Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation

Abstract

Background This study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation. Methods All patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients’ characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression. Results Fifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029). Conclusions MDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage. Trial registration: Retrospectively registered

Microsurgical Strategies after Free Flap Failure in Soft Tissue Reconstruction of the Lower Extremity: A 17-Year Single-Center Experience

“…In a recent retrospective review of patients undergoing flap-based limb salvage for combat-related extremity trauma, Hoyt and colleagues report a decrease in flap failures when an orthoplastic approach is implemented [ 21 ]. In our center, the multidisciplinary approach is well accepted and implemented, leading to a compliance rate of 92% [ 22 ]. However, as proposed by Azoury et al, treatment protocols must be questioned on a constant basis and new guidelines must be implemented to ensure successful limb salvage [ 23 ].…”

Etablierung von interdisziplinären Extremitätenboards: ein wichtiger Beitrag zur Verbesserung der Versorgung von Patienten mit komplexem Extremitätentrauma

“…In den Fällen, in denen Beschlüsse nicht umgesetzt wurden, war dies mit der Nichtakzeptanz des getroffenen Urteils vonseiten des Patienten begründet. Die Bindung an das Urteil des Extremitätenboards vonseiten der involvierten Kliniken war somit als sehr hoch zu beurteilen [8].…”

An Algorithm for Elective Amputation Combined with Targeted Muscle Reinnervation in Complex Regional Pain Syndrome—A Perspective

“…As amputation is an irreversible lifelong consequence for the patient, precise patient selection is of utmost importance. In the decision making process, the first step should be to ensure non-response to any other therapy modalities for more than 2 years [ 25 ]. Therefore, it is most important to establish a complete report of pretreatment strategies and their outcome.…”

“…We present an advanced algorithm which we use in our patients suffering from non-responding CRPS for elective amputation planning. As amputation is the last therapeutical option, a history of resistance to any other therapy options which are recommended for treatment of CRPS for at least two years and having a high level of suffering are requirements [ 25 ]. The expected outcome must be discussed with the patient with regard to his or her desired results and any discrepancies must be addressed.…”