Browsing by Subject "Limb salvage"

Now showing 1 - 4 of 4
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    Comparison of Patient-Reported Outcomes after Local Flap Coverage versus Amputation for Complex Lower Extremity Trauma
    (Thieme, 2024-10-24) Bhagat, Neel; Drake, Connor; Dawson, Steven; Loewenstein, Scott N.; Knox, Kevin R.; Adkinson, Joshua M.; Hassanein, Aladdin H.; Bamba, Ravinder; Surgery, School of Medicine
    Background: There is a paucity of patient-reported outcomes (PROs) data in lower extremity salvage. Limb salvage can often be achieved with the use of local muscle flaps or fasciocutaneous flaps. The purpose of this study was to compare PROs of patients who underwent lower extremity salvage using local fasciocutaneous flaps or muscle flaps to lower extremity amputation. Materials and Methods: The outcomes of 61 patients that underwent lower extremity local flap reconstruction ( n  = 33) or amputation ( n  = 28) between 2014 and 2020 were recorded. Chart reviews were performed to collect perioperative data. Patients were contacted via telephone for participation in the survey portion of our study. PROs were recorded utilizing both the Lower Extremity Functional Scale (LEFS) and the 36-Item Short-Form Health Survey (SF-36). Results: Surveys were completed by 61 patients (response rate 59.2%). The mean time of survey after flap reconstruction or amputation was 2.7 ± 1.4 years. Recent trauma (within 90 days) was the most common indication for local flap coverage ( n  = 23). LEFS score and SF-36 physical functioning scores were significantly lower in patients who underwent muscle flaps compared with fasciocutaneous flaps ( p  = 0.021 and p  = 0.022). Muscle flap patients had similar LEFS and SF-36 scores to amputation patients, while fasciocutaneous flap patients had significantly higher LEFS ( p  = 0.01), SF-36 physical functioning ( p  = 0.031), physical role functioning ( p  = 0.031), and emotional role functioning ( p  = 0.047) scores than amputation patients. Conclusion: Patients who underwent local fasciocutaneous flaps for limb salvage reported higher PRO scores than those undergoing amputation, while patients undergoing muscle flaps reported outcomes similar to those undergoing amputation. PROs for muscle flap patients were significantly lower than those of fasciocutaneous flap patients. These data suggest that while fasciocutaneous and muscle flaps are both useful limb salvage procedures, fasciocutaneous flaps may confer advantages that result in improved patient-perceived outcomes. Further study is needed to better characterize outcomes in limb salvage.
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    Do Surgical Margins Affect Local Recurrence and Survival in Extremity, Nonmetastatic, High-grade Osteosarcoma?
    (Springer, 2016-03) Bertrand, Todd E.; Cruz, Alex; Binitie, Odion; Cheong, David; Letson, G. Douglas; Department of Orthopaedic Surgery, IU School of Medicine
    BACKGROUND: Long-term survival for all patients with osteosarcoma using current aggressive adjuvant chemotherapy and surgical resection is between 60% and 70%. In patients who present with nonmetastatic, high-grade extremity osteosarcoma of bone, limb salvage surgery is favored, when appropriate, over amputation to preserve the limb, because limb salvage may lead to a superior quality of life compared with amputation. However, concern remains that in the attempt to preserve the limb, close or microscopically positive surgical margins may have an adverse effect on event-free survival. QUESTIONS/PURPOSES: (1) Does a positive or close surgical margin increase the likelihood of a local recurrence? (2) Does a positive or close surgical margin adversely affect the development of metastatic disease? (3) What is the relationship of surgical margin on overall survival? METHODS: With institutional review board approval, we retrospectively evaluated 241 patients treated at our institution between 1999 and 2011. Exclusion criteria included nonextremity locations, metastatic disease at initial presentation, low- or intermediate-grade osteosarcoma, treatment regimens that did not follow National Comprehensive Cancer Network (NCCN) guidelines, incomplete medical records, and any part of treatment performed outside of Moffitt Cancer Center or All Children's Hospital. Fifty-one patients were included in the final analysis, of whom 31 (61%) had followup data at a minimum of 2 years or whose clinical status was known but had died before 2 years of followup. Margin status was defined as (1) microscopically positive; (2) negative ≤ 1 mm; and (3) negative > 1 mm. Margin status, histologic response (tumor percent necrosis), type of osteosarcoma, type of surgery, presence of local recurrence, metastatic disease, and overall survival were recorded for each patient. The mean age was 22 years (range, 12-74 years) and the mean followup was 3 years (range, 0.1-14 years). Margin status was positive in 10% (five of 51), negative ≤ 1 mm 26% (13 of 51), and negative > 1 mm 65% (33 of 51). RESULTS: Local recurrence was noted to be 14% (seven of 51) at 3.4 years. After controlling for relevant confounding variables, the presence of a positive margin compared with a negative margin > 1 mm was the only independent predictor of local recurrence (hazard ratio [HR], 8.006; 95% confidence interval [CI], 1.314-48.781; p = 0.0241). At a mean of 3.4 years, 29% (15 of 51) of the patients developed metastatic disease with no difference with the numbers available in the probability of developing metastatic disease among the three margin groups (p = 0.614). Overall survival at 3.8 years was 75% (38 of 51). After controlling for relevant confounding variables, we found that patients with positive margins were more likely to die from disease than those with negative margins (HR, 6.26; 95% CI, 1.50-26.14; p = 0.0119); no other independent predictors of survival were identified. CONCLUSIONS: With the numbers of patients we had, we observed that patients with extremity, nonmetastatic, high-grade osteosarcoma who had positive margins showed a higher probability of local recurrence in comparison to those with negative surgical margins. Given that positive margins appear to be associated with poorer survival in patients with high-grade osteosarcoma of the extremities, surgeons should strive to achieve negative margins, but larger studies are needed to confirm these findings. LEVEL OF EVIDENCE: Level III, therapeutic study.
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    Patient-reported Outcomes after Local Flap Coverage Versus Amputation for Complex Lower Extremity Trauma
    (Wolters Kluwer, 2022) Bhagat, Neel; Drake, Connor; Dawson, Steven; Loewenstein, Scott; Knox, Kevin; Adkinson, Joshua M.; Bamba, Ravi; Surgery, School of Medicine
    PURPOSE: Lower extremity trauma can be devastating, and limb salvage is hypothesized to result in improved quality of life. However, there is a paucity of patient-reported outcomes (PRO) data in lower extremity salvage. Limb salvage can often be achieved with the use of local muscle (e.g. gastrocnemius, soleus) flaps or fasciocutaneous (e.g. reverse sural and propeller) flaps. Limited PRO data is available after local flap reconstruction. Further, PROs comparing these flap types to patients who underwent amputation are limited. The purpose of this study was to compare PROs of patients who received lower extremity salvage using fasciocutaneous flaps or muscle flaps to lower extremity amputation. PURPOSE: Lower extremity trauma can be devastating, and limb salvage is hypothesized to result in improved quality of life. However, there is a paucity of patient-reported outcomes (PRO) data in lower extremity salvage. Limb salvage can often be achieved with the use of local muscle (e.g. gastrocnemius, soleus) flaps or fasciocutaneous (e.g. reverse sural and propeller) flaps. Limited PRO data is available after local flap reconstruction. Further, PROs comparing these flap types to patients who underwent amputation are limited. The purpose of this study was to compare PROs of patients who received lower extremity salvage using fasciocutaneous flaps or muscle flaps to lower extremity amputation. RESULTS: Surveys were completed by 65 patients (response rate 60.7%). The mean time of survey after flap reconstruction was 3.2 years. Recent trauma (within 90 days) was the most common indication for local flap coverage (n=26). Flap complications included wound dehiscence (n=8) and infection (n=4). Other flap complications included partial flap necrosis (n=12), total flap necrosis (n=2), and secondary amputation (n=4). LEFS score and SF-36 physical functioning scores were significantly lower in patients who underwent muscle flaps compared to fasciocutaneous flaps (p=0.021 and p=0.022 respectively). Muscle flap patients had similar LEFS and SF-36 scores to amputation patients, while fasciocutaneous flap patients had significantly higher LEFS (p=0.017), SF-36 physical functioning (p=0.033), and health change (p=0.050) scores than amputation patients. CONCLUSION: PROs for muscle flap patients were significantly lower than those of fasciocutaneous flap patients. Patients who underwent fasciocutaneous flaps for limb salvage reported higher PRO scores than those undergoing amputation, while patients undergoing muscle flaps reported outcomes similar to those undergoing amputation. This data suggests that while fasciocutaneous and muscle flaps are both useful limb salvage procedures, fasciocutaneous flaps may confer advantages that result in improved patient perceived outcomes. Further study is needed to better characterize outcomes in limb salvage.
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    Revascularization Outcomes of Acute Limb Ischemia in Patients With COVID-19
    (Elsevier, 2022) Kabeil, Mahmood; Wohlauer, Max; Moore, Ethan; Harroun, Nikolai; Gillette, Riley; Boggs, Shelbi; Motaganahalli, Raghu L.; Judelson, Dejah R.; Sundaram, Varuna; Mouawad, Nicolas J.; Bonaca, Marc P.; Cuff, Robert; Surgery, School of Medicine
    Objective: Acute limb ischemia (ALI) is one of the most catastrophic thrombotic manifestations of COVID-19 resulting in limb loss if not promptly treated. Our goal is to evaluate revascularization outcomes of ALI in patients with COVID-19 who underwent either open or endovascular treatment. Methods: The Vascular Surgery COVID-19 Collaborative started in March 2020 to assess hematological changes of COVID-19. We performed an interim data analysis on 46 patients with COVID-19 associated ALI submitted to the ALI module of the Vascular Surgery COVID-19 Collaborative REDcap database from 10 institutions in the United States. Results: Among the 46 patients included in the analysis, the mean age was 62.2 (standard deviation [SD]: 9.51) years. The majority of patients were male (73.9%). A total of 67.4% were White, 13% were Hispanic, and 4.3% were Black. In total, 93.5% of patients met Rutherford’s criteria of ALI class 2 or 3. On average, patients developed ALI 12.2 (SD: 13.5) days after a positive COVID test. Revascularization was attempted using open thrombectomy in 50.0%, endovascular lysis or thrombectomy in 23.9%, and bypass in 2.2%, and revascularization was not attempted in 23.9% of the patients (Table). Revascularization was successful in 41.3% with symptom resolution and 15.2% with limb salvage but persistent symptoms; 2.2% had minor amputation, 4.3% ultimately had a major amputation, 4.3% required reoperation, and revascularization was unsuccessful in 10.9% of patients. The average length of hospital stay was 13.2 (SD: 13.3) days, the average intensive care unit (ICU) length of stay was 4.66 (SD: 6.85) days, and the average ventilation days was 12.3 (SD: 10.8) days. Overall, in-hospital mortality was 21.7%, 8.7% had major amputation, 8.7% had stroke, 6.5% required major limb intervention, and 2.2% had sepsis. Successful revascularization rate was 62.5% in the 24 patients who underwent open surgery vs 36.4% in the 11 patients who underwent endovascular repair. The average length of stay in the ICU was shorter in the open group (mean = 3.24 days) than in the endovascular group (mean = 8.60 days). Of the 11 patients who had no revascularization attempt, 36.4% died, 18.2% had a major amputation, 9.1% had a pulmonary embolism, and 9.1% had a stroke. Conclusions: COVID-19-associated ALI carries a high mortality. Patients with COVID-19 who develop ALI can be managed successfully with open surgery or endovascular intervention. In our cohort, open revascularization resulted in reduced ICU stay and reduced ventilation days with improved limb salvage than the endovascular group. Further data are needed to develop management algorithms for ALI in patients with COVID-19.