Background: Restoration of breast sensation has become an important goal in autologous and implan... more Background: Restoration of breast sensation has become an important goal in autologous and implant-based breast reconstruction after cancer-related mastectomy. Although gender-affirming mastectomy with free nipple grafting (FNG) results in similar sensory deficits, chest reinnervation concepts have not been applied to this procedure. Methods: This article describes a novel technique to reinnervate the FNG in patients undergoing double incision gender mastectomy. Results: Our technique differs from previously described reinnervation techniques in several aspects: (1) the donor axon count is maximized by preserving the third to fifth lateral cutaneous nerves for coaptation to the nipple areola complex, (2) the reinnervation approach varies and is based on patient anatomy, (3) the distal graft or donor nerve is split into fascicles to increase the reinnervation zone, and (4) the split fascicles are coapted to the dermatosensory peripheral nerve elements of the dermis. Conclusion: Chest...
Objectives/Interrogation: Sarcomas are rare tumors that make up roughly 1% of all malignancies, a... more Objectives/Interrogation: Sarcomas are rare tumors that make up roughly 1% of all malignancies, and complete resection remains a mainstay of current treatment guidelines for localized disease. Post-extirpative defects following sarcoma resection often pose a difficult challenge to the reconstructive[for full text, please go to the a.m. URL]
Amputation of an extremity is a common procedure performed for a variety of indications. For lowe... more Amputation of an extremity is a common procedure performed for a variety of indications. For lower extremity amputations, certain co-morbid states (peripheral vascular disease, diabetes, etc.), trauma, oncology, and congenital deformities all contribute patients who may require amputation for medical or functional needs. Amputation can be performed at varying levels based on the patient’s need, including partial foot amputation, below-knee or above-knee amputation, or hip disarticulation. Regardless of the reason and site of amputation, there are a set of common principles of amputation that can aid in achieving the best functional outcome for the residual limb [1]. Figure 16.1 summarizes the most common levels of amputation and the most common associated motor nerve targets at each level.
Plastic and Reconstructive Surgery Global Open, 2017
CONCLUSION: In both groups, fat grafting for pedal atrophy positively impacted pain and function.... more CONCLUSION: In both groups, fat grafting for pedal atrophy positively impacted pain and function. These measures demonstrated a persistent improvement, though fat volume returned to baseline. This finding may be attributed to the observed increase in dermal thickness. Together, these results suggest that fat grafting may thicken or stabilize the dermis, contributing to improved clinical outcomes despite loss of grafted fat.
Plastic and Reconstructive Surgery Global Open, 2018
PURPOSE: The medial sural artery perforator (MSAP) flap offers thin, pliable tissue with a relati... more PURPOSE: The medial sural artery perforator (MSAP) flap offers thin, pliable tissue with a relatively long pedicle. Compared to other thin fasciocutaneous flaps, its relatively low donor site morbidity makes the MSAP flap a valuable option for the reconstructive microsurgeon. The purpose of this study is to systematically evaluate the literature on use of MSAP flaps with regards to flap characteristics, indications, recipient site defects, and postoperative outcomes.
Clinical and Diagnostic Laboratory Immunology, 1999
To ascertain if immunization with pneumococcal polysaccharide vaccine is associated with rises in... more To ascertain if immunization with pneumococcal polysaccharide vaccine is associated with rises in the levels of proinflammatory cytokines in the plasma of human immunodeficiency virus type 1 (HIV-1)-infected patients, the levels of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) were measured serially after immunization. IL-6 levels rose an average of 2.2- and 2.1-fold 6 and 8 h after immunization, respectively, but TNF-α levels remained unchanged. The levels of these cytokines were stable in unimmunized controls. Immunization with pneumococcal polysaccharide vaccine induces increases in the levels of IL-6 in the plasma of persons with HIV-1 infection.
In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been ... more In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.
Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins wit... more Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.
Military personnel who survive combat injuries frequently have large soft tissue wounds complicat... more Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.
of the lower limb almost 30 years ago, there has been continued interest in determining which of ... more of the lower limb almost 30 years ago, there has been continued interest in determining which of the two options, muscle flaps or fasciocutaneous flaps, are more suitable for treatment of traumatic limb defects. The debate has raged on over the past three decades, with numerous laboratory-based and clinical studies designed to answer this question. Currently, it would be safe to say that it is far from resolved. Laboratorybased studies have indicated that muscle flaps are better at reducing infectious colonization and promoting enhanced healing of fractures despite their seemingly less superior vascular density compared with fasciocutaneous flaps.3 Clinical studies, in contrast, favor the use of fasciocutaneous flaps in these traumatic defects, highlighting the fact that they provide a more suitable reconstructive substrate while equaling outcomes of muscle flaps in terms of complications.4,5 All of the laboratory work has been carried out on animal models, which are usually oversimplifications of the clinical context, and at the same time incorporate a number of other flaws in the fundamental design of the experiments. The same can be said of the clinical studies, with more or less all of them being retrospective case reviews. Thus, if we are to move forward in this sphere, it is essential that we design experiments with a higher therapeutic index with the capability of answering these questions more accurately. Furthermore, a greater focus on functional and patientreported outcomes following limb salvage in this cohort of patients will help us to better appreciate the impact of these procedures on patients. Finally, muscle and fasciocutaneous flaps have distinct differences that make each of them suitable in different circumstances. It is probably more important that future research focuses more on delineating the circumstances within which each option should be used rather than pitting muscle flaps against fasciocutaneous flaps. DOI: 10.1097/PRS.0000000000001610
War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury w... more War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury with multiple concomitant injuries that can contribute to limited coverage options. Thus, flap availability and choice can become critical in the reconstruction algorithm of these severely traumatized patients. The authors' purpose was to analyze the outcomes of muscle and fasciocutaneous flaps during their extremity reconstructive experience to determine which option had better flap and limb salvage outcomes. A retrospective review of servicemembers treated with flap-based limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Patients were divided into cohorts of patients who underwent muscle or fasciocutaneous flaps. Three hundred fifty-nine flap procedures were performed. Of these procedures, 197 were muscle (55 percent) and 152 were fasciocutaneous flaps (42 percent). There was no difference in overall flap complications between groups (30 percent v...
Background: Limb-sparing wide excision has become as effective as amputation in treating extremit... more Background: Limb-sparing wide excision has become as effective as amputation in treating extremity sarcoma. Limb reconstruction has traditionally involved allografting. The authors evaluated reconstruction of extremity long bone defects after tumor resection using fibula free flaps. Methods: A retrospective chart review (1991 to 2002) was performed of 25 consecutive patients at Memorial Sloan-Kettering Cancer Center who underwent reconstruction with free fibula flaps after limb-sparing resection of extremity sarcomas. Timing of reconstruction, complications, metastasis, survival, bone union, and functional outcome were analyzed. Functional assessment was based on the 1987 Musculoskeletal Tumor Society Score/Enneking classification. Results: Twenty-five patients (14 male patients and 11 female patients) were treated. Osteosarcoma (n ϭ 8), Ewing's sarcoma (n ϭ 8), and chondrosarcoma (n ϭ 6) accounted for the majority of the cases. Reconstructed areas included tibia (n ϭ 9), radius (n ϭ 5), humerus (n ϭ 6), femur (n ϭ 4), and ulna (n ϭ 1). All flaps survived (100 percent). One patient required emergent reexploration (4 percent), one suffered partial flap skin loss (4 percent), and three experienced postoperative infections (12 percent). In patients followed over 6 months, uncomplicated bony union was achieved in 11 of 14 patients (78 percent). After secondary procedures, bony union was ultimately achieved in 13 of 14 patients (93 percent), all of whom had good functional outcomes. Eight patients suffered local recurrences or metastases (32 percent); six died during the study period. Conclusions: The microvascular free fibula flap has a lower infection rate than traditional allograft reconstruction. There is a high rate of bone union, and functional outcome is good. Thus, the authors recommend the microvascular fibula transfer as the technique of choice for reconstructing large, complex long bone defects resulting from tumor extirpation.
Background: A primary goal in traumatic lower extremity amputation management is preservation of ... more Background: A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. Methods: A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. Results: Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with splitthickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle f laps or adjacent tissue rearrangements and free tissue transfers. Conclusions: The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.
Background: Blast exposure is a common cause of soft tissue injury within the battlefield setting... more Background: Blast exposure is a common cause of soft tissue injury within the battlefield setting, with the extremities often critically involved. The resulting injury pattern presents with massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients. Methods: The authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DermaClose RC). Outcome measurements included time to definitive closure and method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA, and related complications. Results: Overall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm 2. Mean wound size was 262.7 cm 2. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33Y91.3). Conclusions: In the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly. The authors propose an algorithm for the use of continuous external tissue expansion system to achieve effective and successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.
Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined b... more Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. Patients and methods: Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an aboveknee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). Results: There were no complications related to the TMR procedure. Average followup time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. Conclusion: TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function. 1 | INTRODUCTION Complex regional pain syndrome (CRPS) is the descriptive term for a constellation of symptoms and signs that present after trauma to the extremity. CRPS has historically been known by different names, including reflex sympathetic dystrophy (RSD), causalgia, and Sudeck's dystrophy (Ratti, Nordio, Resmini, & Murena, 2015). The most widely accepted criteria for CRPS is the Budapest criteria, which includes pain, the presence of signs and symptoms in four domains (e.g., sensory, vasomotor, edema, and motor), and the lack of another diagnosis that explains the presentation (Veldman, Reynen, Arntz, & Goris, 1993). CRPS is classified into two types: type I (RSD) is not associated with a specific nerve injury, whereas type II (causalgia) has a nerve injury identifiable by diagnostic testing (Duman et al., 2007).
Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned... more Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned applied and translated among military and civilian settings. In recent periods of war, improvements in protective equipment, in-theater damage control resuscitation/surgery, delivery of antibiotics locally/systemically, and rapid evacuation to higher levels of medical care capabilities have greatly improved combat casualty survivability rates. Additionally, widespread application of lower extremity tourniquets also has prevented casualties from exsanguination, thus reducing hemorrhagic-related deaths. Secondary to these, a high number of combat casualties suffering lower extremity traumatic injuries have presented for functional limb reconstruction and restoration as well as residual limb care.
Background: Restoration of breast sensation has become an important goal in autologous and implan... more Background: Restoration of breast sensation has become an important goal in autologous and implant-based breast reconstruction after cancer-related mastectomy. Although gender-affirming mastectomy with free nipple grafting (FNG) results in similar sensory deficits, chest reinnervation concepts have not been applied to this procedure. Methods: This article describes a novel technique to reinnervate the FNG in patients undergoing double incision gender mastectomy. Results: Our technique differs from previously described reinnervation techniques in several aspects: (1) the donor axon count is maximized by preserving the third to fifth lateral cutaneous nerves for coaptation to the nipple areola complex, (2) the reinnervation approach varies and is based on patient anatomy, (3) the distal graft or donor nerve is split into fascicles to increase the reinnervation zone, and (4) the split fascicles are coapted to the dermatosensory peripheral nerve elements of the dermis. Conclusion: Chest...
Objectives/Interrogation: Sarcomas are rare tumors that make up roughly 1% of all malignancies, a... more Objectives/Interrogation: Sarcomas are rare tumors that make up roughly 1% of all malignancies, and complete resection remains a mainstay of current treatment guidelines for localized disease. Post-extirpative defects following sarcoma resection often pose a difficult challenge to the reconstructive[for full text, please go to the a.m. URL]
Amputation of an extremity is a common procedure performed for a variety of indications. For lowe... more Amputation of an extremity is a common procedure performed for a variety of indications. For lower extremity amputations, certain co-morbid states (peripheral vascular disease, diabetes, etc.), trauma, oncology, and congenital deformities all contribute patients who may require amputation for medical or functional needs. Amputation can be performed at varying levels based on the patient’s need, including partial foot amputation, below-knee or above-knee amputation, or hip disarticulation. Regardless of the reason and site of amputation, there are a set of common principles of amputation that can aid in achieving the best functional outcome for the residual limb [1]. Figure 16.1 summarizes the most common levels of amputation and the most common associated motor nerve targets at each level.
Plastic and Reconstructive Surgery Global Open, 2017
CONCLUSION: In both groups, fat grafting for pedal atrophy positively impacted pain and function.... more CONCLUSION: In both groups, fat grafting for pedal atrophy positively impacted pain and function. These measures demonstrated a persistent improvement, though fat volume returned to baseline. This finding may be attributed to the observed increase in dermal thickness. Together, these results suggest that fat grafting may thicken or stabilize the dermis, contributing to improved clinical outcomes despite loss of grafted fat.
Plastic and Reconstructive Surgery Global Open, 2018
PURPOSE: The medial sural artery perforator (MSAP) flap offers thin, pliable tissue with a relati... more PURPOSE: The medial sural artery perforator (MSAP) flap offers thin, pliable tissue with a relatively long pedicle. Compared to other thin fasciocutaneous flaps, its relatively low donor site morbidity makes the MSAP flap a valuable option for the reconstructive microsurgeon. The purpose of this study is to systematically evaluate the literature on use of MSAP flaps with regards to flap characteristics, indications, recipient site defects, and postoperative outcomes.
Clinical and Diagnostic Laboratory Immunology, 1999
To ascertain if immunization with pneumococcal polysaccharide vaccine is associated with rises in... more To ascertain if immunization with pneumococcal polysaccharide vaccine is associated with rises in the levels of proinflammatory cytokines in the plasma of human immunodeficiency virus type 1 (HIV-1)-infected patients, the levels of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) were measured serially after immunization. IL-6 levels rose an average of 2.2- and 2.1-fold 6 and 8 h after immunization, respectively, but TNF-α levels remained unchanged. The levels of these cytokines were stable in unimmunized controls. Immunization with pneumococcal polysaccharide vaccine induces increases in the levels of IL-6 in the plasma of persons with HIV-1 infection.
In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been ... more In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.
Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins wit... more Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.
Military personnel who survive combat injuries frequently have large soft tissue wounds complicat... more Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.
of the lower limb almost 30 years ago, there has been continued interest in determining which of ... more of the lower limb almost 30 years ago, there has been continued interest in determining which of the two options, muscle flaps or fasciocutaneous flaps, are more suitable for treatment of traumatic limb defects. The debate has raged on over the past three decades, with numerous laboratory-based and clinical studies designed to answer this question. Currently, it would be safe to say that it is far from resolved. Laboratorybased studies have indicated that muscle flaps are better at reducing infectious colonization and promoting enhanced healing of fractures despite their seemingly less superior vascular density compared with fasciocutaneous flaps.3 Clinical studies, in contrast, favor the use of fasciocutaneous flaps in these traumatic defects, highlighting the fact that they provide a more suitable reconstructive substrate while equaling outcomes of muscle flaps in terms of complications.4,5 All of the laboratory work has been carried out on animal models, which are usually oversimplifications of the clinical context, and at the same time incorporate a number of other flaws in the fundamental design of the experiments. The same can be said of the clinical studies, with more or less all of them being retrospective case reviews. Thus, if we are to move forward in this sphere, it is essential that we design experiments with a higher therapeutic index with the capability of answering these questions more accurately. Furthermore, a greater focus on functional and patientreported outcomes following limb salvage in this cohort of patients will help us to better appreciate the impact of these procedures on patients. Finally, muscle and fasciocutaneous flaps have distinct differences that make each of them suitable in different circumstances. It is probably more important that future research focuses more on delineating the circumstances within which each option should be used rather than pitting muscle flaps against fasciocutaneous flaps. DOI: 10.1097/PRS.0000000000001610
War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury w... more War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury with multiple concomitant injuries that can contribute to limited coverage options. Thus, flap availability and choice can become critical in the reconstruction algorithm of these severely traumatized patients. The authors' purpose was to analyze the outcomes of muscle and fasciocutaneous flaps during their extremity reconstructive experience to determine which option had better flap and limb salvage outcomes. A retrospective review of servicemembers treated with flap-based limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Patients were divided into cohorts of patients who underwent muscle or fasciocutaneous flaps. Three hundred fifty-nine flap procedures were performed. Of these procedures, 197 were muscle (55 percent) and 152 were fasciocutaneous flaps (42 percent). There was no difference in overall flap complications between groups (30 percent v...
Background: Limb-sparing wide excision has become as effective as amputation in treating extremit... more Background: Limb-sparing wide excision has become as effective as amputation in treating extremity sarcoma. Limb reconstruction has traditionally involved allografting. The authors evaluated reconstruction of extremity long bone defects after tumor resection using fibula free flaps. Methods: A retrospective chart review (1991 to 2002) was performed of 25 consecutive patients at Memorial Sloan-Kettering Cancer Center who underwent reconstruction with free fibula flaps after limb-sparing resection of extremity sarcomas. Timing of reconstruction, complications, metastasis, survival, bone union, and functional outcome were analyzed. Functional assessment was based on the 1987 Musculoskeletal Tumor Society Score/Enneking classification. Results: Twenty-five patients (14 male patients and 11 female patients) were treated. Osteosarcoma (n ϭ 8), Ewing's sarcoma (n ϭ 8), and chondrosarcoma (n ϭ 6) accounted for the majority of the cases. Reconstructed areas included tibia (n ϭ 9), radius (n ϭ 5), humerus (n ϭ 6), femur (n ϭ 4), and ulna (n ϭ 1). All flaps survived (100 percent). One patient required emergent reexploration (4 percent), one suffered partial flap skin loss (4 percent), and three experienced postoperative infections (12 percent). In patients followed over 6 months, uncomplicated bony union was achieved in 11 of 14 patients (78 percent). After secondary procedures, bony union was ultimately achieved in 13 of 14 patients (93 percent), all of whom had good functional outcomes. Eight patients suffered local recurrences or metastases (32 percent); six died during the study period. Conclusions: The microvascular free fibula flap has a lower infection rate than traditional allograft reconstruction. There is a high rate of bone union, and functional outcome is good. Thus, the authors recommend the microvascular fibula transfer as the technique of choice for reconstructing large, complex long bone defects resulting from tumor extirpation.
Background: A primary goal in traumatic lower extremity amputation management is preservation of ... more Background: A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. Methods: A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. Results: Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with splitthickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle f laps or adjacent tissue rearrangements and free tissue transfers. Conclusions: The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.
Background: Blast exposure is a common cause of soft tissue injury within the battlefield setting... more Background: Blast exposure is a common cause of soft tissue injury within the battlefield setting, with the extremities often critically involved. The resulting injury pattern presents with massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients. Methods: The authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DermaClose RC). Outcome measurements included time to definitive closure and method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA, and related complications. Results: Overall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm 2. Mean wound size was 262.7 cm 2. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33Y91.3). Conclusions: In the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly. The authors propose an algorithm for the use of continuous external tissue expansion system to achieve effective and successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.
Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined b... more Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. Patients and methods: Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an aboveknee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). Results: There were no complications related to the TMR procedure. Average followup time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. Conclusion: TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function. 1 | INTRODUCTION Complex regional pain syndrome (CRPS) is the descriptive term for a constellation of symptoms and signs that present after trauma to the extremity. CRPS has historically been known by different names, including reflex sympathetic dystrophy (RSD), causalgia, and Sudeck's dystrophy (Ratti, Nordio, Resmini, & Murena, 2015). The most widely accepted criteria for CRPS is the Budapest criteria, which includes pain, the presence of signs and symptoms in four domains (e.g., sensory, vasomotor, edema, and motor), and the lack of another diagnosis that explains the presentation (Veldman, Reynen, Arntz, & Goris, 1993). CRPS is classified into two types: type I (RSD) is not associated with a specific nerve injury, whereas type II (causalgia) has a nerve injury identifiable by diagnostic testing (Duman et al., 2007).
Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned... more Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned applied and translated among military and civilian settings. In recent periods of war, improvements in protective equipment, in-theater damage control resuscitation/surgery, delivery of antibiotics locally/systemically, and rapid evacuation to higher levels of medical care capabilities have greatly improved combat casualty survivability rates. Additionally, widespread application of lower extremity tourniquets also has prevented casualties from exsanguination, thus reducing hemorrhagic-related deaths. Secondary to these, a high number of combat casualties suffering lower extremity traumatic injuries have presented for functional limb reconstruction and restoration as well as residual limb care.
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Papers by Ian Valerio