Patient-reported esthetic outcomes following lower extremity free flap reconstruction: A cross-sectional multicenter study.

INTRODUCTION: The goal of lower-extremity reconstructions is primarily to salvage the leg; however, esthetic outcomes are also important. This study aimed to assess the impact of a lower extremity free tissue transfer regarding social functioning, patient-reported esthetic outcomes, and possible differences between fasciocutaneous vs. muscle flaps. MATERIAL AND METHODS: For this cross-sectional multicenter study, patients operated between 2003 and 2021, with a minimum follow-up of 12 months, were identified. Outcomes were obtained from 89 patients. Patient-reported outcomes were assessed using a questionnaire containing 5-point Likert scale questions grouped in three groups: aspect of the reconstructed leg, the aspect of the donor site, and the negative impact on social functioning. Physical functioning and mental health were assessed with the Short-Form-36. RESULTS: The overall score for negative impact on social functioning was 22.2. This was 46.7 for the esthetic satisfaction of the reconstructed leg and 57.1 for the donor site. No significant differences were seen between patients who underwent a reconstruction with a fasciocutaneous flap compared to a muscle flap. Secondary surgical procedures for improving the esthetic aspect were performed in 12% of the patients in the fasciocutaneous group and 0% in the muscle group. CONCLUSION: Our results show that the most optimal esthetic outcome is not defined by the type of flap. We found a strong correlation between physical functioning and the negative impact on social functioning that a reconstructed lower extremity may have. The result of this study can be taken into consideration during the shared decision-making process of choosing the most optimal reconstruction.

Mental health is strongly associated with capability after lower extremity injury treated with free flap limb salvage or amputation.

BACKGROUND: Knowledge about factors associated with long-term outcomes, after severe traumatic injury to the lower extremity, can aid with the difficult decision whether to salvage or amputate the leg and improve outcome. We therefore studied factors independently associated with capability at a minimum of 1 year after amputation or free flap limb salvage. METHODS: We included 135 subjects with a free flap lower extremity reconstruction and 41 subjects with amputation, between 1991 and 2021 at two urban-level 1 trauma centers with a mean follow-up of 11 ± 7 years. Long-term physical functioning was assessed using the Physical Component Score (PCS) of the Short-Form 36 (SF36) and the Lower Extremity Functional Scale (LEFS) questionnaires. Independent variables included demographics, injury characteristics, and the Mental Component Score (MCS) of the SF36. RESULTS: Greater mental health was independently and strongly associated with greater capability, independent of amputation or limb reconstruction. Mental health explained 33% of the variation in PCS and 57% of the variation in LEFS. Injury location at the knee or leg was associated with greater capability, compared to the foot or ankle. Amputation or limb reconstruction was not associated with capability. DISCUSSION: This study adds to the growing body of knowledge that physical health is best regarded through the lens of the bio-psycho-social model in which mental health is a strong determinant. This study supports making mental health an important aspect of rehabilitation after major lower extremity injury, regardless of amputation or limb salvage.

Patient-reported outcomes after free muscle flap coverage for therapy-resistant neuropathic pain from the ulnar nerve.

Extensive microsurgical neurolysis followed by free gracilis muscle flap coverage can be performed as a last resort for patients with persistent neuropathic pain of the ulnar nerve. All patients who had this surgery between 2015 and 2021 were identified. Data were collected from the medical records of 21 patients and patient-reported outcomes were collected from 18 patients, with a minimum follow-up of 12 months. The median visual analogue pain score decreased significantly 8 months postoperatively from 8.0 to 6.0 and stabilized to 5.4 at the 3-year follow-up. Health-related quality-of-life scores remained diminished compared to normative data. In the treatment of therapy-resistant neuropathic pain of the ulnar nerve, extensive neurolysis with a subsequent free gracilis muscle flap coverage shows a promising reduction of pain that persists at long-term follow-up.Level of evidence: IV.

The origin and course of the infrapatellar branch of the saphenous nerve: An anatomical study.

Nerve injury of the saphenous nerve or infrapatellar branch seems to be a frequent complication following knee surgery or trauma. Denervation results vary, and in some cases, no pain relief is achieved. This might be due to anatomic variation. The purpose of this anatomical study is to identify the variation in the course of the infrapatellar branch and saphenous nerve. We dissected 18 cadavers from adult donors. Medial to the knee, the saphenous nerve and infrapatellar branch were identified and followed proximally to the point where the infrapatellar branch branched from the saphenous nerve. The location where the infrapatellar branch came off from the saphenous nerve relative to the knee joint and where it passed the knee joint were measured. A total of 23 infrapatellar branches were found. We identified 10 branches between 0-10 cm proximal to the knee joint, 3 branches at 10-20 cm, and 9 branches at >20 cm. Between the patella and semitendinosus tendon, the knee joint was crossed by 5 branches in the anterior, 15 in the middle, and 2 in the posterior one-third. The origin of the infrapatellar branch and the location at which it passes the knee are highly variable. This, in addition to people having multiple branches, might explain why denervation is frequently unsuccessful. Based on the anatomical findings, we propose a more proximal diagnostic nerve block to help differentiate between a distal-middle or proximal origin of the infrapatellar branch. Appropriate placement of the nerve block might help identify people who benefit from denervation.

Patient-Level Factors Associated with Health-Related Quality of Life and Satisfaction with Body After Bariatric Surgery: a Multicenter, Cross-Sectional Study.

BACKGROUND: Health-Related Quality of Life (HRQL) is a key outcome of success after bariatric surgery. Not all patients report improved HRQL scores postoperatively, which may be due to patient-level factors. It is unknown which factors influence HRQL after surgery. Our objective was to assess patient-level factors associated with HRQL after surgery. METHODS: This international cross-sectional study included 730 patients who had bariatric surgery. Participants completed BODY-Q scales pertaining to HRQL and satisfaction with body, and demographic characteristics were obtained. The sample was divided into three groups based on time since surgery: 0 - 1 year, 1 - 3 years and more than 3 years. Uni- and multivariable linear regression analyses were conducted to identify variables associated with the BODY-Q scales per group. RESULTS: The 0 - 1 year postoperative group included 377 patients (50.9%), the 1 - 3 years postoperative group 218 (29.4%) and the more than 3 years postoperative group 135 patients (18.2%). Lower current body-mass index (BMI), more weight loss (%TWL), being employed, having no comorbidities, higher age and shorter time since surgery were significantly associated with improved HRQL outcomes postoperatively. None of these factors influenced all BODY-Q scales. The effect of current BMI increased with longer time since surgery. CONCLUSION: Factors including current BMI, %TWL, employment status, presence of comorbidities, age and time since surgery were associated with HRQL postoperatively. This information may be used to optimize patient-tailored care, improve patient education and underline the importance of long-term follow-up with special attention to weight regain to ensure lasting improvement in HRQL.

Prevalence of residual limb pain and symptomatic neuromas after lower extremity amputation: a systematic review and meta-analysis.

ABSTRACT: Residual limb pain (RLP) is associated with (partial) extremity amputations and is defined as pain felt in the remaining part of the amputated limb. A common cause of RLP is neuroma formation after nerve transections. Neuromas can be very painful and severely debilitating pathologies, preventing prosthetic use, reducing quality of life, and requiring medication. Residual limb pain and symptomatic neuromas are often not properly recognized by physicians explaining the varying prevalence in the literature. This systematic review and meta-analysis aim to provide a comprehensive overview of published literature on the prevalence of RLP and symptomatic neuroma after lower extremity amputation. Studies reporting the prevalence of RLP and symptomatic neuroma pain in patients who have had a lower extremity amputation published between 2000 and 2020 were identified in PubMed and Embase. Random-effects meta-analyses of proportions were performed to quantify the prevalence of RLP and symptomatic neuroma. Subgroups were identified and analysed. For RLP, the pooled prevalence was 59% (95% CI: 51-67). For symptomatic neuromas, the pooled prevalence was 15% (95% CI: 7-28). Residual limb pain subgroup analysis showed statistically significant higher prevalence in patients aged >50 years, follow-up >2 years, and in studies using a self-administered questionnaire for data collection. The prevalence of RLP and symptomatic neuroma in patients who have had a lower extremity amputation is 59% and 15%, respectively. Knowledge of their high prevalence may result in better awareness among physicians, in turn providing timely and adequate management.