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The surgical management of extremity bone and soft tissue sarcomas has evolved significantly over the last 50 years. The introduction and refinement of high-resolution cross-sectional imaging has allowed accurate assessment of anatomy and tumor extent, and in the current era more than 90% of patients can successfully undergo limb-salvage surgery. Advances in imaging have also revolutionized the clinician's ability to assess treatment response, detect metastatic disease, and perform intraoperative surgical navigation. This review summarizes the broad and essential role radiology plays in caring for sarcoma patients from diagnosis to post-treatment surveillance. Present evidence-based imaging paradigms are highlighted along with key future directions. [ABSTRACT FROM AUTHOR]

Reconstructive surgeons face challenges when considering limb salvage methods for the treatment of diabetic foot ulcers (DFUs). In this article, we present our experience with autologous fat grafting as a viable alternative in cases where flap reconstruction is difficult. We encountered a 78-year-old female patient with a nonhealing DFU who had multiple comorbidities, including renal failure and severe peripheral arterial disease. During the initial multidisciplinary meeting, due to extensive necrosis and osteomyelitis, amputation was recommended. However, the patient expressed a strong preference for a salvage procedure and refused amputation. After careful consideration, we opted to reconstruct the patient's foot using three-dimensional bioprinted autologous minimally manipulated homologous adipose tissue. The AMHAT was engrafted well without complications such as autolysis, graft failure, or infection. After the operation, the large defect with partial bone exposure was covered with healthy granulation tissue. The size of the wound decreased to less than half its original size after 6 weeks of surgery, and it decreased to less than 25% after 12 weeks of surgery. The AMHAT may be an appealing treatment option for diabetic foot patients who are unsuitable for flap reconstruction due to comorbidities.

Background: Endovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions. Methods: This prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months. Discussion: Endovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a "leaving nothing behind" endovascular approach combining directional atherectomy and DCB compared to surgical therapy. Trial registration: ClinicalTrials.gov NCT02517827. [ABSTRACT FROM AUTHOR]

Purpose: We conducted a systematic review of studies reporting on measurement of health-related quality of life (HRQoL), with a special focus on the use of the preference-weighted instruments, in patients with extremity bone sarcoma treated with limb-salvage surgery or amputation. Methods: We searched MedLine, Embase, Cochrane Library and Web of Science for English-language studies reporting on HRQoL of patients with bone sarcoma from inception to 28 August 2023. All records found were independently reviewed by two reviewers. We used the Newcastle–Ottawa Scale (NOS) and the CONSORT 2010 checklist to assess the quality of the cohort and randomised studies, respectively. Results: The search identified 1225 records, of which 16 studies were included for data extraction. Only one study used a preference-weighted instrument for measuring HRQoL in a small sample of patients (n = 28). Ten studies used the generic SF-36 questionnaire, but no preference-weighted HRQoL based on SF-6D was derived from the SF-36 scores. Most studies comparing HRQoL between amputation and limb-salvage surgery reported no significant differences. Twelve cohort studies scored six or more out of nine points based on the NOS. The only randomised study scored 54% on the CONSORT 2010 checklist. Conclusions: The approaches used to measure HRQoL were inconsistent and outcome scores varied substantially. Only one study used preference-weighted instruments for HRQoL measurement. Future research into the surgical treatment of extremity bone sarcoma should consider the use of preference-weighted instruments to measure HRQoL, which will therefore enable economic evaluation for the growing orthopaedic armamentarium of novel surgical interventions. Registration: This systematic review was registered with the PROSPERO International prospective register of systematic reviews (CRD42021282380). [ABSTRACT FROM AUTHOR]

Background The best option among the endovascular options in long, complex femoropopliteal (FP) lesions, and factors affecting the patency have yet to be well described. There are few studies describing the mid- and long-term patency of endovascular stents in long-segment FP occlusions. Aim This study aimed to determine the technical success and mid-term patency of subintimal angioplasty with vasculomimetic stenting in Trans-Atlantic Inter-Society Consensus II (TASC) C and D FP disease. The patient and imaging factors that affect primary patency were also analyzed. Methods and Materials A single-center prospective study was performed on 52 consecutive patients undergoing endovascular treatment for TASC C and D FP disease from 2017 to 2021. Angioplasty with stenting was performed in all patients and followed up for 36 months. Endpoints were primary patency rates and amputation-free survival of the limb. Kaplan–Meier curves were used to see patency rates and amputation-free survival rates. Results A total of 52 patients underwent stenting with a technical success rate of 100% if the sub-intimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique was used. Primary stent patency at 6, 12, 18, 24, and 36 months was 89.8, 81.4, 76.2, 71.4, and 62.5%, respectively. Amputation-free survival was 98, 95.6, 91.8, and 85.7% at 12, 24, 30, and 36 months, respectively. Cox proportional regression analysis showed smoking and vessel wall calcium score more than 270 degrees as independent predictors of loss of primary patency (hazard ratio 0.35 confidence interval [CI]: 0.003–0.448) and 0.102 (CI: 0.022–0.47), respectively. Conclusion Subintimal angioplasty with vasculomimetic stent has good midterm patency in and amputation-free survival in long-segment FP occlusions. Smoking and severe vessel wall calcification adversely affect patency. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous deep venous arterialisation (DVA) is emerging as a promising alternative for limb salvage in chronic limb threatening ischaemia (CLTI) patients without any reasonable anatomical option for conventional revascularisation techniques. However, its mechanism of action remains incompletely understood. This report aimed to find some of the histological alterations occurring in the limb following DVA. Report: This short report presents the case of a 53 year old female who underwent DVA for Rutherford 5 CLTI. Although the intervention was successful and showed evidence of improved blood flow to the foot, the post-operative course was notable due to worsening infection leading to a below knee amputation four weeks later. The blood vessels were harvested for histological analysis, which found features of venous arterialisation such as smooth muscle cell proliferation and neointimal hyperplasia, even in the paired posterior tibial vein that did not undergo DVA. Discussion: This case demonstrated unexpected histological changes occurring in the paired posterior tibial vein that did not undergo DVA. This warrants further investigations to fully understand the mechanisms at play in DVA and to explore the role of the paired vein in sustaining arterialised flow to the foot.

Objective: A growing proportion of patients with chronic limb threatening ischaemia (CLTI) are elderly, the most challenging for management decisions. The aim was to study the patient profile and outcome of CLTI in octogenarian patients, comparing them with younger patients. Methods: Retrospective cohort of consecutive patients hospitalised for CLTI with infrainguinal disease in a Spanish centre (2013–2020). Data on age, comorbidity, anatomical characteristics, and treatment were gathered. Patients were stratified according to age (

Combined radial and ulnar artery injuries are associated with a >35% amputation rate when not revascularized promptly. We describe a patient who suffered a penetrating injury to both the radial and ulnar arteries. Despite the ulnar artery being ligated and the radial artery primary repair becoming occluded after the index operation, his hand remained salvageable, likely because of collateral arterial pathways. The patient obtained a delayed radial-radial artery bypass and afterward achieved meaningful neuromotor function. This case emphasizes the importance of forearm vascular anatomy variability and the need for prompt management of arterial injuries to reduce limb loss and disability.

Patients with no-option chronic limb-threatening ischemia are not candidates for conventional revascularization options and will inevitably require major amputation. Deep venous arterialization (DVA) is a potential option for these patients. A complete endovascular system to perform DVA has recently received great acclaim and US Foor and Drug Administration approval. However, patients with severe tibial medial calcinosis such as those with diabetes or renal failure may not be candidates for this because most endovascular needles cannot penetrate severe calcium. Here we describe a novel hybrid approach to DVA that provided technical success in three patients with end-stage renal disease and severe medial calcinosis.

A 57-year-old man presented after a fall, which resulted in acetabular and pelvic fractures. He underwent fracture fixation, which was complicated by iliac vein occlusion, leading to phlegmasia cerulea dolens. He underwent lower extremity surgical venous thrombectomy, contralateral iliac vein stent placement, and modified Palma procedure with an expanded polytetrafluoroethylene venous crossover bypass and arteriovenous fistula creation. His postoperative course was unremarkable and he regained full function of the extremity without significant stasis complications. The bypass and stent remain patent 3 years postoperatively. Although iliac vein injury during acetabular fracture repair is rare, prompt recognition and intervention prevent limb loss.

The objectives of this study were to clarify whether localized extremity soft tissue sarcoma (STS) patients who underwent amputation surgery experienced worsened survival and to identify those patients for whom amputation surgery worsened survival. Using the Surveillance, Epidemiology, and End Results database, we identified 8897 patients with localized extremity STS between 1983 and 2016. Of these 6431 patients, 733 patients underwent amputation surgery (Amputation group), and 5698 underwent limb-sparing surgery (Limb-sparing group). After adjusting for patient background by propensity score matching, a total of 1346 patients were included. Patients in the Amputation group showed worsened survival (cancer-specific survival (CSS): hazard ratio (HR) = 1.42, 95% confidence interval (CI) 1.15–1.75, overall survival (OS): HR = 1.41, 95%CI 1.20–1.65). In subclass analysis, patients with high-grade STS, spindle cell sarcoma and liposarcoma in the Amputation group showed shortened survival (high-grade–CSS: HR = 1.44, 95%CI 1.16–1.77, OS: HR = 1.38, 95%CI 1.18–1.62; spindle cell sarcoma–CSS: HR = 4.75, 95%CI 1.56–14.4, OS: HR = 2.32, 95%CI 1.45–3.70; liposarcoma–CSS: HR = 2.91, 95%CI 1.54–5.50, OS: HR = 2.32, 95%CI 1.45–3.70). Survival was shortened in localized extremity STS patients who received amputation surgery. [ABSTRACT FROM AUTHOR]

Background and Objectives: The aim of this study was to evaluate the clinical outcomes of patients suffering from chronic limb-threatening ischemia (CLTI) and tissue loss treated with primary isolated femoral bifurcation endarterectomy (FBE) or with FBE combined with bypass surgery. Materials and Methods: This retrospective study was performed in a tertiary university-based care centre. Between January 2008 and December 2019, a prospectively collected database of patients suffering from CLTI and tissue loss and undergoing either primary FBE (group A) or FBE in combination with bypass surgery (group B) was analysed. Study endpoints were ulcer healing, primary and secondary patency rate, limb salvage, and survival. Results: In total, FBE was performed in 73 patients and FBE with bypass in 60 patients. Between both groups, there were no significant differences regarding demographic data or the Global Limb Anatomic Staging System (GLASS) grade III and IV of femoropopliteal lesions. After 3 years, ulcer healing could be achieved in 72% of FBE and in 75% of FBE with bypass patients. The primary patency rate was 95% and 91% for FBE and 83% and 80% for FBE with bypass after one and three years, respectively. The 3-year limb-salvage rate was 78% for FBE and 84% for FBE with bypass. The secondary patency rate after one and three years was 99% and 97% for FBE and 93% and 88% for FBE with bypass. Conclusions: FBE and FBE with bypass are equally effective for ulcer healing in cases of combined CFA and superficial femoral artery lesions. There was no significant difference between both groups regarding primary and secondary patency rates, limb salvage rates and ulcer healing. Isolated FBE could be an alternative strategy in patients with higher operative risk. [ABSTRACT FROM AUTHOR]

Background: Information on dogs that undergo radiation therapy (RT) with non-stereotactic protocols in addition to surgical stabilization with implant placement for treatment of bone tumors is limited. Objective: Our primary objectives were to describe the clinical characteristics as well as short- and long-term outcomes, including complications, function, and disease progression, in dogs that underwent both surgical stabilization with implant placement and non-stereotactic RT for local treatment of a bone tumor. Methods: A bi-institutional retrospective case series was performed. Animals: Eight client-owned dogs that underwent both surgical stabilization with implant placement and non-stereotactic RT for local treatment of a bone tumor were included. Results: Tumor types included osteosarcoma or suspected osteosarcoma (5), plasma cell tumor (2), and grade 3 fibrosarcoma (1). Radiation protocols were hypofractionated (palliative intent) in 5 dogs and fractionated (definitive intent) in 3 dogs. Five dogs experienced complications following both RT and surgery, including grade 1 complications in two dogs, a grade 2 complication in one dog, both grade 1 and 2 complications in one dog, and both grade 2 and 3 complications in one dog. Clinical signs subjectively improved in all dogs that had outcomes relative to function documented post-surgery/RT (7). Of these 7 dogs, 4 maintained long-term improvement in function and clinical signs, whereas 3 experienced subsequent recurrence/progression of clinical signs at a median of 133 days (range 91-186) postoperatively in association with biomechanical complications (screw loosening), surgical site infection, and local disease progression in 1 dog each; subsequent treatment resulted in improved clinical signs for each of these 3 dogs, such that overall good long-term functional outcomes were experienced. No dogs required amputation or additional vertebral surgery as salvage for local disease control or palliation. The median progression free interval was 206 days (range 25-1078), and the median survival time was 253 days (range 122-1078) with 1 additional dog lost to follow-up at 575 days. Two dogs experienced local disease progression, and 6 dogs experienced systemic disease progression; both dogs that developed local disease progression received palliative intent RT protocols. Clinical relevance: In this cohort, dogs with primary bone tumors that underwent surgical stabilization with implant placement and hypofractionated or fractionated non-stereotactic RT for local treatment had a low incidence of major complications, good limb function and ambulation post-treatment, and relatively prolonged survival times despite disease progression. [ABSTRACT FROM AUTHOR]

Purpose: Limb salvage surgery and amputation are two commonly performed procedures for lower extremity tumors. When comparing these procedures in tumor patients, it is important to consider their impact on quality of life (QOL) and functional mobility. These patients often experience physical, emotional, and psychological challenges, making these factors crucial in determining the most suitable treatment approach. Method: The outcomes of lower extremity tumors patients for QOL were collected from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 28 February 2023. The physical function, mental health, role function, social function, emotional function, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society Score outcomes were analyzed to determine the differences between the two procedures. Results: Five articles were included according to the selection criteria with a total of 245 patients. The standard mean difference (SMD) values of each parameter were slightly higher in limb salvage surgery patients but not higher enough to produce statistically significant results; the SMD values for physical function and mental health were 0.72 and 0.04, respectively. This study did not report any heterogeneity or publication bias. Conclusions: QOL is a large and enhanced term, which carries its importance and is challenging to compare between any procedures. The minimal rise in SMD of different QOL parameters highlighted only a slight advantage of limb salvage surgery over amputation. Therefore, further research is required to explore the impact of this crucial topic. [ABSTRACT FROM AUTHOR]

Introduction: Amputations is the Post graduates first case in the beginning and is one of the most ancient of all surgical procedures done for several indications, including trauma, peripheral vascular disease, tumor, diabetic foot infection and congenital anomalies. 1,2,3 Sometimes limb amputation is considered the last resort when limb salvage is impossible or when the limb is dead or dying, viable but non- functional or endangering the patient's life. 4 Aim of the study is to determine the pattern, indications and short-term complications of major limb amputations in our setting. Methodology: An observational study done retrospectively on 50 cases of amputations in the last one year period in the Department of General Surgery, Sri Venkateswara Medical College, Tirupati. History, clinical examination findings in the case sheets, investigations, management and complications noted in the case sheets were recorded and analyzed for the study purpose. Results: Maximum patients were in age group 41- 50 years and Diabetic Foot Infection was found to be the most common indication for amputation. Below knee amputations were commonly done and revision of stump was done for many cases and infection of the stump was the commonest complication encountered. Conclusion: Complications of diabetic foot ulcers and trauma resulting from road traffic crashes were the most common indications for major limb amputation in our environment. The majority of these indications are potentially preventable through provision of health education, early presentations and adequate treatment of these conditions. [ABSTRACT FROM AUTHOR]

Simple Summary: Radiation-induced soft tissue sarcomas (RISs) are rare cancers with a dire prognosis caused by past radiation therapy. Due to their low recurrence, they are poorly understood. The aim of this systematic review was to analyze how RIS is treated, and the outcomes that patients face. After reviewing 21 studies with 1371 RIS patients, it was found that surgery was the most common treatment, with chemotherapy and radiotherapy used less frequently. The most common histological type was undifferentiated pleomorphic sarcoma (42.2%). Patients with RIS had a 5-year survival rate of 45% and high rates of local recurrence (39%) and cancer spreading (27%). These findings shed light on the challenges of managing RIS and may guide future research to improve treatment outcomes for these patients. Introduction: Radiation-induced soft tissue sarcomas (RISs) are rare secondary malignancies with a dire prognosis. The literature on the management of these tumors remains scarce due to their low incidence. Our systematic review sought to assess the treatment alternatives and outcomes of patients with RIS. Methods: A systematic review was conducted following the PRISMA guidelines. Our study was registered in PROSPERO (ID: CRD42023438415). Quality assessment was performed using the STROBE checklist. Weighted means for both continuous and categorical values were calculated. Results: Twenty-one studies comprising 1371 patients with RIS were included. The mean latency period from radiation to RIS diagnosis was 14 years, and the mean radiation dose delivered to the primary malignancy was 29.2 Gy. The most common histological type was undifferentiated pleomorphic sarcoma (42.2%), and 64% of all tumors were high-grade. The trunk was the most common location (59%), followed by extremities (21%) and pelvis (11%). Surgery was performed in 68% of patients and, among those with an appendicular tumor, the majority (74%) underwent limb-salvage surgery. Negative margins were attained in 58% of patients. Chemotherapy and radiotherapy were administered in 29% and 15% of patients, respectively. The mean 5-year overall survival was 45%, and the local recurrence and metastasis rates were 39% and 27%, respectively. Conclusions: In our study, the most common treatment was surgical resection, with RT and chemotherapy being administered in less than one third of patients. Patients with RIS exhibited poor oncologic outcomes. Future studies should compare RIS with de novo STS while controlling for confounders. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the feasibility, complications, graft survival rate, and clinical outcomes of joint-preserving resection using a custom-made endoprosthesis and liquid nitrogen-inactivated autologous bone graft reconstruction in patients with malignant bone tumors around the knee joint. Methods: We retrospectively analyzed 23 consecutive patients who underwent joint preservation surgery between 2008 and 2018 at our center. The study cohort included 13 patients who underwent custom-made endoprosthesis reconstruction and 10 who underwent liquid nitrogen-inactivated autologous bone graft reconstruction. The resected bone length, distance between the resection line and the joint, intraoperative blood loss, operation time, complications, and MSTS were compared between the two groups. Results: The median follow-up time was 68.5 months in the endoprosthesis group and 65.3 months in the inactivated autograft group. There were no significant differences in baseline characteristics, resected bone length, distance between the resection line and the joint, or intraoperative blood loss between the two groups. The operative time was longer in the inactivated bone graft group than in the endoprosthesis group (p < 0.001). The endoprosthesis group had more complications (six patients) and reoperations due to complications (five) than the inactivated autograft group (one), but there was no significant difference in the incidence of complications between the two groups (p = 0.158). The inactivated autograft group had one patient with type 1b complications, while the endoprosthesis group had one with type 1b complications, one with type 2b complications, and one with type 4a complications. One patient in the endoprosthesis group with type 5a complications experienced two soft tissue recurrences. The overall 5-year survival rate was 86.5% and the graft survival and final limb salvage rates were 100% in both groups. After the follow-up period, the mean MSTS scores were 91% ± 7% in the endoprosthesis group and 94% ± 6% in the inactivated autograft group, with no significant difference (p = 0.280). Conclusion: Joint-preserving resection is a reliable and effective tumor resection method that can achieve good postoperative function. There were no significant differences in the incidence of complications, overall survival rate, or graft survival rate between the two groups. [ABSTRACT FROM AUTHOR]

Background: Traumatic hemipelvectomies are rare and serious injuries. The surgical management was described in several case studies, with primary amputation often performed to save the patient's life. Methods: We report of two survivors with complete traumatic hemipelvectomy resulting in ischemia and paralyzed lower extremity. Due to modern emergency medicine and reconstructive surgery, limb salvage could be attained. Long-term outcome with quality of life was assessed one year after the initial accident. Results and conclusions: The patients were able to mobilize themselves and live an independent life. The extremities remained without function and sensation. Urinary continence and sexual function were present and the colostomy could be relocated in both patients. Both patients support limb salvage, even having difficulties and follow-up treatments. Concomitant cases are required to consolidate the findings. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Abstract Background Shoulder soft tissue function reconstruction during tumor-type hemishoulder replacement is an important step to restore shoulder function. This study evaluates the functional prognosis and postoperative complications of ligament advanced reinforcement system (LARS)-assisted soft tissue functional reconstruction in tumor-type hemi-shoulder replacement. Materials and methods Twenty-two patients with an average age of 37.5 ± 17.8 years diagnosed with benign invasive tumors, primary malignant bone tumors, or bone metastases were enrolled in this study. The patient’s medical records (history and surgical details), histological sections, imaging files, oncological prognosis, functional prognosis, and postoperative complications were collected. The upper limb function and shoulder joint function were evaluated using the Musculoskeletal Tumor Society (MSTS) system and American Shoulder and Elbow Surgeons (ASES) scoring criteria, respectively. Results Twenty-two patients comprising 12 males and 10 females were enrolled. Overall, 9 patients had preoperative pathological fractures. The mean lesion length was 8.6 ± 3.0 cm. The local recurrence was observed in 3 cases, including 2 cases of osteosarcoma and 1 case of MGCT. A further 4 cases had pulmonary metastasis, including 2 cases with local tumor recurrence. The average postoperative MSTS score was 25.8 ± 1.7, and the score of postoperative ASES was 85.7 ± 6.0, both of which showed satisfactory functional recovery. Two cases experienced postoperative complications requiring surgical intervention, including one periprosthetic fracture and one giant cell granuloma. Prosthesis dislocation occurred in 1 case. None of the cases of periprosthetic infection or postoperative complications resulted in implant failure. Conclusions LARS-assisted soft tissue function reconstruction in benign and malignant proximal humerus tumors after a tumor-type hemi-shoulder replacement is an effective technical improvement, which can effectively repair the integrity of the joint capsule to restore joint stability, provide a medium for soft tissue attachment to rebuild the muscular dynamic system, and eliminate residual dead space around the prosthesis, effectively improving limb function and reduce postoperative infection complications.

Crush injury is one of the most challenging decisions for a surgeon to decide whether to proceed with an amputation or salvage a limb.We presented a 24-year-old man who complained of having suffered a crushed thigh 12 h before admission to the hospital. The patient was driving a truck and hit the iron bridge barrier, which penetrated his left thigh. The patient's left foot was cold, pallid, and pulseless, with a MESS score of 11. The femur x-ray showed a displaced fracture of the left femur associated with a 15 cm bone defect. The patient was diagnosed with a crush injury on the left femur with vascular compromise.We performed a proximal femoral megaprosthesis for a crush injury on the lower extremity, After the sixth year's follow-up, it shows a good outcome and increased quality of life for this patient. In addition, there was an improvement in the Harris Hip Score and EQ5D score.Megaprosthesis used to treat a crush injury revealed good functional outcomes despite the MESS score of 11. A multi-professional approach to the patient is essential for decision-making regarding limb salvage rather than the use of a score.

BackgroundTemporary intravascular shunts (TIVS) may allow quick revascularization and distal reperfusion, reducing the ischemic time (IT) when an arterial injury occurs. Furthermore, TIVS temporarily restore peripheral perfusion during the treatment of concomitant life-threatening injuries or when patients require evacuation to a higher level of care. Notwithstanding, there are still disputes regarding the use of TIVS, in view of the paucity of evidence in terms of potential benefits and with regard to the anticoagulation during the procedure. The present study aimed to assess TIVS impact, safety, and timing on limb salvage in complex civilian vascular traumas.Patients and methodsData were retrieved from the prospective database of our department, which included all patients hospitalized with a vascular injury of the extremities between January 2006 and December 2022. Patients undergoing TIVS during vascular injury management were included in group A, and those who could not postpone immediate care for TIVS insertion were included in group B (control group). Data concerning the times required for extremity revascularization or other surgical procedures such as orthopedic interventions and the time of limb ischemia were compared between the two groups. A comparison of the postoperative course between the two groups was also performed.ResultsA total of 53 patients were included: group A (TIVS insertion, n = 31) and group B (control, n = 22). Revascularization time significantly differed (p = 0.002) between the two groups, which is lower in group A (4.17 ± 2.37 h vs. 5.81 ± 1.26 h). TIVS positively affected the probability of limb salvage (p = 0.02). At multivariate analysis, the factors independently associated with limb salvage were TIVS usage, the necessity of hyperbaric oxygen therapy, and the total IT. In group A, there were three deaths and one major amputation, and in group B, there were two deaths and four major amputations.ConclusionsThe use of TIVS minimizes revascularization time and improves limb salvage probability. A multidisciplinary approach is recommended, and correct surgical timing is key to ensure the best outcome.

This article portrays the authors' experience with a complex lower limb bone and soft tissue defect, following chronic osteomyelitis and pathological fracture, which was managed by the multidisciplinary orthoplastic team. The decision for functional amputation versus limb salvage was deemed necessary, enhanced by the principles of "spare parts" in reconstructive microsurgery. This case describes the successful use of the osteocutaneous distal tibia turn-up fillet flap that allowed "lowering the level of the amputation" from a through knee to a below-knee amputation (BKA) to preserve the knee joint function. We comprehensibly review reports of turn-up flaps which effectively lower the level of amputation, also applying "spare-parts" surgery principles and explore how these concepts refine complex orthoplastic approaches when limb salvage is not possible to enhance function. The osteocutaneous distal tibia turn-up fillet flap is a robust technique for modified BKA reconstructions that provides sufficient bone length to achieve a tough, sensate stump and functional knee joint. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate work ability, activity limitations and physical activity in adults that had gone through major bone sarcoma resection and reconstruction surgery in hip and knee. Twenty patients, of 72 enrolled, and 20 controls were included in this cross-sectional study. Work Ability Index scores (general [0–10 points], physical and mental [1–5 points]), the Patient Specific Functional Scale (0–10 points), step counts and the International Physical Activity Questionnaire (IPAQ) were assessed. Adjusted and unadjusted general linear models were applied. The patients had a mean age of 43 (range, 20–71) years and were assessed 7 years (range, 2–12) after surgery (proximal femoral n = 9, distal femoral n = 7, proximal tibia n = 4). Compared with controls, patients had lower general work ability (mean difference [95%CI], −1.3 points [−2.1, −0.5]) and work ability in relation to physical demands at work (−1.4 points [−2.0, −0.8]). The patients reported higher severities of activity limitation (−6.7 points [−7.9, −5.4]). There were no between-group differences in step counts or IPAQ-scores. Despite similar levels of physical activity, patients showed poorer work ability and severe activity limitation. Post-operative rehabilitation in patients of the working-age population should include assessments of work ability and activities important to the individual. Adults that have gone through resection and reconstruction surgery following bone sarcoma in lower extremity show clinically relevant reductions in work ability and self-selected activities To tailor post-operative rehabilitation at short and long term, initial assessment and monitoring should include work ability and activities important to the individual patient. [ABSTRACT FROM AUTHOR]

This report presents the case of a 25-year-old male with an infected tibial diaphyseal nonunion caused by a bone transport procedure carried out to treat an open fracture the patient had sustained 10 years before referral to our hospital. After an initial radical debridement, a bone defect was created, which was subsequently obliterated by placement of an antibiotic-impregnated cement spacer and Stimulan beads and covered by an anterolateral thigh flap. As the patient refused to wear an external fixator and his osseous biology was not amenable to a Masquelet procedure, a decision was made to apply the Capanna technique as soon as the infection healed.The second debridement resulted in a 12-cm-long bone defect that was filled with a tibial allograft and a vascularized fibular graft. At six months, the patient had regained full knee function and was able to bear his full weight, without pain or the need of support equipment. At one year, the bone had healed completely, the infection had subsided and the patient was able to resume his everyday activities.Although the Capanna technique was initially developed to reinforce reconstructions at risk of fracture or nonunion as a result of chemotherapy, its use in post-traumatic cases has been shown to be successful in a selected group of patents. Our study demonstrated that increasing the stability of a reconstruction with an allograft can accelerate the time to heal, and that using a vascularized fibular graft can enhance incorporation of the whole construct.It can be concluded that the Capanna technique is a valid treatment option for managing infected segmental bone defects in selected patients.

Wide resection is the main treatment for sarcomas; however, when they are located near major nerves, their sacrifices might affect limb function. The efficacy of ethanol adjuvant therapy for sarcomas has not been established. In this study, the anti-tumor effect of ethanol, as well as its neurotoxicity, were assessed. In vitro anti-tumor effect of ethanol as evaluated using MTT, wound healing, and invasion assays on a synovial sarcoma cell line (HS-SY-II). In vivo, an assessment was conducted in nude mice (implanted with subcutaneous HS-SY-II) treated with different ethanol concentrations after surgery with a close margin. Sciatic nerve neurotoxicity was assessed with electrophysiological and histological examination. In vitro, ethanol concentrations at 30% and higher showed cytotoxic effects in MTT assay and markedly reduced migration and invasive ability of HS-SY-II. In vivo, both 30% and 99.5% ethanol concentrations, compared to 0% concentration, significantly reduced the local recurrence. However, in the group treated with 99.5% ethanol, nerve conduction tests showed prolonged latency and decreased amplitude, and morphological changes suggestive of nerve degeneration were observed in the sciatic nerve, while the 30% ethanol did not cause neurological damage. In conclusion, 30% is the optimal concentration for ethanol adjuvant therapy after close-margin surgery for sarcoma. [ABSTRACT FROM AUTHOR]

Simple Summary: This study investigated osteoradionecrosis (ORN), a complication after radiotherapy, in 198 patients with extremity soft tissue sarcoma (STS). The incidence rate of extremity ORN was 3.5%, mostly located in lower extremities. Clinical presentations included chronic ulcers, soft tissue necrosis, sinus discharge, bone nonunion, and pathological fractures. The ORN group had a significantly higher total radiation dose and greater use of intraoperative periosteal stripping. Repeat surgeries and subsequent soft tissue reconstruction or limb amputation were performed as treatments. Careful surveillance should be taken to manage the risk of ORN in extremity STS patients. Osteoradionecrosis (ORN) is a major complication after radiotherapy. Most studies on ORN have focused on patients with mandibular lesions, with few studies including patients with extremity soft tissue sarcoma (STS). We included 198 patients with extremity STS who underwent limb-sparing surgery and adjuvant radiotherapy between 2004 and 2017. The incidence rate of extremity ORN was 3.5% (7/198), with most lesions (6/7) located in the lower extremities. The mean follow-up time was 62 months. Clinical presentations included chronic ulcers, soft tissue necrosis, sinus discharge, bone nonunion, and pathological fractures. Compared with the non-ORN group, the ORN group had a significantly higher total radiation dose (68 Gy vs. 64 Gy, p = 0.048) and greater use of intraoperative periosteal stripping (p = 0.008). Repeat surgeries and subsequent soft tissue reconstruction or limb amputation were performed as treatments. The risk and management of ORN in patients with extremity STS was ignored previously. Because the disease is complex and affects both clinicians and patients, careful surveillance should be undertaken. [ABSTRACT FROM AUTHOR]

Abstract Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time. Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution. We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury.

We performed distal bypass and free flap transfer in a single-stage operation to repair an extensive soft tissue defect in an ischemic foot of an 84-year-old woman. The nutrient artery of the free flap was anastomosed to the bypass graft in an end-to-side manner. Subsequently, the bypass graft became occluded on several occasions. Although intravascular and surgical interventions were performed each time, the bypass graft eventually became completely occluded. However, despite late occlusion of the nutrient artery, the free flap has remained viable and the patient is ambulatory. The time required for a transplanted free flap to become completely viable without a nutrient artery is likely longer for an ischemic foot compared with a healthy foot. However, the exact period of time required is not known. A period of month was required in our patient. We report this case to help clarify the process by which a free flap becomes viable when applied to an ischemic foot.

Background: Infection is a devastating complication of endoprosthetic replacement (EPR) in orthopaedic oncology. Surgical treatments include debridement and/or one- or two-stage exchange. This study aims to determine the infection-free survival after surgical treatment for first and recurrent EPR infections and identify the risk factors associated with infection recurrence. Methods: This single-centre cohort study included all patients with primary bone sarcomas or metastatic bone disease treated for infected EPR between 2010 and 2020. Variables included soft tissue status using McPherson classification, tumour type, silver coating, chemotherapy, previous surgery and microorganisms identified. Data for all previous infections were collected. Survival analysis, with time to recurrent infection following surgical treatment, was calculated at 1, 2 and 4 years. Cox regression analysis was used to assess the influence of different variables on recurrent infection. Results: The cohort included 99 patients with a median age of 44 years (29–58 IQR) at the time of surgical treatment. The most common diagnoses were osteosarcoma and chondrosarcoma. One hundred and thirty-three surgical treatments for first or subsequent infections were performed. At 2 years of follow-up, overall success rates were as follows: two-stage exchange 55.3%, one-stage exchange 45.5%, DAIR with an exchange of modular components 44.6% and DAIR without exchange of modular components 24.7%. Fifty-one (52%) patients were infection-free at the most recent follow-up. Of the remaining 48 patients, 27 (27%) were on antibiotic suppression and 21 (21%) had undergone amputation. Significant risk factors for recurrent infection were the type of surgical treatment, with debridement alone as the highest risk (HR 4.75: 95%CI 2.43–9.30; P < 0.001); significantly compromised soft tissue status (HR 4.41: 95%CI 2.18–8.92; P = 0.001); and infections due to Enterococcus spp.. (HR 7.31: 95%CI 2.73–19.52); P = 0.01). Conclusions: Two-stage exchange with complete removal of all components where feasible is associated with the lowest risk of recurrent infection. Poor soft tissues and enterococcal infections are associated with higher risks of recurrent infection. Treatment demands an appropriate multidisciplinary approach. Patients should be counselled appropriately about the risk of recurrent infection before embarking on complex treatment. [ABSTRACT FROM AUTHOR]

In developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. Aim of this study was to assess limb survival and complications after delayed revascularization of extremity following major vascular injury. 20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented >8 h after vascular trauma were included in this study. All patients had road traffic accidents as the cause of extremity injury. These patients were operated by primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma. The commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 h. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses. Limb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications. [ABSTRACT FROM AUTHOR]

BackgroundMany attempts have been made to induce limb salvage as an alternative to amputation for primary bone cancer in the extremities, but efforts to establish its benefits over amputation yielded inconsistent results with regard to outcomes and functional recovery. This study aimed to investigate the prevalence and therapeutic efficiency of limb-salvage tumor resection in patients with primary bone cancer in the extremities, and to compare it with extremity amputation.MethodsPatients diagnosed with T1-T2/N0/M0 primary bone cancer in the extremities between 2004 and 2019 were retrospectively identified from the Surveillance, Epidemiology, and End Results program database. Cox regression models were used to test for statistical differences between overall survival (OS) and disease-specific survival (DSS). The cumulative mortality rates (CMRs) for non-cancer comorbidities were also estimated. The evidence level in this study was Level IV.ResultsA total of 2,852 patients with primary bone cancer in the extremities were included in this study, among which 707 died during the study period. Of the patients, 72.6% and 20.4% underwent limb-salvage resection and extremity amputation, respectively. In patients with T1/T2-stage bone tumors in the extremities, limb-salvage resection was associated with significantly better OS and DSS than extremity amputation (OS: adjusted HR, 0.63; 95% confidence interval [CI], 0.55–0.77; p

We describe a 28-year-old man who sustained an open IIIB left ankle fracture dislocation with heel pad avulsion. The patient underwent formal angiography of the left lower extremity, followed by free tissue transfer of a rectus abdominis flap several days later. Intraoperatively, a thrombus was identified in the deep inferior epigastric artery above the femoral artery access site requiring thrombectomy. Histologic analysis estimated the thrombus age at 12 to 72 hours, raising concern that the thrombus was induced during angiogram instrumentation. Donor and recipient site-specific risks of arterial instrumentation (including invasive diagnostics) should be considered when planning free tissue transfer.

Introduction: Pathologic calcaneal fractures, often arising from osteomyelitis, present intricate challenges in orthopedic surgery. This paper explores the historical context, etiological factors, and evolving treatment approaches for these fractures, with a focus on the interplay between infection and compromised bone integrity. Methods: A retrospective analysis of four cases of pathologic calcaneal fractures complicating osteomyelitis, treated at the University of Pittsburgh Medical Center from 2017 to 2021, was conducted. The patients underwent debridement, external fixation, and long-term antibiotic therapy. A comprehensive literature review was conducted, encompassing all relevant papers discussing surgical treatment strategies for pathologic calcaneal fractures. Results: The case series reveals the complexities of managing these fractures. While external fixation stabilized the fractures and facilitated infection control, the outcomes varied. Some patients achieved fracture union and improved ulceration, while others experienced complications and, tragically, mortality due to underlying comorbidities. Discussion: Treatment modalities for osteomyelitis-related calcaneal fractures encompass debridement, external fixation, and tailored antibiotic therapy. Debridement is essential for infection control and wound preparation. External fixation provides stability, facilitates wound care, and allows for antibiotic delivery. Antibiotic therapy complements surgical interventions and targets the infection. However, challenges persist, including compromised overall health, persistent infection, and limited long-term outcomes. Conclusion: Pathologic calcaneal fractures complicated by osteomyelitis pose a formidable clinical challenge. Despite innovative approaches like the use of suture anchors and external fixation, achieving successful outcomes remains elusive. These cases often result in substantial morbidity and, at times, mortality due to the intricate interplay of infection, compromised bone quality, and comorbidities. Clinicians must balance aggressive intervention with a realistic assessment of the patient's overall health and prognosis. Further research and standardized treatment approaches are imperative to address the unique complexities of these cases and improve patient outcomes.

Failure to achieve union and proper alignment of the first metatarsophalangeal joint after arthrodesis can result in the need for revision of the attempted fusion. If further complications arise following revisional surgery, the risk of toe amputation increases. In recent years, there has been a rise in the utilization of patient specific implants, which have shown promise especially in revisional type surgeries. The following case report details a patient seeking evaluation as a second opinion of a painful first metatarsophalangeal joint after several attempts of fusion. As the patient declined toe amputation, an additive manufactured implant was utilized where the patient recovered and was able to return to pain free ambulation with proper alignment of the hallux. These outcomes suggest that a patient specific implant can be considered as a promising alternative to toe amputation in revisional type pathologies of the forefoot.

At the lower leg, soft tissue defects with exposed bones, tendons, or hardware require flap coverage. In this retrospective study, we analyzed combined bone and soft tissue reconstructions compared to amputations of the lower leg in a civilian setting. Patients who underwent combined bone and flap reconstruction (LR) or amputation (LA) of the lower leg were eligible for the study. Bone conditions included fractures and bony defects due to posttraumatic osteomyelitis and non-union. Besides the analysis of the medical history, the study included clinical examination including extremity functional scale (LEFS) and SF-36-questionnaire. LEFS score was significantly higher in the LR group compared to the LA group. Importantly, 42% in the LR group as opposed to 80% in the LA group could not return to their occupation. Mean hospitalization was 119 in the LR and 49 days in the LA group. SF-36 body item scores were significantly higher in the LR group as compared to LA. Patients undergoing complex extremity reconstructions, including flap transfer to the lower leg have better functionality and higher quality of life than amputated patients. These data emphasize the advantages of these procedures and justify reconstructive efforts for limb salvage. Level of Evidence III. Amputation and combined bone and flap reconstruction in severe injuries of the lower leg can imply functional disabilities even after successful treatment. Albeit longer hospitalizations, patients with complex reconstructions showed better functional outcomes and had a higher quality of life. Limb salvage showed better functional outcomes and a higher rate in reintegration to work as compared to limb amputation. These data emphasize the importance of complex bone and soft tissue reconstruction in this patient cohort. [ABSTRACT FROM AUTHOR]

Abstract Background Periprosthetic hip infections with severe proximal femoral bone loss may require the use of limb salvage techniques, but no agreement exists in literature regarding the most effective treatment. Aim of this study is to analyze the infection eradication rate and implant survival at medium-term follow-up in patients treated with megaprostheses for periprosthetic hip infections with severe bone loss. Methods Twenty-one consecutive patients were retrospectively reviewed at a mean 64-month follow-up (24–120). Functional and pain scores, microbiological, radiological and intraoperative findings were registered. Kaplan Meier survival analysis and log rank test were used for infection free survival and implant survival analyses. Results The infection eradication rate was 90.5%, with an infection free survival of 95.2% at 2 years (95%CI 70.7–99.3) and 89.6%(95%CI 64.3–97.3) at 5 years. Only two patients required major implant revisions for aseptic implant loosening. The most frequent complication was dislocation (38.1%). The major revision-free survival of implants was 95.2% (95%CI 70.7–99.3) at 2 years and 89.6% (95%CI 64.3–97.3) at 5 years. The overall implant survival was 83.35% (CI95% 50.7–93.94) at 2 and 5 years. Subgroup analyses (cemented versus cementless MPs, coated versus uncoated MPs) revealed no significant differences at log rank test, but its reliability was limited by the small number of patients included. Conclusions Proximal femoral arthroplasty is useful to treat periprosthetic hip infections with severe bone loss, providing good functional results with high infection eradication rates and rare major revisions at medium-term follow-up. No conclusions can be drawn on the role of cement and coatings.

We present a case of left proximal femoral artery transection injury in 1½-year-old male child due to a fall over a bike handle after sustaining a road traffic accident. He was presented to the emergency room with a cut proximal end of the left femoral artery and a fracture upper end of the shaft of the femur seen at the wound site. Following initial resuscitation, the patient was planned for wound exploration, fracture stabilization, and femoral artery repair which were executed, and salvage of the lower limb of 1½-year-old child was achieved. We conclude that teamwork, training, and experience in repairing pediatric vessels and timely pediatric vascular repair play a pivotal role in the salvage of a limb and improvement of the quality of life of a child.

Background The reverse sural artery (RSA) flap is widely used for lower extremity reconstruction. However, patients sometimes suffer from donor site complications such as scar contracture and paresthesia, resulting in dissatisfaction with the aesthetic outcomes. This study investigated the characteristics of donor site morbidity associated with RSA flaps and described our experiences of dealing with complications by performing resurfacing surgery using thoracodorsal artery perforator (TDAP) flaps. Methods From April 2008 to August 2018, a total of 11 patients underwent contracture release and resurfacing surgery using TDAP flaps due to donor morbidity associated with RSA flaps. All affected donor sites were covered with a skin graft, the most common of which was a meshed split-thickness skin graft (six cases). Results Eight of the 11 patients (72.7%) suffered from pain and discomfort due to scar contracture, and seven (63.6%) complained of a depression scar. The donor sites were located 6.3±4.1 cm below the knee joint, and their average size was 140.1 cm². After resurfacing using TDAP flaps, significant improvements were found in the Lower Extremity Functional Scale (LEFS) scores and the active and passive ranges of motion (AROM and PROM) of the knee joint. The LEFS scores increased from 45.1 to 56.7 postoperatively (P=0.003), AROM increased from 108.2° to 118.6° (P=0.003), and PROM from 121.4° to 126.4° (P=0.021). Conclusions Planning of RSA flaps should take into account donor site morbidity. If complications occur at the donor site, resurfacing surgery using TDAP flaps achieves aesthetic and functional improvements.

BackgroundExtensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness.MethodsFrom January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed.ResultsThe size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin.ConclusionFree transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage.

Ewing's sarcoma (ES) is a rare primary bone cancer managed by radiotherapy, chemotherapy and surgical resection. The existing literature on limb salvage surgery with endoprostheses combines data for ES patients with osteosarcoma. This review aimed to evaluate surgical and functional outcomes of endoprosthetic reconstruction in exclusively Ewing's patients. We believe that this is the first comprehensive review to evaluate the outcomes of limb salvage surgery with endoprostheses exclusively in Ewing's sarcoma patients. Clinical data and outcomes were collected from PubMed, Embase, Medline and Scopus. The inclusion criteria were studies on limb salvage surgery in ES patients, where individual patient data was available. Seventeen studies with a total of 57 Ewing's patients were included in this review. Fifty-three of the ES patients preserved the limb after limb salvage with endoprostheses. The average five-year implant survivorship was 85.9% based on four studies in this review. Postoperative complications were categorised by Henderson's failure modes. Soft tissue failure was the most common, occurring in 35.1% of patients, followed by deep infection in 15.7% of patients. There was a suggestion of 'good' functional outcomes with limb salvage surgery. The salient limitation of this review is the variability and rarity of the patient population. Homogenous data in a larger population is necessary to provide more insight into outcomes of limb reconstruction in ES. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

We have described a complication of a pseudotumor secondary to metal-on-metal hip arthroplasty. The patient experienced acute limb ischemia after pseudotumor material had invaded and stenosed the external iliac artery and embolized distally. Multiple vascular surgery procedures were performed to revascularize the limb. The present report highlights the importance of involving vascular surgeons early in a limb-threatening presentation of a pseudotumor to achieve limb salvage.

Aim of the study Biologic reconstruction using tumor-bearing bone autografts devitalized by liquid nitrogen or extracorporeal irradiation (oncological sterilization) is a safe and effective method in musculoskeletal surgery. The purpose of this study was to examine the effects of these two oncological sterilization methods on nerve recovery. Methods A total of 48 rats were randomly divided into 3 groups as autograft, irradiation and liquid nitrogen groups. A nerve defect created in the right sciatic nerve was reconstructed with an autograft obtained from the nerve itself. Group I underwent reconstruction with standard nerve autograft. Group II and Group III underwent reconstruction with devitalized nerve autograft treated through extracorporeal irradiation and liquid nitrogen, respectively. The left sciatic nerves of the rats served as control. Electromyography, motor function test and histomorphological analysis were performed to assess the nerve recovery on the 3rd (early stage) and 4th months (late stage). Results Electrophysiological assessment revealed better results in irradiation group compared with liquid nitrogen group in terms of myelinization and axonal regeneration. Motor performance of the autograft group was slightly better than the other groups. Histologically, autograft group demonstrated better results compared with other groups. Late-stage assessments revealed high rates of myelinization in the graft segment in liquid nitrogen group and in the segment distal to the graft in irradiation group. Conclusions This study has demonstrated that nerve autografts treated by oncological sterilization methods may be used for nerve reconstruction in limb salvage surgery. However, further studies are needed to clarify the applicability of these methods.

Abstract Background Adequate margins are technically difficult to achieve for malignant tumors involving the sacroiliac joint due to limited accessibility and viewing window. In order to address the technical difficulties faced in iliosacral tumor resection, we proposed a technique for precise osteotomy, which involved the use of canulated screws and Gigli saw (CSGS) that facilitated directional control, anteroposterior linkage of resection points and adequate surgical margins. The purpose of the current study was to evaluate whether CSGS technique facilitated sagittal osteotomy at sacral side, and were adequate surgical margins achieved? Also functional and oncological outcomes was determined along with the noteworthy complications. Methods From April 2018 to November 2019, we retrospectively reviewed 15 patients who underwent resections for primary tumors of pelvis or sacrum necessitating iliosacral joint removal using the proposed CSGS technique. Chondrosarcoma was the most common diagnosis. The osteotomy site within sacrum was at ipsilateral ventral sacral foramina in 8 cases, midline of sacrum in 5 cases, and contralateral ventral sacral foramina and sacral ala with 1 case each. The average intraoperative blood loss was 3640 mL (range, 1200 and 6000 mL) with a mean operation duration of 7.4 hours (range, 5 to 12 hours). The mean follow-up was 23.0 months (range, 18 and 39 months) for alive patients. Results Surgical margins were wide in 12 patients (80%), wide-contaminated in 1 patient (6.7%), and marginal in 2 patients (13.3%). R0 resection was achieved in 12 (80%) patients and R1 resection in 3 patients. There were three local recurrences (20%) occurred at a mean time of 11 months postoperatively. No local recurrence was observed at sacral osteotomy. The overall one-year and three-year survival rate was 86.7% and 72.7% respectively.Complications occurred in three patients. Conclusions The current study demonstrated that CSGS technique for tumor resection within the sacrum and pelvis was feasible and can achieve ideal resection accuracies. The use of CSGS was associated with high likelihood of negative margin resections in the current series. Intraoperative use of CSGS appeared to be technically straightforward and allowed achievement of planned surgical margins. It is worthwhile to consider the use of CSGS technique in resection of pelvic tumors with sacral invasion and iliosacral tumors, however further follow-up at mid to long-term is warranted to observe local recurrence rate.

Background Soft tissue coverage plays a vital role in replacing the vascularity of the underlying bone in Gustilo type IIIB fractures. The aim of this article was to evaluate the feasibility of local pedicled flaps in type IIIB fractures at a tertiary care center. Methods We included all cases of open Gustilo-Anderson type IIIB fractures of the tibia treated with local flap coverage from January 2017 to February 2019. We carried out a retrospective analysis to investigate the relationships of complications, hospital stay, and cost-effectiveness with the choice of flap, infective foci, site and size of the defect, and type of fixation. Results Out of 138 Gustilo type IIIB fractures analyzed in our study, 27 cases had complications, of which 19 (13.76%) involved flap necrosis, four (2.89%) were infections, three (2.17%) involved partial necrosis, and one (0.72%) was related to bone spur development. Flap complications showed a statistically significant association with the perforator flap category (propeller flaps in particular) (P=0.001). Flap necrosis showed a significant positive correlation with cases treated within 3 weeks after trauma (P=0.046). A significant positive correlation was also found between defect size and the duration of hospital stay (P=0.03). Conclusions Although local flaps are harvested from the same leg that underwent trauma, their success rate is at least as high as microvascular flaps as reported from other centers. Amidst the local flaps, complications were predominantly associated with perforator flaps.

Background: Most retroperitoneal sarcoma (RPS) operations require combined multi-organ resection, and the proportion of unplanned reoperation is high. However, there are no relevant studies on reoperation for RPS. Methods: Patients who underwent at least once unplanned reoperation at Shanghai Public Health Clinical Center, Fudan University, China, from August 2009 to December 2021 were retrospectively analyzed. The baseline characteristics, primary surgery, and reoperation information, postoperative complications, and survival were analyzed. Results: A total of 51 patients were included. Among them, 21 (41.2%) were male and 30 (58.8%) were female. The median age was 51 (interquartile range [IQR], 49-63) years. Most (88.3%) had a history of abdominal surgery. Dedifferentiated liposarcoma, well-differentiated liposarcoma, leiomyosarcoma, and others accounted for 50.9%, 21.6%, 15.7%, and 11.8%, respectively. The conditions of the primary operation were as follows: 35 (68.6%) patients achieved complete surgical resection, 48 patients had combined organ resection, and a median of 3 (IQR, 2–4) organs was removed, of which 5 (9.9%) were combined with pancreaticoduodenectomy. The median operative time was 330 (IQR, 245–440) min, and the median estimated blood loss was 1500 (IQR, 500–2600) ml. The median postoperative hospital stay was 42 (IQR, 23–82) days. For reoperation, the most common reasons were bleeding (31.3%), complications related to intestinal anastomosis (27.4%), and intestinal perforation (19.9%). The mortality rate after reoperation was 39.2% (20/51). Twelve (23.5%) patients underwent reoperation at least twice. Conclusions: Unplanned reoperation among retroperitoneal sarcoma correlates with established measures of surgical quality. [ABSTRACT FROM AUTHOR]

Background: Complex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy. Methods: Between January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up. Results: All 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm2. The flap sizes ranged from 14 × 7.5 to 24 × 21 cm2. The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed. Conclusions: The modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb. [ABSTRACT FROM AUTHOR]