Successful free flap transfer and salvage in sickle cell trait.

The presence of sickle cell haemoglobin is generally regarded as a contraindication to free tissue transfer. We present the case of a 42-year-old male with sickle cell trait who had free transfer of a latissimus dorsi flap to cover a gunshot wound to his thigh. His initial haemoglobin S was 36%. Early flap failure from venous thrombosis was successfully salvaged by re-anastomosis to alternative vessels.     

Limb salvage of infected diabetic foot ulcers with free deep inferior epigastric perforator flaps

Soft-tissue reconstruction of the feet in diabetic patients with angiopathy, sensorial neuropathy, and immunopathy is a complicated problem. Until the mid-1980s, chronic foot ulcers in diabetic patients were treated conservatively, because flap surgery was regarded as too risky. However, in recent years, early debridement and flap coverage have become popular reconstructive methods for diabetic foot wounds. Several flap donor sites are available, depending on the nature of the defect. The deep inferior epigastric artery perforator (DIEP) flap is a relatively new flap that developed as a modification of the transverse rectus abdominis muscle (TRAM) flap. It provides a large amount of skin and subcutaneous tissue, without the donor-site morbidity of the ordinary TRAM flap. Furthermore, using the DIEP flap avoids the loss of major vessels. In this study, we report on the successful use of the DIEP flap in four cases of diabetic foot ulceration.     

Bilateral total knee replacement with tourniquets in a homozygous sickle cell patient

A 27-yr-old male patient, with homozygous sickle cell disease was scheduled for bilateral total knee replacement under tourniquet. The use of tourniquet in sickle cell patients is not without hazard. After preoperative exchange transfusion, total knee replacement was performed. The patient tolerated the procedure well. Patients with sickle cell disease should not be denied the benefit of a tourniquet if hematological correction has been undertaken. IMPLICATIONS: The use of a tourniquet in patients with sickle cell is controversial. The author describes a case of bilateral total knee replacement performed using a tourniquet in a patient with sickle cell disease.     

Sequential free tissue transfers for simultaneous upper and lower limb salvage

Background: The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. Methods: All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free‐flap limb salvage cohorts. Results: Seventy‐four free flap limb salvage cases were performed over the 10‐year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626). Conclusions: The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients. © 2013 Wiley Periodicals, Inc. Microsurgery 33:447–453, 2013.     

Our experience in lower limb reconstruction with perforator flaps

The application of Taylor's concept about body angiosomes, referred to tissue transfers, has meant that the development of the perforator flaps and muscles is no longer needed as a carrier of skin flap vascularity. In this paper, we revise 59 lower limb reconstructions with local and free perforator flaps performed in the last 5 years, and a basic reconstructive algorithm is also suggested to help with the management of the lower limb soft tissue reconstruction with perforator flaps. The advantages of the perforator flaps are (1) muscles and their function are preserved; (2) the main vascular trunks are spared; (3) it is possible to make a more specific reconstruction, replacing "like with like" (even performing compound or chimeric flaps); (4) the donor site can often be closed primarily; (5) the general morbidity is reduced; (6) a better cosmetic result can be achieved.     

A meta-analysis of amputation versus limb salvage in mangled lower limb injuries—The patient perspective

This meta-analysis evaluates the quality of life in post-traumatic amputees in comparison with limb salvage. Studies included in this meta-analysis had a minimum of 24 months of follow-up and used a validated quality-of-life outcome assessment scale (Short Form-36 or Sickness Impact Profile) for physical and psychological outcomes. Two reviewers performed the search and data extraction independent of each other.A total of 214 studies were identified; 11 fulfilled the inclusion criteria; thus, 1138 patients were available for meta-analysis (769 amputees and 369 cases of reconstruction).The meta-analysis demonstrated that lower limb reconstruction is more acceptable psychologically to patients with severe lower limb trauma compared with amputation, even though the physical outcome for both management pathways was more or less the same.     

Aorta-coronary bypass in a patient with sickle cell trait.

A triple aorto-coronary bypass was performed in a patient with sickle cell trait. Partial exchange transfusion with normal packed erythrocytes was used in preparation of the patient for extracorporeal circulation, hypothermia and cardioplegic arrest.     

Bilateral lower limb amputations as a result of landmine injuries.

Landmine explosions cause most of the war injuries in the battlefield. Amputations resulting from severe injuries reveal serious problems despite the improvements in surgery. Bilateral lower limb amputations have more impact than unilateral on social life. Some 29 cases with lower limb amputations due to landmine injuries were treated in the Department of Orthopaedics and Traumatology, Gülhane Military Medical Academy between January 1992 and December 1996. Amputation levels were as follows: 1 case had hip disarticulation and a trans-femoral amputation, 6 had bilateral trans-femoral amputations, 6 had trans-femoral and trans-tibial amputations, 12 had bilateral trans-tibial amputations, 1 had trans-femoral and Chopart amputations and the remaining 3 cases had trans-tibial and Chopart amputations. The initial treatment was done for all cases in the first 6-8 hours after injury at the field hospitals. Aggressive debridement, excision and primary closure were performed. None of the stumps required reamputations and/or revision. No case had gas gangrene or tetanus. Postoperative, pre-prosthetic training programme which ranged between 30-120 days with an average 48 days; and prosthesis fitting and adequate post-prosthetic training programme which ranged 32-126 (average 94) days was applied. All the cases were followed-up with a mean of 38.5 months (14-72 months). Nine (9) cases (31%) returned to their previous occupation, while 20 (69%) cases had to change their jobs.     

Reoperative lower extremity revascularization with cadaver vein for limb salvage

We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded polytetrafluoroethylene bypasses. Operative indications were tissue loss (73%) and ischemic rest pain (27%). The mean preoperative ankle-brachial index was 0.43 +/- 0.16, and this increased to 0.89 +/- 0.18 at 30 days (p = 0.001). Procedure-related complications included graft infection (3, 4%), graft thrombosis (3, 4%), pseudoaneurysm (3, 4%), and bleeding (2, 3%). Cumulative 1-year primary, primary assisted, secondary patencies, limb salvage, and survival rates with confidence intervals were 0.19 (0.10-0.36), 0.29 (0.18-0.47), 0.42 (0.29-0.60), 0.73 (0.62-0.86), and 0.77 (0.65-0.90). Reoperative procedures fared the same as primary procedures. Multivariable analysis showed that predictors for increased risk of secondary patency loss were age >70 (hazard ratio [HR] = 3.13, p = 0.009) and patients with secondary revascularization (HR = 3.36, p = 0.015). Older patients (HR = 2.92, p = 0.042) and those with renal insufficiency (HR = 2.92, p = 0.019) were at increased risk of mortality. CVG remains an option for reoperative lower limb revascularization for limb salvage if there is no autogenous vein available. However, patency rates are poor, and patients older than 70 are more likely to have inferior outcomes.     

Use of distally based saphenous neurofasciocutaneous and musculofasciocutaneous cross-leg flaps in limb salvage.

Neurocutaneous island flaps have been very popular in soft-tissue coverage of the lower extremities. These flaps are based on the arterial network around the superficial sensory nerves. The advantages of these flaps are easy and quick dissection (hence a time-saving operation), acceptable donor site morbidity, and preservation of major arteries of the leg. The authors used five neurofasciocutaneous and three musculofasciocutaneous flaps successfully as cross-leg flaps for the coverage of relatively large defects of the lower two thirds of the leg and foot in 8 patients. They conclude that reverse saphenous neurofasciocutaneous and musculofasciocutaneous flaps as a cross-leg flap in patients who cannot be reconstructed with other flap alternatives have many advantages over traditional cross-leg procedures, such as short vascularization time, minimal patient discomfort, wide arc of rotation and great versatility, and a safe vascular pattern.