The traditional reconstructive ladder has withstood the test of time, serving as a thought paradigm to guide surgeons in choosing their method of wound closure for an assortment of defects. Advances ...in anatomical understanding and technological innovations have improved our ability to achieve definitive closure in a wide variety of patients. In this article, the older construct is updated to reflect the use of negative-pressure wound therapy and dermal matrices. Perforator flap concepts are also discussed in terms of their inclusion as a rung on the ladder.
Background:
Approximately 200,000 people undergo a lower extremity amputation each year. Following amputation, patients suffer from chronic pain, inability to ambulate, and high mortality rates. ...Targeted muscle reinnervation is a nerve transfer procedure that redirects transected sensory and mixed nerves into motor nerves to treat neuroma and phantom limb pain. This study evaluates outcomes with prophylactic targeted muscle reinnervation at the time of below-knee amputation.
Methods:
This is a cohort study comparing 100 patients undergoing below-knee amputation with primary targeted muscle reinnervation and 100 patients undergoing below-knee amputation with standard traction neurectomy and muscle implantation. Outcome metrics included the presence of residual and phantom limb pain, pain severity, opioid use, ambulation ability, and mortality rates.
Results:
The targeted muscle reinnervation group was on average 60 years old with a body mass index of 29 kg/m
2
. Eighty-four percent had diabetes, 55 percent had peripheral vascular disease, and 43 percent had end-stage renal disease. Average follow-up was 9.6 months for the targeted muscle reinnervation group and 18.5 months for the nontargeted muscle reinnervation group. Seventy-one percent of targeted muscle reinnervation patients were pain free, compared with 36 percent (
p
< 0.01). Fourteen percent of targeted muscle reinnervation patients had residual limb pain, compared with 57 percent (
p
< 0.01). Nineteen percent of targeted muscle reinnervation patients had phantom limb pain, compared with 47 percent (
p
< 0.01). Six percent of targeted muscle reinnervation patients were on opioids, compared with 26 percent (
p
< 0.01); and 90.9 percent of targeted muscle reinnervation patients were ambulatory, compared with 70.5 percent (
p
< 0.01).
Conclusion:
Targeted muscle reinnervation reduces pain and improves ambulation in patients undergoing below-knee amputation, which may be critical in improving morbidity and mortality rates in this comorbid patient population.
CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
Ian Taylor introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries. Understanding the angiosomes of the foot and ankle and the ...interaction among their source arteries is clinically useful in surgery of the foot and ankle, especially in the presence of peripheral vascular disease.
In 50 cadaver dissections of the lower extremity, arteries were injected with methyl methacrylate in different colors and dissected. Preoperatively, each reconstructive patient's vascular anatomy was routinely analyzed using a Doppler instrument and the results were evaluated.
There are six angiosomes of the foot and ankle originating from the three main arteries and their branches to the foot and ankle. The three branches of the posterior tibial artery each supply distinct portions of the plantar foot. The two branches of the peroneal artery supply the anterolateral portion of the ankle and rear foot. The anterior tibial artery supplies the anterior ankle, and its continuation, the dorsalis pedis artery, supplies the dorsum of the foot. Blood flow to the foot and ankle is redundant, because the three major arteries feeding the foot have multiple arterial-arterial connections. By selectively performing a Doppler examination of these connections, it is possible to quickly map the existing vascular tree and the direction of flow.
Detailed knowledge of the vascular anatomy of the foot and ankle allows the plastic surgeon to plan vascularly sound reconstructions, the foot and ankle surgeon to design safe exposures of the underlying skeleton, and the vascular surgeon to choose the most effective revascularization for a given wound.
Wound healing: an overview Broughton, 2nd, George; Janis, Jeffrey E; Attinger, Christopher E
Plastic and reconstructive surgery (1963)
117, Številka:
7 Suppl
Journal Article
Recenzirano
Understanding wound healing today involves much more than simply stating that there are three phases: inflammation, proliferation, and maturation. Wound healing is a complex series of reactions and ...interactions among cells and "mediators." Each year, new mediators are discovered and our understanding of inflammatory mediators and cellular interactions grows. This article will attempt to provide a concise overview on wound healing and wound management.
The basic science of wound healing Broughton, 2nd, George; Janis, Jeffrey E; Attinger, Christopher E
Plastic and reconstructive surgery (1963)
117, Številka:
7 Suppl
Journal Article
Recenzirano
Understanding wound healing today involves much more than simply stating that there are three phases: "inflammation, proliferation, and maturation." Wound healing is a complex series of reactions and ...interactions among cells and "mediators." Each year, new mediators are discovered and our understanding of inflammatory mediators and cellular interactions grows. This article will attempt to provide a concise report of the current literature on wound healing by first reviewing the phases of wound healing followed by "the players" of wound healing: inflammatory mediators (cytokines, growth factors, proteases, eicosanoids, kinins, and more), nitric oxide, and the cellular elements. The discussion will end with a pictorial essay summarizing the wound-healing process.
The effectiveness of pedicled muscle flaps versus microsurgical free flaps in patients with diabetes mellitus for complex foot and ankle reconstruction has not been well defined.
The Georgetown Wound ...Registry identified all patients who underwent pedicled muscle flap or free flap reconstruction from 1990 to 2000 with 8.1 ± 3.1-year follow-up. Thirty-eight diabetic and 42 nondiabetic patients were identified. Flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone, with pedicled muscle flaps always selected for smaller defects.
Thirty-two patients received 34 pedicled muscle flaps for 34 wounds, whereas 48 received 52 free flaps for 51 wounds. Thirty-one of 34 wounds covered with pedicled muscle flaps went on to heal, for a 91 percent success rate, a 94 percent limb salvage rate, and a 78 percent patient survival rate. There were 15 complications among 45 reconstructive procedures, for an overall 33 percent complication rate. Forty-eight of the 51 wounds covered with free flaps went on to heal, for a 94 percent healing rate, a 96 percent limb salvage rate, and a 77 percent patient survival rate. There were 17 complications among 93 reconstructive procedures, for an 18 percent complication rate.
Diabetes does not appear to affect the success of pedicled muscle flap or free flap reconstruction except for requiring more débridements, longer healing times, and decreased long-term survival. When compared with historical diabetic controls with amputation, however, limb salvage appears to prolong survival of diabetic patients. Pedicled muscle flaps appear to be as effective as free flaps for the coverage of small complex foot and ankle defects, despite the postoperative complication rate. Diabetes is not a contraindication to either type of flap reconstruction for limb salvage.
Therapeutic, III.(Figure is included in full-text article.).
There are a growing number of wound care centers being established globally. The emergence of these centers reflects the increasing incidence and prevalence of chronic wounds as well as the cost to ...the health care systems these patients represent. A systematic approach to the development and implementation of a comprehensive wound care program is necessary to provide quality wound care as well as to establish a financially viable enterprise. A wound care center can take shape in various forms from small free-standing clinics to large hospital-based programs. Regardless of the physical location, the most important factor for the success of the wound care center is a strong commitment by the members of the multidisciplinary team. The capacity to effectively manage certain wounds can be limited by the absence of key specialties within the team. The physical space and financial support from the sponsoring institution are also important components. This article reviews the critical elements to building and sustaining a successful multidisciplinary wound care center.
A brief history of wound care Broughton, 2nd, George; Janis, Jeffrey E; Attinger, Christopher E
Plastic and reconstructive surgery (1963)
117, Številka:
7 Suppl
Journal Article
Recenzirano
Since the caveman, man has been tending to his wounds. Wound care evolved from magical incantations, potions, and ointments, to a systematic text of wound care and surgery from Hippocrates and ...Celsus. These advances were lost after the fall of the Roman Empire. In Europe, the Middle Ages were a regression of wound care back to potions and charms. It was'nt until the time of large armies using muskets and cannons that surgical wound care emerged again. This article will briefly highlight major milestones in wound care.
Use of biologically engineered acellular dermal matrices in the upper and lower extremities is increasingly recognized as a means of achieving definitive healing in the setting of both acute and ...chronic injuries but data and evidence supporting their use are limited. The authors performed this systematic review to identify all available evidence for the use of matrices in nonburn extremity reconstruction.
A systematic review of the Cochrane and MEDLINE databases was performed to identify all reports of the application of matrices in wounds of the upper and lower extremities. Reports that included fewer than five patients and that involved cellular seeding, nonhuman studies, and burn injuries were excluded. Studies were evaluated for quality of statistical measures and outcomes, and a level of evidence was assigned in accordance with the American Society of Plastic Surgeons' Rating Levels of Evidence.
Of an initial 2422 reports, 13 primary reports were identified (10 case series and three randomized controlled trials) representing a total of 432 patients and 441 discrete wounds. After evidence review, 10 of these studies represented level IV evidence, two studies represented level II evidence, and one study achieved level I evidence.
Extremity wound management continues to rely on adequate vascular supply, débridement with eradication of infection, off-loading, and/or immobilization. Current data, although limited, appear to support the use of acellular dermal matrices in chronic and acute injuries where there is exposed bone, tendon, and/or muscle. They may provide a simple technique to achieve timely and durable tissue coverage in extremity wounds.
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