To Mesh or Not to Mesh: What Is the Ideal Meshing Ratio for Split Thickness Skin Grafting of the Lower Extremity?

Split-thickness skin grafts can provide effective autologous wound closure in patients with dysvascular comorbidities. Meshing the graft allows for reduced donor site morbidity and expanded coverage. This study directly compares outcomes across varying meshing ratios used to treat chronic lower extremity wounds. Patients who received split-thickness skin grafts to their lower extremity for chronic ulcers from December 2014 to December 2019 at a single center were retrospectively reviewed. Patients were stratified by meshing ratios: nonmeshed (including pie crusting), 1.5:1, and 3:1. The primary outcome was clinical "healing" as determined by surgeon discretion at 30 days, 60 days, and the latest follow-up. Secondary outcomes included postoperative complications, graft loss, ulcer recurrence, progression to amputation, and mortality. A total of 321 patients were identified. Wound sizes and location differed significantly, with 3:1 meshing applied to the largest wounds (187.8 ± 157.6 cm2; 1.5:1 meshed, 110.4 ± 103.9 cm2; nonmeshed 38.7 ± 55.5 cm2; p < .0001) mostly of the lower leg (n = 18, 75%; 1.5:1 meshed, n = 23, 43.4%; nonmeshed n = 62, 25.7%; p < .0001). Meshed grafts displayed a significantly higher proportion of healing at 30 and 60 days, but no differences persisted by the final follow-up (16.5 ± 20.5 months). Longitudinally, nonmeshed STSG was associated with most graft loss (46, 19.1%; p = .011) and ulcer recurrence (44, 18.3%; p = .011). Of the 3 meshing ratios, 3:1 exhibited the lowest rates of complications. Our results suggest that 3:1 meshing is a safe option for coverage of large lower extremity wounds to minimize donor site morbidity.

Perioperative evaluation of nutritional status to predict complications in patients with major lower extremity amputation.

INTRODUCTION: Optimization of nutritional status is critical in postoperative wound healing. Perioperative Alb and pAlb levels have been used as proxies for overall nutritional status. OBJECTIVE: This study examines if such biomarkers correlate with postoperative complications after MLEA for chronic wounds. MATERIALS AND METHODS: A retrospective review of patients undergoing MLEA at a single institution from January 2017 through October 2021 was performed. Data collection included demographics, comorbidities, and perioperative laboratory values. The primary outcomes were surgical dehiscence, hematoma, and infection within 30 days of surgery. RESULTS: A total of 303 patients undergoing MLEA met the inclusion criteria. At the threshold of less than 3.2 g/dL for low Alb, no significance was found for any postoperative complications. The threshold of less than 10 mg/dL for low pAlb was associated with significantly increased infection rates. At the threshold of less than 9 mg/dL for low pAlb, hematoma and infection were significantly increased compared with the defined normal perioperative pAlb. Alternatively, low Alb (<3.2 g/dL) did not correlate with postoperative complications. CONCLUSIONS: Further investigation of validated biomarkers and their thresholds is needed to guide perioperative optimization of nutritional status after MLEA for chronic wounds.

A Pilot Investigation into Targeted Muscle Reinnervation for Complex Regional Pain Syndrome, Type II.

Complex regional pain syndrome (CRPS) is a debilitating condition, characterized by severe pain with vascular, motor, or trophic changes. Varied presentations make this a diagnostic and therapeutic challenge. There is a lack of high-quality evidence demonstrating efficacy for most existing therapies, particularly with surgical intervention for type II CRPS (CRPS-II). Targeted muscle reinnervation (TMR) is a surgical technique to transfer the terminal end of a divided nerve to a recipient motor nerve, shown to limit phantom limb pain, residual limb pain, and postamputation neuroma pain. Methods: Herein, we describe a series of 13 patients undergoing TMR for CRPS-II by a single surgeon from 2018 to 2021 in the upper (38%) and lower extremities (62%). All patients had a diagnosis of CRPS-II with either traumatic or postsurgical etiology, each seeking TMR with or without concomitant treatment to control their pain after previous therapies had failed. Three patients had previous lower extremity amputation, whereas three others received lower extremity amputation at the time of TMR, each indicated for control of CRPS pain. Results: Of the patients receiving TMR within 1 year of CRPS diagnosis, all three reported improved function, and two patients were able to tolerate a prosthetic for ambulation after previous pain prevented prosthetic use. Of the entire cohort, all but one patient reported reduced pain interference or improved function. Conclusions: These outcomes suggest that TMR may provide some benefit to reducing pain severity patients with CRPS, even after a more chronic disease course. Further prospective trials are warranted.

Student understanding of type 2 diabetes mellitus.

BACKGROUND: An estimated 25.8 million people in the United States have type 2 diabetes, including seven million people who have the disease but are undiagnosed. These numbers indicate that education about diabetes is needed. METHODS: To evaluate university students' knowledge about diabetes (risk factors, signs and symptoms and complications) we utilized a survey. Specifically, we determined: (1) knowledge of type 2 diabetes; (2) if participants' academic field of study affected their knowledge of type 2 diabetes; (3) if participants who had a family member with type 2 diabetes had a greater knowledge of the disease; and (4) if age affected students' knowledge of the disease. RESULTS: A questionnaire was completed by 469 students from The University of South Dakota. Students' knowledge of type 2 diabetes was poor: 30.1 percent of the students scored higher than 70 percent (with only 6.8 percent of the students scoring higher than 80 percent). No significant differences in knowledge scores were found between students who pursued health-related fields of study versus students who did not. Participants who had a family member with type 2 diabetes had a greater knowledge of the disease and felt that they had a higher risk for getting the disease. Significant differences in knowledge were only found between the youngest and oldest age groups. CONCLUSIONS: USD students' knowledge of type 2 diabetes is limited. Solutions need to communicate the risk factors and severity of the disease. Possible ways for improving diabetes education is to include health fairs as well as to integrate diabetes modules into K-12 education courses.