%) and diabetes (79%) were the most common comorbidities. Mortality rates at 30 days, 1, and 5 years were 10.3, 29.2, and 65.5%, respectively. Mortality was significantly associated with age > 70 at amputation ( p = 0.042), hypertension ( p = 0.003), chronic kidney disease ( p = 0.031), and perioperative sepsis ( p = 0.01). Only 1.6% of patients were discharged into a specialized care center, and only 27% of patients were ambulatory postoperatively, although 90.5% were fitted with a prosthesis. Conclusions Survival following major amputation in a developing country is currently comparable to more developed regions of the world. Major discrepancy seems to exist in ambulatory status following the procedure. Discharge placement policies should be properly set, and rehabilitation centers funding should be increased. Awareness may also be warranted to educate patients and families about the value and positive impact of rehabilitation centers.

Rectus abdominis free tissue transfer in lower extremity reconstruction: Long term follow up in 58 cases

Injury ◽  
2019 ◽  
Vol 50 ◽  
pp. S25-S28 ◽  
Author(s):  
Ramzi C. Moucharafieh ◽  
Alexandre H. Nehme ◽  
Mohammad I. Badra ◽  
Mohammad Jawad H. Rahal
Keyword(s):  
Lower Extremity ◽  
Free Tissue Transfer ◽  
Rectus Abdominis ◽  
Tissue Transfer ◽  
Long Term Follow Up ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

scholarly journals Editor's Choice – Diabetic Limb Salvage With Endovascular Revascularisation and Free Tissue Transfer: Long-Term Follow up

2019 ◽  
Vol 57 (4) ◽  
pp. 527-536 ◽  
Author(s):  
Chien-Hwa Chang ◽  
Chieh-Chi Huang ◽  
Honda Hsu ◽  
Chih-Ming Lin ◽  
Shih-Ming Huang
Keyword(s):  
Limb Salvage ◽  
Free Tissue Transfer ◽  
Tissue Transfer ◽  
Long Term Follow Up

Diabetic Limb Salvage

2002 ◽  
Vol 92 (8) ◽  
pp. 457-462 ◽  
Author(s):  
Chad DeNamur ◽  
Guy Pupp
Keyword(s):  
At Risk ◽  
Lower Extremity ◽  
Limb Salvage ◽  
Retrospective Review ◽  
Diabetic Patients ◽  
Team Approach ◽  
Salvage Procedure ◽  
Knee Amputation ◽  
Below The Knee ◽  
Limb Salvage Procedure

In this retrospective review, 19 diabetic patients with significant lower-extremity pathology were assessed to determine the success of limb salvage in cases of varying complexity. The patients were either scheduled or at risk for below-the-knee amputation before intervention. After the limb-salvage procedure, patients were followed for 4 months to 9 years. Eighteen patients went on to have successful procedures, avoiding below-the-knee amputation; one patient had an above-the-knee amputation. The results demonstrate the benefits of an aggressive team approach with limb salvage as a goal. (J Am Podiatr Med Assoc 92(8): 457-462, 2002)

scholarly journals A Systematic Review of Free Tissue Transfer in the Management of Non-traumatic Lower Extremity Wounds in Patients with Diabetes

2011 ◽  
Vol 41 (3) ◽  
pp. 391-399 ◽  
Author(s):  
E.J. Fitzgerald O’Connor ◽  
M. Vesely ◽  
P.J. Holt ◽  
K.G. Jones ◽  
M.M. Thompson ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Free Tissue Transfer ◽  
Tissue Transfer ◽  
Patients With Diabetes
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