Limb salvage surgery, also called limb sparing surgery, is a surgical approach designed to prevent amputation. The primary goal of limb salvage is to restore or improve function in the traumatized limb and facilitate the return to normal life. The team also takes extensive steps to address aesthetics concerns by minimizing post traumatic scars and contour deformity.
We combine the strategic combination of microvascular surgery and skeletal stabilization—among other complex procedures—to achieve this goal.
There are certain types of fractures that may put a patient at risk for amputation. These include:
Fractures with severe soft tissue compromise
Fractures with severe compromise of the bony architecture
Fractures with extremely poor or non-salvageable blood supply
Limb sparing surgeons will attempt to salvage most extremities, open wounds, and fractures in a shared-decision making model with patients and their families. This means you or your loved one will understand the injury, its effects, the surgical process and rehabilitation, and together with your medical team, make the decision that offers the best outcome.
Before any limb salvage reconstruction is performed, our surgical team will clean out any infection and assess tissue. Damaged tissue must be carefully examined for extent of injury. Only when this information is known can the Penn surgical team determine if a reconstruction is possible or advisable.
To quantify the severity of your trauma, our experts will evaluate your case based on:
Ischemia (inadequate blood supply to part of the body)
Soft tissue injury
Overall health/any comorbidities
Several scoring systems are also in place to help physicians assess the severity of the trauma. They include:
Mangled Extremity Severity Score– a grading system for the early assessment of severely injured lower extremities
Predictive Salvage Index (PSI)
Limb Salvage Index (LSI)
Mangled Extremity Syndrome Index (MESI)
Hannover Fracture Scale
If our surgical team concludes that a reconstruction is possible and the limb can be saved, the next step will be to repair broken bones, reconnect arteries and veins, and cover wounds with flaps of tissue and grafts of tissue.
Microvascular Surgery for Limb Salvage
Microvascular surgery is a subspecialty of microsurgery and involves highly specialized skill. It is performed on tiny blood vessels ranging from three to five millimeters in diameter using an operating microscope and sutures small enough to pass through a human hair. In reconstructive surgery, microvascular surgeons are able to restore form and function by grafting soft tissue, repairing nerves, and repairing blood vessels.
Using an array of microsurgical tissue transfers, Penn surgeons will provide new living tissue for wound closure by taking living tissue from a donor site in your body and transferring it to fill the damaged area using microsurgical techniques. Using your own tissue is referred to as an autologous tissue transfer or free tissue transfer (free flaps), whereas an allograft flap is taken from a donor.
Reconstruction includes tissue and muscle transfer, reconnecting or replacing major blood vessels, and nerve repairs with the goal of optimizing function.
Types of Flaps Used in Microvascular Surgery
In limb salvage cases, free flaps are used in a variety of ways to not only avoid amputation but to also optimize function. Free flaps can save a limb by closing a wound or filling in a defect.
The types of flaps used in microvascular surgery include:
Free skin flap— a flap made of healthy skin and tissue
Free muscle flap— a flap of muscle that is used primarily to provide a well-vascularized soft tissue that is relatively resistant to infection
Free vascularized bone flap— a live bone placed in the area of a defect where the blood supply is re-attached so the bone continues to receive the nutrients it needs to heal
Types of free vascularized bone flaps include:
Iliac Crest Flaps
Periosteal flap— refers to the membrane several cell layers thick that covers almost all of every bone; flap that covers the outer surface of bone
Allograft flaps– a donor flap of skin, tissue, and/or muscle.
Revascularization of Affected Tissue
In cases of severe trauma, blood flow to affected tissues can be compromised resulting in necrosis–death of body tissue. Early treatment is critical if necrosis is suspected. Using microvascular techniques, our team is able to restore blood flow to the affected area and avoid amputation or more severe debridement (removal of damaged tissue).
In patients with traumatic skeletal defects, bone infection, or tumor removal, there are several options for skeletal reconstruction including autologous bone grafts, vascularized bone transfer (pedicled or free), and the Ilizarov technique.
Autologous bone graft is bone that is harvested from your own body, usually from the pelvis. This procedure is done to augment bone regeneration.
Allograft bone replacement is harvested from a cadaver and used in bone regeneration.
Vascularized bone transfer is a transfer of a bone or portion of a bone in which the circulation is maintained and allows it to be immediately established after surgery in the transplanted area.
Ilizarov technique is an apparatus with a set of external fixators consisting of rings, rods and wires, all made of stainless steel that stimulates bone growth in non‐unions and regenerates bone lost due to infection.
Complex Fracture Care uses advanced reconstruction techniques beyond standard plates, screws and rods, Penn uses 3D printing for custom fracture solutions.
Limb Lengthening For some patients, limb salvage requires the removal of bone resulting in limb length discrepancies. For these patients, as well as other individuals with limb length imbalance, the Penn Orthoplastic Limb Salvage Center provides the most advanced limb lengthening procedures. This treatment corrects height proportion, balances the patient’s gait, and addresses aesthetic concerns.
Our surgeons will select the appropriate method as determined by the size and severity of your bone defect for a skeletal reconstruction.
For patients who are experiencing pain, deformity or functional limitations caused by initial trauma surgery or previous reconstruction, our surgeons are equipped to provide care unavailable elsewhere in the region.
Our team of experts works tirelessly to see that you receive a thorough evaluation and treatment plan to address these issues with the goal of getting you to where you want to be–and can be.
Our limb restoration program offers experts in the fields of orthopaedics, vascular surgery, plastic surgery, rehabilitation, diabetes management, infectious disease, prosthetics, orthotics and others to review your unique case and develop a proper limb revision surgery plan.
Patients who qualify for limb restoration include those dealing with:
Suboptimal function of the limb–limited range of motion, problems with weight bearing, and loss of strength
Painful limb caused by nerve damage
Severe post-traumatic scarring and contour deformity
For patients with malunions or non unions, Penn will develop a dedicated care and reconstruction plan that addresses the cause and fixes the fracture.
Functional impairment following trauma or surgery may include impaired range of motion, problems with weight bearing, and loss of strength. These issues often require a complex treatment plan to correct. The causes for these issues range from bone loss, muscle loss, scar tissue, retraction of muscle, inadequate soft tissue coverage, and other complications – each of which must be addressed.
The surgeons specialize in microsurgery, a type of surgery that requires the use of specialized microscope technology and precision tools to perform intricate operations on tiny structures such as tissue and blood vessels.
For patients dealing with functional limitations following trauma reconstruction, microsurgery enables surgeons to resolve these complex issues, and restore form and function to patients impaired by disease, trauma, or suboptimal surgical results.
Depending on your specific case, our surgical team may opt for one of the following treatment options.
Soft Tissue Revision
Using microvascular surgery, surgeons are able to repair soft tissue defects that may have occurred due to free flap failures performed in previous surgeries.
Especially found in patients following joint replacements, revision microvascular surgery aims to repair soft tissue defects that have exposed bone, tendons, nerves, vessels, hardware, or soft tissue that has persistent infection that does not clear up.
Proper soft tissue reconstruction is a vital factor of limb sparing surgery. Through advances in microsurgery, Penn surgeons are able to correct soft tissue complications with better outcomes and improved cosmetic appearances.
Microvascular Free Tissue Transfer (Free Flaps)
Free tissue transfer or flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site. Free flaps are used to provide blood supply, tissue, and sensation to the injured site.
In cases where there are functional issues of a limb, free flap transfer may be the recommended option.
There are various types of flaps. Your surgeon will determine which type of flap is appropriate for your limb restoration.
Free skin flap
Free muscle flap
Free vascularized bone flap
Microvascular Scar Revision
Scar tissue that develops over time may interfere with range of motion, movement of muscle, and may cause pain. It is important that scar tissue is removed in order to address these issues and restore the strength and proper range of motion in your limb.
Our surgeons connect tissue and blood vessels using microvascular techniques to transplant tissue during your scar revision. Your surgeon will discuss this option with you in detail so you know what to expect.
Nerve Transfer Microsurgery/Total Muscle Innervation for Nerve Pain
Chirurgiaplastica.md offers the latest advancements in nerve reconstruction surgical methods to ensure optimal outcomes and patient satisfaction for those who are experiencing impaired mobility or pain due to an injured limb.
Nerve transfer microsurgery is essentially a re-wiring of a nerve to eliminate pain or restore function and sensation. The nerve is taken from another part of your body and transplanted at the injury site. The transplanted nerve will grow and strengthen the connection between the brain and the injury site. Within time, the nerve transfer will restore communication between the brain and limb and should restore function.
The same technique applies to total muscle innervation where a nerve is transplanted into muscle fiber, innervating the muscle, bringing function and sensation.
These types of procedures may also be useful for amputees who suffer from phantom limb pain.
Complex Fracture Care
COMPLEX FRACTURE CARE
A complex fracture refers to a break that is severe and includes injury to joints, ligaments, soft tissues and tendons. If you have a complex fracture, our team is uniquely equipped to provide the comprehensive care you need. Complex fractures require intensive treatment, surgical expertise and proper rehabilitation.
Our multidisciplinary team approach ensures that you receive the best possible treatment through the use of cutting edge diagnostic tools combined with advanced soft tissue and bone reconstruction techniques. We utilize sophisticated imaging like 3D CT scans and digital tomography to provide the best possible view of the fracture when planning for treatment.
Our orthopaedic surgeons combine 3D printing and radiologic studies to create personalized, implantable metal devices for patients with challenging and complex reconstructions.
Complex Fracture Care includes:
Advanced 3D imaging for superior visualization
3D printed, custom fracture solutions
Coordinated plan for soft tissue and bone reconstruction
Ring fixation which is less invasive and has less risk for infection long term
Dynamic fixation for fractures that require more flexibility for optimal recovery
Implants impregnated with antibiotics for patients at high risk of infection
Optimized bone growth by using biologics and the Masquelet technique which promote healing
Complex fractures are complicated and require a lengthy healing process from surgery to rehabilitation since more than just bones are impacted. It’s important for treatment plans to be carefully designed since no two fractures are the same.
After debridement, which is the removal of dead tissue and cleaning of healthy tissue, stabilization may be accomplished through several ways: external, internal or ring fixation with extensive antibiotic coverage. We often use what is called external ring fixation which requires no implants or metal – eliminating the risk of implant infection.
Once the soft tissue and bone are stabilized, surgeons will evaluate the injury with additional studies and imaging and determine the best treatment plan including techniques and expertise from all specialties in the center including orthopaedic trauma, microvascular surgery, plastic surgery, and other specialties.
A treatment strategy may include a range of options including:
Fracture fixation: A fracture fixation is a surgical procedure that stabilizes the affected limb, preparing for transfer or reconstruction.
Debridement: Removal of dead tissue which is necessary for proper wound healing.
Soft tissue coverage: Soft tissue coverage comes mostly from the patient’s own tissue. Surgeons use local tissue and grafts – usually taking a much smaller amount of skin or tissue than previously required to cover injuries.
Revascularization: In cases of severe trauma, blood flow to affected tissues can be compromised resulting in necrosis–death of body tissue. Early treatment is critical. Using microvascular techniques, the Penn team is able to restore blood flow to the affected area and avoid amputation or more severe debridement (removal of damaged tissue).
Fracture reconstruction:Surgery to fix a broken bone typically using metal screws, rods, or plates to hold the bone in place as it heals. In addition to traditional screws, Penn also uses state-of-the-art dynamic screws and plates for fractures in locations that require more flexibility for optimal healing. Penn also utilizes 3D printed implants for custom reconstruction.
Limb lengthening is a process used to correct limb length discrepancies due to a number of factors including:
Disease such as scoliosis, polio
Congenital defect such as hemimelia
Constitutional low stature
In many cases, patients with limb length discrepancies use shoe lifts, canes, crutches, braces, or other devices for mobility. However, without limb equality, body mechanics–or the way we move–is greatly impacted.
Limb lengthening is a surgical treatment that corrects height proportion, balances the patient’s gait, and addresses aesthetic concerns. The process of limb lengthening requires time, patience, and precision. The reconstructive surgeon performs a surgical osteomy (breaks) on the femur and/or tibia through small incisions in the affected leg.
Benefits of Limb Lengthening
Patients who undergo limb lengthening report the following benefits:
Balanced gait and walk
Bone Tumors Surgery
BONE TUMORS SURGERY
The diagnosis and treatment of bone tumors requires a multidisciplinary approach, which involves the close collaboration of a team of physicians from different medical specialties.
There are numerous studies showing that early detection of tumors and multidisciplinary therapeutic approach to cases could improve outcomes and chances of survival in patients with bone tumors.
The management of a bone tumor depends on several factors, such as the type, size and stage of the tumor, family history and the presence or absence of a genetic predisposition. In general, most benign bone tumors are kept under observation, while surgical treatment is the main therapeutic approach for malignant bone tumors. Ideally, however, each suspected case of bone tumor should be evaluated by an oncology commission (Tumor Board), which establishes an order and priority in the recommended treatments.
The main symptom of a primary bone tumor is pain, pain that is not usually associated with movement and physical exertion and that manifests itself especially at night. As the tumor grows, a mass of tissue (nodule) may be visible or palpable, and a disturbance of local circulation or local sensitivity may occur in a particular area – lower limb (foot) or upper limb (hand). Also, another sign associated with bone tumors is the functional deficits, the inability to do certain things, installed relatively suddenly, within one or two months, compared to the functional deficits associated with osteoarthritis that sets in in a few years.
Regarding the accurate determination of the diagnosis of a bone tumor, it is essential that the patient who reaches the doctor perform a series of imaging investigations. It starts with an X-ray, after which, depending on the type of tumor – bone or soft tissue tumor – a CT scan or MRI is performed, investigations that must be done to establish the differential diagnosis.
Surgery – the main option and rescue in most bone cancers
Most bone tumors are usually treated with surgery. And the type of surgery depends on the type of tumor, its stage and location.
When it comes to bone tumor surgery, there is a great emphasis on curative surgery, in the sense that surgeons opt for surgery that allows them to remove as much or completely of the tumor.
We have the surgical techniques currently used in the world in the treatment of bone cancers: classic tumor excision, about resections followed by stents with tumor reconstruction prostheses.
As for benign bone tumors, the vast majority of them – chondromas, solitary bone cysts, nonosifying syndrome – are life-threatening tumors. Therefore, some benign tumors need to be monitored and supervised.
However, there are also benign bone tumors that require surgery. For example, a myeloplaxis tumor or a giant cell tumor that is theoretically a bordeline tumor that has the potential for malignancy and can lead to complications. Giant bone cysts or aneurysmal cysts can also lead to bone fractures and affect quality of life.
Soft Tissues Tumors Surgery
What are the soft parts of the body?
The soft parts are tissues of common embryological origin, including fibrous, fatty, muscular tissue, blood and lymph vessels, and the peripheral nervous system.
Soft tissue tumors are of many types, depending on the tissue they come from.
lipoma – a benign tumor made up of fat cells
liposarcoma – a malignant tumor made up of fat cells
fibroid – a benign tumor made up of fibrous cells
fibrosarcoma – a malignant tumor made up of fibrous cells
hemangioma – a benign tumor made up of blood vessels
hemangiosarcoma – a malignant tumor derived from fibrous cells
What are the causes of these tumors?
certain genetic abnormalities predispose to the appearance of soft tissue tumors
irradiation probably produces certain genetic changes responsible for cell multiplication
exposure to certain toxic substances in the environment (arsenic, thorium dioxide, vinyl chloride, etc.) can lead to tumors
chronic lymphedema, ie prolonged accumulation of lymph in tissues can cause malignant tumors of lymphatic vessels
Certain viral infections may increase the risk of soft tissue tumors
How are soft tissue tumors classified?
Depending on the local or remote aggression, soft tissue tumors were divided into 4 categories:
Benign – does not recur (does not reappear after being surgically removed), does not cause significant local damage, does not metastasize at a distance
Intermediate, locally aggressive – are locally aggressive (cause local destruction), may recur, do not metastasize
Intermediate, rarely metastatic – they are aggressive locally, may recur, sometimes may metastasize
Malignant (soft tissue sarcomas) are aggressive locally, recur frequently, the risk of metastasis is high.
What is the evolution of soft tissue tumors?
In general, soft tissue tumors grow centipedes, most often remaining confined to a specific region of the body; Depending on their nature, tumors can grow slowly (over several years) or rapidly (in weeks-months). Aggressive tumors can exceed the limits of a compartment of the body, invading the surrounding regions.
As they grow, tumors can compress neighboring tissues or invade neuro-vascular structures, causing pain, sensitivity or motor disorders. Certain types of tumors tend to local recurrence (to reappear after being surgically removed) or distant metastasis (lymph node invasion or the appearance of secondary tumors in tissues distant from the primary tumor).
What treatment is indicated?
Surgery is an essential component of any treatment plan for soft tissue tumors. Complete excision (removal) of the formation is the appropriate treatment for benign tumors. Sarcomas (malignant tumors) often require combined treatment (surgical excision associated with radiotherapy or chemotherapy).
The purpose of the operation is the complete removal of the tumor, within the limits of oncological safety (ie obtaining resection margins that do not contain tumor cells).
During the preoperative consultation, the plastic surgeon will follow the following aspects:
will establish the location and size of the tumor;
will evaluate the consistency of the tumor (eg the lipoma is soft, while the fibroid is firm to the touch)
will evaluate the mobility of the tumor (a fixed tumor may suggest invasion in neighboring tissues)
will feel the lymph nodes in the vicinity of the tumor; the presence of lymphadenopathy may suggest an inflammatory process or the spread of a malignant tumor in the lymph nodes.
will evaluate the patient’s health condition and will obtain information related to his medical history. Last but not least, the doctor will recommend preoperative investigations (blood tests, imaging investigations) and will adjust or stop the administration of drugs that increase the risk of bleeding (aspirin, oral anticoagulants, natural medication, etc.).
will recommend quitting smoking at least 2 weeks before the operation
will provide details about the therapeutic plan, postoperative evolution, possible risks and complications
What preoperative investigations are needed?
Blood tests – usually only routine investigations are needed to attest to the patient’s health.
Imaging investigations (soft tissue ultrasound, CT, MRI, angiography, PET) are useful to define the anatomical location of the tumor, invasion in neighboring structures, relationship with vital structures, identification of metastases in the lymph nodes and at a distance.
Biopsy is a diagnostic procedure indicated for large tumors, those that grow in a relatively short time and symptomatic ones. It involves harvesting a piece of tissue from the tumor structure (either surgically, by removing a small tumor fragment, or by aspirating tumor cells with a fine needle) and microscopically analyzing it from a histopathological point of view.
What types of excisions can be performed?
partial excision, in which only part of the tumor can be removed
marginal excision, ie removal of the tumor only
wide excision – removal of the tumor along with a wide edge of surrounding tissue
radical excision / amputation – removal of the entire muscle compartment in which the tumor is located.
The wide or radical excision may result in a soft tissue defect, the covering of which is done with the means specific to plastic surgery (skin graft, neighborhood flaps or remote flaps, microsurgically transferred).
At the end of the surgery, the incisions are sutured and the operated regions will be covered with a compressive bandage. This has the role of limiting the swelling of the area and the appearance of hematomas or seromas. Sometimes drainage tubes can be placed in the operated area, which will eliminate the collections accumulated under the skin (blood, serosity). The sutures will be removed 7-14 days after the operation.
Malignant and intermediate tumors will be monitored for a period of 3-5 years after treatment, to assess possible local recurrence or distant metastasis.
What are the risks and complications of the operation?
Common complications of any invasive procedure include bleeding, infection, and certain cardio-respiratory complications that may occur due to general anesthesia.
tumor recurrence (tumor recurrence) depends on the type and histological degree of the tumor (benign tumors do not recur, intermediate tumors sometimes recur, and sarcomas have a high recurrence rate, between 20-100%). The more complete the resection of the tumor and does not leave tumor cells in the adjacent tissues (wide / radical excision), the lower the risk of recurrence. Associated treatments (radio and chemotherapy), performed pre or postoperatively, reduce the risk of local recurrence.
distant metastasis (spread of tumor cells in the lymph nodes or in tissues located away from the tumor) is possible in the case of intermediate and malignant tumors (sarcomas). The larger the tumor and the higher the histological grade (the less differentiated the tumor cells are), the higher the risk of metastasis. Associated therapy (radio and chemotherapy), as well as the removal of isolated metastases contribute to improving the prognosis of the disease.
postoperative wound dehiscence (suture opening) occurs especially if the suture was made in tension
vicious scarring (appearance of hypertrophic, keloid, hypo or hyperpigmented scars, etc.)
sensitivity disorders can occur especially if the wide excision of the tumor requires the sacrifice of certain nerve pathway
alteration of the motility of the limbs, if the excision of the tumor was accompanied by the removal of a muscular compartment.
specific post-radiation complications and post-chemotherapy: the appearance of sacs due to radiotherapy, ulcerations and skin necrosis, infections due to immunosuppression, etc.
Foot surgery deals with deformities of the foot accompanied or not by pain.
Foot conditions that can be treated with surgery are:
Hallux valgus (mounts)
Hallux rigidus (osteoarthritis)
Deformities of the fifth finger (tailor’s mount, quintus varus)
Digital claw (fingers in the “hammer”)
Metatarsalgia (foot pain) Morton’s disease
Other congenital and acquired deformities
Hallux valgus (mounts)
The mounts are a protrusion under the skin of the first metatarsal, a normal bone moved progressively to the medial (inside the foot). This change determines in time the movement of the toe (thumb) towards the neighboring fingers, which it pushes and deforms progressively.
The surgical treatment of the mounts aims at a painless and deformation-free foot, in which the patient can regain the functionality and aesthetics of the foot. Current surgical techniques are easily tolerated and allow the patient to walk with immediate support and rapid resumption of daily activities. Through surgery, the orthopedist realigns the toe (thumb) with the first metatarsal.
Surgical treatment planning
The interventions are performed in turn on both legs, at a time interval of 6-7 weeks, this being
the variant best tolerated by patients. The operation is performed in a properly equipped operating room, requiring anesthesia.
The method of anesthesia is general and short-lived and is established at the pre-anesthetic consultation by the anesthesiologist.
Hospitalization for surgery is 3 days.
Postoperatively, the patient will walk from day one. After discharge, patients return to the clinic for dressing 2-3 times, and after 10-14 days after surgery to remove the sutures.
The return to normal activity is done after about 3 weeks.
After surgery, it is recommended to wear comfortable shoes for 4-6 weeks.
Although, complications have a very low frequency should be mentioned: infection, recurrence, consolidation deficiencies. A good communication with the attending physician and the observance of the orthopedic doctor’s instructions in the postoperative period are important for reducing the incidence of complications.
Lower Limb Lymphedema
Lymphedema is a condition characterized by painful swelling in the extremities (arms and/or legs). The swelling occurs when lymph nodes are no longer facilitating the proper drainage of lymph fluid from an area of the body. Primary lymphedema is a congenital condition; however, in the developed world, secondary lymphedema is the most common type of lymphedema. This condition may be caused by infection, trauma or, most commonly, treatment of cancer.
What causes lymphedema?
Lymphedema affects some cancer survivors who have been treated for breast cancer, gynecologic cancers, melanomas and other types of skin and urologic cancers. Lymphedema may impact cancer survivors on a daily basis and is a constant reminder of the disease that they have fought. The onset of symptoms may be delayed by months or even years after the initial injury.
There are a number of symptoms that affect patients with lymphedema that typically worsen over time:
Extremity swelling caused by lymphatic fluid
Change in skin quality such as skin fibrosis
Extremity tenderness or pain
Intermittent redness of the extremity, known as cellulitis
Excess fat in the extremity
Once the diagnosis of lymphedema is established, nonsurgical treatment is initiated as soon as possible including extremity elevation, skin care, elastic stockings, physical therapy and pneumatic compression devices. These treatments, although beneficial, can be burdensome to patients and require lifelong commitment. Surgery for lymphedema may be appropriate when nonsurgical therapy is inadequate to control the symptoms.
There are several options of surgical treatment for lymphedema:
Liposuction: Once lymphatic fluid spills into your surrounding tissues, it can cause inflammation and stimulate fat stem cells to grow. Your surgeon removes this extra fat caused by lymphedema. Liposuction for lymphedema is typically an outpatient procedure with a very short recovery time.
Lymphaticovenous anastomosis (also referred to as lymphovenous bypass): Your surgeon uses microsurgical techniques and equipment to reroute your lymphatic system, bypassing damaged nodes and connecting lymphatic channels directly into your veins. The lymphovenous bypass is an outpatient surgery. You can return to regular activity within a few days.
Vascularized lymph node transfer surgery (lymphovenous transplant): Your surgeon transplants a group of lymph nodes from a healthy part of your body to the affected area, effectively rewiring the lymphatic system. This is an inpatient procedure with a recovery time of a few days before resuming regular activity.
Charles procedure (skin grafts): Affected tissue is removed and your surgeon uses part of it as skin grafts to repair the area. Skin grafts require more extensive care of the surgical site after your procedure, and it can take up to one month to return to normal activity.
Surgical treatment options for lymphedema include Lymphatic Bypass Procedures, where lymphatic vessels are connected and drained into the body’s venous system and Vascularized Lymph Node Transfer, where lymph nodes are harvested from one part of the body and surgically implanted in the affected area to rebuild a failed system.
Who is a good candidate for lymphedema surgery?
You are able to cope well with your diagnosis and treatment
You do not have additional medical conditions or other illnesses that may impair healing
You have a positive outlook and realistic goals for restoring your extremity and body image
You have maximized all nonsurgical therapies for lymphedema
Although lymphedema surgery can improve the symptoms of lymphedema, the results are highly variable:
Visible incision lines will always be present on the extremity, depending on the type of procedure
Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the neck, abdomen or groin region.
What results should I expect after lymphedema surgery?
The long-term results of lymphedema surgery can help lessen the physical and emotional impact of lymphedema. Many patients experience reduction in extremity circumference or volume over several months after surgery. In addition, other symptoms such as extremity tightness and heaviness may improve after surgery. Aggressive nonsurgical therapies are advised after surgery to maintain the best outcomes, depending on the type of procedure performed. If the lymphedema improves, patients may gradually decrease their dependence on nonsurgical strategies. If lymphedema worsens, additional surgical interventions can be considered.
Diabetic arthropathy is a destructive disease of the joints initiated by minimal trauma to a neuropathic pelvic limb.
Early diagnosis and correct treatment of the diabetic foot are imperative to reduce the permanent deformation of the foot and maintain a stable and plantigrade foot necessary for walking!
Charcot neuroarthropathy (CN) affects 0.1% – 0.9% of patients with diabetes;
Approx. 63% of patients with neuropathic osteoarthropathy will develop a plantar ulcer!
CN remains undiagnosed in 0.4-13% of diabetic patients!
Bilateral Charcot’s foot is observed in 9-39% of cases!
The mortality rate is 28.3% in the first 5 years in patients with CN!
If you have a callus – a popular weft – or more calluses in the area of the feet or soles, specialized care of the area is needed especially in patients with neuropathy or peripheral vasculopathy. In the case of hyperkeratosis, that physiological or pathological thickening of the superficial, horny layer of the skin, a number of topical – topical medications may be prescribed by a doctor to soften thick calluses (areas with hardened skin, usually on the sole). Do not try to remove by cutting with a sharp object, even if it looks like a small weft in the sole or heel – you better access a specialized center. Moisturizers can help soften the skin and remove cracked calluses.
The idea is that you can also consider surgery to remove plantar calluses, but there is no guarantee that that callus will not recur if local biomechanical conditions – starting with the type of gait, foot anatomy or type of footwear – do not. are modified!
Weight loss, physiotherapy with gait re-education, making heels or specialized footwear can be considered the best therapeutic options.
Treatment of diabetic foot ulcers
Ulcers in the diabetic foot can be treated depending on the type and severity. A foot ulcer is a skin lesion or a deep wound that is infected. Foot ulcers can also result from minor scratches, cuts or wounds that heal slowly, or from shoes that don’t fit.
Early intervention is important in the treatment of diabetic foot ulcers. Seek medical advice on the best methods of caring for wounds and ulcers.
The protocol that the doctor will adopt varies depending on the severity of the ulcer. Your doctor will usually recommend an X-ray of your foot to make sure the bone is not affected. At the same time, the doctor can intervene by cleaning the infected or dead tissue (necrosis) – a procedure called debridement. These small surgeries are performed in the hospital, under conditions of surgical supervision. The doctor may also ask for a microbial culture test to find out what type of infection is present and which antibiotic will work best.
The protection of the foot is, after any surgical gesture, very important! If you walk and step on an ulcer, it may become larger and may force the infection to penetrate deeper. The protection is performed with the help of plaster-type discharge devices – the so-called Total Contact Cast is the gold standard in treatment. Specialized boot orthoses can also be used
Treatment of diabetic foot infections
An infection is one of the most serious complications of a foot ulcer and requires immediate and sustained treatment.
Not all infections are treated the same way. Tissues around ulcers can be sent to a laboratory to determine what kind of antibiotic will help the patient. If your doctor suspects a serious infection, he or she may recommend further examinations to look for signs of a bone infection – a MRI Exam and a local biopsy may be helpful.
Infection of a foot ulcer can be prevented by:
disinfecting the skin around an ulceration;
keeping the ulceration as dry as possible, with frequent changes of clothing;
clothing (socks) containing calcium alginate to inhibit the growth of bacteria.
If the infection progresses even after preventive or anti-pressure treatments (ie the patient no longer steps on the affected foot), the doctor may prescribe antibiotics and anticoagulant drugs to treat that infected ulcer. The surgeon intervenes to clean.
Treatment of gangrene
In patients with diabetic foot syndrome, deep skin infections and soft tissue infections can occur. For example, extreme pain and tenderness in the area may indicate compartment syndrome or clostridial infection (also called gas gangrene). Gangrene and infected foot ulcers that do not heal with the prescribed treatment can lead to amputation of the thumb, amputation of the foot, or amputation of part of the foot. The surgeon can perform the amputation operation to prevent the infection from spreading to the rest of the body and to save the patient’s life. Proper foot care is very important to prevent serious infections and gangrene (tissue necrosis).
Treatment of diabetic foot deformities
Quite often, nerve damage due to diabetes can lead to changes in the shape of your foot, such as the “Charcot foot” (or Charcot arthropathy). When the doctor suspects Charcot’s arthropathy in the foot, this is a medical emergency and should be addressed immediately by a multidisciplinary team of specialists. A simple x-ray may be normal, but a bone scan may show a “hot” spot, showing exactly the deformities of the diabetic foot.
Arthropathy – Charcot’s foot, can lead to dislocations and fractures of the foot, even minimal trauma.
Deterioration and development of deformities should be limited by immobilizing the foot in a cast. Realignment of certain bones of the foot can often prevent amputation of the foot.
Plaster immobilization diabetic foot orthosis
If the deformities of the foot persist, they greatly increase the risk of a secondary ulceration!
Due to the technical advancement in foot surgery, reconstruction interventions are performed earlier and more complex to avoid amputation. Arthrodesis is used – blocking of joints, using various instruments and specialized implants, much more resistant than those used in normal foot surgery, due to special clinical conditions – patient weight, polyarticular touches, poor bone quality, etc.
Trophic Ulcers And Chronic Wounds
TROPHIC ULCERS AND CHRONIC WOUNDS
A trophic ulcer is a necrotic lesion of the dermal tissues. It most often occurs in the elderly (after 45 years), but no one is insured.
At first glance, it seems that trophic ulcer is not dangerous. This is a false proposition: this type of pathology is not terrible in itself, but because of possible complications.
Ulcers almost always appear on the legs or feet.
Causes of trophic ulcer
The ulcer is caused by impaired blood circulation in the lower extremities. Therefore, the source of the problem may be:
Diabetes mellitus. Disorders of the endocrine system lead to problems with blood circulation in the blood, changes in vascular permeability, their fragility. As a result, a trophic ulcer forms. In diabetes, the course of ulcerative lesions is particularly aggressive. One of the main causes of trophic foot ulcer.
Varicose veins. Due to the development of blood clots, stenosis of the lower vessels occurs, the tissues do not receive enough food and oxygen and begin to die. The condition is no less dangerous than diabetes, because it is full of limb loss.
Inguinal lymphadenitis. In this case, the trophic ulcer is caused by a possible thrombophlebitis.
Hypertension. During the constant increase in pressure there is a spasm of small vessels of the extremities. As a result, the tissue again has no nutrition. Usually, such lesions differ in superficial depth and do not affect the hypodermis (lower layer of skin and subcutaneous tissue).
Diseases and injuries of the brain and spinal cord. These are so-called neurotrophic ulcers.
Ulcers can occur due to non-compliance with the simplest rules of hygiene. In this case, the origin of the pathology is infectious. The most common pathogen is Staphylococcus aureus. Before the symptom manifests itself in all its glory, furunculosis is observed. These skin lesions are called pyogenic.
Injuries can also cause trophic ulcers.
Atherosclerosis of the lower vessels. Apparently, including because of smoking.
Dermatitis (most common in children).
Without a thorough examination to determine the “root of evil” is impossible.
Wet wound dressings
The humid environment facilitates the rapid migration of keratocytes over the entire surface of the wound. When applying a damp dressing, a balance must be maintained between wetting the wound and avoiding, if possible, maceration of the surrounding tissues. Classic wet dressings keep the wound moist with the constant use of irrigation fluid or a spray.
The use of NPWT has recently increased significantly and has proven its viability. It is used after surgical treatment of wounds in trophic ulcers for healing, which leads to delayed closure of primary and secondary wounds. The results of a large, randomized, controlled NPWT study showed that this method is also safe and superior in terms of the effectiveness of the wet wound therapy method in the treatment of diabetic foot ulcers. Complete ulcer closure and granulation tissue formation occurred in a significantly higher number of patients with NPWT. Also, the overall healing time is reduced.
Hyperbaric oxygenation method (HBO)
It is an effective treatment for severe diabetic foot ulcers and should be used if possible. Especially preferred in patients with ischemia, its use avoids amputation. It has been shown to be treated for severe or threatening limbs that have not responded to other types of treatment, especially during ischemia and inability to establish blood flow.
Locally applied growth factors can accelerate healing by stimulating granulation tissue formation and accelerating epithelialization.
A key factor in the successful treatment of trophic ulcers is discharge. This can be a strict rest in bed, the use of crutches, wheelchairs, pedestrians. To reduce the pressure, you can use an inflatable pillow, a water mattress, tires, removable tires, half or special shoes. The transition from one method of discharge to another should be gradual.
After healing of the ulcer for prophylaxis, you should use special orthopedic devices or shoes that maintain optimal stress. In each case, he should be assigned his own therapy. Full-length shoes should have inserts that maintain optimal pressure, as well as a balance between cosmetic perception and functionality.
The option of surgical reconstruction is considered for ulcers affecting the bones, tendons and if the ulcer area has not decreased by 10% or more as a result of appropriate conservative therapy that has lasted at least two months. These can be skin grafts from local, regional or free skin grafts or donor tissue, depending on the defect.