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The aim of this study is to determine the critical time intervals and influencing covariates for in-hospital mortality in geriatric trauma and orthopedic patients. During a period of five years, we retrospectively review patients aged > 60 years who were hospitalized at the Department of Trauma, Orthopedic, and Plastic Surgery. The primary outcome is the mean time to death. Survival analysis is performed using an accelerated failure time model. A total of 5388 patients are included in the analysis. Two-thirds underwent surgery (n = 3497, 65%) and one-third were conservatively treated (n = 1891, 35%). The in-hospital mortality rate is 3.1% (n = 168; surgery, n = 112; conservative, n = 56). The mean time to death is 23.3 days (±18.8) after admission in the surgery group and 11.3 days (±12.5) in the conservative treatment group. The greatest accelerating effect on mortality is found in the intensive care unit (16.52, p < 0.001). We are able to identify a critical time interval for in-hospital mortality between days 11 and 23. The day of death on weekend days/holidays, hospitalization for conservative treatment, and treatment at the intensive care unit significantly increase the risk of in-hospital mortality. Early mobilization and a short hospitalization duration seem to be of major importance in fragile patients.

Objective: The aim of this study was to assess the effectiveness of gentamicin containing collagen implants in the reduction of surgical site infections (SSIs) in patients undergoing an inguinal incision for vascular surgery.Methods: Prospective blinded randomised controlled multicentre trial (RCT), performed in four hospitals in The Netherlands and Belgium. This study included 288 patients who underwent an inguinal incision for primary arterial repair (femoral endarterectomy, femorofemoral or femoropopliteal bypass, aortobifemoral bypass, thrombectomy, embolectomy, endovascular aneurysm repair) between October 2012 and December 2015. Patients were randomised to receive a gentamicin implant (study group) or no implant (control group). The calculated sample sizes of 304 patients per group were not reached. Primary outcome was SSI incidence after six weeks. Secondary outcomes were time to onset of infection, length of hospital stay, allergic reactions, treatment with antibiotics, need for re-admission, re-operation and mortality.Results: One hundred fifty-one patients were allocated to the study group (mean age 69 +/- 9.2 years) and 137 patients were allocated to the control group (mean age 70 +/- 10.4 years). Both groups were homogeneous regarding baseline and intra-operative characteristics. Gentamicin implants did not result in a significant overall reduction of SSIs in the study group (7% vs. 12%, p = .17). In a post hoc analysis comparing two study sites with low (10%) infection rates in the control group, gentamicin implants significantly reduced SSIs in high risk centres (22% vs. 1%, p < .001), whereas there was no significant effect in low risk centres (13% vs. 7%, p = .30). There were no allergic reactions and all secondary outcomes were comparable between groups.Conclusion: Gentamicin implants did not result in a significant overall reduction of SSIs in this RCT. Gentamicin implants did reduce the incidence of SSIs in high risk centres and may be a valuable adjunct to improve outcomes in such vascular centres with a high incidence of wound infections. However, the limitation of not reaching the calculated sample sizes should be considered.

Background Inguinal wound complications often cause postoperative morbidity and also mortality following vascular surgical interventions. The aim of this study was to report experiences and a comparison of the outcomes using rectus femoris muscle flaps (RFF) and sartorius muscle flaps (SMF). Material and methods A retrospective study was performed at two locations of a cross-border vascular center and all muscle flap interventions performed at the two centers within the vascular surgery department were reviewed. Primary outcomes were muscle flap survival, graft salvage and major amputations. Results A total of 44 RFFs were performed in 39 patients (mean age 67 years, 73% males) and 25 SMFs in 24 patients (mean age 64 years, 76% males). Wound infections were the most common indications for muscle flap reconstruction. At a mean follow-up of 24 months (±24) and 17 months (±20), respectively, comparable flap survival rates (91% vs. 84%), wound healing rates (72% vs. 83%), graft salvage (65% vs. 73%) and amputation rates (9% vs. 8%) were found. Conclusion Muscle flap reconstruction is an effective way to cover groin defects resulting from deep wound infections after vascular surgery, achieving good results in a high-risk group of patients. No differences were found between SMF and RFF regarding amputation and graft loss. Both techniques can be safely performed, depending on the preference and experience of the surgical team. The RFF technique should be preferentially used to cover large tissue defects, whereas the SMF procedure can be preferred to cover smaller defects in the groin.

Supplemental Digital Content is available in the text., Objective: Patients with lower extremity peripheral artery disease (PAD) are at increased risk of major adverse cardiovascular events. Numerous plasma biomarkers have been investigated in lower extremity PAD, but none are used for clinical risk assessment. We aimed to provide a comprehensive overview of biomarker testing in PAD as a first step to improve risk stratification. Approach and Results: A systematic literature review in MEDLINE/PubMed, Cochrane, and Embase was performed, identifying all studies investigating plasma biomarkers in association with cardiovascular events and mortality in lower extremity PAD. Forty-seven studies comprising 21 473 PAD patients met our criteria and were included. Effect estimates were provided by the studies based on a minimum follow-up of 1 year. Meta-analyses were performed by pooling studies per biomarker for each end point. Patients with increased high-sensitivity CRP (C-reactive protein) levels had a relative risk of 1.86 (1.48–2.33) for major adverse cardiovascular events and a relative risk of 3.49 (2.35–5.19) for mortality. Increased fibrinogen and d-dimer levels were associated with an increased relative risk of mortality of 2.08 (1.46–2.97) and 2.22 (1.24–3.98), respectively. Additionally, patients with increased NT-proBNP (N-terminal pro-B-type natriuretic peptide) and high-sensitivity cTnT (cardiac troponin T) levels were at an even higher risk of mortality with relative risks of 4.50 (2.98–6.81) and 3.33 (2.70–4.10), respectively. Conclusions: This systematic review identifies promising biomarkers representing different pathophysiological processes implicated in lower extremity PAD, including high-sensitivity CRP, neutrophil-lymphocyte ratio, fibrinogen, d-dimer, NT-proBNP, and high-sensitivity cTnT. Clinical implementation should be preceded by a management study to test the utility of a combination of these markers for individual risk stratification. Ultimately, this may contribute to tailored treatment and increased effectiveness of current treatment strategies in PAD.

Objective The aim of this systematic review and meta-analysis was to assess the clinical outcomes after revascularisation in octogenarians with chronic limb threatening ischaemia (CLTI). Methods This was a systematic review and meta-analysis, in which the Medline, Embase, and Cochrane Library databases were searched systematically by two independent researchers. Meta-analyses were performed to analyse one year mortality, one year major amputation, and one year amputation free survival (AFS) after revascularisation. Pooled outcome estimates were reported as percentages and odds ratio (OR) with 95% confidence intervals (CI). In addition, sensitivity and subgroup analyses were performed and the quality of evidence was determined according to the GRADE system. Results The review includes 21 observational studies with patients who were treated for CLTI. Meta-analysis of 12 studies with a total of 17 118 patients was performed. A mortality rate of 32% was found in octogenarians (95% CI 27–37%), which was significantly higher than in the non-octogenarians (17%, 95% CI 11–22%/OR 2.52, 95% CI 1.93–3.29; GRADE: “low”). No significant difference in amputation rate was found (octogenarians 15%, 95% CI 11–18%; non-octogenarians 12%, 95% CI 7–14%; GRADE: “very low”). AFS was significantly lower in the octogenarian group (OR 1.55, 95% CI 1.03–2.43; GRADE: “very low”). In a subgroup analysis differentiating between endovascular and surgical revascularisation, amputation rates were comparable. For octogenarians, those treated conservatively had a mortality rate significantly higher than those treated by revascularisation (OR 1.76, 95% CI 1.19–2.60; GRADE: “very low”). No significant difference in mortality rate was found between primary amputation and revascularisation in octogenarians (OR 0.70, 95% CI 0.24–2.03; GRADE: “very low”). Conclusion In octogenarians with CLTI, a substantial one year mortality rate of 32% was found after revascularisation. The amputation rates were comparable between both age groups. However, only low quality evidence could be obtained supporting the results of this meta-analysis because only observational studies were available for inclusion.

Objective The aim of this systematic review is to assess potential differences in effectiveness (graft loss and limb loss) between the sartorius muscle flap (SMF) and the rectus femoris muscle flap (RFF) coverage technique for deep groin wound infection following vascular surgery. Our hypothesis was that RFF reconstruction is more effective in groin coverage. Methods The PubMed, Embase, and Medline databases were systematically searched by two independent researchers for articles reporting effectiveness of both muscle flaps in the treatment of groin infections following vascular surgery. After quality assessment using the Newcastle-Ottawa Scale and Methodological Index for NOn-Randomized studies (MINOR) scores and data extraction, individual results of the included studies were reviewed. Weighted pooled outcome estimates were calculated. Results A total of 17 studies comprising 544 SMF reconstructions and 238 RFF reconstructions were included. The pooled flap survival rate was 100% in both groups, with a pooled amputation rate of 0% and 2%, respectively. In the RFF group, a pooled 30-day mortality rate of 0% was found, compared with 1% in the SMF group. Pooled graft loss rates were 2% in the RFF group and 21% in the SMF group. Only one head-to-head comparison between both muscle flaps was performed, finding no significant differences. Conclusions Deep groin infection after vascular surgery can be treated with debridement and local muscle flap coverage. In this systematic review, superiority of either muscle flap on amputation or mortality rates was not demonstrated; however, there was a lower rate of vascular graft loss after RFF reconstruction. These conclusions are based on low-quality evidence because of limited data. Local muscle flap reconstruction using both techniques is effective in the treatment of infected groin wounds, achieving good results in a fragile group of patients. Therefore, anatomical and patient characteristics, which were not assessed in this analysis, are critical in the decision-making process on which muscle flap reconstruction is the best treatment option for an individual patient.

Objective: The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage.Methods: All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay.Results: A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%).Conclusions: This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.