Adjunctive hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries: a systematic review.

PURPOSE: Traumatic crush injuries of the lower limb often accompany severe complications. The incorporation of hyperbaric oxygen therapy to standard trauma care may have the potential to diminish injury-related complications and improve outcome in such cases. This systematic review aims to evaluate the effectiveness of hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries. METHODS: The electronic databases Medline, Embase and Cochrane Library were searched to identify studies involving patients with crush-associated sever lower limb soft tissue injuries who received hyperbaric oxygen therapy in conjunction with standard trauma care. Relevant data on type of injury, hyperbaric oxygen therapy protocol and outcome related to wound healing were extracted. RESULTS: In total seven studies met the inclusion criteria, involving 229 patients. The studies included two randomized clinical trials, one retrospective cohort study, three case series and one case report. The randomized placebo-controlled clinical trial showed a significant increase in wound healing and decrease in the need for additional surgical interventions in the patient group receiving hyperbaric oxygen therapy when compared to those undergoing sham therapy. The randomized non-placebo-controlled clinical trial revealed that early hyperbaric oxygen therapy reduces tissue necrosis and the likelihood of long-term complications. The retrospective cohort study indicated that hyperbaric oxygen therapy effectively reduces infection rates and the need for additional surgical interventions. The case series and case report presented beneficial results with regard to wound healing when hyperbaric oxygen therapy was added to the treatment regimen. CONCLUSION: Hyperbaric oxygen therapy is generally considered a safe therapeutic intervention and seems to have a beneficial effect on wound healing in severe lower limb soft tissue injuries when implemented as an addition to standard trauma care.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis.

INTRODUCTION: Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center. METHODS: A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score. RESULTS: The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes. CONCLUSION: Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures. LEVEL OF EVIDENCE: Therapeutic level IIa.

Strategies Following Free Flap Failure in Lower Extremity Trauma: A Systematic Review.

Background: Free flap reconstructions are an important reconstructive option for soft tissue defects in mangled lower extremities. Microsurgery facilitates soft tissue coverage of defects that otherwise would result in amputation. However, the success rates of traumatic lower extremity free flap reconstructions remain lower than those in other locations. Nevertheless, post-free flap failure salvage strategies have rarely been addressed. Therefore, the current review aims to provide an overview of post-free flap failure strategies in lower extremity trauma and their subsequent outcomes. Methods: A search of Pubmed, Cochrane, and Embase databases was performed on June 9, June 2021 using the following medical subject headings (MeSH) search terms: 'lower extremity', 'leg injuries', 'reconstructive surgical procedures', 'reoperation', 'microsurgery' and 'treatment failure'. This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Partial and total free flap failures after traumatic reconstruction were included. Results: Twenty-eight studies with a total of 102 free flap failures fulfilled the eligibility criteria. Following the total failure, a second free flap is the predominant reconstructive strategy (69%). In comparison to the failure rate of a first free flap (10%), the fate of a second free flap is less favorable with a failure rate of 17%. The amputation rate following flap failure is 12%. The risk of amputation increases between primary and secondary free flap failures. After partial flap loss, the preferred strategy is a split skin graft (50%). Conclusion: To our knowledge, this is the first systematic review on the outcome of salvage strategies after free flap failure in traumatic lower extremity reconstruction. This review provides valuable evidence to take into consideration in the decision-making regarding post-free flap failure strategies.

The Pedicled Fibula Flap for Lower Limb Reconstruction.

The pedicled fibula flap is a reliable technique to treat large defects in the tibia. Despite increasing evidence of its efficacy and good long-term outcomes, a knowledge gap exists in its indications and technique. This instructional article presents a comprehensive overview of the indications, pre-operative planning, step-by-step surgery, and subsequent post-operative management. How to cite this article: Noorlander-Borgdorff MP, Giannakópoulos GF, Winters HAH, et al. The Pedicled Fibula Flap for Lower Limb Reconstruction. Strategies Trauma Limb Reconstr 2023;18(3):186-193.

Therapeutically Targeting Microvascular Leakage in Experimental Hemorrhagic SHOCK: A Systematic Review and Meta-Analysis.

BACKGROUND: Microvascular leakage is proposed as main contributor to disturbed microcirculatory perfusion following hemorrhagic shock and fluid resuscitation, leading to organ dysfunction and unfavorable outcome. Currently, no drugs are available to reduce or prevent microvascular leakage in clinical practice. We therefore aimed to provide an overview of therapeutic agents targeting microvascular leakage following experimental hemorrhagic shock and fluid resuscitation. METHODS: PubMed, EMBASE.com, and Cochrane Library were searched in January 2021 for preclinical studies of hemorrhagic shock using any therapeutic agent on top of standard fluid resuscitation. Primary outcome was vascular leakage, defined as edema, macromolecule extravasation, or glycocalyx degradation. Drugs were classified by targeting pathways and subgroup analyses were performed per organ. RESULTS: Forty-five studies, published between 1973 and 2020, fulfilled eligibility criteria. The included studies tested 54 different therapeutics mainly in pulmonary and intestinal vascular beds. Most studies induced trauma besides hemorrhagic shock. Forty-four therapeutics (81%) were found effective to reduce microvascular leakage, edema formation, or glycocalyx degradation in at least one organ. Targeting oxidative stress and apoptosis was the predominantly effective strategy (SMD: -2.18, CI [-3.21, -1.16], P < 0.0001). Vasoactive agents were found noneffective in reducing microvascular leakage (SMD: -0.86, CI [-3.07, 1.36], P = 0.45). CONCLUSION: Pharmacological modulation of pathways involved in cell metabolism, inflammation, endothelial barrier regulation, sex hormones and especially oxidative stress and apoptosis were effective in reducing microvascular leakage in experimental hemorrhagic shock with fluid resuscitation. Future studies should investigate whether targeting these pathways can restore microcirculatory perfusion and reduce organ injury following hemorrhagic shock. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42018095432.