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Background This study compares outcomes of patients with severe, multiplanar, fixed, pantalar deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA). Methods Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17–72 years) and median follow-up duration was 49.9 months (24.0–253.7 months). Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgery and whether they would have the same surgery again. Results There was no statistically significant difference in functional outcomes, satisfaction, or complications between the groups. Twenty-two patients undergoing PTF (81.5%), 6 patients undergoing TCF (75%), and 15 patients undergoing BKA (93.8%) were satisfied overall (p = 0.414). There was no difference in the proportion of patients who would opt for the same procedure again (p = 0.142): 23 in the PTF group (85.2%), 8 in the TCF group (100%), and 11 in the BKA group (68.8%). Seven patients undergoing PTF (25.9%), 2 patients undergoing TCF (25%) and 6 patients undergoing BKA (37.5%) had major complications (p = 0.692). Conclusion This study concludes that PTF, TCF and BKA can all provide an acceptable outcome in treatment of severe, degenerative pantalar deformities. This data may be useful in counselling patients when considering salvage versus amputation in such cases. Level of evidence Level 3(Original) Clinical Research Article.

Background This systematic review investigated the outcomes of revision surgery after periprosthetic ankle infection (PAI). Methods According to the PRISMA statement, 9 studies with 131 PAIs surgically treated and analyzed were included. Demographics and surgical techniques with eradication rates and complications were reported. Results Methicillin-sensitive Staphylococcus aureus (MSSA) (30.4%) and coagulase-negative Staphylococcus (CNS) (26.5%) were the most common microorganisms. The eradication rate was 91.7% with permanent antibiotic spacers (SPC), 84.4% with 2-stage, 79.4% with arthrodesis (AA), and 58.8% with debridement and implant retention (DAIR). DAIR showed a significantly lower eradication rate than 2-stage (p = 0.016) and SPC (p = 0.043). Amputations occurred in 25% of patients after SPC, 8.8% after AA and 3.9% after DAIR. SPC showed a significantly higher amputation rate than DAIR and 2-stage (p = 0.044, and p = 0.017, respectively). Conclusions SPC and 2-stage revision show the highest eradication rates, but 2-stage has a lower risk of amputation.

Background Vascular thrombosis secondary to frostbite can lead to ischemic tissue damage in severe cases. Threatened extremities may be salvaged with thrombolytics to restore perfusion; however, current data are limited to single institution case series. The authors performed a systematic review to determine the efficacy of thrombolytic therapy in treating upper extremity frostbite. Methods PubMed, EBSCO, and Google Scholar were queried using the keywords “thrombolytics,” “frostbite,” “fibrinolytics,” and “tPA.” Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as intraarterial (IA) or intravenous (IV) administration of tissue plasminogen activator (tPA), alteplase, urokinase, streptokinase, or any tPA derivative. Results A total of 42 studies were identified, with 13 satisfying inclusion criteria. Eight studies reported catheter-directed IA thrombolysis, four reported systemic IV administration, and 1 reported both methods. A total of 157 patients received thrombolytics. In all, 73 upper extremity digits were treated by IA route and 136 digits were treated by IV route. Overall upper extremity digit salvage rate was 59%. There was a significantly higher salvage rate in digits treated by the IA route compared to the IV route. Conclusions Thrombolytics, particularly when administered by the intra-arterial route, are emerging as a promising treatment of severe frostbite of the upper extremity, increasing digit salvage rates.

OBJECTIVES The Global Limb Anatomic Staging System (GLASS) was proposed for evaluating the anatomic complexity of arterial disease in patients with chronic limb-threatening ischemia (CLTI). We aimed to examine the relationship between GLASS stage and treatment outcomes after infrainguinal revascularization in patients with CLTI. METHODS We retrospectively analyzed data of patients undergoing infrainguinal revascularization for CLTI between 2010 and 2018 to examine whether GLASS stage affects the limb salvage, wound healing, and overall survival (OS). RESULTS Throughout the study period, 153 CLTI patients and 190 limbs with Fontaine classification III and IV were analyzed for major amputation and OS, and 125 patients and 157 limbs of Fontaine classification IV were analyzed for wound healing. The number of patients with WIfI stage 1, 2, 3, and 4 was 14 (7.4%), 44 (23.2%), 65 (34.2%), and 67 (53.3%), respectively. The number of patients with GLASS stage I, II, and III was 23 (12.1%), 48 (25.3%), and 119 (62.6%), respectively. Among the 190 limbs, the number subject to bypass surgery, endovascular therapy, and hybrid therapy was 132 (69.5%), 39 (20.5%), and 19 (10.0%), respectively. A multivariate analysis showed that only WIfI stage and inframalleolar (IM) disease were risk factors for major amputation and impaired wound healing. There was no relationship between GLASS stage and limb salvage or wound healing. A multivariate analysis revealed that age, geriatric nutritional risk index and GLASS stage were risk factors for 2-year OS (P < .01). Patients with all risk factors had a poor prognosis (35.3% at 2 years). CONCLUSION WIfI stage and IM disease predicted limb salvage and wound healing after infrainguinal revascularization in patients with CLTI. Although GLASS stage did not affect limb salvage or wound healing, it was a prognostic factor for poor OS. The GLASS staging could be useful for deciding between bypass surgery and endovascular therapy in prediction of prognosis.

OBJECTIVES This study aimed to investigate the relationship between pre-procedure high-sensitivity C-reactive protein (hsCRP), free fatty acid (FFA), and uric acid (UA) levels and post-procedure mortality and morbidity of endovascular revascularization of arterial femoropopliteal occlusion lesions. METHODS This was a retrospective review of clinical data retrieved from a prospectively held database in Peking Union Medical College Hospital. 71 Patients who underwent endovascular treatment (EVT) for femoropopliteal occlusive disease between January 1, 2014 and November 1, 2017, were included in this study. Endpoints were defined as major adverse limb events (MALE; target vessel revascularization, amputation, or disease progression) and major adverse cardiovascular events (MACE; stroke, myocardial infarction, or all-cause death) during the entire follow-up period. Univariate and multivariate Cox proportional hazards regression models were used to evaluate the relationship of elevated biomarker levels (hsCRP, FFA and UA, measured by immunoturbidimetry assay, enzymatic assay and enzymatic assay, respectively) to MALE and MACE outcomes. RESULTS Seventy-one patients (72 limbs) with sufficient follow-up information were included in the analysis. The mean age was 69.7±8.6 years; 21.1% were female. The Rutherford class of target limbs were ≥ 3. The median follow-up was 36 (range 18-59 months). Univariate analyses revealed that patients with elevated hsCRP levels had an increased risk of MALE (hazard ratio [HR], 2.682; 95% confidence interval [CI], 1.281-5.617, P=0.009). High FFA levels were associated with an increased risk of MALE (HR, 2.658; 95% CI, 1.075-6.573; P=0.034). Multivariate analyses demonstrated that elevated hsCRP values (HR, 4.015; 95% CI, 1.628-10.551; P=0.003) and FFA value (HR, 3.034; 95% CI, 1.102-8.354; P=0.032) were both significantly associated with increased MALE. Elevated UA levels predicted MACE in the presence of confounders (HR, 11.446; 95% CI, 1.367-95.801 P=0.023). CONCLUSION Pre-procedure hsCRP and FFA levels could serve as predictors of adverse events after EVT in patients with arterial femoropopliteal occlusive disease. The role of UA in MACE may warrant further investigation, because the correlation is not as powerful as the other two in the study.

Objectives : Spiral saphenous vein grafts (SSVG) or paneled vein grafts (PVG) can be used when the diameter of the autologous great saphenous vein does not match the vessel that needs to be repaired. This study aimed to present early results of complex vascular reconstruction with SSVGs and PVGs in the lower extremities. Methods : From May 2019 through January 2021, six SSVGs and three PVGs were used for vascular reconstruction in nine patients. Patient data were collected retrospectively, including age, gender, cause of vascular pathology, target vessels, concomitant injury, surgical method, additional surgical methods, and hemodynamic status. The Kaplan-Meier method was used to calculate the rate of freedom from reintervention. Results : Among these patients, seven had trauma, one had graft infection, and one had vascular reconstruction after tumor excision. The mean duration of follow-up was 6 ± 6.6 months (range 1–19 months). The rate of freedom from reintervention for any reason was 77.8% at 1 year. Two patients underwent amputation after vascular reconstruction with patent vascular reconstructions. One of the two amputations was performed because of infection, and the other was due to ischemia >24 hours. The success rate of reconstruction was 100%, and the primary patency rate was 100%. The rate of limb salvage was 77.8%. There was no death, bleeding, embolism, skin ulcers, graft-related complication, or aneurysmal dilation during follow-up. Conclusions : SSVG and PVG were associated with low infection rates and satisfactory short-term patency rates. These two grafts may be good choices when there is a diameter mismatch in vascular reconstructions.

OBJECTIVE Evaluate the results of open surgery treatment of popliteal artery aneurysms (PAAs), performed in our department for over 25 years, comparing those treated with a medial approach with those treated with a posterior approach. MATERIAL AND METHOD A retrospective analysis of a total of 88 PAAs, performed between January 1994 and December 2018, with an average of 65 months follow-up, comparing the results of 59 patients operated by a medial approach (group 1) in which aneurysm exclusion and femoro-popliteal bypass below the knee was carried out, with 29 cases treated by a direct posterior approach (group 2) - aneurismectomy and graft interposition-. The postoperative complications, immediate and long term patency, limb salvage and mortality rate were studied. RESULTS In group 1 the chosen material for the bypass was reversed greater saphenous vein (GSV) in 45 cases (76.3%), expanded polytetrafluoroethylene (ePTFE) grafts in 12 (20.3%) and Dacron grafts on 2 (3.4%), while in group 2, a 6 mm diameter ringed ePTFE graft was used in 27 cases (93.1%) and reversed GSV in 2 (6.9%). There were eight (13.6%) postoperative graft thrombosis in group 1, five (8.9%) of them needing amputation, and one (3.4%) graft thrombosis in group 2 (p=0.077). During the follow up, major amputation was necessary in 2 cases (3.7%) in group 1, while there were no cases of major amputation in group 2. Mortality was 61% (36 patients) in group 1 and 27% (8 patients) in group 2 (p=0.003), at the end of surveillance. CONCLUSIONS In our experience, in the open surgical treatment of PAAs, the posterior approach could be considered as the first choice in selected cases.

Background: The Impella transaortic microaxial left ventricular assist device (MLVAD) bears the risk of severe ipsilateral limb ischemia due to its percutaneous insertion through the common femoral artery (CFA). As long as the MLVAD is required for cardio - circulatory support, treatment options are limited. Therefore, we developed a temporary extracorporeal femoral - femoral crossover bypass to restore and maintain perfusion of the affected leg. Methods: From October 2018, we treated all patients with severe limb ischemia due to the MLAVD with a femoral - femoral crossover bypass. For comparison, a consecutive cohort of patients undergoing placement of the MLAVD between January 2011 and October 2018 was identified. The primary outcome is the feasibility and safety of our percutaneously established extracorporeal femoral - femoral crossover bypass. Results: Between January 2011 and July 2019, 25 of 245 (10.3%) patients developed a severe ipsilateral limb ischemia following the MLVAD placement. Until October 2018, 20 patients were treated conventionally (C - cohort) and since October 2018, five (consecutive) patients have been treated by an extracorporeal femoral - femoral cross over bypass (BP - Cohort). Following the BP - procedure, an immediate improvement of the perfusion was seen in all patients. Limb salvage was documented in 100% of our patients and 30 - day mortality was 60% in both groups. Conclusion: This is the first case series reporting on this novel technique. We demonstrated that the percutaneous creation of an extracorporeal crossover bypass is feasible, safe and effective and should therefore be promoted.

Aim This study aimed to demonstrate the clinical impact of various frailty-related aspects in poor-risk patients undergoing revascularization for chronic limb-threatening ischemia (CLTI). Methods We analyzed a clinical database of a prospective multicenter observational study. A total of 562 CLTI patients who required assistance for their daily lives and were candidates for revascularization were included. We examined various measures of frailty severity, including activities of daily living (ADL)/mobility, physical performance, nutritional status, cognitive function, and cardiac function at baseline (before revascularization). Data on inflammatory markers at baseline and ADL/mobility before CLTI onset were also collected. Results The patients were aged 77±10 years, 65% were non-ambulatory, and 38% were categorized as mild dementia or severer. The correlation coefficients between the frailty measures ranged from 0.00 to 0.91. The random forest analysis for one-year mortality risk showed that these frailty-related measures, as well as age and inflammatory markers, had a relatively high variable importance compared with comorbidities and limb severity. Conclusion The correlations between measures of frailty severity were not always strong but rather widely varied in CLTI patients who required assistance for their daily lives and were candidates for revascularization. Measures of frailty severity, as well as age and inflammatory markers, had a relatively large predictive impact on one-year mortality risk compared with comorbidities and limb severity in the population.

e23539 Background: Induction isolated limb perfusion (ILP) followed by limb-sparing resection or extended resection are frequently used limb salvation strategies (LSS) in locally advanced extremity soft tissue sarcoma (eSTS) to prevent amputation. However little is known about the long term health-related quality of life (HRQoL) in these patients. The aim of this study was to compare long-term patient reported outcomes (PROs) such as HRQoL after ILP compared to extended resection or amputation. Methods: Patients treated with an ILP, extended resection, or amputation were selected from the respondents of a multi-institutional cross-sectional cohort survivorship study (SURVSARC) conducted 2-10 years after diagnosis among sarcoma survivors registered in the Netherlands Cancer Registry (NCR). Extended resection was defined as resection for stage III eSTS, details regarding amputation levels other than upper or lower extremity are unknown. Used PROs were the EORTC QLQ-C30, Cancer worry scale (CWS), the Hospital Anxiety and Depression Scale (HADS), and the Toronto Extremity Salvage Score (TESS). Results: We identified 96 eSTS survivors and assigned them into four groups: ILP (N = 20), extended resection (N = 48), primary amputation (N = 20), and amputation after ILP (N = 8). While there were no differences in PROs between ILP and extended resections, results showed better functioning and functionality after these two LSS groups versus the amputation groups. The amputation groups scored significantly lower on the EORTC QLQ-C30 physical functioning scale (p < 0.001, 62.7 and 65.7 versus 78.0 and 84.1) and role functioning scale (p = 0.038, 67.5 and 52.8 versus 79.2 and 80.9), which both account for a difference with ‘medium’ clinical relevance. Also for the TESS, the scores were significantly lower for the amputation groups compared to the LSS groups (upper extremity p = 0.007 with 68.9 and 71.6 versus 93.3 and 91.1; lower extremity p < 0.001 with 72.2 and 50.9 versus 84.5 and 85.5). There were no significant differences on cancer worry, anxiety and depression were found between all groups. Conclusions: Based on this survivorship study, HRQoL in eSTS survivors treated with ILP followed by limb-sparing resection is not inferior to extended resections, however it is superior in maintenance of physical functioning and functionality compared to an amputation.[Table: see text]

The current study aimed to reveal clinical features and prognosis of asymptomatic contralateral limbs in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI).We analyzed a database of 520 CLTI patients registered in a prospective, multicenter registry in Japan. Severe ischemia in asymptomatic contralateral limbs was determined as the Wound, Ischemia, and foot Infection (WIfI) classification system Ischemia (I) grade 2/3.The prevalence of diabetes mellitus and dialysis-dependent renal failure was 74.2% and 53.5%, respectively. Asymptomatic limbs accounted for 65.0% [95% confidence interval (CI), 60.9-69.1%] of the overall population, and 55.0% (95% CI, 49.6-60.4%) of the asymptomatic contralateral limbs had WIfI I-2/3. The multivariate analysis identified age ≥65 years, dialysis-dependent renal failure, WIfI I-3 in the index limb, and loss of pressure sensation in the contralateral limb as independent risk factors for WIfI I-2/3 in asymptomatic contralateral limbs (all p 0.05). The 3-year cumulative incidence rate of major adverse limb events (MALE) in asymptomatic contralateral limbs was 19.3% (95% CI, 15.1-23.7%), whereas that of all-cause mortality was 46.9% (95% CI, 41.0-52.5%). The corresponding rate including a composite of mortality and MALE was 58.8% (95% CI, 52.9-64.6%). In asymptomatic contralateral limbs, the adjusted hazard ratio of WIfI I-2/3 versus I-0/1 was 1.53 (95% CI, 1.11-2.10) for a composite of mortality and MALE, 1.96 (95% CI, 1.14-3.36) for MALE, and 1.37 (95% CI, 0.95-1.96) for mortality (p = 0.009, 0.015, and 0.091, respectively).Two-thirds of CLTI patients had an asymptomatic contralateral limb, and approximately half of the asymptomatic contralateral limbs were exposed to severe ischemia. Older age, dialysis-dependent renal failure, WIfI I-3 in the index limb, and loss of pressure sensation in the contralateral limb were independently associated with severe ischemia in asymptomatic contralateral limbs. In addition to mortality, MALE commonly occurred in asymptomatic contralateral limbs, especially with WIfI I-2/3.

INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome facility (loss of independence) after lower extremity revascularization and resultant outcomes. METHODS Data from the NSQIP database for years 2015-2017 was utilized to assess sex-based differences in loss of independence and associated unplanned readmission and 30-day amputation using chi-square, student t-test, and multivariate logistic regression analyses where appropriate. RESULTS There was increased loss of independence in women (34.9% vs. 26.1 %, p

Objective:\ud Chronic limb-threatening ischemia (CLTI) is a growing global problem due to the widespread use of tobacco and increasing prevalence of diabetes. Although the financial consequences are considerable, few studies have compared the relative cost-effectiveness of different CLTI management strategies. The Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial is randomizing patients with CLTI to primary infra-popliteal (IP) vein bypass surgery (BS) or best endovascular treatment (BET) and includes a comprehensive within-trial cost-utility analysis. The aim of this study is to compare over a 12-month time horizon, the costs of primary IP BS, IP best endovascular treatment (BET), and major limb major amputation (MLLA) to inform the BASIL-2 cost-utility analysis.\ud \ud Methods:\ud We compared procedural human resource (HR) costs and total in-hospital costs for the index admission, and over the following 12-months, in 60 consecutive patients undergoing primary IP BS (n = 20), IP BET (n = 20), or MLLA (10 transfemoral and 10 transtibial) for CLTI within the BASIL prospective cohort study.\ud Results\ud \ud Procedural:\ud HR costs were greatest for BS (BS £2551; 95% confidence interval [CI], £1934-£2807 vs MLLA £1130; 95% CI, £1046-£1297 vs BET £329; 95% CI, £242-£390; P < .001, Kruskal-Wallis) due to longer procedure duration and greater staff requirement. With regard to the index admission, MLLA was the most expensive due to longer hospital stay (MLLA £13,320; 95% CI, £8986-£18,616 vs BS £8714; 95% CI, £6097-£11,973 vs BET £4813; 95% CI, £3529-£6097; P < .001, Kruskal-Wallis). The total cost of the index admission and in-hospital care over the following 12 months remained least for BET (MLLA £26,327; 95% CI, £17,653-£30,458 vs BS £20,401; 95% CI, £12,071-£23,926 vs BET £12,298; 95% CI, £6961-£15,439; P < .001, Kruskal-Wallis).\ud \ud Conclusions:\ud Over a 12-month time horizon, MLLA and IP BS are more expensive than IP BET in terms of procedural HR costs and total in-hospital costs. These economic data, together with quality of life data from BASIL-2, will inform the calculation of incremental cost-effectiveness ratios for different CLTI management strategies within the BASIL-2 cost-utility analysis.

Background Guidelines for the treatment of long femoropopliteal lesions are not based on a high level of evidence and recent randomized controlled trials (RCTs) challenge vein bypass (VBP) as the recommended therapy. This study compared prosthetic (PTFE) bypass, VBP and angioplasty with nitinol stents in long femoropopliteal lesions. Methods Pooled data from a RCT and a retrospective database with the same inclusion criteria were analyzed with primary and secondary patency as well as freedom from target lesion revascularization (TLR) as primary endpoints. Results Between 2016 and 2018 a total of 172 lesions were treated in three groups (PTFE: n = 62, VBP: n = 55, stent: n = 55). Clinical and lesion characteristics were similar with mean lesion lengths between 260 and 279mm. Technical success rate in the stent group was 87%. There were no significant differences between the groups in patency rates, freedom from TLR, limb salvage and survival during 2-year follow-up. The primary patency rates for the PTFE, VBP and stent groups were 50%, 56% and 60% at 2 years. The PTFE group had significantly less complications compared to the other groups and a shorter hospital-stay compared to the VBP group. Clinical improvement was significantly better in the PTFE and VBP group compared to the stent group. Conclusions The 2-year results indicate that the role of VBP as the recommended therapy for long femoropopliteal lesions may not be unchallenged due to the similar results in all three groups. Further RCTs are needed to determine the best revascularization modality for long femoropopliteal lesions.

Background The obesity paradox is a well-documented phenomenon in cardiovascular disease, however it remains poorly understood. We aimed to investigate the relationship between body mass (as measured by body mass index [BMI]) and 1-year amputation-free survival (AFS) for patients undergoing lower limb revascularisation for chronic limb-threatening ischaemia (CLTI). Methods A retrospective analysis was undertaken of all consecutive patients undergoing lower limb revascularisation for CLTI at the Leicester Vascular Institute between February 2018–19. Baseline demographics and outcomes were collected using electronic records. BMI was stratified using the World Health Organization criteria. One-year AFS (composite of major amputation/death) was the primary outcome. Kaplan-Meier survival analysis and adjusted Cox's proportional hazard models were used to compare groups to patients of normal mass. Results One-hundred and ninety patients were included. Overall, no difference was identified in 1-year AFS across all groups (pooled P = 0.335). Compared to patients with normal BMI (n = 66), obese patients (n = 43) had a significantly lower adjusted combined risk of amputation/death (aHR 0.39, 95% CI 0.16–0.92, P = 0.032), however no significant differences were observed for overweight (aHR 0.89, 95% CI 0.47–1.70, P = 0.741), morbidly obese (aHR 1.15, 95% CI 0.41–3.20, P = 0.797) and underweight individuals (aHR 1.86, 95% CI 0.56–6.20, P = 0.314). Conclusions In the context of CLTI, obesity is potentially associated with favourable amputation-free survival at 1 year, compared to normal body mass. The results of this study support the notion of an obesity paradox existing within CLTI and question whether current guidance on weight management requires a more patient-specific approach.

Introduction Local recurrence (LR) is one of the main pitfalls in surgery for extremities soft tissue sarcoma (eSTS). Achieving clear histopathological margins is the most important factor to reduce the risk of LR, but the ability to do so depends on not only surgical technique but also the interplay between tumour biology, anatomical location and surgical approach. The balance between postoperative morbidity and oncological benefits in reducing the risk of LR needs to be considered. Areas covered This review will cover which aetiological factors for the development of eSTS lead to an increased risk of LR and discuss histological subtypes that have a high risk of LR and which surgical and neoadjuvant therapeutic strategies can minimise the risk of LR. Expert opinion The traditional view that surgical radicality always results in low rates of LR, while marginality alone always leads to high rates of relapse, is outdated. In the modern era of surgical oncology, limb salvage and high-level function after resectional surgery are the key surgical goals. The best results are achieved by combining effective neoadjuvant treatments with planned bespoke oncological operations that consider the biological and anatomical factors of each individual sarcoma.

International audience; Background:Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life.Methods:This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically.Results:The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204 ± 108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30 ± 9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6 ± 9.4 and mental component score was 44.6 ± 13.2 (minimum 0, maximum 100).Conclusions:Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.; Introduction :Le purpura fulminans infectieux est une pathologie invalidante entraînant souvent des amputations. L’objectif est d’évaluer le sauvetage de membre inférieur par lambeaux libres dans le purpura fulminans infectieux : la prise en charge chirurgicale, la marche, et la qualité de vie des patients.Méthodes :Il s’agit d’une étude observationnelle, descriptive, rétrospective de 2016 à 2019. Les patients inclus étaient des adultes survivants au purpura fulminans, bénéficiant d’un lambeau libre pour sauvetage d’un membre inférieur. Les données recueillies étaient les caractéristiques des patients, la prise en charge chirurgicale et la rééducation. L’évaluation à distance portait sur les patients, la marche, leur qualité de vie.Résultats :Six patients ont été inclus, avec 38 ans de moyenne d’âge. Neuf lambeaux libres ont été réalisés, et se sont déroulés avec succès. La reprise de la marche s’est effectuée en moyenne 204 ± 108 jours après le purpura fulminans. L’évaluation à distance était en moyenne réalisée à 30 ± 9,3 mois. Cinq patients sur 6 ont nécessité des corrections secondaires. Tous les patients sont autonomes dans la vie quotidienne. Le score résumé physique était en moyenne de 37,6 ± 9,4, le score résumé psychique de 44,6 ± 13,2 (minimum 0, maximum 100).Conclusion :Le lambeau libre chez les patients atteints de purpura fulminans infectieux est une procédure adaptée, permettant de préserver la longueur de membre, avec un bénéfice pour le patient malgré les complications secondaires, permettant une reprise de la marche, une autonomie, et une qualité de vie relativement bonne.

Background Endovascular therapy is effective for non-traumatic iliac arterial diseases. The role of endovascular surgery in traumatic iliac lesions is unclear. The aim of this study is to compare outcomes for open versus endovascular management of traumatic iliac injuries. Materials and methods The National Trauma Data Bank was searched for patients from 2002to 2016 with iliac arterial injury. Patients were sorted by treatment modality (open versus endo) and mechanism (blunt versus penetrating) and matched using mangled extremity score variables. The proportion of patients undergoing amputation were compared using the chi-square test. Results In the blunt group, 1550 (82%) had endovascular and 342 (18%) had open repair. Endovascular repair was associated with a significantly lower amputation rate than open repair (0.6% versus 3.6%, P = 0.015) despite higher incidence of concomitant injuries. Venous injury was more frequent in the open group (13.7% versus 1.8%, P Within the penetrating group, 209 (22%) had endovascular and 755 (78%) had open repair. Again endovascular repair was associated with a lower amputation rate (0% versus 5.1%, P = 0.004). Patients undergoing endovascular repair had more severe extremity/orthopedic injury, with venous injury again associated with open repair (48.5% versus 37.4%, P = 0.03). Conclusions Endovascular repair of iliac injuries was associated with a significantly lower rate of amputation than open surgery. Endovascular repair was associated with a higher incidence of several injuries, although open repair was associated with concomitant venous injury. Further work is required to delineate the benefit of endovascular intervention and role of venous injury in limb salvage.

Purpose: The calcium score is a measure of vessel wall calcification and has clinical applications when studied in different vascular beds. The presence of vascular calcification in the arteries of the lower limbs is very common in patients with peripheral arterial disease; however, its relationship with the postoperative outcomes in patients undergoing lower limb revascularization is still poorly studied. The aim of this study is to evaluate association between the calcium score of lower limbs and the postoperative outcomes in patients with peripheral arterial disease undergoing revascularization procedures. Methodology: We retrospectively analyzed 88 lower limb revascularization procedures in 72 patients with critical limb ischemia who had enhanced computed tomography for preoperative evaluation. The calcium score was calculated, from the angiographic phase of preoperative computed tomography, in the segments of the aorta, iliac, femoropopliteal, and infrapopliteal. It was also calculated the calcium score of the operated limb, and the total calcium score using a standardized method. The outcomes evaluated were the occurrence of acute myocardial infarction, amputation, patency, technical success, and death from any cause. Patients were followed up through a 12 month period. Results: Among the 88 procedures performed, 31 (43.1%) lesions were classified as Trans-Atlantic Inter-Society Consensus Document II D. There were 66 (75%) endovascular procedures, 16 (18.2%) open surgery, and 6 (6.8%) hybrid interventions. No statistically significant relationship was found between the calcium score of the segments (aorta, iliac, femoropopliteal, infrapopliteal, the operated limb, and total calcium score) and the outcomes of acute myocardial infarction, amputation, patency, and technical success in any of the periods analyzed. The calcium score of the operated limb was higher in patients who died within 30 days and 6 months (6571 vs 2590.6; p=0.026) and (5227.8 vs 2335.3; p=0.036). Conclusion: A standardized calcium score calculation method with the angiographic phase of the computed tomography is feasible and reproducible. Higher values of the calcifications of the operated limb are related to a greater chance of death in the postoperative period. The calcium score of the operated limb can be considered as a marker of clinical severity and prognosis in this group of patients

Modular megaprostheses have widely replaced allografts, as a reconstructive option; however, failures of these devices remain high. Aim of this study was to analyze outcomes, survival of the implants, incidence and types of complications with Mutars modular endoprostheses at long term. Between 2000 and 2019, 187 Mutars prostheses were implanted in two dedicated centers: 72 upper limbs and 115 lower limbs reconstructions. Diagnoses included 107 primary malignant bone or soft tissue tumors, 65 metastases, 8 benign bone tumors and 7 non-oncologic cases. Silver-coated prostheses were used in 118/187 (63%) cases. At last follow-up, 76.5% of patients had retained their implant. The overall failure rate was 23.5% at a mean of 1.7 years. There were 22 mechanical failures and 22 non-mechanical failures. The overall implant survival to all types of failure was 68% and 52% at 5 and 10 years, respectively. Infection was the most common mode of failure with an incidence of 6.9%. Implant survival to infection was better for silver-coated implants than for standard implants even if with no significant difference (p = 0.56). Functional results were satisfactory in 97% of patients. The overall implant survival at long term was satisfactory with Mutars prostheses. The incidence of complications with Mutars prosthesis is in line with the incidence reported in the literature with other types of tumor prosthesis. The most frequent cause of failure was infection with a lower incidence in silver-coated prostheses; silver coating seems to prevent infection in distal femur and proximal tibia. The silver coating seems to be particularly useful in two-stage revisions with a lower incidence of secondary amputation. In higher risk patients, silver-coated prostheses are the preferable choice for the reduction of the reinfection rate. The functional results of Mutars prostheses were excellent or good in most of cases. The current paper is design to enhance the literature on megaprosthesis in tumor surgery, proven that this system is one of the most used all over the word and one of the best performing.

Objective We report the 6- and 12-month outcomes of the PROMISE I early feasibility study after treatment of no-option chronic limb-threatening ischemia (CLTI) with percutaneous deep vein arterialization (pDVA) using the LimFlow System. Methods Thirty-two patients with no-option CLTI, previously offered major amputation, were enrolled in this single-arm early feasibility study of the LimFlow pDVA System. No-option CLTI was defined as being ineligible for surgical or endovascular arterial revascularization. Patients were assessed for clinical status, pain, wound healing, and duplex ultrasound at 30 days, 6 months, and 12 months post-treatment. Primary endpoint analysis was amputation-free survival (AFS) at 30 days and 6 and 12 months. AFS was defined as freedom from above-ankle amputation of the index limb and freedom from all-cause mortality. Secondary endpoints evaluated included technical success of the procedure, and wound healing at 6 and 12 months. Results Of 32 enrolled patients, 31 (97%) were successfully treated with the LimFlow System at the time of the procedure, and two (6.3%) were lost to follow-up. The 30-day, 6-month, and 12-month AFS rates were 91%, 74%, and 70% respectively. The wound healing status of fully healed or healing was 67% at 6 months, and 75% at 12 months. Reintervention was performed in 16 patients (52%) with 14 (88%) of the maintenance reinterventions occurring within the first 3 months. The majority of reinterventions (n = 12; 75%), involved the arterial inflow tract proximal to the stented LimFlow circuit, and no in-stent stenoses were determined to have been the cause of reintervention. Conclusions The LimFlow pDVA System was utilized in treating patients with no-option CLTI. A high technical success rate was observed, with a significant percentage of patients surviving free of major amputation at 12 months. These results suggest early safety and provide an initial assessment of the efficacy of the LimFlow pDVA System that supports the expansion of carefully executed studies to determine whether this is a viable option that can be used in this critically disadvantaged and growing patient population.

Summary Background Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. Methods This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. Results Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10–20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. Conclusions Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

The Intrepid Dynamic Exoskeletal Orthosis (IDEO) brace is a custom energy-storing orthosis design meant to improve gait, stability, and function after lower extremity injury or limb salvage. Early studies demonstrated the potential for the IDEO to improve functional performance, in conjunction with its paired return to run (RTR) rehabilitation program, compared to other brace types, and an impressively decreased rate of late amputation. The current study aimed to investigate these functional and revision outcomes from our institution to determine which patients may benefit most from IDEO bracing and what factors of the IDEO design and rehabilitation program are most important for improved outcomes after lower extremity trauma and/or loss of function.We performed a retrospective review of all patients treated with a IDEO style brace at a single military lower extremity trauma referral center between May 2003 and November 2017. We reviewed the medical records for initial diagnosis, post-orthotic rehabilitation program, IDEO use characteristics, pain, change in desire for amputation, and whether patient underwent eventual amputation.We identified 213 patients with 222 lower extremities treated with IDEO brace. Of these, 76 limbs were treated for combat-related injuries. At one year follow-up, use status could not be determined for 37 extremities (16.7%). Of the 185 limbs with use data available, 116 (61.1%) continued regular brace use, and 37 (15.7%) reported intermittent use. Patients diagnosed with footdrop or weakness were more likely to continue use (OR 2.33, p=0.04), while patients with a previous fusion were less likely to continue use (OR 0.45, p=0.049). Undergoing any dedicated therapy increased chances of continued use (OR 3.37, p0.001). At final follow-up, 16 patients (7.5%) underwent delayed lower extremity amputations following IDEO treatment. Overall, 27.2% of patients who initially desired amputation eventually underwent amputation despite IDEO brace use. Patients who underwent amputation reported higher pain levels (2 versus 5, p0.001).In select patients, the IDEO may decrease the desire for delayed amputation and permit higher levels of activity; however, its efficacy appears tied to the rehabilitative regimen, pain levels, and initial diagnosis. These findings should guide post-surgical extremity bracing prescriptions and expectations.

Background: Endovascular techniques have revolutionized the treatment of lower extremity artery disease (LEAD). Despite this, the treatment of complex femoropopliteal lesions is a field of debate. This report summarizes the current experience in the treatment of complex femoropopliteal lesions in the author's center. Material and methods: This is a retrospective, observational cohort study of patients with complex femoropopliteal lesions. The patients were treated using either endovascular procedure or surgical bypass. Details of the procedure, complications, mortality and amputation rate, primary and secondary patency rates, and reinterventions were analyzed. Results: 201 patients were included. 130 patients received endovascular treatment (ET), whereas in 67 a femoropopliteal bypass (FB) was implanted. The hybrid approach was utilized in 4 patients. ET was preferred in primary (88.5% vs. 47.8%, p

Purpose: To perform a systematic review assessing the safety and efficacy of percutaneous transluminal angioplasty (PTA) for treatment of critical hand ischemia (CHI) due to below-the-elbow (BTE) obstructive arterial disease. Materials and Methods: MEDLINE and EMBASE systematic searches were performed from inception to December 2020 to identify studies assessing PTA for management of BTE obstructive arterial disease. Three independent reviewers performed abstract selection, data extraction, and quality assessment. The Newcastle-Ottawa Scale was used to assess individual study bias for non-randomized controlled trials. Results: Eight studies comprising 176 patients with obstructive BTE vessel disease were included. All studies had a score >5 on the Newcastle-Ottawa Scale, indicative of high quality. All studies used low-profile balloons (1.5–4 mm) for PTA of stenotic lesions or chronic total occlusions (CTOs). The weighted average technical success and clinical success rates were 89.3% (range = 82%–100%) and 69.9% (range = 19%–100%), respectively, at a mean follow-up of 29.7 ± 17.1 months. The short-term (Conclusions: PTA for CHI due to BTE obstructive arterial disease is feasible with a high technical success rate and a low short-term complication rate. Additional long-term comparative studies are required to unequivocally establish the clinical benefit of endovascular treatment compared with conservative management or surgical bypass.

We assessed the clinical outcomes of patients with critical limb-threatening ischemia (CLTI) who underwent interwoven nitinol stent (Supera) implantation for significant stenoses of the femoropopliteal segment. In this retrospective cohort study, 116 consecutive patients with CLTI who were treated with Supera stents between September 2015 and March 2020 were included in this analysis. Primary endpoint analysis was completed for amputation-free survival, target lesion revascularization (TLR), and mortality. After a mean follow-up time of 3.4 years, 21 (18%) patients had undergone amputations, 3 (2.6%) died, and, overall, the amputation-free survival rate was 81%. TLR occurred in 21 (18%) patients, resulting in the freedom from target lesion revascularization of 82%. The average Wagner score for all patients was 2.8 ± 1.1. A subgroup analysis of 57 patients revealed a median ulcer size of 3.0 cm2 [1.65, 9.0], with complete healing for 45 patients by 20 months. The Wagner score of this subgroup decreased by an average of 3.4 ± .9 points. Supera stents can be used together with other endovascular therapies and are a safe and effective treatment modality for CLTI.

Objective Aortic dissection can result in devastating cerebral, visceral, renal, spinal, and extremity ischemia. We describe the management and outcomes of patients presenting with aortic dissection and lower extremity malperfusion (LEM). Methods A single-center institutional aortic database was queried for patients with aortic dissection and LEM from 2011 to 2019. The primary end point was resolution of LEM after aortic repair. Secondary end points were amputation, in-hospital mortality, time to intervention, and postoperative complications. Results Of 769 patients with aortic dissection, 42 (5.5%) presented acutely with LEM: 16 with Stanford type A and 26 Stanford type B aortic dissection (age 55 ± 13 years; 90% men). Most presented as Rutherford IIB symptoms, but patients with type A had Rutherford III more often, compared with those with type B. Aortic repair was performed before limb interventions in 36 patients (86%; 19 TEVAR, 16 open arch and ascending repair, and 1 open descending aortic repair with fenestration). Seven (19%) had immediate failure with persistent malperfusion recognized in the operating room and underwent additional limb intervention, including extra-anatomic revascularization (n = 4), iliac stenting (n = 2), and femoral patch with septal fenestration or tacking (n = 2). Three patients (8%) had early delayed failure requiring extra-anatomic bypass in two and amputation in one. In contrast, six patients had limb-first intervention with extra-anatomic revascularization. None had immediate failure, but one-half had early delayed failure requiring proximal aortic intervention: two TEVAR and one open aortic fenestration. Limb-first patients were more likely to have early delayed failure compared with aortic dissection treated first patients (50% vs 8%; P = .029). The amputation rate was 2%, occurring in one type A patient. The overall in-hospital mortality was 7% (n = 3), with no difference between type A and type B aortic dissection. There was no difference in surgical site infection, postoperative dialysis need, stroke, and myocardial infarction. Conclusions In patients presenting with acute aortic dissection with limb ischemia, resolution of the malperfusion occurs in the majority of cases after primary aortic dissection intervention, emphasizing the usefulness of urgent TEVAR for complicated type B and open repair of type A before lower extremity intervention. Limb-first interventions have a higher early delayed failure rate and thus require more frequent reoperation. However, the overall amputation rate in LEM owing to aortic dissection remains low.

Background Vascular patients with tissue loss requiring minor amputations could be an early sign of a terminal event. The long-term outcomes and timing of revascularisation for these patients are not well-studied. The aim of this study was to determine the clinical outcomes following minor amputations. Primary outcomes were functional status, limb loss, and mortality. Secondary outcomes compared immediate and delayed revascularisation. Methods A retrospective analysis of 200 vascular patients who required minor amputations at Austin Hospital, Melbourne was performed over 5 years. Demographics, details of revascularisation, functional status, and clinical outcomes such as recurrent tissue loss, limb loss and death were recorded. Results Of the entire cohort requiring minor amputations, 118 (59%) patients underwent revascularisation. 111 (94%) revascularisation procedures were performed within 90 days of minor amputation. Over all 5-year limb preservation was 89.9%. Patients who required revascularisation were not statistically significantly more at risk for limb loss at 5 years [13.6% vs. 6.6%; P=0.08]. Limb salvage at 1 year was not different between groups revascularized before and after amputation [89.5% vs. 90.9%; P=0.70]. Over all 5-year mortality rate was 50%. In the diabetic subset, those who had revascularisation after minor amputation had a greater 5-year mortality [67.9% vs. 50%; P=0.03]. A scoring system based on risk factors was developed but was not reliable based on the study data. Conclusions The data from this study suggest that patients with diabetes who undergo revascularisation after minor amputation have worse outcomes than those revascularised prior to minor amputation. A predictive model applied at presentation could help detect high-risk patients but requires further work.

Background: Coverage of distal leg defects is quite challenging. Usually, free tissue transfer is used for the reconstruction of such defects. Lack of microsurgical team/setup or patient contraindication to undergo a lengthy procedure would divert the decision to local tissues for coverage typically using local fasciocutaneous/propeller flaps or muscle flaps. Also, those local flaps options would be the first choice for relatively small defects, with plenty of healthy tissue available for coverage. If a local fasciocutaneous flap is not feasible or desired, the distally based medial hemisoleus flap is a common reliable alternative for reconstruction of middle and/or distal third leg defects of small to moderate size. In the current series, relatively larger defects were successfully reconstructed using this flap. Intraoperative confirmation of the adequacy of the explored flap distal pedicle underly the reported high flap survival rate. PATIENTS AND METHODS: The study enrolled 13 cases (12 male & 1 female) with distal and/or middle third leg defects. Patients' age ranged from 12–51 years age (mean 37 years), with defect sizes ranging from 3.5x5cm (17.5cm2) to 8x10cm (80cm2) with a mean of 41cm2. Distally based medial hemisoleus flap was used to reconstruct all cases, based on its distal pedicle(s) from the posterior tibial vessels. A split thickness skin graft was used to cover the muscle typically one week later in a second procedure. RESULTS: All flaps survived completely except partial-thickness surficial flap necrosis in one case. This was conservatively managed by debridement and later skin grafting. All cases achieved complete healing of their wounds with successful limb salvage. CONCLUSIONS: Intraoperative confirmation of distal medial hemisoleus flap pedicle would ensure better flap survival and would allow safe reconstruction of moderately large distal leg defects in selected cases with appropriate distal pedicle size and location.

Introduction Lower extremity (LE) arterial injuries are common in military casualties and limb salvage is a primary goal. Bypass grafts are the most common reconstructions; however, their specific outcomes are largely unreported. We sought to describe the outcomes of LE arterial grafts among combat casualties and their association with limb loss. Methods Retrospective cohort study of 2004-2012 Iraq/Afghanistan casualties with LE arterial injury undergoing bypass graft from a database containing follow-up until amputation, death, or military discharge. Primary outcome was composite graft complications (GC-thrombosis, stenosis, pseudoaneurysm, blowout, and/or arteriovenous fistula). Results Two hundred and twenty-two grafts were included (99 femoral, 73 popliteal, 48 tibial). 56 (26%) had at least one GC; thrombosis was most common in femoral, stenosis most common in popliteal and tibial. GC was not associated with graft level but was associated with synthetic conduit (P = 0.01) and trended towards an association with multiple-level arterial injuries (P = 0.07). Four of eight (50%) synthetic grafts had amputations, all within 72h. Two of the eight synthetic grafts thrombosed, and both limbs were amputated. There were 52 total amputations. Amputation was performed in 13 (23%) of limbs with a GC and 24% of those without (P = 0.93) Overall, 24 (11%) of grafts thrombosed, 16 within 48h and 13 (25%) in limbs undergoing amputation (P = 0.001 for association of thrombosis with amputation). Conclusion GC are common among LE bypass grafts in combat casualties but are not associated with limb loss. Thrombosis is predominantly early and is associated with amputation. Closer attention to ensuring early patency may improve limb salvage.

OBJECTIVES To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN Retrospective. SETTING Nine trauma centers. PATIENTS This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Aims In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. Methods We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up. Results We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. Conclusion Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of ‘long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion’ is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611–1618.

Objective The optimal antiplatelet regimen after lower extremity revascularization in patients with chronic limb-threatening ischemia (CLTI) is unknown because current recommendations are based on extrapolation of data from trials in coronary artery disease and stroke. Methods We identified all patients undergoing an elective lower extremity revascularization for CLTI in the Vascular Quality Initiative registry discharged on a mono antiplatelet agent (MAPT) or dual antiplatelet therapy (DAPT). Results From 2003 to 2018, 50,890 patients underwent revascularization procedures for CLTI, and were discharged on MAPT or DAPT. Of these, 33,781 patients underwent endovascular therapy (EVT), and 17,109 patients underwent open surgery (OS) procedures. The rate of major amputation at 30 days in the target limb in the EVT group was 0.3% and 0.4% in the OS group (P = .22). On Kaplan-Meier analyses, patients on MAPT at discharge had a higher risk of 1-year major amputation compared with DAPT after EVT but not after OS procedures. Patients on MAPT had lower overall survival and amputation-free survival at 30 days and 1 year compared with DAPT after both EVT and OS. At 1 year, the MAPT group was at higher risk for target lesion reintervention after EVT compared with the DAPT group (15.9% vs 13%; P = .0012). There was no significant difference in thrombosis at 1 year between the MAPT and DAPT groups either after EVT (3.9% vs 3.7%; P = .3048) or OS (3.1% vs 3.2%; P = .2893). On Cox regression analysis, DAPT was associated with improved survival but not major amputation after both EVT and OS. Conclusions In patients with CLTI, DAPT at the time of discharge has a positive impact on amputation-free survival and overall survival after both EVT and OS as well as target lesion reintervention after EVT. DAPT was not associated with a positive impact on major amputation after either EVT or OS.

There is increasing preference for limb salvage techniques in the management of pediatric musculo- skeletal tumors. This study was aimed at evaluating femoral growth following proximal tibia resection (PTR) and placement of an extendible endoprosthesis with sliding stem. This was a retrospective study. The demographic and clinical data were collected. All the patients with malignant tumors were fully staged and commenced on appropriate chemotherapy. An expected discrepancy of > 3cm was considered sub- stantial enough to warrant extendible prosthesis. Twelve patients who had follow up full length scanogram of the lower limbs were included for the evaluation of femoral growth. The last available scanograms were used for growth comparison of the femur. The age at resection for all twelve patients ranged from 4-13 years. The commonest histological diagnosis was Osteosarcoma. In the twelve patients assessed for the growth of femur, the mean femoral length was 96% [89%-102%] of the unaffected femur. Distal femoral physeal growth continued after im- plantation of a sliding extendible prosthesis after resection of proximal tibia tumors.

Background Free flap coverage in the setting of a total knee arthroplasty is rare. The purpose of the current study was to evaluate the outcome of patients who underwent a free flap to assist with soft-tissue coverage following a complex total knee arthroplasty. Methods The authors used their institutional total joint registry to retrospectively review patients undergoing a free soft-tissue flap in the setting of complex primary and revision total knee arthroplasty. Among 29,069 primary and 6433 revision total knee arthroplasties from 1994 to 2017, eight (0.02 percent) required a free flap for wound coverage. This included three primary total knee arthroplasties (0.01 percent) for posttraumatic arthritis and five revision total knee arthroplasties (0.07 percent) in the setting of infection. Median follow-up was 4 years. Results Free flaps included vertical rectus abdominis (n = 3), anterior lateral thigh (n = 2), latissimus (n = 2), and transverse rectus abdominis (n = 1). There were no total flap losses; however, one patient required additional skin grafting. Reoperation occurred in six patients, of which four were revisions of the total knee arthroplasty for infection (n = 2) and tibial component loosening (n = 2). One patient ultimately underwent transfemoral amputation for persistent infection. Following reconstruction, there was improvement in the median Knee Society Score (49 versus 82; p = 0.03) and total range of motion between preoperative and postoperative assessments (70 degrees versus 85 degrees; p = 0.14). Conclusion Free flap coverage in the setting of total knee arthroplasty was associated with a high rate of reoperation; however, the limb was able to be preserved in the majority of patients, with a reasonable functional outcome. Clinical question/level of evidence Therapeutic, IV.

Objectives: Limited data support the use of fasciotomies in acute limb ischemia (ALI) in patients with isolated arterial occlusion. This study describes an experience in which fasciotomies are not regularly performed post-revascularization. Methods: Using International Classification of Diseases, Ninth and Tenth Edition codes, patients presenting to the University of California Davis Medical Center between January 2003 and July 2018 with ALI, excluding those with traumatic injuries were identified. The primary outcome was major amputation, and the secondary outcome was foot drop. Additionally, the characteristics of those patients in each category of ischemic severity excluding those with grade 3 ischemia were summarized. Results: Of the 253 patients identified, revascularization was successful in 230 patients with 11 total fasciotomies performed. One hundred thirty-five patients were Rutherford Class 1/2A and 95 were 2B. In those with 1/2A ischemia, 134 (102 had >6 hours of symptoms) did not undergo fasciotomy with only one amputation occurring in this group. In those with 2B ischemia, 65 had >6 hours of symptoms; 58 did not undergo fasciotomy with 4 major amputations. In the 30 patients with ≤6 hours of ischemic symptoms, 27 did not undergo fasciotomy with 1 major amputation occurring in this group. There were no amputations in those patients who underwent fasciotomies. Additionally, there were 14 patients with a foot drop, of which 11 were in patients with 2B ischemia without fasciotomy. Conclusions: The data suggest that regardless of ischemic duration, 1/2A patients may not need fasciotomies, while those patients with 2B ischemia may benefit.

Limb-threatening sarcomas invading major vessels present an oncological and reconstructive challenge. Curative resection involves either performing an amputation or an immediate reconstruction of the invaded vessels. We present our 15-year experience of these cases at the North of England Bone and Soft Tissue Tumour Service.A Strengthening the Reporting of Observational studies in Epidemiology (STROBE) compliant retrospective review of our prospective database was performed including patients who required major vessel reconstruction following sarcoma excision from 2003 until 2018. Patient demographic data along with tumour and histological subtypes, treatment modality, complications and outcomes were inquired. Autologous and prosthetic vessel reconstruction approaches were compared.Nineteen patients were identified with the most common tumour locations being the thigh and groin areas. Five cases involved recurrent tumours. Clear resection margins were obtained in 15 cases. Autologous vein grafts were preferred over polytetrafluoroethylene (PTFE) prosthesis in 17 cases. A pedicled flap or free flap was required to achieve adequate soft tissue cover in six patients, while the rest underwent primary closure. Five patients lost the patency of the reconstructed vessels with one of these requiring an amputation. The estimated disease-specific survival at 5 years was 58%.Limb-preservation surgery in the context of vessel compromise is not only safe, but also a functionally and psychosocially beneficial means of avoiding an amputation. We believe that careful pre-operative planning and discussion in a multidisciplinary setting is key for obtaining positive outcomes.

Objective Patients with peripheral artery disease (PAD) have an increased risk of lower limb amputation. Given the international wide variance in major amputations, the high mortality rates and follow up costs as well as the significantly reduced quality of life of patients with amputations, vascular diagnostics and vascular surgery treatments are of great importance for lower limb preservation in patients with PAD. This study examines these guideline based procedures in patients before a first lower limb amputation and PAD. Methods This was a retrospective longitudinal study. Data from a large German statutory health insurance scheme were examined on patients with first amputation of lower extremities and PAD between 2013 and 2015 (incidence). Pre-defined vascular diagnostic and vascular surgical procedures were considered, as specified by guidelines within inpatient and outpatient care in a defined time before lower limb amputation. Results The overall estimated incidence of lower extremity amputations in the total population was 0.12% from 2013 to 2015. Of these, 51.7% had PAD; 81.8% of patients received at least one vascular diagnostic measure and 61.0% a vascular surgery procedure before the lower extremity amputation. There were only minor variations in the use of diagnostic or surgical treatments between patients with major and minor amputation. In total, 63.9% of patients had vascular surgery before the incident major amputation compared with 60.0% of patients with a minor amputation. Noticeable regional differences were found ranging from 91% (Berlin) to 67% (Bremen) regarding diagnostic procedures provided before amputation, and from 83% (Hamburg) to 55% (Saxony-Anhalt) regarding vascular surgery before amputations. Conclusion Of patients with PAD, 18.2% did not receive a vascular diagnostic examination before amputation as specified in the guidelines, which reflects an underuse of health services. In one third of patients who did not receive vascular surgery, major amputation probably could have been avoided.

BackgroundProsthesis-related complications, after knee reconstruction with endoprosthesis during operation for tumors around the knee, remain an unresolved problem which necessitate a revision or even an amputational surgery. The purpose of the current study was to identify significant risk factors associated with implant failure, and establish a novel model to predict survival of the prosthesis in patients operated with endoprostheses for tumor around knee.MethodsWe retrospectively reviewed the clinical database of our institution for patients who underwent knee reconstruction due to tumors. A total of 203 patients were included, including 123 males (60.6%) and 80 (39.4%) females, ranging in age from 14 to 77 years (mean: 34.3 ± 17.3 years). The cohort was randomly divided into training (n = 156) and validation (n = 47) samples. Univariable COX analysis was used for initially identifying potential independent predictors of prosthesis survival with the training group (p ResultsThe 1-, 5-, and 10-year prosthetic survival rates were 94.0, 90.8, and 83.0% in training sample, and 96.7, 85.8, and 76.9% in validation sample, respectively. Anatomic sites, length of resection and length of prosthetic stem were independently associated with the prosthetic failure according to multivariate COX regression model (pConclusionsThe length of resection, anatomical location of tumor, and length of prosthetic stem were significantly associated with prosthetic survival in patients operated for tumor around knee. A user-friendly novel online model model, with favorable discrimination ability and accuracy, was generated to help surgeons predict the survival of the prosthesis.

Objectives The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI). Background There is a paucity of data on the relationship between hospital procedural volume and outcomes of eLER for CLI. Methods The authors queried the Nationwide Readmission Database (2013-2015) for hospitalized patients who underwent eLER for CLI. Hospitals were divided into tertiles according to annual eLER volume: low volume ( 550 eLER procedures). Stepwise multivariable regression models were used. The main outcomes were in-hospital mortality and 30-day readmission with major adverse limb events, defined as the composite of amputation, acute limb ischemia, or repeat revascularization. Results Among 145,785 hospitalizations for eLER for CLI, 5,199 (3.6%) were at low-volume eLER hospitals, 27,857 (19.1%) at moderate-volume eLER hospitals, and 112,728 (77.3%) at high-volume eLER hospitals. On multivariable analysis, there was no difference with regard to in-hospital mortality among moderate-volume hospitals (adjusted odds ratio [OR]: 0.78; 95% CI: 0.60-1.01) and high-volume hospitals (adjusted OR: 0.84; 95% CI: 0.64-1.05) compared with low-volume hospitals. There was lower risk of in-hospital major amputation (adjusted OR: 0.82; 95% CI: 0.70-0.96) and minor amputation at high- versus low-volume hospitals. The length of hospital stay was shorter and discharges to nursing facilities were fewer among moderate- and high-volume hospitals compared with low-volume hospitals. Compared with low-volume hospitals, eLER for CLI at high-volume hospitals had a lower risk for 30-day readmission with major adverse limb events (adjusted OR: 0.83; 95% CI: 0.70-0.99), while there was no difference among moderate-volume hospitals (adjusted OR: 0.92; 95% CI: 0.77-1.10). Conclusions This nationwide observational analysis suggests that annual eLER volume does not influence in-hospital mortality after eLER for CLI. However, high eLER volume (>550 eLER procedures) was associated with better rates of limb preservation after eLER for CLI.

Purpose: To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach. Materials and Methods: Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis Results: Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal–plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771–18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475–17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642–18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296–17.621) (Log-rank p=0.098). Conclusion: Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal–plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

Background Infected diabetic foot ulcers (DFU) complicated with calcaneal osteomyelitis are a real challenge for limb preservation. Very few alternatives to amputation are available, mainly the resection of a part or the totality of the calcaneal bone. Calcanectomies were advanced as limb-sparing procedures in patients with heel osteomyelitis. However, there is a lack of pooled quantitative evidence on their efficacy and complications. Objectives The present systematic review and meta-analysis was conducted to determine the primary outcome of healing rates following partial (PC) and total calcanectomies (TC) in treating calcaneal osteomyelitis due to diabetic heel ulcers. Additionally, secondary outcomes such as secondary TC following PC, secondary below knee amputation (BKA), mortality and the change in the ambulation status were analyzed. Methods Medline, Scopus, Web of science, Cochrane Library and Google Scholar were searched since inception. All types of study design were included. Single case report studies and studies reporting osteomyelitis due to other etiologies than DFU were excluded. Results Twenty studies met the inclusion criteria comprising 295 patients with 300 calcanectomies (270 PC and 30 TC). With a mean follow-up period of 29.3 ± 17.7 months, the weighted results were as follows: a) the osteomyelitis healing rate was of 80% (95% CI = 0.728 to 0.861, I2 = 48.3%), b) the rate of secondary total calcanectomy was of 5.4% (95% CI = 0.022 to 0.097, I2 = 7.5%), c) the rate of secondary BKA was of 17.1% (95% CI = 0.111 to 0.241, I2 = 50.6%) with no difference between subgroups of TC and PC, and d) the combined mortality rate of both calcanectomies was of 13.4% (95% CI = 0.064 to 0.224, I2 = 73.6%); however, significant higher mortality was found following TC compared to PC (p Conclusion Partial and total calcanectomies were found to yield very good healing rates with acceptable complication frequencies. When compared to the reported outcomes of below and above-knee amputations in the literature, calcanectomies could be fairly considered as good alternatives to above ankle amputations.

Background To evaluate outcomes of endovascular treatment (EVT) using a combination of multiple endovascular techniques for acute lower limb ischemia (ALLI) and to compare outcomes based on vessel type and artery location. Methods A total of 95 consecutive patients with ALLI (mean age, 72.0 years; 65 males; 104 lower limbs) who received emergency EVT using a combination of multiple endovascular techniques including thrombolysis, aspiration thrombectomy, stenting, and balloon angioplasty with or without surgical thromboembolectomy, between January 2005 and December 2017 were included. Vessel type was classified into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft. Additionally, native arteries were categorized into below-knee occlusion and non-below-knee occlusion. Technical success, perioperative death (POD), ALLI-related death, amputation, amputation-free survival (AFS), and complications were compared according to vessel type (native occlusion vs. graft occlusion) and artery location (below-knee occlusion vs. non-below-knee occlusion). Results Of all patients with ALLI, 16.8% underwent a single endovascular technique, whereas 83.2% underwent a combination of multiple endovascular techniques. The technicalsuccess, POD, and ALLI-related death rates in the total number of patients were 94.7%, 11.6%, and 4.2%, respectively. A total of 67 patients (75 limbs) and 28 patients (29 limbs) were classified as having native occlusion and graft occlusion (prosthetic, 24 limbs; vein, 5 limbs), respectively. No significant differences in technical success (native occlusion: 92.5% vs. graft occlusion: 100%), POD (14.9% vs. 3.6%), and ALLI-related death (6.0% vs. 0%) were noted between native occlusion and graft occlusion. However, the 30-day AFS rate of native occlusion was significantly lower than that of graft occlusion (75.2% vs. 96.3%, P=0.01). The amputation rate (P=0.03) and AFS rate (P=0.03) of below-knee occlusion were significantly worse for below-knee occlusion patients than for non-below-knee occlusion patients. Conclusions EVT using multiple endovascular techniques for ALLI is effective and safe. A combination of multiple endovascular techniques is crucial for successful treatment. However, native occlusion may have a lower AFS rate than graft occlusion, and below-knee occlusion may have a higher risk of amputation than non-below-knee occlusion.

Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention.We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models.A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization.An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.

Objective The aim of this study was to provide long term survival and limb salvage rates for patients with non-revascularisable (NR) chronic limb threatening ischaemia (CLTI). Methods This was a retrospective review of prospectively collected data, derived from a randomised controlled trial (JUVENTAS) investigating the use of a regenerative cell therapy. Survival and limb salvage of the index limb in CLTI patients without viable options for revascularisation at inclusion were analysed retrospectively. The primary outcome was amputation free survival, a composite of survival and limb salvage, at five years after inclusion in the original trial. Results In 150 patients with NR-CLTI, amputation free survival was 43% five years after inclusion. This outcome was driven by an equal rate of all cause mortality (35%) and amputation (33%). Amputation occurred predominantly in the first year. Furthermore, 33% of those with amputation subsequently died within the investigated period, with a median interval of 291 days. Conclusion Five years after the initial need for revascularisation, about half of the CLTI patients who were deemed non-revascularisable survived with salvage of the index limb. Although the prospects for these high risk patients are still poor, under optimal medical care, amputation free survival seems comparable with that of revascularisable CLTI patients, while the major amputation rate within one year, especially among NR-CLTI patients with ischaemic tissue loss, is very high.

Background In the setting of Peripheral Arterial Disease (PAD), pedal arch interrogation by ultrasound has not been well described. Patients with noncompressible vessels and/or open wounds of the foot may preclude the use of ankle-brachial indices, toe pressure measurements, or TcPO2, respectively. We propose that pedal artery interrogations with Pedal Acceleration Time (PAT) can be a predictor for limb salvage in patients with Chronic Limb-Threatening Ischemia (CLTI). Methods A retrospective review of a prospectively kept database was performed from 2018 to 2019. Patients with pending amputation due to severe infection (WIFI infection class 2 and 3) were excluded from the study. We identified 73 limbs with CLTI that fit the inclusion criteria. Data included WIFI classification, age, gender, cardiovascular risk factors, PAT, ABI, and TBI when reliable, were collected. PAT measurements were categorized into 4 classifications; 1 (40–120 msec), 2 (121–180 msec), 3 (181–224 msec), and 4 (Greater than 225 msec). Statistical analyses were performed. Results Seventy-three limbs with CLTI were included in our study. All patients underwent arterial revascularization with either percutaneous technique or arterial bypass. Limb salvage was achieved in 59 (81%) of the 73 limbs. All 59 limbs had a 2-classification improvement in their PAT following interventions. A total of 14 (19%) limbs without improvement in their PAT underwent above ankle level amputations. An improvement in PAT classes to class 1 or 2 is associated with limb salvage. Conclusions Patients with noncompressible ankle pressures or nonobtainable toe pressures poses a challenge in the complete assessment of WIFI classification. Our group has shown that PAT can be used in the scoring system for severity of ischemia in conjunction with current WIFI classification. Our data suggests that limb salvage correlates with post procedure PAT in category 1 and 2. Therefore we propose that PAT be added as part of the WIFI classification.

Objective Anatomic grading systems have historically been poor predictors of patency after endovascular tibial interventions. The Global Vascular Guidelines proposed a new Global Anatomic Staging System (GLASS) to estimate one-year limb-based patency (LBP). The purpose of this study was to determine the association of GLASS with LBP following endovascular tibial interventions. Methods We included all patients presenting to our multidisciplinary diabetic limb preservation service between 01/2012 and 8/2020 who underwent first-time endovascular tibial revascularization for chronic limb-threatening ischemia. Diagnostic angiograms were reviewed to define the preferred target artery pathway and assign a GLASS stage to each treated limb. One-year LBP was calculated and compared across GLASS stages using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models. Results We performed tibial revascularization in 96 limbs (5.2% rest pain, 56.3% ulcer, 37.5% gangrene), including isolated tibial interventions in 61.5% and tibial + femoropopliteal interventions in 38.5%. 15.6% of limbs were GLASS stage 1, 28.1% were GLASS stage 2, and 56.3% were GLASS stage 3. Overall, one-year LBP was 43.2 ± 6.3%, and did not differ significantly across GLASS stages (P = 0.42). The hazard ratio for failed LBP was 1.94 (95% CI 0.70–5.41) for GLASS stage 2 and 1.49 (95% CI 0.56–3.94) for GLASS stage 3 limbs (versus GLASS stage 1). When analyzed excluding the calcium modifier, LBP remained similar across GLASS stages (P = 0.72). Major amputation was uncommon, occurring in 9.3 ± 3.4% of limbs at one year, and did not significantly differ by GLASS stage (P = 0.98). Conclusion The Global Anatomic Staging System did not predict limb-based patency following tibial endovascular interventions. Given the low major amputation rates in this cohort, anatomic complexity should not preclude endovascular limb salvage efforts below the knee.

Introduction High-energy lower extremity trauma (HELET) may cause severe damage within the foot-ankle complex. Occasionally, arthrodesis or amputation are the only remaining options to increase activity levels. The modified passive dynamic ankle-foot orthosis (PDAFO) may prove to be a nonsurgical alternative. This study evaluated the effect of a modified PDAFO with a 6-week training program on pain and performance in patients after HELET. Materials and methods A retrospective cohort study was conducted on seventeen patients who considered an arthrodesis or an amputation after HELET. In an attempt to avoid surgery, the modified PDAFO with a 6-week training program was provided. Pain scores was measured with the Numeric Rating Scale and administered at the start of testing, immediately after the two performance tests and at the end of the day of testing. Performance was evaluated with the 6-min walk test (6MWT) and the Comprehensive high-level activity mobility predictor (CHAMP). Results A significant pain reduction was achieved after the treatment procedure. At the start of the test days (p = 0.002), after the 6MWT (p = 0.001), after the CHAMP (p < 0.001) and at the end of the day (p < 0.001). In addition, a significant improvement on performance was observed in the 6MWT (p < 0.001) and the CHAMP (p = 0.01). None of the patients considered a surgical intervention anymore. Conclusions Patients after HELET show a decrease in pain and an improvement in performance after a 6-week training program with modified PD-AFO. The results suggest that the modified PDAFO is an effective alternative for a surgical approach.

BACKGROUND Foot and ankle soft tissue sarcomas (STS) are challenging for reconstruction due to limited surrounding soft tissue and weight-bearing requirements. Currently, there is a paucity of data examining the outcome of flap reconstruction following resection of a foot and ankle sarcoma. METHODS We reviewed 44 (31 female, 13 male) patients with STS arising from the ankle or foot which required coverage in the form of a free (n = 21), pedicled (n = 13), or rotational perforator flap (n = 10). The mean tumor size was 6 ± 5 cm, with 39 (89%) patients receiving radiotherapy. The mean follow-up was 10 ± 7 years. RESULTS There were no cases of amputation due to flap failure, with a 10-year limb salvage rate of 84%. Complications occurred in 19 (43%) patients, most commonly wound infections. There was no difference in the incidence of complications between patients undergoing a free flap and pedicled or perforator flap (odds ratio = 0.97, p = 1.0); with no difference in the mean Musculoskeletal Tumor Society (MSTS) score between patients with a free flap versus a pedicled/perforator flap (84% vs. 76%, p = 0.11). CONCLUSION Flap reconstruction is an essential part of limb salvage for foot and ankle STS. At final follow-up nearly all the patients are ambulatory with an acceptable MSTS score.

Objective: Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. Method: This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5–10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×10 10 ) with CD34+ cells (2.1±1.2×10 8 ) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle–brachial index, toe–brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. Results: Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. Conclusion: Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.