Microangiopathy in Inflammatory Diseases—Strategies in Surgery of the Lower Extremity

Abstract

Background: Patients with an inflammatory disease frequently develop chronic angiopathy of the capillaries. Due to this pathology, there is an increased rate of complications in lower extremity surgical procedures. It is not uncommon for microangiopathic wound healing disorders to cause deep infections and fistulas, which lead to prolonged courses and hospitalizations. In addition, adhesions and ossifications of the contractile elements occur regularly. This sometimes results in serious limitations of the mobility of the patients. The study aims to present the results of a combination of vacuum and physical therapy. Patient and methods: A retrospective study of six patients with systemic sclerosis undergoing joint-related procedures of the lower extremity between 2015 and 2020 was performed. In addition to characterization of the patients and therapy, special attention was paid to cutaneous wound healing, affection of the fascia and displacement layers, and sclerosis of the muscle and tendon insertion. Results: The characterized structures (skin, tendon, fascia) show pathological changes at the microangiopathic level, which are associated with delayed healing and less physical capacity. Early suture removal regularly results in secondary scar dehiscence. With a stage-adapted vacuum therapy with sanitation of the deep structures and later on a dermal vacuum system, healing with simultaneous mobilization of the patients could be achieved in our patient cohort. Conclusion: In the case of necessary interventions on the lower extremity, such as trauma surgery, additional decongestive measures in the sense of regular and sustained lymphatic therapy and adapted physiotherapy are indispensable.

Microangiopathy in Rheumatic Diseases

“…They may develop over bony prominences, over calcinosis, and on lower extremities [ 42 ]. Their etiology is complex and includes microvascular damage at the levels of the skin, tendons, fascia [ 42 , 43 ], and disturbances in tissue repair, i.e., the reduced proliferative potential of mesenchymal stem cells, defective circulating endothelial progenitor cells with ineffective vasculogenesis that results in impaired wound healing, development of chronic skin ulcers [ 42 ], and compromised physical capacity [ 43 ]. Thus, the treatment of ulcerations in SSc is a significant challenge in clinical practice.…”

“…Novel therapeutic strategies have been suggested, such as local administration of mesenchymal stem cells derived from bone marrow or adipose tissue and initial promising results have been reported in patients with chronic skin ulcers resistant to treatment, including in SSc cases [ 44 , 45 ]. In a recent paper of Biehl et al (2022), a new approach to ulcerations of lower extremities associated with calcinosis in SSc has been presented that includes the surgical removal of calcifications, vacuum therapy for the improvement of vascularization, and tissue perfusion by stimulating neoangiogenesis, lymphatic drainage, and intensified physiotherapy [ 43 ]. Further observations of the therapeutic efficacy of these new strategies are awaited to improve the complex care of SSc patients with chronic skin ulcers resistant to treatment.…”