Morbidity and mortality associated with ischemia-reperfusion injury after prolonged tourniquet use: A wartime single-center treatment algorithm

BACKGROUND

The evolving warfare tactics used by near-peer adversaries are expected to increase the incidence of severe extremity injuries and delayed evacuations. Initial reports from combat in Ukraine suggest high complication rates associated with prolonged tourniquet use. This study aimed to evaluate the systemic effects of limb reperfusion following tourniquet application lasting 4 hours or more in patients with isolated extremity injuries. Patients were treated according to an evidence-based protocol designed to mitigate ischemia-reperfusion injuries.

METHODS

This retrospective review was conducted at a forward surgical facility in Ukraine during combat operations from May 2023 to February 2024. Patients with tourniquets in place for at least 4 hours were included, while those with contraindications to limb salvage or significant confounding injuries were excluded. Short-term outcomes assessed included limb salvage, organ failure, and survival rates.

RESULTS

Of the 1,945 casualties screened, 90 (4.6%) met the inclusion criteria. After excluding 16 patients, outcomes were analyzed for 74 males, with an average age of 41.6 ± 8.5 years and a mean tourniquet duration of 7.1 ± 2.9 hours. Among these, 19 patients (25.67%) had vascular injuries, and compartment syndrome was present in all cases. Hemodialysis was required for 58 patients (70.8%), while 27 (36.3%) needed a delayed limb amputation, and 5 patients (6.7%) died. Patients requiring dialysis underwent an average of 3 ± 2 sessions to recover kidney function. Longer tourniquet times increased the need for dialysis, which increased the likelihood of patient death.

CONCLUSION

We used a standardized ischemia-reperfusion algorithm to reduce the systemic effects of ischemia and reperfusion during attempts to salvage limbs following 4 hours or more of tourniquet time. Preliminary outcomes indicate that survival is probable, kidney function may improve with brief periods of dialysis, and limb salvage is possible in most cases.

LEVEL OF EVIDENCE

Retrospective Cohort Study; Level V.

Management of combat-related extremity injuries in modern armed conflicts

While the first conflicts of the 21st century involved asymmetric warfare in the fight against terrorism, recent geopolitical events require us to prepare for the possibility of high-intensity conflicts. Modern wounding agents mainly consist of explosive devices and high-velocity bullets. Every trauma surgeon must be familiar with the mechanisms of injury specific to armed conflicts. The initial care of these injuries is based on applying damage control surgery to save the patient's life, save their limb if possible and preserve their function. Blast injuries are the most common in modern armed conflicts; the resulting combination of severe injuries can be challenging to treat. Limb reconstruction involves a sequential strategy based on simple, reliable and reproducible techniques which can be used by non-specialized surgeons working in sometimes austere situations. LEVEL OF EVIDENCE: Expert opinion.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Hand Compartment Syndrome After Prolonged Robotic-Assisted Laparoscopic Rectal Resection: A Case Report and Literature Review

Hand compartment syndrome is a rare condition due to trauma and vascular obstruction or injury, such as fluid extravasation, vascular obstruction, or arterial injury from arterial line insertion during anesthesia. However, perioperative hand compartment syndrome with no apparent preexisting cause during anesthesia that requires fasciotomy is extremely rare. We report a case on a 54-year-old male with history significant for stage IIIA moderately differentiated adenocarcinoma of the rectum who was scheduled for ultralow rectal resection and cystourethroscopy with insertion of urethral stent. Following surgery, in which he was in a safe-T-Secure positioner in a prolonged Trendelenburg position, the patient developed compartment syndrome of the right hand. This case and literature review highlights the risk for hand compartment syndrome when patients have increased Body Mass Index, positioning involves tucking of the arms, and the procedure duration is prolonged.

Clinical Readiness: Can Providers Learn to Perform Lower Leg Fasciotomy Through a Tablet-based Augmented Reality Surgical Training Environment?

INTRODUCTION

The uses of on-demand, interactive tablet-based surgical training environments are of interest as potential resources for both the acquisition and maintenance of rarely performed, critical procedures for expeditionary surgical care. This study examined the effectiveness of a tablet-based augmented reality (AR) procedural training environment for lower leg fasciotomy with a cohort of novice surgical trainees in (1) procedural knowledge, (2) tablet-based procedural skills, (3) tablet-based procedural time, and (4) procedural performance on a cadaver. We hypothesized that engaging with the AR procedural training would increase procedural knowledge and tablet-based skills and procedural time. We hypothesized that the tablet-based AR training environment would be insufficient to acquire the ability to perform lower leg fasciotomy on a cadaver.

MATERIALS AND METHODS

This study was approved as exempt by the Institutional Review Board at USU. Surgical interns, sub-interns, and independent duty corpsman (n = 30) with no prior lower leg fasciotomy experience voluntarily participated. Tablet-based training activities included pre-training assessment, engagement with instruction, interactive procedural practice, and post-training assessment. Tablet-based knowledge assessment included 17 multiple choice questions covering concepts, reasoning, and judgment associated with the procedure. Tablet-based procedural completion and time were assessed within the training environment. Within 1 week of completing the tablet activities, participants were assessed by fellowship-trained trauma surgeons while performing cadaver-based lower leg fasciotomy. Statistical analysis included paired t-tests and effect size (Cohen's d). Statistical significance was set at P < .05.

RESULTS

Tablet-based AR procedural training significantly improved procedural knowledge (P < .001), tablet-based procedural skills (P < .001), and reduced tablet-based procedural time (P < .002). Effect sizes were very large for tablet-based procedural knowledge (d = 1.75) and skills (d = 3.2) and small (d = 0.42) for procedural time. There were no significant effects of procedural knowledge, tablet-based procedural skills, or time on cadaver-based performance. No participant was able to accurately and independently complete lower leg fasciotomy procedure on a cadaver.

CONCLUSIONS

Tablet-based AR procedural training improved procedural knowledge and tablet-based skills; however, those gains did not transfer to the ability to perform the procedure on a cadaver. The tablet's limited AR interface did not support the acquisition of requisite surgical technique, tissue handling, and decision-making in novice surgical trainees. Experienced surgeons may have different outcomes because their mature understanding of surgical constructs would allow extrapolation of abilities to other procedural contexts. Further investigation of the tablet-based training environments for surgical care is necessary before distributing such resources to support clinical readiness.

Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?

BACKGROUND

This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods.

METHODS

A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed.

RESULTS

In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001).

CONCLUSION

The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.

Unidentified Recurrent Acute Compartment Syndrome of the Right Upper Limb

Acute compartment syndrome (ACS) is a surgical emergency that requires urgent fasciotomy to prevent irreversible sequelae. Symptoms usually include intense pain, tenderness in the affected area, tingling or burning sensation, and in severe cases, numbness or weakness and limb amputation due to ischemia from compression of the blood vessels, respectively. This case report describes a 19-year-old female who presented with complaints of severe pain and swelling in her right forearm. On examination, no bite marks, blisters, or skin necrosis were noted except for several surgical scars from her previous surgeries for the same condition, i.e., compartment syndrome. Upon thorough examination, including relevant investigation and clinical judgment, she was diagnosed with acute compartment syndrome, for which she underwent fasciotomy. There was no basic underlying pathology found in her case, making it an unidentified case of acute compartment syndrome.

Defining Incidence of Acute Compartment Syndrome in the Research Setting: A Proposed Method From the PACS Study

OBJECTIVE

To compare the retrospective decision of an expert panel who assessed likelihood of acute compartment syndrome (ACS) in a patient with a high-risk tibia fracture with decision to perform fasciotomy.

DESIGN

Prospective observational study.

SETTING

Seven Level 1 trauma centers.

PATIENTS/PARTICIPANTS

One hundred eighty-two adults with severe tibia fractures.

MAIN OUTCOME MEASUREMENTS

Diagnostic performance (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operator curve) of an expert panel's assessment of likelihood ACS compared with fasciotomy as the reference diagnostic standard.

SECONDARY OUTCOMES

The interrater reliability of the expert panel as measured by the Krippendorff alpha. Expert panel consensus was determined using the percent of panelists in the majority group of low (expert panel likelihood of ≤0.3), uncertain (0.3-0.7), or high (>0.7) likelihood of ACS.

RESULTS

Comparing fasciotomy (the diagnostic standard) and the expert panel's assessment as the diagnostic classification (test), the expert panel's determination of uncertain or high likelihood of ACS (threshold >0.3) had a sensitivity of 0.90 (0.70, 0.99), specificity of 0.95 (0.90, 0.98), PPV of 0.70 (0.50, 0.86), and NPV of 0.99 (0.95, 1.00). When a threshold of >0.7 was set as a positive diagnosis, the expert panel assessment had a sensitivity of 0.67 (0.43, 0.85), specificity of 0.98 (0.95, 1.00), PPV of 0.82 (0.57, 0.96), and NPV of 0.96 (0.91, 0.98).

CONCLUSION

In our study, the retrospective assessment of an expert panel of the likelihood of ACS has good specificity and excellent NPV for fasciotomy, but only low-to-moderate sensitivity and PPV. The discordance between the expert panel-assessed likelihood of ACS and the decision to perform fasciotomy suggests that concern regarding potential diagnostic bias in studies of ACS is warranted.

LEVEL OF EVIDENCE

Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Musculoskeletal injuries and management of victims from collapsed buildings in the 2016 Taiwan earthquake: Experiences in a tertiary medical center

BACKGROUND

Previous studies have seldom focused on injury patterns, especially musculoskeletal injuries, caused by building collapse during earthquakes. The aim of this study was to investigate the musculoskeletal injury profiles and management of patients rescued from collapsed buildings in the 2016 Taiwan earthquake.

METHODS

We conducted a retrospective study using the electronic medical record (EMR) system. We enrolled 31 patients rescued from specific collapsed buildings (the WJ group) and 56 patients injured in the same earthquake as a control group. We investigated the admission history, injury profile, treatment, and outcomes for these patients.

RESULTS

The WJ group (51%) had significantly higher admission rates compared to the control group (25%) (p = 0.012). Although the odds ratio (OR) of fracture incidence was lower in the WJ group (OR: 0.79), there was a higher OR of multiple fractures (OR: 2.617) and axial skeletal fractures (OR: 2.893 for vertebral fracture, and OR: 1.893 ribs for rib fractures) in the WJ group. Among the 28 fracture patients, 9 (32.1%) underwent surgical interventions. A higher incidence of rhabdomyolysis was noted in the WJ group (OR: 34.73). Also, all 5 rhabdomyolysis cases combined with acute kidney injury were in the WJ group, and 1 of them required emergent hemodialysis for severe hyperkalemia.

CONCLUSION

Patients extricated from collapsed buildings have a higher incidence of multiple fractures and axial skeletal fractures. More severe soft tissue injuries, including rhabdomyolysis and compartment syndrome, were also identified. The medical system should develop rescue and treatment strategies for this rare situation.

Portable Oxygen-Sensing Device for the Improved Assessment of Compartment Syndrome and other Hypoxia-Related Conditions

Measurement of intramuscular oxygen could play a key role in the early diagnosis of acute compartment syndrome, a common condition occurring after severe trauma leading to ischemia and long-term consequences including rhabdomyolysis, limb loss, and death. However, to date, there is no existing oxygen sensor approved for such a purpose. To address the need to improve the assessment of compartment syndrome, a portable fiber-optic device for intramuscular oxygen measurements was developed. The device is based on phosphorescence quenching, where the tip of an optical fiber was coated with a poly(propyl methacrylate) (PPMA) matrix containing a brightly emitting Pt(II)-core porphyrin. The optoelectronic circuit is highly portable and is based on a microspectrometer and a microcontroller readout with a smartphone. Results from an in vivo tourniquet porcine model show that the sensor is sensitive across the physiological oxygen partial pressure range of 0-80 mmHg and exhibits an appropriate and reproducible response to changes in intramuscular oxygen. A commercial laboratory oxygen sensor based on a lifetime measurement did not respond as expected.

Lessons learned in the challenging case of evolving compartment syndrome with atypical presentation

We present the rare case of a non-painful compartment syndrome of the forearm in a 35-year old man with a history of intravenous drug abuse, and lessons learned which would have enabled earlier consideration of this limb threatening condition and earlier therapeutic intervention.On initial assessment in the emergency department, the patient was drowsy, tachycardic and pyrexic. There was no obvious pain outwith expectation, and his forearm was erythematous and swollen. Due to the constellation of symptoms and signs, he was presumed to be septic from a forearm cellulitis and was thus treated for sepsis with intravenous antibiotics under the care of the medical team. As his arm swelling continued, he was then thought to possibly have a vascular issue and was given a therapeutic dose of low molecular weight heparin. He was otherwise pain free throughout and had no evidence of neurological compromise. A subsequent orthopaedic review raised the concern of compartment syndrome, and this, alongside a clinically evolving picture, resulted in a diagnosis of developing compartment syndrome being made. The patient underwent subsequent surgical management with dual incision fasciotomies and definitive wound management with split skin graft under the care of plastic surgery.This is a rare presentation of a masked developing compartment syndrome. This case highlights the importance of considering atypical presentations of compartment syndrome in high risk patients, and the importance of early specialist orthopaedic referral, particularly in those who do not present with typical features in their history and examination. We summarise the lessons learned in this case which would have enabled earlier identification of this limb-threatening diagnosis and could have improved further definitive outcome.