Tammer Elmarsafi

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

Abstract 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. &NA; Level of Clinical Evidence: 4

Effect of Semi‐quantitative Culture Results from Complex Host Surgical Wounds on Dehiscence Rates

The primary aim of this study was to determine the effect of positive bacterial cultures at the time of closure on dehiscence rates. Pre‐ and post‐débridement wound cultures from patients undergoing serial surgical débridement of infected wounds were compared with outcomes 30 days postoperatively. One‐hundred patients were enrolled; 35 were excluded for incomplete culture data. Sixty‐five patients were evaluated for species counts, including Coagulase negative Staphylococcus (CoNS), and semiquantitative culture data for each débridement. The post‐débridement cultures on the date of closure had no growth in 42 patients (64.6%) of which 6 dehisced (14.3%), and 36 remained closed; with no statistically significant difference in dehiscence rates (p = 0.0664). Pre‐débridement cultures from the 1st débridement of the 65 patients showed 8 patients had no growth, 29 grew 1 species, 19 grew 2 species, and 9 had 3–5 species. There was a reduction in the number of species and improvement of semiquantitative cultures with each subsequent débridement. The dehiscence rate for those who had 2 débridements (n = 42) was 21.4% at 30 day follow‐up and 21.7% in those who had 3 débridements (n = 23). The number of débridements had no statistical significance on dehiscence rates. The presence of CoNS on the day of closure was a statistically significant risk for dehiscence within 30 days (p = 0.0091) postoperatively. This data demonstrates: (1) positive post‐débridement cultures (scant/rare, growth in enrichment broth) at the time of closure did not affect overall dehiscence rates (p = 0.0664), (2) the number of species and semiquantitative culture results both improved with each subsequent débridement, (3) the number of surgical débridement did not influence postclosure dehiscence rates. (4) Positive cultures containing CoNS at the time of closure is a risk factor for dehiscence (p = 0.0091).

Amputations of the Lower Extremity

Non-traumatic amputations of the lower extremities are a consequence of various medical conditions. The two most common etiologies which lead to lower extremity amputations are peripheral arterial disease and infections. For patients with lower extremity pathology of an ischemic etiology, endovascular and reconstruction options are critical to favorable long-term outcomes. When these corrective measures are exhausted, amputations may become essential. Chronic soft tissue and osseous infections as well as acute infections in the unstable septic patient that require operative management increase the risk of lower extremity amputations. The patient populations most prone to develop both peripheral arterial disease and infections are those with advanced age, smokers, immune compromise, diabetes mellitus, and patients with renal disease. When peripheral polyneuropathy is encountered, patients are at the highest risk for lower extremity amputations. A thorough algorithm provides both the clinician and the patient with the opportunity to moderate disease, mitigate risk, and implement a management strategy that incorporates postoperative function and ambulation as the primary objectives.

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.

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

Abstract 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. &NA; Level of Clinical Evidence: 3

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

&NA; 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 Fishers 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. &NA; Level of Clinical Evidence: 3

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

Highlights • 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.• Charcot Neuroarthropathy often requires osseous reconstruction, which can be complicated with osteomyelitis and hardware infection.• 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.