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Qu YF, Yang J, Wang JY, Wei B, Ye XH, Li YX, Han SL. Valve repair after infective endocarditis secondary to perforation caused by Streptococcus gordonii: A case report. World J Clin Cases 2023; 11:3822-3829. [PMID: 37383117 PMCID: PMC10294171 DOI: 10.12998/wjcc.v11.i16.3822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/24/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND We report a case of infective endocarditis (IE) in a patient with congenital heart valve lesions accompanied by IE, which was diagnosed based on blood culture analysis that revealed the presence of a gram-negative bacterium, Streptococcus gordonii.
CASE SUMMARY The patient had a history of precordial valve disease diagnosed by cardiac ultrasound, as well as a 4-mo history of fever. He was subjected to comprehensive anti-infection and anti-heart failure treatment in the internal medicine department. Further examination revealed sudden dislodgement from and perforation through the aortic valve by the superfluous organisms, as well as occurrence of bacterial emboli dislodgement, which caused bacteremia and infectious shock. He recovered and was discharged from the hospital after surgical and postoperative anti-infection treatments.
CONCLUSION We review the treatment process and highlight inspirations and reflections from this case; suggest possible future changes in treatment modalities.
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Affiliation(s)
- Yi-Fan Qu
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
| | - Jun Yang
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
| | - Jun-Yu Wang
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
| | - Bing Wei
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
| | - Xing-Hua Ye
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
| | - Yi-Xuan Li
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
| | - Si-Lu Han
- Department of Emergency, Beijing Chaoyang Hospital Jingxi Branch, Beijing 100000, China
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Lewis RH, Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg 2022; 92:21-27. [PMID: 34670960 DOI: 10.1097/ta.0000000000003430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE Prognostic study, Level IV.
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Affiliation(s)
- Richard H Lewis
- From the Department of Surgery University of Tennessee Health Science Center, Memphis, Tennessee
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Kleinsorge GHD, Teixeira PGR, Pfannes CCB, Lago RDVD, Abib SDCV. Prognostic factors in treatment of traumatic femoropopliteal arterial injuries at a Brazilian trauma center. J Vasc Bras 2022; 21:e20220020. [PMID: 36187215 PMCID: PMC9499723 DOI: 10.1590/1677-5449.202200202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Abstract
Background Despite significant improvements in outcomes, traumatic arterial limb injuries remain a significant cause of limb loss and mortality. Objectives This study sought to identify predictors of mortality and major amputation in patients undergoing revascularization after femoropopliteal arterial trauma. Methods This was a retrospective review of a trauma registry from an urban trauma center in Brazil. All patients admitted to our hospital with a femoropopliteal arterial injury from November 2012 to December 2017 who underwent vascular reconstruction were included. Univariate analyses and logistic regression analyses were conducted to identify factors independently associated with the primary outcome of amputation and the secondary outcome of mortality. Results Ninety-six patients were included. Eleven patients (11.5%) had an amputation and 14 (14.6%) died. In the logistic regression model for amputation, patients with ischemia duration greater than 6 hours were approximately 10 times more likely to undergo an amputation compared to those with ischemia duration less than or equal to 6 hours (adjusted odds ratio (AOR) [95% confidence interval (CI)]: 9.6 [1.2-79.9]). The logistic regression model for mortality revealed that patients with ischemia duration greater than 6 hours were approximately 6 times more likely to die compared to those with ischemia duration less than or equal to 6 hours (AOR [95% CI]: 5.6 [1.3 to 24.7). Conclusions Ischemia duration remains the most important factor independently associated with limb loss and mortality for patients undergoing femoropopliteal arterial revascularization after traumatic injuries. Physiological status on admission and trauma scores are also important.
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Leland HA, Kim JS, Badash I, Burtt KE, Rounds AD, Wlodarczyk J, Carey JN. A Quantitative Evaluation of Functional Recovery after Traumatic Lower Extremity Salvage. J Surg Res 2021; 270:85-91. [PMID: 34644622 DOI: 10.1016/j.jss.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 08/12/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Soft tissue reconstruction is a routine component of lower extremity trauma care and focus is increasingly being directed towards understanding functional outcomes. This study aims to quantify functional recovery and identify variables associated with functional outcomes of patients who undergo traumatic limb salvage. METHODS A retrospective review was performed of patients with lower extremity traumatic injuries requiring vascularized soft tissue reconstruction at a Level 1 trauma center between July 2007-December 2015. Postoperatively, patients were administered the 36-Item Short Form Health Survey Version 2 (SF-36v2) and the Lower Extremity Functional Scale (LEFS) questionnaires by telephone. Demographics, perioperative variables, and postoperative outcomes were analyzed by univariate and bivariate analysis. RESULTS Forty-two patients with 42 flaps and a mean of 12.7 months follow up were included in the study. Limb salvage was successful in 38 patients (90.5%). Patients ≥ 40 years old had significantly worse SF-36v2 scores in physical functioning (P ≤0.01) and mental health (P ≤0.05) than their younger counterparts. Patients who had pre-existing hypertension demonstrated significantly lower physical functioning (P ≤0.01). Role limitation due to emotional health was significantly lower in patients who were female (P ≤0.01) or required revision surgery (P ≤0.01). The mean LEFS score was 37.7 ± 18.5. CONCLUSIONS Patients exhibited poor functional outcomes following major limb trauma with attempted limb salvage based on two validated patient reported outcomes measures (PROMs). Patient characteristics should be considered in evaluating candidates for reconstruction to optimize outcomes and to effectively counsel patients on their functional prognosis.
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Affiliation(s)
- Hyuma A Leland
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer S Kim
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ido Badash
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Karen E Burtt
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Alexis D Rounds
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jordan Wlodarczyk
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Kouzelis A, Balasis SB, Bavelou A, Lampropoulos GC, Antoniadou E, Athanasiou V, Kokkalis ZT, Panagopoulos A. A Case of Reconstruction of a Type IIIc Open Tibial Fracture with Bone Loss and Warm Ischemia Time of 13 Hours: Quality of Life and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929993. [PMID: 33878102 PMCID: PMC8072184 DOI: 10.12659/ajcr.929993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. CASE REPORT We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. CONCLUSIONS The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.
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Affiliation(s)
- Antonios Kouzelis
- Department of Orthopedics, University Hospital, Patras Medical School, Patras, Greece
| | - Stavros B Balasis
- Department of Plastic Surgery, Patras University Hospital, Patras, Greece
| | - Aikaterini Bavelou
- Department of Orthopedics, University Hospital, Patras Medical School, Patras, Greece
| | | | - Eleftheria Antoniadou
- Department of Physical Medicine and Rehabilitation, Patras University Hospital, Patras, Greece
| | - Vasileios Athanasiou
- Department of Orthopedics, University Hospital, Patras Medical School, Patras, Greece
| | - Zinon T Kokkalis
- Department of Orthopedics, University Hospital, Patras Medical School, Patras, Greece
| | - Andreas Panagopoulos
- Department of Orthopedics, University Hospital, Patras Medical School, Patras, Greece
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Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience. J Trauma Acute Care Surg 2019; 88:197-206. [DOI: 10.1097/ta.0000000000002548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes. Ann Plast Surg 2018; 78:S180-S184. [PMID: 28118229 DOI: 10.1097/sap.0000000000000972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Open tibial fractures are orthopedic emergencies that may present with severe soft tissue damage. Free tissue transfer is often required when local tissues are insufficient and patients may require hospital transfer to tertiary care centers for this purpose. Although the negative impact of inter-facility transfer has been well demonstrated in trauma patients, less is known regarding transfers for lower extremity injury patients. This study investigates differences in outcomes based on transfer status after open tibial fracture. METHODS Thirty-four consecutive open tibial fractures requiring free tissue transfer over a 13-year period (2001-2014) were retrospectively reviewed. Patients transferred from outside facilities were compared to non-transferred patients in regards to demographics, injury, surgical characteristics, and outcomes (mean follow-up of 2.5 years). Student t tests and chi square analysis were used to compare means and proportions, respectively. RESULTS One-half of patients were transferred from an outside hospital. Transferred and nontransferred patients were not significantly different in regard to age, sex, comorbidities, mechanism of injury, and Gustilo grade. There was no significant difference in the method of bony fixation or free flap used for soft tissue coverage. The time to wound vacuum-assisted closure placement was longer in transferred patients, though this difference was not found to be significant (2.4 vs 3.3 days, P = 0.55). Time to definitive bony fixation was delayed in the transfer group by 9 days (5.2 vs 14.1 days, P = 0.05) and to tissue coverage by 7 days (14.2 vs 20.9 days, P = 0.13). Rates of flap loss and amputation did not differ between the groups. However, transferred patients were more likely to develop osteomyelitis (risk ratio [RR], 3.0; P = 0.03), nonunion (RR, 5.0; P = 0.09), and require hardware removal (RR, 3.3; P = 0.01). CONCLUSIONS Transferred and nontransferred patients were not significantly different in their demographics or presentation. However, an analysis of clinical outcomes showed that transfer was associated with increased rates of osteomyelitis, nonunion, and hardware removal. Although likely multifactorial, this study suggests that a delay to definitive fixation and soft tissue coverage contributes to the increased rate of complications and poorer prognosis.
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Gopinathan NR, Santhanam SS, Saibaba B, Dhillon MS. Epidemiology of lower limb musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Indian J Orthop 2017; 51:199-204. [PMID: 28400667 PMCID: PMC5361472 DOI: 10.4103/0019-5413.201702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. MATERIALS AND METHODS All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. RESULTS Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20-39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere 16.7% when the patient had presented more than 24 h after injury. CONCLUSION MVAs are the leading cause of vascular injuries in India. Road safety measures and prevention programs are the need of the hour to prevent these kinds of injuries in the future.
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Affiliation(s)
- Nirmal Raj Gopinathan
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Siva Swaminathan Santhanam
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Dr. Siva Swaminathan Santhanam, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail:
| | - Balaji Saibaba
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Singh Dhillon
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gustilo type IIIC open tibia fractures with vascular repair: minimum 2-year follow-up. Eur J Trauma Emerg Surg 2016; 43:505-512. [PMID: 27273011 DOI: 10.1007/s00068-016-0689-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 05/28/2016] [Indexed: 01/06/2023]
Abstract
PURPOSE Salvage or amputation for grade 3C open fracture of tibia is not well responded question universally because of surgical innovations, cultural believes, difficulties in estimate the outcome, coasts, and different results in the literature. The aim of this study was to evaluate the surgical outcomes of Gustilo grade 3C open tibia fractures with at least two years follow-up in non-military adults. METHODS Twenty-two non-military patients with a mean age of 31.1 were operated with grade 3c open fractures at tibia level in last 10 years in our clinic. We evaluated them retrospectively and asked about their daily life, pain, and if present, about the wish for secondary amputation. We also asked if they would prefer a first day amputation rather than their present status. RESULTS Mean operation time after the injury was 13 h. Seven patients had nerve injury. Mean operation number was 3.5. Eight patients (%36) (all due to circulatory problem) had to have amputation. All patients treated with temporary unilateral external fixation than converted to circular external fixators when soft tissue healing was completed. Two patients were reoperated because of deformity. Four patients needed revision surgery because of non-union. At long term follow, we had osteomyelitis in one patient. CONCLUSIONS Scoring systems and the ischemic time are not the only predictors of amputation. The decision of the treatment mode should be made by the patient and the care team after discussing the options and outcomes rather than relying on a scoring system.
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Feliciano DV, Subramanian A. Temporary vascular shunts. Eur J Trauma Emerg Surg 2012; 39:553-60. [PMID: 26815539 DOI: 10.1007/s00068-011-0171-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 12/05/2011] [Indexed: 01/03/2023]
Abstract
Temporary vascular shunts have been used for nearly 100 years in patients. Originally, they were used as vascular grafts that were likely to thrombose as collaterals would hopefully develop. More recently, they have been used as a device to be replaced by a permanent vascular graft during the same operation or at a reoperation. Indications for the use of shunts are a "damage control" procedure for a peripheral or truncal vascular injury, Gustilo IIIC fracture of an extremity, need for perfusion as a complex revascularization is performed, and planned replantation of a hand, forearm, or arm. They are used in approximately 8% of vascular injuries treated in urban trauma centers in the United States and have an excellent patency rate without heparinization.
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Affiliation(s)
- D V Feliciano
- Atlanta Medical Center, Atlanta, GA, USA.
- Mercer University School of Medicine, Macon, GA, USA.
- , 1244 Village Run, NE, Atlanta, GA, 30319, USA.
| | - A Subramanian
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
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García AF, Sánchez ÁI, Millán M, Carbonell JP, Ferrada R, Gutíerrez MI, Peitzman AB, Puyana JC. Limb amputation among patients with surgically treated popliteal arterial injury: analysis of 15 years of experience in an urban trauma center in Cali, Colombia. Eur J Trauma Emerg Surg 2011; 38:281-93. [DOI: 10.1007/s00068-011-0158-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 09/21/2011] [Indexed: 10/16/2022]
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Tan TW, Joglar FL, Hamburg NM, Eberhardt RT, Shaw PM, Rybin D, Doros G, Farber A. Limb Outcome and Mortality in Lower and Upper Extremity Arterial Injury. Vasc Endovascular Surg 2011; 45:592-7. [DOI: 10.1177/1538574411415125] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To examine the outcomes of lower extremity (LE) and upper extremity (UE) arterial trauma. Methods: Retrospective review of 2008 version of National Trauma Databank. Adult patient with LE and UE arterial trauma was identified and outcomes were compared. Results: There were 8311 cases of extremity arterial trauma and 37% involved the LE. The LE cohort had higher blunt injury (56.2% vs 37.4%; P < .0001). The LE cohort was more likely to require fasciotomy (23.6% vs 6.7%; P < .0001) and amputation (7.8% vs 1.3%; P < .0001). Complication (18.8% vs 5.1%; P < .0001) and mortality rate (7.7% vs 2.2%, P < .0001) were higher in the LE cohort. Regardless of extremity, blunt trauma was associated with higher mortality (4.8% vs 3.8%; P = .03) and amputation (6.7% vs 1.3%; P < .0001). In multivariable analysis, LE arterial trauma was associated with increased mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9; P < .0001) and amputation (OR 4.3, 95% CI 3.2-5.8; P < .0001). Conclusions: Lower and upper extremity arterial injuries have different modes of presentation and outcomes. Lower extremity arterial trauma is more commonly caused by blunt injury and associated with worse outcomes despite more intensive intervention.
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Affiliation(s)
- Tze-Woei Tan
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Fernando L. Joglar
- Section of Vascular Surgery, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Naomi M. Hamburg
- Section of Cardiovascular Medicine, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Robert T. Eberhardt
- Section of Cardiovascular Medicine, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Palma M. Shaw
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Denis Rybin
- Department of Biostatistics, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Alik Farber
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
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Blast-induced lower extremity fractures with arterial injury: prevalence and risk factors for amputation after initial limb-preserving treatment. J Orthop Trauma 2011; 25:543-8. [PMID: 21654527 DOI: 10.1097/bot.0b013e3181fc6062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study is to determine the rate of late (secondary) amputation and to identify risk factors for amputation in injuries that were initially treated with limb preservation on the battlefield. METHODS A retrospective review at our institution identified 24 consecutive patients with 26 blast-induced open fractures distal to the joint that had associated arterial injuries. All injuries were initially cared for on the battlefield and during the evacuation chain of care with limb preservation protocols. All definitive orthopaedic care was provided by a single fellowship-trained orthopaedic trauma surgeon at a tertiary care stateside facility. Injury factors were analyzed based on radiographic and chart review to determine associations with amputation. RESULTS Twenty of 26 injured limbs received an amputation for a total amputation rate of 76.9% (95% confidence interval, 57.9-88.9%). Fourteen limbs received early amputation before limb salvage attempts. Six of the 12 limbs that received limb salvage underwent late amputation. CONCLUSIONS The rate of amputation in severe blast-induced extremity fractures combined with an arterial injury initially treated with limb preservation on the battlefield and before transfer to the definitive military treatment facility is extremely high. Blast-injured lower limbs with a combined severe bony and soft tissue injury should be carefully assessed when arterial injury is present because they may require early amputation during initial surgical care on the battlefield.
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The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. ACTA ACUST UNITED AC 2010; 69:174-8. [PMID: 20622589 DOI: 10.1097/ta.0b013e3181e03e71] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The use of temporary vascular shunts (TVS)s in the management of wartime extremity vascular injuries has received an increasing amount of attention. However, the overall impact of this adjunct remains incompletely defined. The objective of this study is to characterize outcomes of those patients who suffered wartime extremity vascular injuries managed with TVSs. METHODS This is a retrospective review of the Navy and Marine Corps Combat Trauma Registry examining peripheral vascular injuries treated during the military conflicts in the Middle East. Patient demographics, injury severity score, mechanism of injury, and vessels injured were recorded. Operative reports were reviewed for use of TVSs, type of definitive repair, the need for amputation, and survival. RESULTS Eighty patients were included. Forty-six (57%) had TVSs placed and 34 (43%) underwent repair at initial presentation. The mean injury severity score for the TVS group and the non-TVS groups were 15.0 +/- 5.05 and 12.9 +/- 10.18, respectively, (p = 0.229). There were a total of 13 amputations, 6 (13%) in the TVS group and 7 (21%) in the non-TVS group (p = 0.38). There was no difference in amputation rates between either group. There were no recorded mortalities in either group. Median patient follow-up was 24.5 months (range, 3-48 months). CONCLUSIONS This study demonstrates the importance and utility of TVSs in the management of wartime extremity vascular injury. When used to restore perfusion to an injured extremity, there seems to be no adverse effects or overall increase in limb loss rates and therefore a useful adjunct in the surgery for limb salvage.
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Abstract
The battlefield has provided a multitude of advancements in the management of hemorrhage and vascular repair. Basic understanding of the anatomy and exposures of lower extremity injuries is essential to any surgeon caring for these patients. The techniques of repair and potential adjunctive measures (eg, shunts) available should always be considered when approaching a vascular injury. The most important concept from a vascular standpoint is the fact that a multidisciplinary approach to these complex patients is required with maximal tissue preservation when feasible and safe.
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Ball CG, Kirkpatrick AW, Rajani RR, Wyrzykowski AD, Dente CJ, Vercruysse GA, Mcbeth P, Nicholas JM, Salomone JP, Rozycki GS, Feliciano DV. Temporary Intravascular Shunts: When Are We Really Using Them According to the NTDB? Am Surg 2009. [DOI: 10.1177/000313480907500712] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = –7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period ( P > 0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.
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Affiliation(s)
- Chad G. Ball
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Andrew W. Kirkpatrick
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Trauma, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Medicine, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Ravi R. Rajani
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Amy D. Wyrzykowski
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Christopher J. Dente
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Gary A. Vercruysse
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Paul Mcbeth
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Jeffrey M. Nicholas
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Jeffrey P. Salomone
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Grace S. Rozycki
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - David V. Feliciano
- Department of Surgery, Emory School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
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Fowler J, Macintyre N, Rehman S, Gaughan JP, Leslie S. The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: A meta-analysis. Injury 2009; 40:72-6. [PMID: 19070837 DOI: 10.1016/j.injury.2008.08.043] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 08/29/2008] [Accepted: 08/29/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The optimal sequence of surgical repair for lower extremity injury with associated vascular injuries is unclear. Lower extremity injury in our study is defined as femoral fracture, tibial fracture, and/or knee dislocation. Advocates of performing the vascular repair prior to lower extremity fixation argue that reversal of ischaemia in the limb is the most important factor in limb survival and should take precedence. Advocates of lower extremity fixation prior to revascularisation worry that the manipulation during fixation could disrupt the vascular repair and that total ischaemia time is more relative than absolute. METHODS A literature search was performed to identify studies with the following criteria: adult population, femoral fracture, tibial fracture, and/or knee dislocation with associated vascular injury, an intervention of fracture fixation or knee stabilisation prior to revascularisation and/or revascularisation prior to fracture fixation, and amputation as an outcome measurement. RESULTS 934 articles were identified and narrowed to 14 articles through exclusion criteria. Meta-analysis of the data shows no statistical difference in regards to the incidence of amputation between lower extremity fixation prior to revascularisation and revascularisation prior to fracture fixation. CONCLUSION Lower extremity injuries with associated vascular injury are uncommon. There has been a widespread but unsupported belief that manipulation and traction during lower extremity fixation will disrupt the vascular repair. Ischaemic time should be considered a relative, but not absolute predictor of amputation. Soft tissue injury and neurologic deficits have been found highly correlated with disability and amputation. Surgical sequence has not been shown to affect the rate of amputations in lower extremity fractures.
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Affiliation(s)
- John Fowler
- Department of Orthopaedic Surgery, Temple University, Philadelphia, PA, United States
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18
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Abstract
OBJECTIVE Our objective is to report the nature and incidence of major complications after severe lower extremity trauma. DESIGN Multicenter, prospective, observational study. SETTING Eight level-1 trauma centers. PATIENTS/PARTICIPANTS Five hundred forty-five patients were followed for 2 years. INTERVENTION Amputation or reconstruction. MAIN OUTCOME MEASUREMENTS The type and number of complications associated with these injuries were recorded at baseline, 3-, 6-, 12-, and 24-month intervals. RESULTS One hundred forty-nine underwent amputation during the initial hospitalization. The revision amputation rate was 5.4%. Among the amputation group, a complication was noted most frequently at 3 months (24.8%), and the most commonly seen complication was wound infection (34.2%). Wound complications including dehiscence (13.4%) were seen more commonly in the amputation group. Three hundred seventy-one limb reconstructions were performed with 25 patients (3.9%) requiring late amputation. The most frequently reported complication was at 6 months for the salvage group (37.7%), and the most commonly seen complication was wound infection (23.2%). Not surprisingly, osteomyelitis (8.6%) and nonunions (31%) were seen more commonly in the salvage group. Complications of wound infection, osteomyelitis, nonunion, malunion, and prominent hardware resulted in rehospitalization in at least one-third of patients. However, patients who underwent reconstruction were more likely to be hospitalized for these complications. CONCLUSIONS Patients with severe lower extremity injuries can expect a significant number of complications, most notably wound infection, nonunion, wound necrosis, and osteomyelitis. A large portion of these will require additional inpatient or operative treatment. Patients electing for reconstruction can expect a higher risk of complications.
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19
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Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular injury: collective review. Injury 2008; 39:970-7. [PMID: 18407275 DOI: 10.1016/j.injury.2008.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 01/02/2008] [Indexed: 02/02/2023]
Abstract
In this systemic review, we summarise the types, configurations, durations, indications and complications of the temporary intravascular shunts used as an adjunct of damage control surgery (DCS) in severe vascular injuries. We conclude that temporary intravascular shunts can be used without systemic anticoagulation for a prolonged time to maintain distal perfusion in combined orthopaedic and vascular injuries, in the setting of DCS and transferring.
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20
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General Management of the Gunshot Victim With Musculoskeletal Injury. Tech Orthop 2006. [DOI: 10.1097/01.bto.0000240883.11677.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Asensio JA, Kuncir EJ, García-Núñez LM, Petrone P. Femoral vessel injuries: analysis of factors predictive of outcomes. J Am Coll Surg 2006; 203:512-20. [PMID: 17000395 DOI: 10.1016/j.jamcollsurg.2006.06.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Revised: 06/07/2006] [Accepted: 06/08/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Femoral vessel injuries are the most common vascular injuries treated in a Level I trauma center. No studies have identified risk factors for survival and complications. STUDY DESIGN We performed a retrospective, 132-month study that included univariate and multivariate analyses. RESULTS We studied 204 patients with 298 vessel injuries: 204 were arterial, 94 were venous. Mean age (+/- SD) was 29+/-13 years and mean Injury Severity Score (+/- SD) was 17+/-8. There were 176 (86%) penetrating injuries and 28 (14%) blunt injuries. Arterial repairs included: reverse saphenous vein graft bypass, 108 (53%); primary repair, 53 (26%); PTFE, 21 (10.2%); ligation, 13 (6.4%); and vein patch, 9 (4.4%). Venous repairs included: ligation, 49 (52%); primary repair, 41 (44%); and bypass, 4 (4%). Fasciotomies included: calf, 56 (27%); thigh, 25 (12%); traumatic amputations, 6 (3%); and delayed amputations, 0. Overall survival rate was 91% (186 of 204), and adjusted survival was 95% (excluding emergency department thoracotomy deaths). There were 1 or more complications in 47 (23%), including wound infection, 31 (15%); venous thrombosis, 6 (3%); bleeding, 5 (2.5%); ARDS, 4 (2%); and arterial thrombosis, 1 (0.5%). Predictors of mortality were age>45 years, Injury Severity Score>25, common femoral artery injury, associated venous and abdominal injury, hypotension, hypothermia, and acidosis; coagulopathy in the operating room and the need for PTFE repair also predicted outcomes. Predictors of postoperative complications were intraoperative hypotension, arterial intimal injury, bony fracture, and thoracic injury. CONCLUSIONS Although survival and limb salvage rates are high for femoral vessel injuries, these injuries incur high complication rates. Independent predictors for mortality are: Injury Severity Score > 25, Glasgow Coma Scale 28, presence of coagulopathy in the operating room, presence of two or more vascular signs, and age > 45 years.
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Affiliation(s)
- Juan A Asensio
- Division of Trauma and Critical Care, Department of Surgery, Los Angeles County and the University of Southern California Medical Center, Los Angeles, CA, USA
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22
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Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower Extremity Trauma: Trends in the Management of Soft-Tissue Reconstruction of Open Tibia-Fibula Fractures. Plast Reconstr Surg 2006; 117:1315-22; discussion 1323-4. [PMID: 16582806 DOI: 10.1097/01.prs.0000204959.18136.36] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Open lower leg fractures with exposed bone or tendon continue to be challenging for plastic surgeons. Microvascular free-tissue transfer increases the ability to close wounds, transfer vascularized bone, and prevent amputation, yet remains a complex, invasive procedure with significant complication rates, donor-site morbidity, and failure rates. This review documents the changing treatment protocol in the authors' institution for these injuries. METHODS Two hundred ninety consecutive open tibia-fibula fractures over a 12-year period (1992 to 2003) were retrospectively reviewed and methods and outcomes were compared by grouping the fractures into 4-year intervals. RESULTS The number of open lower extremity fractures increased, whereas the distribution of Gustilo grade I to III fractures remained unchanged. Overall, free-tissue transfer was performed less frequently and constituted 20 percent of reconstructions in period 1 (1992 to 1995), 11 percent in period 2 (1996 to 1999), and 5 percent in period 3 (2000 to 2003). For the most severe fractures, Gustilo grade III, free-flap reconstruction has decreased significantly, constituting 42 percent, 26 percent, and 11 percent of procedures in periods 1, 2, and 3, respectively. Local flaps for grade III fractures have remained relatively constant throughout the study. In contrast, local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures has significantly increased from 22 percent to 49 percent of reconstructions from periods 1 through 3. In 1997, the authors began to use the vacuum-assisted closure device and now use it in nearly half of all open fractures. Despite this trend, there has been no change in infection, amputation, or malunion/nonunion rates and a decrease in reoperation rate with at least 1-year follow-up. CONCLUSIONS These results demonstrate a change in practice, with a trend down the reconstructive ladder, currently using fewer free flaps and more delayed closures and skin grafts with frequent use of the vacuum-assisted closure sponge. Possible reasons for this change are a better understanding of lower leg vascular anatomy and better use of improved wound care technology.
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Affiliation(s)
- Brian M Parrett
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02478, USA
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23
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Abstract
Foot and ankle reconstruction following blast trauma is particularly challenging based on the devastating soft tissue injuries associated with open comminuted fractures. Considering the difficulties encountered in reconstruction, the functional limitations associated with many salvaged limbs, and the superior performance of contemporary prosthetics, many injured service members may benefit more from below knee amputation than from limb salvage. Limb salvage of blast-injured extremities is a multidisciplinary effort directed toward eradication of infection, treatment of soft tissue and bone defects, and management of late reconstructive procedures. External ring fixators have an important and expanding role in the treatment algorithm.
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Affiliation(s)
- Francis X McGuigan
- Department of Orthopaedic Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
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24
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Hossny A. Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified? J Vasc Surg 2004; 40:61-6. [PMID: 15218463 DOI: 10.1016/j.jvs.2004.03.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Complete lower limb ischemia as a result of blunt popliteal artery injury is associated with the highest morbidity and amputation rates among all of the peripheral vascular injuries. The purpose of this study was to determine the possible benefits of routine use of a temporary intraluminal arterial shunt in patients with complete limb ischemia from blunt popliteal trauma. PATIENTS AND METHODS Over 3 years seven blunt popliteal artery injuries with complete lower limb ischemia were managed with insertion of a shunt at the initial phase of the operation. Data from these procedures was analyzed and compared with retrospectively collected data for 10 injuries with complete ischemia treated without shunts during the preceding 5 years. RESULTS Mean injury severity score and mangled extremity severity score were 9.3 +/- 3.49 and 5.7 +/- 0.95, respectively, in the shunt group, and 9.9 +/- 3.57 and 5.9 +/- 0.56, respectively in the non-shunt group. Mean ischemic time was 244.3, 24.3, and 268.6 minutes, respectively, for preoperative, intraoperative, and total ischemic time in the shunt group, and 273, 56.5, and 329.5 minutes in the non-shunt group. The difference was significant for intraoperative (P <.001) and total (P <.05) ischemic time. In the entire group, 92.8% of patients with total ischemic time greater than 4 hours underwent fasciotomy, 100% required repeat operation, and 57.1% had complications and required fasciotomy wound debridement. All patients (100%) with ischemic time greater than 6 hours required amputation, compared with no patients with ischemic time less than 5 hours. One patient in the shunt group (14.3%) experienced one fasciotomy wound complication (11.1%), compared with seven patients in the non-shunt group (70%) had 8 complications (88.9%) (P <.05). Mean number of repeat operations was 0.8 +/- 1.06 in the shunt group, and 1.9 +/- 0.73 in the non-shunt group (P <.05). One patient in the shunt group (14.3%) required fasciotomy wound debridement, compared with seven patients in the non-shunt group (70%; P <.05). Mean hospital stay was 14.4 and 23 days, respectively, in the shunt and non-shunt groups (P <.05). Four limbs in the non-shunt group (40%) required amputation, compared with 100% limb salvage in the shunt group. CONCLUSION Temporary arterial shunting after blunt lower limb trauma significantly reduces total ischemic time, complications, repeat operations, amputation, and hospitalization. I recommend routine use of shunts in blunt popliteal artery injuries with complete lower limb ischemia.
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Affiliation(s)
- Ahmed Hossny
- Vascular Surgery Department, Faculty of Medicine, Menofia University, Egypt.
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25
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Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. ACTA ACUST UNITED AC 2003; 55:814-24. [PMID: 14608150 DOI: 10.1097/01.ta.0000087807.44105.ae] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. METHODS A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. RESULTS From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. CONCLUSION Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.
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Affiliation(s)
- Grace S Rozycki
- Department of Surgery, Emory University School of Medicine, Glenn Memorial Building, Room 302, 69 Jesse Hill Drive SE, Atlanta, GA 30303, USA.
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26
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McHenry TP, Holcomb JB, Aoki N, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence. THE JOURNAL OF TRAUMA 2002; 53:717-21. [PMID: 12394872 DOI: 10.1097/00005373-200210000-00016] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The sequence of surgical repair for penetrating extremity injuries requiring both vascular repair and fracture fixation is controversial. The optimal determination of repair order and its consequences is the purpose of this study. METHODS A retrospective review was performed of 27 patients over a 10-year period requiring acute revascularization and fracture fixation for isolated gunshot wound injuries. Injuries to the brachial artery and the femoral and popliteal vessels with accompanying fractures requiring operative stabilization were considered. The Mangled Extremity Severity Score, surgical sequence, limb viability, fasciotomy, incidence of iatrogenic vascular repair disruption, and length of hospitalization were analyzed. RESULTS There were 17 lower and 10 upper extremity injuries, with a mean Mangled Extremity Severity Score of 4.1. Fracture fixation preceded vascular repair in five cases, whereas revascularization preceded bone fixation in 22 cases. A temporary vascular shunt was used in 13 and definitive vascular repair with used in 9 patients. There were no cases of vascular repair, shunt disruption, or amputation after fracture fixation. Four of five (80%) patients with orthopedic fixation before revascularization required fasciotomies, whereas 8 of 22 (36%) patients with revascularization before fixation required fasciotomies, and this difference approached significance (p = 0.10). Patients with fasciotomies had a significantly longer mean length of hospitalization, 18.3 +/- 8.6 days compared with 10.8 +/- 8.1 days (p = 0.03). CONCLUSION For patients with combined injuries, priority should be given to revascularization before orthopedic fixation because of shorter hospitalization and a trend toward lower fasciotomy rates. Revascularization before fracture fixation did not result in iatrogenic disruption of the vascular repair.
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Affiliation(s)
- Timothy P McHenry
- Joint Trauma Training Center, Ben Taub General Hospital, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas 77030, USA
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27
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Abstract
Although popliteal artery injuries are uncommon, the consequent lack of management protocols may contribute to an already high level of outcome morbidity. We critically reviewed all nine cases of popliteal artery trauma treated at our institution in the last 5 years. The main findings were that blunt trauma was predominant and most patients presented with severe signs of ischaemia. Long delays occurred between injury and treatment, mostly due to the tyranny of distance. Nevertheless, most patients were subjected to further delay whilst undergoing unnecessary formal angiography. Interposition vein graft using contralateral long saphenous vein was the predominant procedure for arterial injury. Most patients did not receive systemic anticoagulation or fasciotomy, and none received intra-operative thrombolysis. Our limb salvage rate was 7/9, although two of these had persistent neurological disability. We criticise our shortcomings in the light of the current literature.
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Affiliation(s)
- R Gupta
- Department of General Surgery, Royal Perth Hospital, Wellington Street Campus, Box X2213 GPO, Perth, WA 6847, Australia.
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28
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Hoogendoorn JM, van der Werken C. Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstruction. Injury 2001; 32:329-34. [PMID: 11325370 DOI: 10.1016/s0020-1383(00)00250-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to assess the long-term functional outcome and the quality of life of patients who were treated for a (Gustilo) Grade III open tibial fracture. We included 43 patients with successful limb salvage (group A) and 21 amputees (group B). The groups were similar with regard to age, sex, and Injury Severity Score (ISS). The functional outcome was scored using the "Guides to the Evaluation of Permanent Impairment". To compare quality of life we used the Nottingham Health Profile (NHP), the SF-36, and a questionnaire especially designed for this study. The mean lower extremity impairment (AMA) of patients in group A was 17.6%, compared to 73.5% for patients in group B. The results with both NHP and SF-36 show that patients in both groups have more problems in most categories than a healthy reference group. With the NHP, the difference in score was largest for the categories of pain, mobility, energy and sleep. The SF-36 scores correlated well with the NHP scores. No significant difference was found between the two groups. This type of injury has an enormous impact on every aspect of life--irrespective of the chosen treatment. A significant difference in lower extremity impairment is found between patients with a successful reconstruction and those who are amputees. However, the quality of life was shown to be the same.
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Affiliation(s)
- J M Hoogendoorn
- University Medical Centre Utrecht, Department of Surgery, Postbus 85500, 3508 GA Utrecht, The Netherlands
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29
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MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson TM, McCarthy ML. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma 2000; 14:455-66. [PMID: 11083607 DOI: 10.1097/00005131-200009000-00001] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other. DESIGN AND STUDY POPULATION A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers. PROCEDURES Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared. RESULTS Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05). CONCLUSION In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.
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Affiliation(s)
- E J MacKenzie
- Johns Hopkins School of Public Health, Baltimore, Maryland 21205, USA
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30
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Abstract
The salvage of upper limbs mangled by industrial machinery became possible with the development of predictable techniques of vascular and microvascular anastamosis. Unfortunately, many of these salvaged limbs are associated with fair and poor functional outcomes. The quality of the skeletal fixation can have a substantial effect on the functional outcome and should be a major focus of the limb repair process. Internal plate fixation facilitates wound care and limb mobilization without tethering muscle-tendon units and is safe in the majority of severe upper limb injuries provided that all devitalized tissue is debrided and, if necessary, reconstructed using microvascular tissue transfers. Injury patterns, especially those which involve associated injury of the elbow or forearm ligaments, must be identified and treated appropriately. Internal fixation should restore anatomical alignment and provide sufficient stability to allow immediate active mobilization of the limb without contributing to devascularization of the soft tissues or skeleton.
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Affiliation(s)
- D Ring
- Massachusetts General Hospital, Boston 02114, USA
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31
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Reber PU, Patel AG, Sapio NL, Ris HB, Beck M, Kniemeyer HW. Selective use of temporary intravascular shunts in coincident vascular and orthopedic upper and lower limb trauma. THE JOURNAL OF TRAUMA 1999; 47:72-6. [PMID: 10421190 DOI: 10.1097/00005373-199907000-00017] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combined vascular and skeletal injuries are associated with a high limb loss rate. One of the major factors resulting in amputation is frequently because the allowable warm ischemia time for skeletal muscle is exceeded before adequate revascularization. METHODS Temporary vascular shunting has been used in selected patients with complete ischemia to minimize the ischemic time of the injured limb, allowing identification of vital structures, thorough debridement, and rigid internal fixation before definitive vascular repair. RESULTS Five male and two female patients with a median age of 46 years (range, 27-76 years) admitted with combined orthopedic and vascular injuries of the upper limbs in four and the lower limbs in three patients underwent primary vascular shunting. The median ischemic time for all patients was 180 minutes (range, 120-210 minutes). Shunt insertion was accomplished in all cases within 30 minutes. Median dwell time for the shunt was 185 minutes (range, 90-390 minutes). No shunt-related complications or limb loss occurred. During follow-up ranging from 2 to 24 months, all vascular repairs remained patent. All fractures healed primarily, except for one patient in whom a necrosis of the humeral head occurred. Five patients had an excellent and two patients a good result. CONCLUSION Initial temporary vascular shunting in selected patients with combined skeletal and vascular injury of the upper or lower limb may reduce the complications resulting from prolonged ischemia and permits an unhurried and reasonable sequence of treatment.
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Affiliation(s)
- P U Reber
- Department of Vascular Surgery, Inselspital, University of Bern, Switzerland
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32
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Baqué P, Trojani C, Batt M, Hassen-Khodja R, Bariseel H, Pittaluga P, Declémy S, Prate B, Le Bas P. Lower limb trauma caused by power-driven cultivators: report of 23 cases. THE JOURNAL OF TRAUMA 1998; 45:485-8. [PMID: 9751537 DOI: 10.1097/00005373-199809000-00009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the mechanism and the severity of injuries caused by power-driven cultivators. METHODS This retrospective study analyzed the clinical records of 20 patients treated from 1984 to 1996 for a total of 23 lower limb injuries caused by power-driven cultivators (three patients had bilateral injuries) in the Nice University Hospital. RESULTS A total of 90% of the accidents occurred when the machine was put into reverse and the limb was caught by the rotary blades; the cause of the remaining accidents was unknown. Of the 23 patients, 10 patients (43.5%) suffered posterior dislocation of the knee due to forced hyperextension. Injuries were classed in two groups as a function of their prognosis: group I consisted of osteomuscular lesions without vascular or nerve involvement (11 lower limbs, 11 patients). The mortality rate in this group was 9%, the rate of major amputation was 18%, and the prognosis was favorable in 82% of the cases. Group II corresponded to lower limb injuries with neurovascular involvement (12 lower limb injuries in 10 patients: one patient belonged to both group I and group II). Acute lower limb ischemia was constant in group II; the mortality rate was 20% (two of 10 patients), and the rate of major amputation was 41.6% (five of 12 patients; three emergency amputations and two secondary amputations). CONCLUSION These agricultural machines can cause severe trauma, and the resulting wounds are contaminated by telluric germs in rural areas. Paradoxically, power-driven cultivators are not legally classified as "dangerous machines." Modification of existing legislation in this field would seem advisable.
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Affiliation(s)
- P Baqué
- Service de Chirurgie Vasculaire, Hôpital Saint-Roch, Nice, France
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Melton SM, Croce MA, Patton JH, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage. Ann Surg 1997; 225:518-27; discussion 527-9. [PMID: 9193180 PMCID: PMC1190789 DOI: 10.1097/00000658-199705000-00009] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.
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Affiliation(s)
- S M Melton
- Department of Surgery, University of Tennessee at Memphis, Presley Regional Trauma Center, USA
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Faris IB, Raptis S, Fitridge R. Arterial injury in the lower limb from blunt trauma. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1997; 67:25-30. [PMID: 9033372 DOI: 10.1111/j.1445-2197.1997.tb01889.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The present study was performed to identify the factors associated with amputation in patients with blunt injuries to the lower limb associated with arterial injury. The ability of a scoring system to predict the outcome was tested. METHODS There were 122 lower limb arterial injuries in 119 patients treated at the Royal Adelaide Hospital in the years 1962-1994. Prognostic factors considered were the site of the injury, the severity of the soft-tissue injury and shock, the presence of associated injuries and a description of the bone or joint injury. The mangled extremity severity score (MESS) was calculated retrospectively for each patient. RESULTS The outcome was primary amputation in 27 patients, delayed amputation in 36 patients and limb salvage in 59 patients. The seven deaths were all due to associated injuries. Factors associated with amputation were the severity of shock and soft-tissue injury (P < 0.01), and tibial artery injury compared with more proximal injury (P < 0.001). Factors that did not affect outcome included delay before repair, method of fracture fixation, or performance of fasciotomy. Amputation was performed in 48/71 (68%) patients with Gustilo type-IIIC fractures of the tibia. Applying the MESS to our patients resulted in a positive predictive value (PPV) of 71%, a negative predictive value (NPV) of 84% and an overall accuracy of prediction of 75%. CONCLUSIONS The major factor determining outcome was the severity of the soft-tissue injury. Progressive necrosis and infection was a major cause of late amputation. The MESS is not sufficiently precise to allow the decision regarding amputation to be made at the initial operation.
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Affiliation(s)
- I B Faris
- Vascular Surgery Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Seybold EA, Busconi BD. Traumatic popliteal artery thrombosis and compartment syndrome of the leg following blunt trauma to the knee: a discussion of treatment and complications. J Orthop Trauma 1996; 10:138-41. [PMID: 8932676 DOI: 10.1097/00005131-199602000-00013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Blunt trauma to the knee has been associated with both musculoskeletal and neurovascular injury to the leg. Popliteal artery thromboses secondary to such trauma can be complicated by a compartment syndrome. The loss of distal pulses in the leg following blunt knee trauma should always be attributed to a suspected vascular lesion and not to the presence of the compartment hypertension. We present a case in which the diagnosis of a popliteal artery thrombosis was delayed because the loss of distal pulses was initially attributed to the compartment syndrome.
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Affiliation(s)
- E A Seybold
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical Center, North Worcester, USA
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Sfeir RE, Khoury GS, Kenaan MK. Vascular trauma to the lower extremity: the Lebanese war experience. CARDIOVASCULAR SURGERY (LONDON, ENGLAND) 1995; 3:653-7. [PMID: 8745189 DOI: 10.1016/0967-2109(96)82865-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The authors' experience with 386 patients who were operated on for vascular injuries to the lower extremities is reviewed. Of these, 118 had popliteal injuries, 252 had femoral injuries and 16 had tibial injuries. The overall mortality rate was 2.33% with no mortality in the popliteal and tibial injuries group whereas there were nine deaths in the femoral injuries group. The overall amputation rate was 5.95%, with 3.17% amputation rate for the femoral injuries group versus 11.86% for the popliteal injuries group and 6.25% for the tibial injuries group. Delay in repair (more than 6 h from injury), associated femoral fractures and shocked condition on admission led to increased amputation rate. Prompt surgical repair, arterial as well as venous repair for popliteal and femoral injuries especially if femoral fracture is present, external skeletal fixation and/or traction, and fasciotomy when necessary led to improved limb salvage.
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Affiliation(s)
- R E Sfeir
- Department of Surgery, American University of Beirut Medical Center, Lebanon
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Ingram R, Hunter G. Revascularization, limb salvage and/or amputation in severe injuries of the lower limb. ACTA ACUST UNITED AC 1993. [DOI: 10.1016/0268-0890(93)90006-d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Padberg FT, Rubelowsky JJ, Hernandez-Maldonado JJ, Milazzo V, Swan KG, Lee BC, Hobson RW. Infrapopliteal arterial injury: Prompt revascularization affords optimal limb salvage. J Vasc Surg 1992. [DOI: 10.1016/0741-5214(92)90050-i] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Büchler U. Traumatic soft-tissue defects of the extremities. Implications and treatment guidelines. Arch Orthop Trauma Surg 1990; 109:321-9. [PMID: 2073451 DOI: 10.1007/bf00636170] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The presence of traumatic soft-tissue defects in the extremity indicates serious damage that may compromise the systems of motion, circulation or sensibility and therefore jeopardize functional rehabilitation. This overview highlights the significance and the various causes of soft-tissue defects, of which several types may be distinguished. Principles for the selection of various flap procedures are outlined, in accordance with the need for elevation and early motion therapy. The requirements placed on flap tissue are described, such as surface characteristics, ability to restore sensibility, cosmesis, capacity to fill voids in the depth of defects and revascularization of adjacent areas.
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Affiliation(s)
- U Büchler
- Division of Hand Surgery, University of Bern, Switzerland
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