The Belfast approach to managing complex lower limb vascular injuries

Mangled extremity: limb salvage for reconstruction versus primary amputation

PURPOSE OF REVIEW

While MESS has historically influenced limb salvage versus amputation decisions, its universal applicability remains uncertain. With trauma systems expanding and advancements in trauma care, the need for a nuanced understanding of limb salvage has become paramount.

RECENT FINDINGS

Recent literature reflects a shift in the management of mangled extremities. Vascular surgery, plastic surgery, and technological advancements have garnered attention. The MESS's efficacy in predicting amputation postvascular reconstruction has been questioned. Machine learning techniques have emerged as a means to predict peritraumatic amputation, incorporating a broader set of variables. Additionally, advancements in socket design, such as automated adjustments and bone-anchored prosthetics, show promise in enhancing prosthetic care. Surgical strategies to mitigate neuropathic pain, including targeted muscle reinnervation (TMR), are evolving and may offer relief for amputees. Predicting the long-term course of osteomyelitis following limb salvage is challenging, but it significantly influences patient quality of life.

SUMMARY

The review underscores the evolving landscape of limb salvage decision-making, emphasizing the need for personalized, patient-centered approaches. The Ganga Hospital Score (GHS) introduces a nuanced approach with a 'grey zone' for patients requiring individualized assessments. Future research may leverage artificial intelligence (AI) and predictive models to enhance decision support. Overall, the care of mangled extremities extends beyond a binary choice of limb salvage or amputation, necessitating a holistic understanding of patients' injury patterns, expectations, and abilities for optimal outcomes.

Predictive factors of amputation in infra-inguinal vascular trauma: a monocentric experience

OBJECTIVES

Infra-inguinal vascular injuries (IIVI) are emergencies involving both functional and vital prognosis. The choice between saving the limb or doing a first-line amputation is difficult even for an experienced surgeon. The aims of this work are to analyze early outcomes in our center and to identify predictive factors for amputation.

M METHODS

Between 2010 and 2017, we reviewed retrospectively patients with IIVI. The main criteria for judgement were: primary, secondary and overall amputation. Two groups of potential risk factors of amputation were analyzed: Those related to the patient: age, shock, ISS score; those related to the lesion: mechanism, above or below the knee, bone lesions, venous lesions and skin decay. A univariate and multivariate analysis were performed to determine the risk factor(s) independently associated with the occurrence of amputation.

RESULTS

57 IIVI were found in 54 patients. The mean ISS was 32,3 ± 21. A primary amputation was performed in 19%, and secondary in 14% of cases. Overall amputation rate was 35% (n=19). Multivariate analysis reveals that the ISS is the only predictor of primary (p=0.009; OR:1.07; CI:1.01-1.12) and global (p=0.04; OR:1.07; IC:1.02-1.13) amputation. A threshold value of 41 was selected as a primary amputation risk factor with a negative predictive value of 97%.

CONCLUSIONS

The ISS is a good predictor of the risk of amputation in IIVI. A threshold of 41 is an objective criterion helping to decide for a first-line amputation. Advanced age and hemodynamic instability should not be important in the decision tree.

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center

BACKGROUND

The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma.

METHODS

This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience.

RESULTS

Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009).

CONCLUSIONS

Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

Limb Salvage Versus Amputation for the Mangled Extremity: Factors Affecting Decision-Making and Outcomes

Complex limb injuries are severe injuries of the extremities that affect most or all components of the limb. Industrial/farm accidents and motor vehicle crashes are the mechanisms of injury for a large proportion of these presentations in the civilian population. While recent advances in surgery have led to more patients with complex limb injuries (that would have qualified for a primary amputation a few decades ago) undergoing limb-reconstruction surgeries, the existing evidence is inconclusive on the merits of limb salvage over amputation. Limb salvage surgery still carries considerable morbidity and mortality risks and requires careful consideration of several factors by the managing surgeons.

Risk factors for major amputation after arterial vascular trauma of the lower extremity

Background & objective:

Arterial vascular trauma bears a great risk of poor functional outcome or limb loss. The aim of this study was to analyze amputation rates of patients after vascular trauma and to perform a predictor analysis for the risk of major amputation.

Methods:

In a single-center retrospective analysis of 119 extremities treated for arterial vascular injury between 1990 and 2018 amputation rates and factors associated with limb loss were assessed. All patients were treated for traumatic vascular injuries; iatrogenic injuries were not included in the study.

Results:

During the study period, a total of 119 legs in 118 patients were treated after arterial vascular trauma. The in-hospital major amputation rate was 16.8% and the mortality rate was 2.5%. In the predictors analysis, vascular re-operation (amputation rate 53.8% vs 12%, odds ratio = 8.56), a Rutherford category ⩾IIb (25.4% vs 4.2%, odds ratio = 6.43), work-related or traffic accidents (28.2% vs 0%, odds ratio = 4.86), concomitant soft tissue or bone injuries (26.7% vs 7.3%, odds ratio = 4.64), polytrauma (33.3% vs 12%, odds ratio = 3.68), and blunt trauma (18.9% vs 0% for penetrating trauma, odds ratio = 1.64) were found to be associated with amputation.

Conclusions:

Lower extremity arterial vascular trauma was associated with a significant major amputation rate. Several predictors for limb loss were identified, which could aid in identifying patients at risk and adapting their treatment.

Limb Salvage Versus Amputation: A Review of the Current Evidence

In the trauma situation where the trauma team is faced with a severely injured limb, it requires judicious thinking and evaluating not only the injury in isolation but the patient as a whole when considering the management options. The aim must be to give the best quality of life and avoid repeated admissions to hospital for associated complications in the future.

The decision to amputate or salvage a limb should be based on numerous factors, such as the patient’s pre-injury status, injury factors (soft tissue injury, location, contamination and physiological status), patient’s wish and available resources.

The biggest challenge when faced with a complex limb injury is deciding what management route to take with a satisfactory outcome for the patient being the main goal.

Many studies have been undertaken looking at the outcome of successful limb salvage versus primary amputation. Studies such as the Lower Extremity Assessment Project (LEAP) study have concluded that there was no difference of outcome at the two-year stage between the two strategies.

Belfast Limb Arterial and Skeletal Trauma (BLAST): the evolution of punishment shooting in Northern Ireland

Introduction

Northern Ireland has developed significant experience in specific punishment injuries due to its unique civil unrest. Simple gunshot wound (GSW) injuries have begun to evolve into more complex injuries.

Case presentation

We describe three cases of young male victims who suffered from GSW injuries—from a single GSW injury to multiple GSW injuries involving all four limbs; the phenomenon of Belfast Limb Arterial and Skeletal Trauma. We describe the management of these injuries, with a review of current literature.

Conclusion

Due to the unique political situation of Northern Ireland, there has been significant development of surgical experience in GSW management. Historically, single knee-capping injuries were prevalent. However, these shootings have evolved into targeted injuries resulting in significant trauma as demonstrated by this case series.

Vascular Shunts in Civilian Trauma

Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management.

A decade of major vascular trauma: Lessons learned from gang and civilian warfare

INTRODUCTION Trinidad and Tobago is a trans-shipment point for the illegal trade of drugs, arms and ammunition and, as such, has a high incidence of gang-related warfare and drug-related crimes. This has led to a high incidence of gunshot and stab wounds, with associated major vascular injuries. We describe our management strategies learned from a decade of vascular trauma experience. METHODS A retrospective analysis of age, gender, type of trauma, vessel injured, procedure and outcome for all cases of vascular trauma between 2006 and 2015 at two surgical units in Trinidad and Tobago. RESULTS There were 198 vascular trauma cases (232 procedures), involving 159 (80%) males at a mean age of 33 years. Gunshots accounted for 103 (52%) cases, followed by stabs/chops (n=50; 25%) and lacerations (n=15; 8%). The most commonly injured vessels were the radial/ulnar arteries (n=39; 20%) and the superficial femoral artery (n=37; 19%). There were seven pseudoaneurysms and three traumatic arteriovenous fistulae. Repair techniques included primary (n=82; 35%), reversed vein (n=63; 27%), polytetrafluoroethylene (n=58; 25%), oversew (n=24; 10%) and endovascular (n=5; 2%) techniques. There were eight (4%) secondary amputations and eight (4%) deaths. CONCLUSIONS Major vascular trauma causes significant morbidity and mortality in Trinidad and Tobago, with the majority of cases due to gunshot injuries secondary to gang-related warfare and civilian violence. We compare our experience with that in the literature on the epidemiology and management of vascular trauma.

Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation

OBJECTIVE

To elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI).

MATERIAL AND METHODS

This retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n=69), in which the limb was salvaged and group II (n=21), in which the patients received amputation.

RESULTS

The overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of nine or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p=0.042). They were also more likely to be injured as a result of an explosion (p=0.004). Along with the MESS (p<0.001), the duration of ischemia (DoI) (p<0.001) were higher in group II. The rate of bony fracture (p<0.001) and wound infection (p=0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p=0.011), nerve injury (OR: 136.23, p=0.004), DoI (OR: 2.03, p=0.003), vascular ligation (OR: 8.65, p=0.040) and explosive device injury (OR: 10.8, p=0.041) were significant. Although the DoI (p<0.001) and the MESS (p=0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilisation of a TVS did not influence the amputation rate (p=1.0).

CONCLUSIONS

The DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS>7 seem to benefit from revascularisation with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.

Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons

In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.

Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma

Background

Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision-making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT.

Methods

A systematic review was conducted to identify potential prognostic factors. Bayesian meta-analysis was used to calculate an absolute (pooled proportion) and relative (pooled odds ratio, OR) measure of the amputation risk for each factor.

Results

Forty-five studies, totalling 3187 discrete LEVT repairs, were included. The overall amputation rate was 10·0 (95 per cent credible interval 7·4 to 13·1) per cent. Significant prognostic factors for secondary amputation included: associated major soft tissue injury (26 versus 8 per cent for no soft tissue injury; OR 5·80), compartment syndrome (28 versus 6 per cent; OR 5·11), multiple arterial injuries (18 versus 9 per cent; OR 4·85), duration of ischaemia exceeding 6 h (24 versus 5 per cent; OR 4·40), associated fracture (14 versus 2 per cent; OR 4·30), mechanism of injury (blast 19 per cent, blunt 16 per cent, penetrating 5 per cent), anatomical site of injury (iliac 18 per cent, popliteal 14 per cent, tibial 10 per cent, femoral 4 per cent), age over 55 years (16 versus 9 per cent; OR 3·03) and sex (men 7 per cent versus women 8 per cent; OR 0·64). Shock and nerve or venous injuries were not significant prognostic factors for secondary amputation.

Conclusion

A significant proportion of patients who undergo lower extremity vascular trauma repair will require secondary amputation. This meta-analysis describes significant prognostic factors needed to inform surgical judgement, risk assessment and patient counselling.

Management of major limb injuries

Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.

Penetrating arterial trauma to the limbs: outcome of a modified protocol

Background

Penetrating arterial injuries to the limbs are common injuries in high volume trauma centers. Their overall surgical results reported in the literature are satisfactory - apart of those of the popliteal artery that still may lead to a significant incidence in amputations. With the present study we assessed our outcome with penetrating arterial injuries to the limb as to see if the direct involvement of vascular surgeons in the management of popliteal artery injuries leads to an improved (lowered) amputation rate. Results were benchmarked with our published results from previous years.

Methods

All patients sustaining penetrating arterial injuries to the limbs admitted to the Chris Hani Baragwanath Academic Hospital during an 18- month period ending in September 2011 were included in this study. Axillary, brachial and femoral artery injuries were operated on by the trauma surgeons as in the past. All popliteal artery injuries were operated on by the vascular surgeons (new).

Results

There were a total of 113 patients with 116 injuries, as some patients had multiple vascular injuries: 10 axillary, 47 brachial, 34 femoral and 25 popliteal artery injuries. Outcome of axillary, brachial and femoral artery injury repair were excellent and not significantly different from our previous reported experience. Injury to the popliteal artery showed a diminished re-exploration rate from 34% down to 10% (p = 0,049) and a decrease of amputation rate from 16% to 11% which was statistically not significant (p = 0,8).

Conclusion

Penetrating arterial trauma to the axillary, brachial and femoral artery is followed by excellent results when operated by trauma surgeons. In the case of popliteal artery injury operated by the vascular surgeons, the results of this study do not show any statistically significant difference related to amputation rate from our previous reported studies when operated by trauma surgeons. Taking into consideration the diminished re-exploration rate and a tendency to a lower amputation rate, we feel that there is possible tendency of better outcome if operated by vascular surgeons. Multicenter studies with large number of enrolled patients will be required to prove the validity of this suggestion.

Complex wounds and their management

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

Use of a Javidtrade mark shunt in the management of axillary artery injury as a complication of fracture of the surgical neck of the humerus: a case report

INTRODUCTION

Axillary artery injury is a rare but severe complication of fractures of the surgical neck of the humerus.

CASE PRESENTATION

We present a case of axillary artery pseudoaneurysm secondary to such a fracture, in a 82-year-old white woman, presenting 10 weeks after the initial injury, successfully treated with subclavian to brachial reversed vein bypass together with simultaneous open reduction and internal fixation of the fracture. We discuss the use of a Javidtrade mark shunt during combined upper limb revascularisation and open reduction and internal fixation of the fractured humerus.

CONCLUSION

This case highlights the usefulness of a Javidtrade mark shunt, over other forms of vascular shunts, in prompt restoration of blood flow to effect limb salvage. It can be considered as a temporary measure whilst awaiting definitive revascularisation which can be performed following fracture fixation.

Management of Vascular Injuries in a Forward Hospital

BACKGROUND

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

METHODS

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

RESULTS

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

CONCLUSIONS

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.