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Objective: Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19. Method: A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019–2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement. Results: A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29–1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26–1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10–1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36–1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05–1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31–1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13–1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07–1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22–2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00–1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage. Conclusion: PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures. Declaration of interest: The authors have no conflicts of interest to declare. [ABSTRACT FROM AUTHOR]

Copyright of Plastic Surgery is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Plastic Surgery is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background Patients that undergo mastectomy for breast cancer with reconstruction may be prone to prolonged opioid use. As risk factors are not well-established, this article sought to better understand the risk factors that may be associated with this. Methods Patients that underwent breast reconstruction between 2010 and 2018 were identified in PearlDiver, a national insurance claims database. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis was used to evaluate the association of risk factors and complications. Results Breast reconstruction patients of 24,765 were identified from this database. Obesity, tobacco use, benzodiazepine use, and anticonvulsant use were all associated with prolonged opioid prescriptions greater than 90 days after both alloplastic and autologous reconstruction. Conclusion Prolonged opioid use continues to remain a topic of concern, and particularly in cancer patients that undergo breast reconstruction. Providers should be aware of potential risk factors for this to reduce this chance following breast reconstruction surgery. [ABSTRACT FROM AUTHOR]

Background  As our population ages, the demand for total knee arthroplasty (TKA) will dramatically increase to ensure an independent lifestyle with unimpeded and pain-free ambulation. Complications will be inevitable, especially in that patient with preexisting soft tissue deficits or extensive scarring in the knee region. Under these circumstances, prophylactic soft tissue augmentation should be strongly considered and be extremely beneficial. Methods  A retrospective review of all TKA procedures at our institutions over the past two decades revealed seven patients who specifically had soft tissue augmentation prior to their definitive TKA. Each had a single perforator flap used to achieve this. In no cases was a muscle flap used for this purpose. Excluded were all patients who had a flap of any kind for coverage of an exposed prosthesis or to accomplish wound healing after the TKA. Results  Seven perforator flaps were utilized in seven patients for soft tissue replacement prior to the ultimate TKA. For smaller defects in three patients, a local island medial sural artery perforator flap was used. For larger defects in four patients, an anterolateral thigh perforator free flap was necessary. All flaps were successful. The only complication was an implant infection after one anterolateral thigh free flap that required a revision arthroplasty that eventually allowed salvage. Unrestricted ambulation was possible in all patients except for one who had a preexisting contralateral below-knee amputation. Conclusion  As the number of TKA procedures in the near future increases, prevention of the absolute number of complications becomes even more important. An awareness that any knee region suboptimal soft tissue base can lead to wound breakdown and then periprosthetic infection should alert all involved that prevention of this sequela can be best achieved by prior soft tissue augmentation. Preferably, this may be possible by capturing the assets of local and free perforator flaps. [ABSTRACT FROM AUTHOR]

Background  Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation. Methods  A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol. Results  Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes. Conclusion  The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible. [ABSTRACT FROM AUTHOR]

Background  Traumatic limb salvage with free flap reconstruction versus primary amputation for lower extremity (LE) injuries remains an oft debated topic. Limb salvage has well-studied benefits and advances in microsurgery have helped reduce the complication rates. A subset of patients eventually requires secondary amputation after a failed attempt at limb salvage. A better understanding of risk factors that predict subsequent amputation after failed free flap reconstruction of LE injuries may improve operative management. Patients and Methods  A retrospective study (2002–2019) was conducted on all patients who underwent free flap reconstruction of the LE within 120 days of the original inciting event at a single institution. Patient and operative factors were reviewed including comorbidities, severity of the injury, flap choice, outcomes, and complications. Predictors of subsequent amputation were analyzed. Results  A total of 129 patients requiring free flap reconstructions for LE limb salvage met inclusion criteria. Anterolateral thigh flaps (70.5%) were performed most frequently. Secondary amputation occurred in 10 (7.8%) patients. Preoperative factors associated with eventual amputation include diabetes mellitus (p  = 0.044), number of preoperative debridements (p  = 0.013), evidence of any arterial injury/pathology (p  = 0.008), specifically posterior tibial artery (p  = < 0.0001), and degree of three-vessel runoff (p  = 0.007). Operative factors associated with subsequent amputation include evidence of recipient artery injury/pathology (p  = 0.008). Postoperative factors associated with secondary amputation include total flap failure (p  = 0.001), partial flap failure (p  = 0.002), minor complications (p  = 0.037), and residual osteomyelitis (p  = 0.028). Conclusion  Many factors contribute to the reconstructive surgical team's decision to proceed with limb salvage or perform primary amputation. Several variables are associated with failed limb salvage resulting in secondary amputation. Further studies are required to better guide management during the limb salvage process. [ABSTRACT FROM AUTHOR]

Background  The distal lower extremity poses unique reconstructive challenges due to its requirements for durability of the load-bearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. This study compares outcomes between muscle and fasciocutaneous flaps in patients with foot and ankle defects. Methods  A retrospective review of soft tissue free flaps used for traumatic foot and ankle defects was performed. Outcomes included takebacks, partial flap failure, total flap failure, and wound complications. Results  A total of 165 cases met inclusion criteria, with muscle flaps (n  = 110) comprising the majority. Defects involving the non–weight-bearing surface were more common (n  = 86) than those of the weight-bearing surface (n  = 79). Complications occurred in 56 flaps (33.9%), including 11 partial losses (6.7%) and 6 complete losses (3.6%). There were no differences in take backs, partial flap failure, or total flap failure between muscle and fasciocutaneous flaps; however, fasciocutaneous flaps had significantly fewer wound complications compared with muscle flaps (7.3% vs. 19.1%, p  = 0.046). On multivariable regression analysis, defects of the weight-bearing surface had significantly increased risk of wound breakdown compared with those in the non–weight-bearing surface (odds ratio: 5.05, p  = 0.004). Conclusion  Compared with fasciocutaneous flaps, muscle flaps demonstrated higher rates of wound complications. While the flap selection in foot and ankle reconstruction depends on the nature of the defect, our findings support the use of fasciocutaneous over muscle flaps in this region. [ABSTRACT FROM AUTHOR]