Patients with chronic limb-threatening ischemia, advanced foot wounds, and no pedal revascularization targets often face amputation. Deep vein arterialization has significant drawbacks. We report three cases using flow-through free flaps with microvascular distal foot arterialization to salvage ischemic feet with complex wounds. All flaps survived. Patients achieved wound healing and ambulation. Two maintained perfusion at 3 and 6 years. One required transmetatarsal amputation at 14 months but remains ambulatory. This technique provides a novel salvage option for the “no-option” foot by combining soft tissue coverage and selective arterialization of small distal veins, avoiding complications of deep vein arterialization and offering durable perfusion.

Heel wounds in patients with diabetes and peripheral vascular disease present significant reconstructive challenges due to their location on a weight-bearing surface and the high risk of delayed wound healing. These wounds require durable coverage that can withstand mechanical stress. The medial plantar flap is the ideal reconstruction for glabrous defects, but may be limited by insufficient tissue availability and donor site morbidity, which is more significant in patients with compromised healing potential. A 64-year-old man with uncontrolled type 2 diabetes presented with a severe right heel wound, complicated by osteomyelitis and extensive tissue loss. Surgical treatment included excisional debridement, partial calcaneal resection, and reconstruction with a pedicled medial plantar artery flap (MPAF) for the weight-bearing heel subunit. A chimeric thoracodorsal artery perforator (TDAP) flap was used to provide additional coverage for the posterior subunit of the wound and the MPAF donor site. Postoperatively, the patient had no flap-related complications. Two minor areas of wound dehiscence were treated with re-excision and closure. At the final follow-up, the patient demonstrated full wound healing and resumed ambulation without further complications. The combined use of MPAF and TDAP flaps provides immediate, durable coverage for wounds encompassing multiple heel subunits, as well as immediate closure of the high-risk MPAF donor site. The thick back skin of the TDAP is ideal for durability with weight-bearing. This dual-flap approach offers a promising solution for challenging reconstructions in weight-bearing areas and may help prevent complications such as donor site wound breakdown.

The increasing prevalence of chronic limb-threatening ischemia and diabetes mellitus has led to a surge in lower extremity amputations, driven by the combination of peripheral arterial disease and extensive wounds. Although revascularization often addresses ischemia, severe wounds pose a significant risk of amputation. Flaps, which involve the transfer of vascularized tissue, can provide immediate closure of complex wounds, particularly those involving bone or tendon exposure, where skin grafts are insufficient. Flap reconstruction of wounds can prevent amputation in cases when revascularization alone would not, but these complex efforts require close collaboration between vascular and plastic surgeons. Despite their potential to prevent amputations, flaps are underused in vascular surgery due to limited availability and expertise, particularly in complex cases involving diabetes and peripheral vascular disease. There are also socioeconomic and reimbursement challenges that limit interest on the part of plastic surgeons. This article explores the principles, techniques, and challenges of flap reconstruction in lower extremity limb salvage, emphasizing the need for multidisciplinary care.

Thumb opposition is an essential component of human hand function, and loss of the thenar musculature creates substantial disability of the hand. Additionally, first web space contracture as a result of trauma is a substantial limitation in reconstruction of thumb opposition. Reconstruction of thenar function is most commonly performed via opponensplasty tendon transfers. Although beneficial, tendon transfers require cortical retraining and fall short of native function. These may be the only option in the case of median nerve palsy. However, at times, thenar function is lost owing to thenar muscle injury with preserved median nerve function. Common examples include palmar soft tissue trauma and compartment syndrome. In such cases, intuitive thumb opposition can be restored with free functional muscle transfer innervated by the thenar motor branch of the median nerve. In addition, first web space release can be achieved in the same procedure. Here, we have demonstrate the benefits of this procedure versus opponensplasty, review long-term outcomes of successful cases including videographic documentation of function, and provide expert guidance to surgeons considering performing this procedure.

BACKGROUND:Chronic lower extremity (LE) wounds in diabetic and vasculopathic populations frequently lead to amputation. Microvascular free tissue transfer (FTT) is a limb salvage option, but outcomes in patients with peripheral vascular disease (PVD) are variable. This study aimed to assess the severity of PVD using accepted standardized metrics to predict morbidity and negative outcomes in patients undergoing LE FTT. METHODS:A retrospective review of 97 FTT procedures performed between January of 2018 and April of 2023 was conducted. PVD severity was assessed using Wound, Ischemia, and Foot Infection (WIfI), Global Limb Anatomic Staging System (GLASS), and medial arterial calcification (MAC) scores. Outcomes of interest included flap failure, amputation, mortality, and major morbidity at various time points. RESULTS:Overall, flap failure occurred within 30 days in 8.2% of cases, and amputation within 90 days occurred at a rate of 5.2%. In patients with incomplete pedal arches (ie, pedal GLASS scores of P1 or P2), there were increased rates of 90-day mortality (11.1% versus 0; P = 0.026) and 30-day flap failure (18.5% versus 3.2%; P = 0.026). Severe MAC scores were associated with increased 90-day mortality ( P = 0.002), 1-year mortality ( P = 0.003), and major morbidity. WIfI scores were not significantly associated with negative outcomes. CONCLUSIONS:PVD severity can be objectively assessed using pedal GLASS and MAC scores to guide patient selection for LE FTT. In patients with an incomplete pedal arch and extensive vascular calcifications, there is a significantly higher risk of major adverse outcomes, emphasizing the need for careful preoperative assessment and shared decision-making in limb salvage procedures.

SUMMARY:Optimal reconstruction of weight-bearing plantar foot defects is challenging due to the need for relatively thin coverage with simultaneous durability. The medial plantar flap provides an excellent tissue match but is not always available or appropriate. Microsurgical free-flap reconstruction provides many options for coverage. However, few skin flaps are thin enough to contour appropriately but still provide thick dermis for durable weight-bearing, particularly in patients with an average or obese body habitus. The back and buttocks provide the thickest skin in the body, but relatively little attention has been paid to use of these flaps in the foot. The suprascarpal plane of elevation has been increasingly used to provide tailored coverage with appropriate thickness matching to the surrounding tissues. Even thinner "ultrathin flaps" are raised within the subcutaneous fat superficial to the Scarpa layer. Little attention has been paid to applying this concept specifically to flaps from the back that provide thicker skin. The scapular and parascapular flaps have many ideal characteristics for foot reconstruction, including minimal donor-site morbidity, simple pedicle dissection, short pedicle for appropriate reach to nearby recipient vessels, and thick skin for durable weight-bearing. However, thus far, these flaps seem to have been overlooked as candidates for suprascarpal or ultrathin elevation to provide a thin flap with thick skin coverage for plantar foot reconstruction. In this article, the authors present a case series exemplifying the utility of the thinned parascapular flap elevated at the ultrathin plane for reconstruction of weight-bearing plantar foot defects.

Distal lower extremity wounds are a challenging problem for reconstructive surgeons and can lead to major lower extremity amputations in patients with comorbid conditions. The reverse sural artery flap (RSAF) is a local flap supplied by perforators of the peroneal artery that can cover defects of the distal lower extremity, ankle, and foot. There has been concern over performing the RSAF in patients with venous insufficiency, peripheral artery disease, and diabetes, and in older patients due to the increased risk of flap necrosis. In patients who are not microsurgical candidates, the RSAF may be the final option for reconstruction before undergoing major lower extremity amputation. We describe our experience with two patients with significant comorbidities and single vessel runoff from the peroneal artery due to atherosclerotic disease who successfully underwent RSAF reconstruction for distal lower extremity wounds.

Summary:. Chronic neuropathic pain following major limb amputation has historically been difficult to treat. In patients undergoing lower extremity amputation, “preemptive” targeted muscle reinnervation (TMR) nerve transfers may be performed concurrently with the amputation to help mitigate the risk of chronic neuropathic postoperative pain. Despite clinical studies demonstrating efficacy of TMR in lower extremity amputations, few procedural descriptions have been written, and none have been written regarding performing TMR at the knee disarticulation (KD) level of amputation. Although uncommonly utilized, the KD amputation has clear functional benefits over other levels of amputation for nonambulatory patients. As nonambulatory patients are also subject to the occurrence of chronic neuropathic postamputation pain, it stands to reason that the addition of TMR to KD surgery could be an improvement to standard techniques. In this report, we provide a technical description for concurrent TMR with KD and describe the rationale for its use.

Summary:. The reconstruction of distal extremity wounds poses a unique surgical challenge. In free tissue transfer, a thin, pliable skin flap is the ideal. Obese patients have a paucity of thin skin donor sites. Herein we report the discovery of a free SHRIMP flap (Superthin Harvest of a Reliable Islanded Medial Pannus flap) based on the SIEA vessels, harvested from a thick abdominal pannus at the time of cosmetic abdominoplasty. A 61-year-old woman with a chronic wound of the right Achilles tendon was evaluated for reconstruction after failing conservative measures. At the time of consultation, the patient expressed interest in abdominoplasty. Therefore, a skin flap from the abdomen or rectus abdominis muscle flap in the context of an abdominoplasty was offered. Despite obesity affecting the pannus, the superficial inferior epigastric vessels were found to course superficially beneath the dermis at time of abdominoplasty. This allowed straightforward harvest of a superthin flap of skin and minimal subcutaneous fat, which contoured to the ankle with an aesthetically pleasing outcome. The patient was satisfied with the results of her abdominoplasty and coverage of her chronic wound. The SHRIMP flap provides a straightforward, axial pattern, superthin free skin flap based on the superficial inferior epigastric vessels, and represents a useful option in obese patients. The flap can be combined with abdominoplasty for an aesthetic donor site.

The WIfI (wound, ischemia, and foot infection), MAC (medial arterial calcification), and GLASS (global limb anatomic staging system) grading scales have recently been adopted by the Society of Vascular Surgery as predictors of amputation rates and failure of revascularization in patients with chronic limb-threatening ischemia (CLTI). However, these metrics have not taken into account the ability of free tissue transfer (FTT) to shift these outcomes. This study seeks to characterize whether the addition of free tissue transfer can facilitate limb salvage in patients who would otherwise be deemed as high risk for failure using these grading systems.

People with lower limb loss, especially of dysvascular etiology, are at substantial risk for both ipsilateral and contralateral reamputation. Additionally, while not as well documented for reamputation, there is recognition that amputation incidence is influenced by not only sociodemographic factors such as sex, race, socioeconomic status, but also by system factors such as service access. A systems strategy to address this disparity within the field of limb-loss rehabilitation is for Limb-loss Rehabilitation Programs (LRP) to partner with medical specialists, mental health professionals, and Limb Preservation Programs (LPP) to provide comprehensive limb care. While LPPs exist around the nation, design principles for such programs and their partnership role with LRPs are not well established. Using a socioecological model to incorporate hierarchical stakeholder perspectives inherent in the multidisciplinary field of limb care, this review synthesizes the latest evidence to focus on LPP design and implementation principles that can help policymakers, healthcare organizations and limb-loss rehabilitation and limb-preservation professionals to develop, implement, and sustain robust LPP programs in partnership with LRPs.

Summary: Targeted muscle reinnervation (TMR) has emerged as a useful solution to the problem of painful neuromas and is increasingly being applied in many clinical circumstances. Relatively little has been written about TMR for painful neuromas of the hand, and what has been written describes use of the intrinsic muscles as recipients for the nerve transfer. Except in cases of amputation, intrinsic muscle sacrifice carries morbidity. Furthermore, TMR to intrinsic muscles will place the nerve coaptation in areas subject to pressure with loading of the palm. For these reasons, the pronator quadratus may be a preferable target muscle when performing TMR for painful neuromas of the hand. In this report, we describe the rationale for its use and demonstrate the surgical technique and outcomes with case examples.

Introduction Little emphasis has been paid toward characterizing the socioeconomic burdens experienced by patients seeking treatment for chronic nerve injuries. The aim of this study was to characterize the direct and indirect costs faced by patients with chronic nerve injuries and their attendant health care utilization. Materials and Methods A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice treated for chronic nerve injuries in the ambulatory setting between 2014 and 2020. Data collected included demographics, etiology, comorbidities, duration and severity of symptoms, history of prior medical and interventional treatments, work or school time lost due to injury or treatment, money spent on treatment, and health care utilization. Results Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years, 68.9% female and 31.1% male. Patients with chronic nerve injury reported significant direct costs, indirect costs, and health care utilization associated with their nerve injury symptoms. Direct costs consisted of out-of-pocket spending (68.4% had spent >$1000 per year), physician specialists visits (71.3% had seen at least 4 specialists), and prior interventional procedures intended to address symptoms. Indirect costs included lost time from work or school (24.6% had missed more than 12 months). Health care utilization, represented by annual emergency room visits and hospitalizations related to nerve symptoms, was increased relative to the general population. Detailed statistics are presented in the manuscript. Conclusions Chronic nerve injuries may be associated with a notable socioeconomic burden to the patient, including missed work or school, frequent physician visits and procedures, hospital visits, and out-of-pocket costs. Interdisciplinary algorithms recognizing a role for surgical evaluation in patients with chronic neuropathic pain due to underlying nerve injuries would facilitate future research into whether timely surgical intervention may reduce this economic burden.

Background:. Although it was initially described for improved myoelectric control, targeted muscle reinnervation (TMR) has quickly gained popularity as a technique for neuroma control. With this rapid increase in utilization has come broadening indications and variability in the described technique. As a result, it becomes difficult to interpret published outcomes. Furthermore, there is no literature discussing the management of failed cases which are undoubtedly occurring. Methods:. This is a retrospective case series of two patients who underwent revision surgery for failed TMR. The authors also review the current literature on TMR and outline technical and conceptual pitfalls and pearls based on our local experience. Results:. Excessive donor nerve redundancy, kinking, donor–recipient nerve size mismatch, superficial placement of the nerve coaptation, inappropriate target selection, and incomplete target muscle denervation were identified as technical pitfalls of TMR surgery. Techniques to avoid these pitfalls were described. Conclusions:. Although TMR has been a major development in amputee care for both pain management and improved myoelectric control, it is important to acknowledge that it is not a foolproof surgery and does not provide a guaranteed result. Failed cases of TMR represent opportunities to learn about factors contributing to unfavorable outcomes and refine our techniques empirically.

The department of surgery at Washington University is putting increased emphasis on outcomes for amputees. This multidisciplinary effort begins with choosing the correct surgery and incorporating the latest technical advances in amputation surgery.

Background: Little emphasis has been paid to characterize quality of life (QoL) burdens experienced by patients seeking surgical treatment for nerve injuries and neuropathic pain. Methods: A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice between 2014 and 2019. Data collected included demographics, specifics of the injury and symptoms, time to referral, and effects of the injury, surgery, and timing of surgery on QoL. Results: Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 years; 68.9% of patients were women and 31.1% men. At presentation, 68% had experienced symptoms for more than 1 year; 86.1% reported severity as being profound; 97.6% reported QoL was at least moderately negatively impacted by nerve injury; 70% felt they should have been referred earlier for surgical evaluation; 51.2% were not told that nerve surgery was an option for their problem; 83.1% felt that earlier referral would have improved their QoL. After surgery, symptoms were significantly mitigated in 55.5% of the patients, moderately mitigated in 21.5%. Patients reported QoL was significantly (59.8%) or at least moderately (76.6%) improved by nerve surgery. Conclusions: The majority of patients reported that nerve injuries imparted a moderate to severe impact on QoL, and that surgical treatment improved QoL. Most patients felt that earlier referral for surgical intervention would have led to better outcome and positively impacted QoL. Interdisciplinary treatment algorithms, including a role for surgical intervention, may be helpful in facilitating timely diagnosis, referral, and thus improved outcomes.

Background and objective High-frequency alternating current (HFAC) can yield a rapid-acting and reversible nerve conduction block. The present study aimed to demonstrate the successful implementation of HFAC block delivery via regenerative macro-sieve electrodes (MSEs). Methods Dual-electrode assemblies in two configurations [dual macro-sieve electrode-1 (DMSE-I), DMSE-II] were fabricated from pairs of MSEs and implanted in the transected and subsequently repaired sciatic nerves of two male Lewis rats. After four months of postoperative nerve regeneration through the MSEs' transit zones, the efficacy of acute HFAC block was tested for both configurations. Frequencies ranging from 10 kHz to 42 kHz, and stimulus amplitudes with peak-to-peak voltages ranging from 2 V to 20 V were tested. Evoked muscle force measurement was used to quantify the nerve conduction block. Results HFAC stimulation delivered via DMSE assemblies obtained a complete block at frequencies of 14 to 26 kHz and stimulus amplitudes of 12 to 20 V p-p. The threshold voltage for the complete block showed an approximately linear dependence on frequency. The threshold voltage for the partial conduction block was also approximately linear. For those frequencies that displayed both partial and complete block, the partial block thresholds were consistently lower. Conclusion This study provides a proof of concept that regenerative MSEs can achieve complete and reversible conduction block via HFAC stimulation of regenerated nerve tissue. A chronically interfaced DMSE assembly may thereby facilitate the inactivation of targeted nerves in cases wherein pathologic neuronal hyperactivity is involved.