Neither Antiplatelet nor Anticoagulant Therapy Increases Graft Failure after Split-thickness Skin Grafting.

Split-thickness skin grafts (STSG) are an effective modality for lower extremity wound coverage. Many patients in the highly comorbid chronic wound population present with cardiovascular disease requiring chronic antiplatelet or anticoagulant therapy, theoretically increasing risk for bleeding complications, donor site morbidity, and poor graft take. Some surgeons advocate temporary cessation of antithrombotic therapy, which may increase cardiovascular risk. The objective of this study was to examine the effects of anticoagulation use on STSG outcomes. Methods: All patients receiving STSGs for lower extremity wounds from 2014 to 2016 at a single institution were retrospectively reviewed. Successful grafts were defined as greater than 99.5% wound coverage. Patients were divided into two groups: anticoagulation/antiplatelet or no anticoagulation/antiplatelet. Continuous variables were described by means and SDs and analyzed using student's t-test. Categorical variables were described by frequencies and percentages and analyzed using Chi-square or Fisher exact tests as appropriate. Results: In total, 231 wounds were identified among 189 patients; 124 patients were receiving at least one antiplatelet/anticoagulant at time of grafting. Three hematomas were reported during 30 days of follow-up; there was no significant difference between groups (P > 0.05). Anticoagulation/antiplatelet therapy in the perioperative period had no significant impact on STSG take and overall healing. Conclusions: The findings from this study demonstrate that administration of anticoagulant/antiplatelet agents in the perioperative period does not increase the risk of skin graft failure. Based on these findings, STSG can be performed without cessation of anticoagulation or antiplatelet therapy.

Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy.

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.

Evaluation of Polymerase Chain Reaction in the Identification and Quantification of Clinically Relevant Bacterial Species in Lower Extremity Wound Infections.

Identification of bacteria by polymerase chain reaction (PCR) is known to be more sensitive than culture, which brings to question the clinical applicability of the results. In this study, we evaluate the ability of PCR to detect clinically relevant bacterial species in lower extremity wound infections requiring operative debridement, as well as the quantitative change in biodiversity and bacterial load reflected by PCR during the course of treatment. Thirty-four infected lower extremity were examined by analysis of 16S ribosomal RNA subunit and by culture. McNemar's test was used to measure the concordance of clinically relevant bacterial species identified by PCR compared to culture during each debridement. Change in wound biodiversity from initial presentation to final closure was evaluated by Wilcoxon signed-rank test. Kaplan-Meier survival curve was used to characterize change in measured bacterial load over the course of operative debridement. A total of 15 and 12 clinically relevant bacterial species were identified by PCR and culture, respectively. The most common bacterial species identified were Coagulase-negative Staphylococcus, Staphylococcus aureus, and Enterococcus spp. PCR was less likely to detect Enterococcus spp. on initial debridement and Coagulase-negative Staphylococcus on closure in this study population. A significant decrease in mean number of clinically relevant species detected from initial debridement to closure was reflected by culture (p = .0188) but not by PCR (p = .1848). Both PCR (p = .0128) and culture (p = .0001) depicted significant reduction in mean bacterial load from initial debridement to closure. PCR is able to identify common clinically relevant bacterial species in lower extremity surgical wound infections. PCR displays increased sensitivity compared to culture with relation to detection of biodiversity, rather than bacterial load. Molecular diagnostics and conventional culture may serve a joint purpose to assist with rendering clinical judgment in complex wound infections.

Utility of Porcine-Derived Xenograft as an Adjunct to Split-Thickness Skin Grafting in Lower-Extremity Wounds.

OBJECTIVE: Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds. METHODS: Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected. RESULTS: There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P30 = .818; 82.2% versus 80.9%, P60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P30 = .902; 1.2 cm2 versus 1.1 cm2, P60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group. CONCLUSIONS: Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.

Complications of Charcot Reconstruction in Patients With Peripheral Arterial Disease.

The primary aim was to determine the rate of complications in patients with peripheral arterial disease and diabetic Charcot neuroarthropathy who underwent osseous reconstruction. Complications included delayed healing, dehiscence, and major lower extremity amputation. A review of patients with Charcot neuroarthropathy requiring reconstruction secondary to ulceration or acute infection was performed. Descriptive analysis compared outcomes between those with and without peripheral arterial disease. Bivariate analysis and multivariate logistic regression were analyzed for delayed healing, dehiscence, and major amputation. In a cohort of 284 patients with diabetic Charcot neuroarthropathy who underwent osseous reconstruction, the rate of peripheral arterial disease was 20.8% (59/284). Bivariate analysis for delayed healing found hypertension (p = .0352), peripheral arterial disease (p = .0051), and smoking history (p = .0276) to be statistically significant factors. Delayed healing was 2.012 times more likely in the presence of peripheral arterial disease [OR 2.012 (95% CI 1.088-3.720)]. Bivariate analysis for major lower extremity amputation found renal disease (0.0003) (renal disease: ESRD and CKD) and peripheral arterial disease (0.0001) to be statistically significant factors. Major amputation was 4.414 times more likely in the presence of peripheral arterial disease [OR 4.414 (95% CI 2.087-9.334)]. Peripheral arterial disease was identified in 20.8% (59/284) of diabetic patients who underwent Charcot osseous reconstruction. Peripheral arterial disease increased the risk of delayed healing by 2.012 fold, and increased the risk of major lower extremity amputation by 4.414 fold. The rates of complications in patients with peripheral arterial disease were significantly higher than those without peripheral arterial disease who underwent osseous reconstruction.

Charcot Reconstruction: Outcomes in Patients With and Without Diabetes.

The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.

Long Term Outcomes of Split-Thickness Skin Grafting to the Plantar Foot.

The most common consequence of neuropathy is a diabetic foot ulcer, which usually occurs on the plantar surface of the foot. Split-thickness skin grafting (STSG) has been shown in numerous studies to be an effective treatment for rapid coverage of diabetic ulcers. The purpose of this study is to retrospectively examine the outcomes of STSG to the plantar foot and determine the durability of this treatment compared to non-plantar surface STSG. This is a retrospective, single-center, institutional review board approved, case-control study of all patients who received STSG to their lower extremity for chronic ulcers from November 2013 to February 2017. Patients with ulcers on the plantar surface were considered cases, and non-plantar surface ulcers were considered controls. There were 182 patients who received STSG to the lower extremity, 52 to the plantar surface foot and 130 to non-plantar surface locations. Healing at 30 days was not significantly different between plantar and nonplantar ulcers (19% versus 28%, p = .199) but did become significant at 60, 90, and 365 days (21% versus 45%, p = .003; 33% versus 49%, p = .043; 38% versus 64%, p = .002, respectively). However, time to full healing was not significantly different between plantar and nonplantar groups (18.2 ± 19.5 versus 17.4 ± 21.6 weeks, mean ± standard deviation, p = .84). Recurrence was low for both groups (17% versus 10%, respectively), and there was no significant difference between groups (p = .17). Patients with plantar surface ulcers can achieve a durable coverage/closure of their wounds with STSG. When combined with appropriate patient selection and postoperative offloading, acceptable recurrence rates can be achieved.

Peripheral Vascular Disease Diagnostic Related Outcomes in Diabetic Charcot Reconstruction.

Postreconstructive outcomes were compared in diabetic patients with Charcot neuroarthropathy (CN) who had peripheral arterial disease (PAD) diagnosed with angiography versus patients who were diagnosed clinically. A retrospective review was performed of patients with diabetic CN requiring reconstruction secondary to ulceration and/or acute infection. Of the 284 patients in the CN osseous reconstruction cohort, after accounting for exclusion criteria, 59 (20.8%) patients with PAD were included in the analyses. Forty (67.8%) of these 59 patients were diagnosed with PAD clinically and 19 (32.2%) were diagnosed with the use of angiography. Bivariate analysis was used to compare outcomes between those diagnosed with PAD via angiography versus those diagnosed clinically for the following postreconstruction outcomes: wound healing, delayed healing, surgical site infection, pin tract infection, osteomyelitis, dehiscence, transfer ulcer, new site of Charcot collapse, contralateral Charcot event, nonunion, major lower extremity amputation, and return to ambulation. Bivariate analysis found return to ambulation postreconstruction (p = .0054) to be the only statistically significant factor. There was a trend toward significance for major lower extremity amputation, with higher rates of amputation in the clinically diagnosed PAD arm. Return to ambulation indicates improved functional outcomes. The main goal of limb salvage should be focused on improving the patient's functional performance. With significantly faster rates of return to ambulation and a trend toward decreased rates of major amputation, angiography was found to be a better assessor of PAD than clinical evaluations.

Use of hyperbaric oxygen therapy for tissue ischemia after breast reconstruction.

INTRODUCTION: Mastectomy skin flap necrosis represents a significant complication of breast reconstructive procedures and is reported to occur in 30%-52% of patients undergoing breast reconstruction. Early identification of ischemia and early initiation of hyperbaric oxygen (HBO2) therapy can mitigate the effects of ischemia and rescue otherwise non-viable breast flap tissue. METHODS: We retrospectively examined the outcomes of HBO2 therapy in eight breasts with compromised mastectomy skin flaps between September 2015 and January 2017. Indocyanine green angiography (ICGA) was used to assess perfusion intraoperatively and post-HBO2 administration. RESULTS: Seven patients were referred for HBO2 within 24 hours of mastectomy. One patient failed to improve despite starting hyperbaric treatment within 24 hours. All other patients manifested successful healing of their mastectomy skin flaps with acceptable cosmesis after 10 HBO2 treatments. The mean relative perfusion of the at-risk area was 13.8% (±3.7%) pre-HBO2 and 101.6% (±37.3%) post-HBO2. The average area at-risk pre-HBO2 was 17.1 cm2 and reduced to zero post-HBO2. Relative perfusion values after HBO2 were found to be 6.8 (±3.4) times greater than those measured prior to HBO2. CONCLUSIONS: A short course of HBO2 may be sufficient to successfully rescue at risk post-mastectomy breast flaps. ICGA is a useful adjunct for evaluating post-mastectomy breast flap perfusion before and after HBO2 therapy.

Risk Factors Associated With Major Lower Extremity Amputation After Osseous Diabetic Charcot Reconstruction.

Patients with diabetic Charcot neuroarthropathy (CN) are at high risk for ulcerations and major lower extremity amputations (LEAs). Osseous reconstruction is an important component in ulcer healing and prevention; however, despite such efforts, major LEAs remain a serious postreconstruction concern. The aim of this study was to identify risk factors for major LEA in patients who underwent osseous Charcot reconstruction. A retrospective review was performed on 331 patients with the diagnosis of CN in the foot and ankle treated over a 16-year period. Two hundred eighty-five patients were included after exclusion of those without diabetes. Demographic data, anatomic wound location, surgical interventions, wound healing status, and the level of eventual amputation were recorded. Multivariate logistic regression and Fisher's exact test were used for analysis. All patients had diabetes, neuropathy, or CN and required osseous reconstruction. Risk factors and their respective odds ratios (ORs) are as follows: postoperative nonunion (OR 8.5, 95% confidence interval [CI] 2.2 to 33.5, 0.0023), development of new site of CN (OR 8.2; 95% CI 1.1 to 62.9; p = .0440), peripheral arterial disease (OR 4.3; 95% CI 1.7 to 11.0; p = .0020), renal disease (OR 3.7; 95% CI 1.6 to 8.8; p = .0025), postoperative delayed healing (OR 2.6; 95% CI 1.1 to 6.5; p = .0371), postoperative osteomyelitis (OR 2.4; 95% CI 1.0 to 5.9; p = .0473), or elevated glycated hemoglobin (OR 1.2; 95% CI 1.0 to 1.4; p = .0053). Independent risk factors found to be statistically significant for major LEA in diabetic CN in the setting of osseous reconstruction must be mitigated for long-term prevention of major amputations.

The Vertical Contour Calcanectomy: An Alternative Surgical Technique to the Conventional Partial Calcanectomy.

Heel ulcers have a significant impact on lower extremity morbidity and confer a high risk for major amputations. Although there are many conservative treatment options, once calcaneal osteomyelitis occurs or a heel ulcer becomes chronic or recalcitrant, more invasive management is required. The partial calcanectomy is a surgical solution that can address both pathologies-the ulceration and the infected bone. The conventional partial calcanectomy, however, does not ensure complete soft tissue closure. Often, closure under tension is required for primary closure of the soft tissue deficit or the wound must be closed by secondary intention. This process occurs, in part, when the proportion of bone resected is insufficient in relation to the size of the wound. Closure under tension increases the possibility of dehiscence and subsequent postoperative surgical site complications that lead to the same risks for major amputation as the index heel ulcer. This article introduces and describes a novel modification to the conventional partial calcanectomy and addresses these aforementioned concerns. The vertical contour calcanectomy incorporates improvements to an already accepted limb salvage technique. The purpose of this article was to describe the indications, contraindications, intraoperative technique and postoperative management of the vertical contour calcanectomy for patients who present with heel ulcers in the limb salvage setting.

Limb Salvage and Functional Outcomes following Free Tissue Transfer for the Treatment of Recalcitrant Diabetic Foot Ulcers.

BACKGROUND: Recent evidence documenting high success rates following microvascular diabetic foot reconstruction has led to a paradigm shift in favor of more aggressive limb preservation. The primary aim of this study was to examine reconstructive and functional outcomes in patients who underwent free tissue transfer (FTT) for recalcitrant diabetic foot ulcers (DFUs) at our tertiary referral center for advanced limb salvage. METHODS: Between June 2013 and June 2016, 29 patients underwent lower extremity FTT for diabetic foot reconstruction by the senior author (K.K.E.). In all cases, microsurgical reconstruction was offered as an alternative to major amputation for the management of recalcitrant DFUs. Overall rates of flap survival, limb salvage, and postoperative ambulation were evaluated. The lower extremity functional scale (LEFS) score was used to assess functional outcomes after surgery. RESULTS: Overall rates of flap success and lower limb salvage were 93 and 79%, respectively. Flap failure occurred in two patients with delayed microvascular compromise. Seven patients in this series ultimately required below-knee amputation secondary to recalcitrant infection (n = 5), intractable pain (n = 1), and limb ischemia (n = 1). The average interval between FTT and major amputation was 8 months (r, 0.2-15 months). Postoperative ambulation was confirmed in 25 patients (86%) after a mean final follow-up of 25 months (r, 10-48 months). The average LEFS score for all patients was 46 out of 80 points (r, 12-80 points), indicating the ability to ambulate in the community with some limitations. CONCLUSION: FTT for the management of recalcitrant DFUs is associated with high rates of reconstructive success and postoperative ambulation. However, several patients will eventually require major amputation for reasons unrelated to ultimate flap survival. These data should be used to counsel patients regarding the risks, functional implications, and prognosis of microvascular diabetic foot reconstruction.

Long Term Follow Up of a Vascularized Osteocutaneous Free Flap for Reconstruction in Charcot Neuroarthropathy: A Case Report.

Vascularized osteocutaneous free flaps have seen increasing use in foot and ankle surgery for the repair of bony defects secondary to chronic nonunion, osteomyelitis, and fractures. One example is the Medial Femoral Condyle (MFC) Flap. The utility of the MFC flap for the repair of a bony defect in a diabetic patient, however, has yet to be explored. We report the long-term results of a case describing the use of an MFC flap to reconstruct an osseous defect resulting from first metatarsophalangeal joint resection in a diabetic patient.

Incidence of heparin-induced thrombocytopenia in lower-extremity free flap reconstruction correlates with the overall surgical population.

BACKGROUND: Lower-extremity free flap reconstruction is a growing trend in the management of lower extremity wounds. Heparin-induced thrombocytopenia (HIT) is a significant risk to free flap reconstruction. The purpose of this study was to investigate the incidence of HIT in patients receiving lower-extremity free flap surgery. METHODS: We conducted a retrospective, single center, IRB approved cohort study in which we reviewed all patients who received lower-extremity free flap surgeries between 2011 and 2016. The 4T and HIT Expert Probability (HEP) scores were calculated to assess the likelihood of HIT. RESULTS: One hundred patient charts revealed three patients with HIT. One patient was excluded due to a prior diagnosis of HIT. HIT incidence in patients receiving lower-extremity free flaps was between 1% and 3%, which is consistent with the national average. 4T scores indicated that two of three HIT-positive patients had a high probability of HIT (approximately 64%), and one of three HIT-positive patients had an intermediate probability (approximately 14%). HEP scoring indicated that all the three (100%) patients had HIT. CONCLUSIONS: These data suggest that the incidence of HIT in patients receiving lower-extremity free flaps correlates with the incidence of HIT nationally. The use of available scoring methods and other algorithms, combined with patient history helps to assess the immediate perioperative risks of HIT in the absence of rapid immunologic confirmatory tests. This knowledge can allow for successful free flap salvage or for performance of free flaps in patients with a history of HIT.

Concordance Between Bone Pathology and Bone Culture for the Diagnosis of Osteomyelitis in the Presence of Charcot Neuro-Osteoarthropathy.

The diagnosis of osteomyelitis (OM) is a challenging but critical pathology to uncover in patients with concomitant Charcot neuro-osteoarthropathy (CN). The reference standard to diagnose OM is bone biopsy for histopathologic and microbiologic examination. The presence of CN, however, can have a negative effect on the accuracy of either method to identify OM. The aim of the present study was to examine the concordance between bone pathology and bone cultures in the presence of CN in the diagnosis of OM. A total of 286 patients with diabetes mellitus (DM) and CN were identified retrospectively, with 48 patients identified with OM. OM was confirmed by radiographs, magnetic resonance imaging, erythrocyte sedimentation rate, and C-reactive protein, positive probe-to-bone test results, and intraoperative inspection. Seventy matched pairs of bone pathology and cultures with complete data were compared and analyzed. Statistical analysis included concordance, positive predictive value, negative predictive value, sensitivity, specificity, and kappa coefficient. Concordance between bone pathology and bone culture was 41.4%, with agreement in 29 of 70 paired specimens. The diagnostic test accuracy of histopathologic examination to diagnose OM in CN bone in our study was 51.4%. The diagnostic test accuracy of microbiologic examination to diagnose OM in CN bone was 50%. The positive predictive value was 72.2%. The negative predictive value was 44.1%. The sensitivity was 57.8%. The specificity was 60.0%. The kappa coefficient was 0.165. The reference standard method of histopathologic and microbiologic examination of bone specimens has little concordance and can lead to inaccurate or inconclusive information. The low sensitivity and specificity demonstrated in the present study does not support the use of the current reference standard method of bone biopsy for histologic and microbiologic diagnosis of OM when CN is present. Thus, a diagnosis of OM in patients with CN should only be considered in the presence of strong clinical, laboratory, and imaging correlates.

Viability of permanent PMMA spacer with combined free fasciocutaneous tissue transfer for failed charcot reconstruction: A 38 month prospective case report.

INTRODUCTION: Charcot Neuroarthropathy is a complex lower extremity pathology which predisposes the afflicted limb to ulcerations, osteomyelitis, and risk of major amputation. Charcot Neuroarthropathy often requires osseous reconstruction, which can be complicated with osteomyelitis and hardware infection. When soft tissue and osseous deficits must be concomitantly addressed, the use of PMMA spacers can be combined with free tissue transfers. PRESENTATION OF CASE: 71year old Caucasian male with Diabetic Charcot Neuroarthopathy underwent osseous reconstruction with internal hardware. The surgical site was complicated by acute infection, osteomyelitis, exposed hardware requiring removal, and multiple surgical débridement. The degree of soft tissue and osseous deficit post-débridement required complex reconstruction. DISCUSSION: The osseous deficit was addressed with the use of a permanent PMMA cement spacer. The soft tissue deficit was reconstructed with a free tissue transfer. This case report demonstrates the long term viability and utility of the use of permanent cement spacers when combined with free tissue transfer for closure of complex diabetic foot wounds. This case is an example of a multidisciplinary team approach to limb salvage with successful long term outcome; a plantigrade stable functional foot in an ambulatory highly active patient. Follow up time since initial intervention was 38 months. CONCLUSION: The use of a permanent PMMA cement spacer does not preclude free tissue transfer in complex host lower extremity reconstruction. A multidisciplinary team approach is a vital component to successful salvage outcomes.

Septic Shock following Prostate Biopsy: Aggressive Limb Salvage for Extremities after Pressor-Induced Ischemic Gangrene.

Vasopressors used to treat patients with septic shock can cause ischemic necrosis of appendages such as the ears and nose, as well as the extremities. Cases of quadruple-extremity necrosis have high morbidity and mortality, and a profound negative impact on quality of life. This case report details the successful limb salvage and return to function using free tissue transfer as a means to salvage bilateral lower extremities in a patient who suffered vasopressor-induced ischemia of upper and lower extremities after prostate biopsy-induced septic shock. Septic shock following transrectal ultrasound-guided prostate biopsy is a rare, yet life-threatening complication. Successful treatment included thorough planning and staging of therapies such as awaiting tissue demarcation and serial surgical debridement to adequately prepare the tissue bed for free tissue transfer. Adjunctive treatments such as hyperbaric oxygen therapy, negative-pressure wound therapy, and meticulous wound care played a crucial role in wound healing. This vigilant planning and coordinated care resulted in the successful lower extremity salvage, consisting of bilateral transmetatarsal amputations and free tissue transfer to both limbs. We present our long-term follow-up of a functional ambulatory patient after catastrophic, life-threatening infection and appropriate multidisciplinary care.

Comparison of Completion Rates for SF-36 Compared With SF-12 Quality of Life Surveys at a Tertiary Urban Wound Center.

Patient-reported outcome measures derived from quality of life instruments are an important tool in monitoring disease progression and treatment response. Although a number of validated instruments are available, the Short Form-36 (SF-36) quality of life survey is the most widely used. It is imperative that the patients answer all the questions in this instrument for appropriate analysis and interpretation. It has been hypothesized that fewer questions (i.e., the Short Form-12 [SF-12]), will result in greater survey completion rates. The present study was a randomized prospective study comparing the completion rates for the SF-36 and SF-12 quality of life surveys. Patients presenting with a chronic wound were asked to complete the SF-36 or SF-12 survey. After an a priori power analysis was performed, the completion rates, patterns of skipped questions, and demographic information were analyzed using t tests for continuous variables or Fisher's exact test for categorical variables and both multivariate linear regression and logistic regression. A total of 59 subjects (30 completed the SF-12 and 29 completed the SF-36) participated in the present study. The SF-12 group had an 80% (24 of 30) completion rate compared with a 55% (16 of 29) completion rate for the SF-36 group (p < .05). However, the length of the survey did not affect the completion rate nor was a statistically detectable pattern of skipped questions found. College graduates were more likely to complete both surveys compared with high school graduates (p < .07). Although it is unclear why, our study results indicate that the SF-12 yields a higher total survey completion rate. However, completion appears independent of the shorter survey length.

Long-Term Outcomes of Permanent Cement Spacers in the Infected Foot.

When osteomyelitis occurs in the infected foot, cement spacers have been used as a limb salvage tool. The aim of the present study was to assess the longevity and outcomes in high-risk, low-demand patients who have undergone resection of bone and subsequent placement of permanent antibiotic-eluting cement spacers in the foot. A retrospective review case series of 30 patients who had undergone placement of a permanent antibiotic-eluting cement spacer in the foot were evaluated for retention, spacer exchange, removal, amputation, and functional status. The minimum follow-up time for inclusion was 12 months. Two thirds of all patients had successful spacers (n = 20) that were either retained (n = 14) or successfully exchanged (n = 6). One third of all patients experienced spacer failure (n = 10) and required removal. Of the 10 patients requiring spacer removal, 4 underwent removal with subsequent arthrodesis and 6 underwent removal with subsequent pseudoarthrosis. Also, 8 of these patients (26.7%) required partial foot amputation of the ipsilateral foot. These amputations were not directly related to the use or removal of the spacer. The average time to spacer removal or partial amputation was 20.9 (range 0.2 to 60.9) months. The longest retained spacer in the foot was 76 months at the last follow-up visit. The longest exchanged spacer at the last follow-up visit was 111 months. All surviving patients were ambulatory at the last follow-up visit.