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Vaidya A, Rilo N, Steigerwald S, Rajani RR. Outcomes of Endovascular and Open Surgical Therapy for Popliteal Artery Injury. Ann Vasc Surg 2024; 104:282-295. [PMID: 38493887 DOI: 10.1016/j.avsg.2023.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND Popliteal arterial injury carries an appreciable risk of limb loss and, despite advances in stent and stent-graft technology, endovascular therapy for popliteal arterial trauma is infrequently used when compared with traditional open repair. Thus, this study aims to assess outcomes of endovascular management (EM) with open surgery (OS) as a historical reference. METHODS An electronic search was performed (from January 2010 until June 2023) using multiple databases. Initial records were screened against eligibility criteria. Next, the full-text manuscript of articles that passed the title and abstract assessment was reviewed for relevancy of data points. Data from articles passing the inclusion criteria were extracted and tabulated. Comparative analysis was completed by performing chi-square tests and 2-sampled t-tests (Welch's). RESULTS The 24 selected studies described 864 patients (96 EM; 768 OS). In the endovascular group, patients underwent procedures primarily for blunt trauma using covered, self-expanding stents, resulting in universal technical success and patency. Patients had an average length of stay of 7.99 ± 7.5 days and follow-up time of 33.0 ± 7.0 months, with 21% undergoing fasciotomies, 6% undergoing amputation, and 4% having pseudoaneurysms. Patients in the OS group were evenly divided between blunt and penetrating trauma, chiefly undergoing vein graft interposition and exhibiting fasciotomy and amputation rates of 66% and 24%, respectively. Patients had an average length of stay of 5.66 ± 4.6 days and a 96% survival rate at discharge. CONCLUSIONS The current evidence sheds light on the nature of treatment offered by EM and OS treatment and suggests EM is associated with several important positive outcomes. Although it is difficult to directly compare endovascular and open surgical techniques, the data with respect to open surgical management of popliteal artery trauma can still provide a powerful frame of reference for the outcomes of EM to date. However, this claim is weak due to the little published data for EM of popliteal trauma, publication bias accompanying the published studies, and general, selection bias. Additional prospective data are necessary to define patients who specifically benefit from endovascular repair.
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Affiliation(s)
| | - Natalie Rilo
- Emory University School of Medicine, Atlanta, GA
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Ascoli Marchetti A, Naldi V, Potenza V, Oddi FM, De Maio F, Ciattaglia R, Fazzini S, Battistini M, Farsetti P, Ippoliti A. The role of body mass index in high- and low-velocity trauma causing knee injury associated with popliteal artery lesions. J Orthop Surg Res 2024; 19:347. [PMID: 38858784 PMCID: PMC11165826 DOI: 10.1186/s13018-024-04821-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/29/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Among arterial traumas, osteoarticular traumas are particularly dangerous, and those involving the popliteal artery are associated with a high amputation rate. Despite representing a minority of arterial traumas, with an incidence that varies considerably by population and geographic location, traumatic lesions of the popliteal artery are challenging. This study aimed to verify the impact of body mass index (BMI) on arterial trauma damage and patient outcomes. METHODS Data were retrospectively collected from the electronic medical reports of all patients with osteoarticular and vascular associated lesions treated in the emergency operating room at our institution between 1 January 2005 and 1 May 2022. Forty-one patients presented with lower limb arterial trauma (43.2%); popliteal artery lesions occurred in 11 of these patients (26.8%), who were eligible for inclusion in the study. The lesion mechanism was dislocation by high-velocity trauma in 9 patients and dislocation by low-velocity trauma in 3 patients. All 7 males (63.6%) experienced high-velocity trauma, and 2 of the 3 females experienced low-velocity trauma. Only one patient had an isolated popliteal artery lesion associated with fractures in the leg or the contralateral limb. Patients with low-velocity trauma were older than 54 years, while those with high-velocity trauma were aged 22 to 71 years. RESULTS In 10/11 patients (90.9%), revascularization was performed after osteoarticular stabilization and reduction of the dislocation or fracture. Intraoperative angiography was selectively used. Two patients required above-the-knee amputation after the procedure: one due to infection of the surgical access point and the other due to severe soft tissue injury. One patient died during hospitalization due to trauma-related complications and comorbidities. CONCLUSIONS High-velocity trauma and low-velocity trauma in patients with a body mass index > 35 kg/m2 and knee lesions are associated with popliteal artery lesions. Revascularization success is not associated with high- or low-velocity trauma.
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Affiliation(s)
- Andrea Ascoli Marchetti
- Unit of Vascular Surgery, Biomedicine and Prevention Department, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
| | - Valerio Naldi
- Unit of Vascular Surgery, Biomedicine and Prevention Department, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Vito Potenza
- Orthopedic and Traumatology Unit, Surgical Sciences Department, University of Rome Tor Vergata, Rome, Italy
| | - Fabio Massimo Oddi
- Unit of Vascular Surgery, Biomedicine and Prevention Department, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Fernando De Maio
- Orthopedic and Traumatology Unit, Surgical Sciences Department, University of Rome Tor Vergata, Rome, Italy
| | - Riccardo Ciattaglia
- Unit of Vascular Surgery, Biomedicine and Prevention Department, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Stefano Fazzini
- Unit of Vascular Surgery, Biomedicine and Prevention Department, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | | | - Pasquale Farsetti
- Orthopedic and Traumatology Unit, Surgical Sciences Department, University of Rome Tor Vergata, Rome, Italy
| | - Arnaldo Ippoliti
- Unit of Vascular Surgery, Biomedicine and Prevention Department, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
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Kontopodis N, Tosounidis T, Kehagias E, Kouraki A, Tzirakis K, Ioannou CV. Concomitant vascular and orthopedic trauma: 10 points to consider. J Clin Orthop Trauma 2024; 51:102407. [PMID: 38681997 PMCID: PMC11053217 DOI: 10.1016/j.jcot.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
Although vascular injuries complicate only 1-2% of patients with orthopedic trauma, they may be encountered in a much higher rate of around 10 % in injuries around the knee and elbow joints following both fractures and dislocations. In case of vascular involvement, specific diagnostic and therapeutic challenges arise and there is a higher risk for significant morbidity (i.e. limb loss) or mortality. In the absence of randomized data, diagnostic and therapeutic algorithms are not always straightforward and clinical practice may be based on experience and local protocols rather than firm evidence. With this article we intend to review available literature regarding concomitant skeletal and vascular trauma in order to provide concise information and clear guidelines of when to operate with least investigations and when to go for a full spectrum of investigations in the absence of hard clinical signs. Additionally, other aspects concerning the manipulation of these patients are discussed, such as the indications of primary amputation, the potential role of endovascular techniques and the value of the Resuscitative Endovascular Balloon Occlusion of the Aorta. In summary, this scoping review summarizes current practices in the diagnostic and therapeutic management of patients with concomitant orthopedic and vascular injuries, discusses different treatment strategies and gives a practical perspective for implementation on every day practice.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Theodoros Tosounidis
- Orthopedic Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, University of Crete-Medical School, Heraklion, Crete, Greece
| | | | - Konstantinos Tzirakis
- Department of Mechanical Engineering, Hellenic Mediterranean University, Heraklion, Crete, Greece
| | - Christos V. Ioannou
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
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Ateş O, Ancar C, Çağlar C. Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02495-x. [PMID: 38466401 DOI: 10.1007/s00068-024-02495-x] [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: 08/15/2023] [Accepted: 02/27/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures. METHODS A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms. RESULTS The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries. CONCLUSION Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.
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Affiliation(s)
- Okan Ateş
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Ankara, Turkey
| | - Cahit Ancar
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Ankara, Turkey
| | - Ceyhun Çağlar
- Department of Orthopaedics and Traumatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey.
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Izawa Y, Futamura K, Murakami H, Sato K, Tsuchida Y. Efficacy of Orthoplastic Management in the Treatment of Traumatic Popliteal Artery Injury. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5696. [PMID: 38528846 PMCID: PMC10962880 DOI: 10.1097/gox.0000000000005696] [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: 12/07/2023] [Accepted: 02/06/2024] [Indexed: 03/27/2024]
Abstract
Background Popliteal artery injury (PAI) is a challenging condition. Even with appropriate initial treatment and reconstruction of the associated injuries, extensive soft-tissue necrosis may occur, requiring lower leg amputation. There are no reports on the effectiveness of orthoplastic surgery in treating traumatic PAI. However, orthoplastic surgery is also considered very effective in PAI treatment, which requires delicate handling of soft-tissue and blood vessels. This study aimed to examine the treatment outcomes of traumatic PAI at a trauma center with the capacity for orthoplastic management. Methods Patients with PAI who were treated at our institution between August 2013 and December 2021 were included in this study. The surgeons included multiple orthoplastic surgeons with capabilities in vascular repair, bone and ligament reconstruction, and soft-tissue reconstruction. Patient demographics, injury characteristics, degree of ischemia, and treatment were investigated. We also investigated whether soft-tissue reconstruction and lower limb amputation were necessary as outcomes of treatment. Results Fifteen limbs of 14 patients with PAI met the inclusion criteria. Extensive soft-tissue necrosis was observed in three limbs. Two of these limbs were covered with a free latissimus dorsi flap and could be salvaged. In the remaining limb, lower limb amputation was unavoidable because of unexplained cardiac arrest during the initial surgery, but a fillet flap was used to successfully preserve the knee joint. Conclusion Orthoplastic management has the potential to improve limb salvage rates and provide good outcomes for the treatment of traumatic PAI.
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Affiliation(s)
- Yuta Izawa
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Hiroko Murakami
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Kazuo Sato
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
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Izawa Y, Futamura K, Murakami H, Shirakawa T, Nishida M, Suzuki T, Tsuchida Y. Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury. Ann Vasc Surg 2024; 99:305-311. [PMID: 37858669 DOI: 10.1016/j.avsg.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the case series of traumatic PAI treated using CLS and verify the usefulness of CLS. METHODS All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on the Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. RESULTS We used CLS as treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and 4 with grade 3. Amputation of the lower extremities was avoided except for 1 extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CONCLUSIONS CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.
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Affiliation(s)
- Yuta Izawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan.
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Hiroko Murakami
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Tetsuya Shirakawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Masahiro Nishida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Takafumi Suzuki
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
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Tamteki̇n B, Gülsen Ersoy G. Our Surgical Results in Popliteal and Infrapopliteal Artery Injuries: 21 Cases without Amputation. Emerg Med Int 2024; 2024:1721047. [PMID: 38298963 PMCID: PMC10830198 DOI: 10.1155/2024/1721047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/07/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024] Open
Abstract
Objectives Popliteal and infrapopliteal artery injuries have significant morbidity and mortality rates, especially in terms of amputation. In our study, we aimed to evaluate patients who operated due to popliteal and infrapopliteal vascular injuries in our clinic. Patients and Methods. Between 2016 and 2023; 21 patients who were operated in our clinic due to popliteal and infrapopliteal artery injuries were retrospectively evaluated. Results 2 of the patients were female (9.5%) and 19 were male (90.5%). Age ranges were 21-78. The causes of injury were gunshot wounds in 9 patients (42.86%), blunt trauma in 7 patients (33.33%), and sharp object injuries in 5 patients (23.80%). Reversed saphenous vein interposition in 7 patients (33.33%), primary repair in 6 patients (28.57%), 6 mm polytetrafluoroethylene graft (PTFE) interposition in 3 patients (14.28%), end-to-end anastomosis in 2 patients (9.52%), saphenous-PTFE composite graft interposition in 2 patients (9.52%), and embolectomy in 1 patient (4.76%) were performed. Arterial ligation was not performed. Simultaneous orthopedic intervention was performed in 8 patients. Fasciotomy was performed in 3 patients. Venous repair was performed in 5 patients with venous injuries. Vein ligation was not performed. Mortality was observed postoperatively in 1 patient. No patient developed amputation. Foot drop developed with nerve damage in 2 patients. Conclusion Mortality and morbidity rates may increase in popliteal and infrapopliteal artery injuries in cases of hemodynamic disorder, simultaneous bone fracture, multivessel injury, and nerve transection. These rates can be reduced by appropriate surgical repair and ensuring hemodynamic stability.
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Affiliation(s)
- Burak Tamteki̇n
- Department of Cardiovascular Surgery, Faculty of Medicine, Kastamonu University, Kastamonu, Türkiye
| | - Güler Gülsen Ersoy
- Department of Cardiovascular Surgery, Faculty of Medicine, Kastamonu University, Kastamonu, Türkiye
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Gratl A, Kluckner M, Gruber L, Klocker J, Wipper S, Enzmann FK. The Mangled Extremity Severity Score (MESS) does not predict amputation in popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:2363-2371. [PMID: 36449024 PMCID: PMC10728240 DOI: 10.1007/s00068-022-02179-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Vascular injuries in lower extremity trauma, especially with involvement of the popliteal artery, are associated with considerably high rates of limb loss, especially with blunt trauma mechanisms. The aim of this study was to evaluate the risk of amputation in patients with traumatic popliteal artery lesions with special focus on the validity of the Mangled Extremity Severity Score (MESS). METHODS In this retrospective study, all patients treated for isolated lesions of the popliteal artery following trauma between January 1990 and December 2020 at a high-volume level I trauma center were included. Primary outcome was limb salvage dependent on MESS and the influence of defined parameters on limb salvage was defined as secondary outcome. The extent of trauma was assessed by the MESS. RESULTS A total of 50 patients (age 39.2 ± 18.6 years, 76% male) with most blunt injuries (n = 47, 94%) were included. None of the patients died within 30 days and revascularization was attempted in all patients with no primary amputation and the overall limb salvage rate was 88% (44 patients). A MESS ≥ 7 was observed in 28 patients (56%) with significantly higher rates of performed fasciotomies (92.9% vs. 59.1%; p < 0.01) in those patients. MESS did not predict delayed amputation within our patient cohort (MESS 8.4 ± 4.1 in the amputation group vs. 8.1 ± 3.8 in the limb salvage group; p = 0.765). CONCLUSION Revascularization of limbs with isolated popliteal artery injuries should always be attempted. MESS did not predict delayed amputation in our cohort with fasciotomy being an important measure to increase limb salvage rates.
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Affiliation(s)
- Alexandra Gratl
- Department of Vascular Surgery, Medical University Innsbruck, University Hospital of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Michaela Kluckner
- Department of Vascular Surgery, Medical University Innsbruck, University Hospital of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, University Hospital of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Josef Klocker
- Department of Vascular Surgery, Medical University Innsbruck, University Hospital of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Sabine Wipper
- Department of Vascular Surgery, Medical University Innsbruck, University Hospital of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Florian Karl Enzmann
- Department of Vascular Surgery, Medical University Innsbruck, University Hospital of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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Gumbs S, Guevarra-Kissel M, Ausqui G, Nazir S, Donaldson B. A Rare Cause of Popliteal Artery and Vein Transection: A Case Report and Literature Review. Cureus 2023; 15:e49591. [PMID: 38033441 PMCID: PMC10685989 DOI: 10.7759/cureus.49591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
We present a rare occurrence of popliteal vascular injury due to blunt trauma. The patient had an isolated blunt lower extremity trauma. The patient subsequently experienced moderate tenderness and non-expanding hematoma at the popliteal fossa, reduced range of motion at the knee, and diminished distal pulses. X-rays showed a patella dislocation and tibial plateau non-displaced fracture but no knee dislocation. CT angiography showed an abrupt non-opacification of the distal portion of the popliteal artery with an overlying large hematoma. Surgical exploration was performed which revealed a concomitant transection of the popliteal artery and vein with a 5 cm defect. It was repaired with an interposition graft, and a fasciotomy was also performed. Literature has noted that although the overall incidence of popliteal injuries is low, when present due to blunt trauma there is increased morbidity. A high index of suspicion is recommended for vascular injuries in all patients with blunt trauma to the lower extremities. Minimizing time to diagnosis and intervention for limb salvage and improved outcomes.
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Affiliation(s)
- Shamon Gumbs
- General Surgery, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Maria Guevarra-Kissel
- General Surgery, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Gonzalo Ausqui
- General Surgery, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
| | - Sharique Nazir
- Minimally Invasive Surgery/General Surgery, NYC Health +Hospitals/Harlem, New York, USA
| | - Brian Donaldson
- General Surgery, Columbia University College of Physicians and Surgeons, Harlem Hospital Center, New York, USA
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Goldman SM, Eskridge SL, Franco SR, Souza JM, Tintle SM, Dowd TC, Alderete J, Potter BK, Dearth CL. A Data-Driven Method to Discriminate Limb Salvage from Other Combat-Related Extremity Trauma. J Clin Med 2023; 12:6357. [PMID: 37835001 PMCID: PMC10573244 DOI: 10.3390/jcm12196357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/22/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION The aim of this study was to address and enhance our ability to study the clinical outcome of limb salvage (LS), a commonly referenced but ill-defined clinical care pathway, by developing a data-driven approach for the identification of LS cases using existing medical code data to identify characteristic diagnoses and procedures, and to use that information to describe a cohort of US Service members (SMs) for further study. METHODS Diagnosis code families and inpatient procedure codes were compiled and analyzed to identify medical codes that are disparately associated with a LS surrogate population of SMs who underwent secondary amputation within a broader cohort of 3390 SMs with lower extremity trauma (AIS > 1). Subsequently, the identified codes were used to define a cohort of all SMs who underwent lower extremity LS which was compared with the opinion of a panel of military trauma surgeons. RESULTS The data-driven approach identified a population of n = 2018 SMs who underwent LS, representing 59.5% of the combat-related lower extremity (LE) trauma population. Validation analysis revealed 70% agreement between the data-driven approach and gold standard SME panel for the test cases studied. The Kappa statistic (κ = 0.55) indicates a moderate agreement between the data-driven approach and the expert opinion of the SME panel. The sensitivity and specificity were identified as 55.6% (expert range of 51.8-66.7%) and 87% (expert range of 73.9-91.3%), respectively. CONCLUSIONS This approach for identifying LS cases can be utilized to enable future high-throughput retrospective analyses for studying both short- and long-term outcomes of this underserved patient population.
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Affiliation(s)
- Stephen M. Goldman
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Susan L. Eskridge
- Leidos, Reston, VA 20190, USA
- Naval Health Research Center, San Diego, CA 92152, USA
| | - Sarah R. Franco
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Jason M. Souza
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Scott M. Tintle
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Thomas C. Dowd
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Houston, TX 78234, USA
| | - Joseph Alderete
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Houston, TX 78234, USA
| | - Benjamin K. Potter
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Christopher L. Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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Harutyunyan M, Hnath JC, Jacobson X, Le J, Shah MD, Kleene J, Darling RC. Trauma bypass performed by vascular surgeons demonstrate excellent long-term outcomes and limb preservation. J Vasc Surg 2023; 78:779-787. [PMID: 37330703 DOI: 10.1016/j.jvs.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Long-term outcomes in civilian trauma patients requiring upper or lower extremity revascularization is poorly studied secondary to limitations of certain large databases and the nature of the patients in this specific vascular subset. This study reports on the experience and outcomes of a Level 1 trauma center that serves both an urban and a large rural population over a 20-year period to identify bypass outcomes and surveillance protocols. METHODS Database of a single vascular group at an academic center was queried for trauma patients requiring upper or lower extremity revascularization between January 1, 2002, and June 30, 2022. Patient demographics, indications, operative details, operative mortality, 30-day nonoperative morbidity, revisions, subsequent major amputations, and follow-up data were analyzed. RESULTS A total of 223 revascularizations were performed, 161 (72%) lower and 62 (28%) upper extremities. One hundred sixty-seven patients (74.9%) were male, with a mean age of 39 years (range, 3-89 years). Comorbidities included hypertension (n = 34; 15.3%), diabetes (n = 6; 2.7%), and tobacco use (n = 40; 17.9%). Mean follow-up time was 23 months (range, 1-234 months), with 90 patients (40.4%) lost to follow-up. Mechanisms included blunt trauma (n = 106; 47.5%), penetrating trauma (n = 83; 37.2%), and operative trauma (n = 34; 15.3%). Bypass conduit was reversed vein (n= 171; 76.7%), prosthetic (n = 34; 15.2%), and orthograde vein (n = 11; 4.9%). Bypass inflow artery was superficial femoral (n = 66; 41.0%), above-knee popliteal (n = 28; 17.4%), and common femoral (n = 20; 12.4%) in the lower extremity, and brachial (n = 41; 66.1%), axillary (n = 10; 16.1%), and radial (n = 6; 9.7%) in the upper extremity. Lower extremity outflow artery was posterior tibial (n = 47; 29.2%), below-knee popliteal (n = 41; 25.5%), superficial femoral (n = 16; 9.9%), dorsalis pedis (n = 10; 6.2%), common femoral (n = 9; 5.6%), and above-knee popliteal (n = 10; 6.2%). Upper extremity outflow artery was brachial (n = 34; 54.8%), radial (n = 13; 21.0%), and ulnar (n = 13; 21.0%). Total operative mortality was nine patients (4.0%), all involving lower extremity revascularization. Thirty-day non-fatal complications included immediate bypass occlusion (n = 11; 4.9%), wound infection (n = 8; 3.6%), graft infection (n = 4; 1.8%), and lymphocele/seroma (n = 7; 3.1%). All major amputations (n = 13; 5.8%) were early and in the lower extremity bypass group. Late revisions in the lower and upper extremity groups were 14 (8.7%) and four (6.4%), respectively. CONCLUSIONS Revascularization for extremity trauma can be performed with excellent limb salvage rates and has demonstrated long-term durability with low limb loss and bypass revision rates. The poor compliance with long-term surveillance is concerning and may require adjustment in patient retention protocols; however, emergent returns for bypass failure are extremely low in our experience.
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Affiliation(s)
- Misak Harutyunyan
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Jeffrey C Hnath
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Xander Jacobson
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Jeremy Le
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Melissa D Shah
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Julia Kleene
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - R Clement Darling
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY.
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12
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Qiu C, Cheng L, Wang L, Li Z, Liu X. Therapeutic management and amputation options in a long time delayed blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1811-1819. [PMID: 36847787 DOI: 10.1007/s00068-023-02236-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors. METHODS From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared. RESULTS A total of 55 patients with a median age of 41.4 years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6 h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56 months (range 12-132), no death, another limb loss, or claudication was found in all patients. CONCLUSIONS Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.
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Affiliation(s)
- Cheng Qiu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Lin Cheng
- Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Lianlei Wang
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China
| | - Zhenfeng Li
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China.
| | - Xinyu Liu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China.
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13
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Liu G, Li L, Xu H, Kang B. Five-year outcomes after bypass graft versus Fogarty balloon catheter for the treatment of acute blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1989-1996. [PMID: 37039830 DOI: 10.1007/s00068-023-02268-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To evaluate long-term clinical outcomes after revascularization by bypass graft versus Fogarty balloon catheter in acute blunt popliteal artery injury and identify risk factors contributing to amputation. METHODS A retrospective review was conducted in patients treated for acute blunt PAI between 2011 and 2019. Inclusion criteria were patients who underwent bypass graft and Fogarty balloon catheter. The cumulative limb salvage rate was calculated by the Kaplan-Meier test and compared with Breslow-Wilcoxon test. Cox proportional hazard model was performed to estimate the potential risk factors for amputation. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off value for the potential risk factors. RESULTS The overall limb salvage rate was 60.4% (29/48), including 24 patients (66.7%) in bypass graft, and 5 patients (41.7%) in Fogarty balloon catheter with mean follow-up of 5 years (range, 2-10 years). Among amputees, 15 patients (15/19, 78.9%) received primary amputation due to vascular failure or severe soft tissue damage, and 4 received secondary amputation because of chronic bone infection or neurologic deficit. Kaplan-Meier curves showed patients who received Fogarty balloon catheter had significantly higher amputation rate than those received bypass graft, with a hazard ratio of 3.801 (95% CI: 1.162-12.43, p = 0.009). In addition, Cox proportional hazard model revealed that MESS was the only independent risk factor for patients developing amputation, and the optimal cut-off value of MESS was 8. CONCLUSION Five-year outcome demonstrated that Fogarty balloon catheter is not a safe procedure and has significantly higher amputation rate in severe blunt PAI. MESS is the only risk factor for amputation.
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Affiliation(s)
- Gang Liu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Lin Li
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Han Xu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Bin Kang
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China.
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14
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Van Nut L, Thanh Son H, Lam Vuong N. Revisiting the Mangled Extremity Severity Score (MESS) in Popliteal Artery Injury: A Single-Centre Experience in Vietnam. Cureus 2023; 15:e38813. [PMID: 37303452 PMCID: PMC10251213 DOI: 10.7759/cureus.38813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Popliteal artery injury is a severe condition that can lead to limb loss. Early intervention is essential to achieve optimal outcomes, including limb salvage. The Mangled Extremity Severity Score (MESS) is a scoring system used to predict amputation rates for mangled limb injuries. The effectiveness of the MESS in predicting amputation in patients with traumatic popliteal artery injury is unclear, particularly in settings with a high prevalence of motorcycle accidents. METHODS This retrospective study was conducted at a single center in Vietnam between January 2018 and June 2020. The study included 120 patients who underwent surgical treatment for popliteal artery injury. Data were collected from electronic medical records, radiology reports, and operative notes. Logistic regression model and the area under the curve (AUC) were used to evaluate the predictive value of the MESS. RESULTS Patients with a MESS score of ≥8 had a higher rate of amputation compared to those with a MESS score of <8. However, the predictive value of the MESS was limited, with an AUC of 0.68. Higher skeletal/soft tissue injury score, limb ischemia score, and shock score were associated with a higher risk of amputation. The age score of the MESS was unexpectedly higher in the limb salvage group. CONCLUSIONS The MESS score can be useful in predicting amputation rates in patients with popliteal artery injury, but its predictive value is limited. A team approach involving experienced surgeons is recommended for decision-making regarding amputation.
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Affiliation(s)
- Lam Van Nut
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, VNM
| | - Huynh Thanh Son
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, VNM
| | - Nguyen Lam Vuong
- Department of Medical Statistics and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
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15
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Figueras JH, Johnson BM, Thomson C, Dailey SW, Betz BE, Grawe BM. Team Approach: Treatment of Traumatic Dislocations of the Knee. JBJS Rev 2023; 11:01874474-202304000-00004. [PMID: 37058579 DOI: 10.2106/jbjs.rvw.22.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
» Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee. » Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category. » Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.
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Affiliation(s)
- Jorge H Figueras
- Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
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16
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García AM, Gutiérrez J, Villamil E, Sánchez W, Villarreal L, Lozada-Martinez ID, Picón-Jaimes YA, Pérez M, Cabrera-Vargas LF. Predictors for limb amputation in war vascular trauma: A 20-years retrospective analysis from the Colombian armed conflict. Am J Surg 2023; 225:787-792. [PMID: 36220700 DOI: 10.1016/j.amjsurg.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Latin American military vascular trauma is virtually unknown. The aim of this study was to describe severe war vascular trauma during the last 20 years of the Colombian armed conflict, and to identify predictors of limb amputation. METHODS Retrospective analysis of a follow-up cohort from 1999 to 2019 of patients with associated severe vascular injuries (ISS >15) in the Colombian armed conflict treated at the Hospital Militar Central. RESULTS Out of 5948 patients, 243 had military vascular trauma with 430 vascular injuries. The most frequent trauma mechanisms were gunshot wounds (n = 153; 63%). The most common injured vessels were femoral. 24 (10%) patients required amputations. Mortality was 4.1%. Amputation was associated with arteriovenous lesions (RR 4.82, p = 0.025), compartment syndrome (RR 4.2, p = 0.007), arteriovenous femoropopliteal injuries (RR 3.5, p = 0.0026), multiple arterial injuries (RR 3.35, p = 0.0218), associated fractures (RR 3.1, p = 0.0032). CONCLUSIONS Concomitant arteriovenous injuries in popliteal and femoropopliteal lesions, multiple arterial lesions, bone fractures, and compartment syndrome are associated with amputation in severe vascular injury.
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Affiliation(s)
- Ana Maria García
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Jorge Gutiérrez
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia; Department of Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Edwin Villamil
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - William Sánchez
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Laura Villarreal
- Department of Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ivan David Lozada-Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia; International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua.
| | | | - Mauricio Pérez
- Department of Surgery, Universidad El Bosque, Bogotá, Colombia
| | - Luis Felipe Cabrera-Vargas
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia; Department of Surgery, Universidad El Bosque, Bogotá, Colombia
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17
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Amro C, Parekh AT, Diamond K, Lissauer ME, Butts CA. Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation. Am Surg 2023:31348231160846. [PMID: 36871965 DOI: 10.1177/00031348231160846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38 days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.
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Affiliation(s)
- Chris Amro
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Akshat T Parekh
- Department of Orthopedic Surgery, 8395Walter Reed Army Medical Center, Bethesda, MD, USA
| | - Keith Diamond
- Department of Orthopedic Surgery, 2042Maimonides Medical Center, Brooklyn, NY, USA
| | - Matthew E Lissauer
- Department of Surgery, 12227University of Connecticut School of Medicine, Hartford, CT, USA
| | - Christopher A Butts
- Department of Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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18
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Davidovic LB, Koncar IB, Dragas MV, Markovic MD, Bogavac-Stanojevic N, Vujcic AD, Mitrovic AC, Ilic NS, Trailovic RD, Kostic DM. Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:74-81. [PMID: 36168950 DOI: 10.23736/s0021-9509.22.12243-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Lazar B Davidovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Igor B Koncar
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia - .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko V Dragas
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav D Markovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Aleksandra D Vujcic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandar C Mitrovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikola S Ilic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ranko D Trailovic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dusan M Kostic
- Clinic for Vascular and Endovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Joarder M, Noureddine El Moussaoui H, Das A, Williamson F, Wullschleger M. Impact of time and distance on outcomes following tourniquet use in civilian and military settings: A scoping review. Injury 2023; 54:1236-1245. [PMID: 36697284 DOI: 10.1016/j.injury.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/01/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The last two decades have seen the reintroduction of tourniquets into guidelines for the management of acute limb trauma requiring hemorrhage control. Evidence supporting tourniquet application has demonstrated low complication rates in modern military settings involving rapid evacuation timeframes. It is unclear how these findings translate to patients who have prolonged transport times from injury in rural settings. This scoping review investigates the relationship between time and distance on metabolic complications, limb salvage and mortality following tourniquet use in civilian and military settings. METHODS A systematic search strategy was conducted using PubMed, Embase, and SafetyLit databases. Study characteristics, setting, mechanism of injury, prehospital time, tourniquet time, distance, limb salvage, metabolic response, mortality, and tourniquet removal details were extracted from eligible studies. Descriptive statistics were recorded, and studies were grouped by ischemia time (< 2 h, 2-4 h, or > 4 h). RESULTS The search identified 3103 studies, from which 86 studies were included in this scoping review. Of the 86 studies, 55 studies were primarily in civilian environments and 32 were based in military settings. One study included both settings. Blast injury was the most common mechanism of injury sustained by patients in military settings (72.8% [5968/8200]) followed by penetrating injury (23.5% [1926/8200]). In contrast, in civilian settings penetrating injury was the most common mechanism (47.7% [1633/3426]) followed by blunt injury (36.4% [1246/3426]). Tourniquet time was reported in 66/86 studies. Tourniquet time over four hours was associated with reduced limb salvage rates (57.1%) and higher mortality rates (7.1%) compared with a tourniquet time of less than two hours. The overall limb salvage and mortality rates were 69.6% and 6.7% respectively. Metabolic outcomes were reported in 28/86 studies with smaller sample sizes and inconsistencies in which parameters were reported. CONCLUSION This scoping review presents literature describing comparatively safe tourniquet application when used for less than two hours duration. However, there is limited research describing prolonged tourniquet application or when used for protracted distances, such that the impact of tourniquet release time on metabolic outcomes and complications remains unclear. Prospective studies utilizing the development of an international database to provide this dataset is required.
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Affiliation(s)
- Maisah Joarder
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
| | - Hussein Noureddine El Moussaoui
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Arpita Das
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Frances Williamson
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Martin Wullschleger
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Trauma Service, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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20
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Edwards J, Treffalls RN, Abdou H, Stonko DP, Walker PF, Morrison JJ. Lower Extremity Staged Revascularization (LESR) as a new innovative concept for lower extremity salvage in acute popliteal artery injuries: a hypothesis. Patient Saf Surg 2022; 16:39. [PMID: 36522769 PMCID: PMC9756456 DOI: 10.1186/s13037-022-00349-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time.Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution.We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury.
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Affiliation(s)
- Joseph Edwards
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Rebecca N. Treffalls
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Hossam Abdou
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - David P. Stonko
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA ,grid.411935.b0000 0001 2192 2723Department of Surgery, Johns Hopkins Hospital, Baltimore, MD USA
| | - Patrick F. Walker
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Jonathan J. Morrison
- grid.66875.3a0000 0004 0459 167XDepartment of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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21
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Abdou H, Edwards J, Stonko D, Elansary N, Ottochian M, DuBose JJ, Scalea TM, Morrison JJ, Kundi R. The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting. Ann Vasc Surg 2022; 87:522-528. [PMID: 35760265 DOI: 10.1016/j.avsg.2022.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. METHODS The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the pre-defined noninferiority margin. RESULTS 3698 patients met inclusion criteria, with blunt injury accounting for 2117 (57%) and penetrating injury accounting for 1581 (43%). Within the blunt group, 1976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6). CONCLUSION These data suggest that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation . Further examination of endovascular repair in popliteal artery injury is warranted.
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Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - David Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Marcus Ottochian
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
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Stefanou N, Arnaoutoglou C, Papageorgiou F, Matsagkas M, Varitimidis SE, Dailiana ZH. Update in combined musculoskeletal and vascular injuries of the extremities. World J Orthop 2022; 13:411-426. [PMID: 35633747 PMCID: PMC9125001 DOI: 10.5312/wjo.v13.i5.411] [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: 02/25/2021] [Revised: 10/31/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.
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Affiliation(s)
- Nikolaos Stefanou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Christina Arnaoutoglou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Fotios Papageorgiou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Sokratis E Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Zoe H Dailiana
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
- Department of Hand, Upper Extremity and Microsurgery, IASO Thessalias, Larissa 41500, Greece
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Liu G, Chen J, Xiang Z. Five-year outcomes of trauma-specific function in patients after acute blunt popliteal artery injury: a matched cohort analysis. J Orthop Surg Res 2022; 17:256. [PMID: 35525991 PMCID: PMC9077808 DOI: 10.1186/s13018-022-03145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/26/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Few studies focus on the trauma-specific functional outcomes after surgical revascularization and risk factors contributing to poor outcomes in patients with acute blunt popliteal artery injury (PAI). The objective of this study was to investigate the long-term trauma-specific functional outcomes in patients with acute blunt PAI and identify the associated risk factors. METHODS There were 36 patients with acute blunt PAI who require surgical revascularization at a national trauma center of West China Hospital of Sichuan University between March 2010 and April 2019. After propensity matching, each patient was matched to one patient who did not have a concomitant vascular injury in control cohort. Functional outcomes were assessed with trauma-specific functional scores, physical examination of range of motion, nerve functional status and knee stability. A logistics regression model was established to determine the independent risk factors. RESULTS The 5-year (range 2-10 years) follow-up showed that 22 patients (22/36, 61.1%) had functional deficit due to limited activity or chronic neurological symptoms. Patients in vascular cohort had significantly decreased FIM score and AHFS score compared with matched patients without vascular involvement (P = 0.003 and P < 0.001), whereas there was no statistically significant difference in KSS (P = 0.136). Spearman correlation analysis of functional scores in vascular cohort showed that the FIM score was positively correlated with AHFS score (r = 0.926, P < 0.001), but not correlated with the KSS (r = - 0.007, P = 0.967). Additionally, there was significant difference in the range of motion of ankle between two groups (P < 0.001 and P = 0.034). Logistic regression analysis further demonstrated nerve injuries and compartment syndrome were risk factors for poor ankle function after surgery (OR 22.580, P = 0.036 and OR 12.674, P = 0.041). CONCLUSION Most patients who sustained blunt PAI had significant functional deficit associated with limited activity and chronic neurological symptoms of ankle and foot, and poor functional outcomes were related to nerve injury and compartment syndrome. Therefore, early and effective decompression for compartment syndrome remains the only potentially modifiable risk factor for improving functional outcomes following PAI.
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Affiliation(s)
- Gang Liu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Jialei Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Zhou Xiang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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The accuracy of routine knee MR imaging in detection of acute neurovascular injury following multiligamentous knee injury. Skeletal Radiol 2022; 51:981-990. [PMID: 34557951 DOI: 10.1007/s00256-021-03907-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. MATERIALS AND METHODS Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. RESULTS Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. CONCLUSION Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI.
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Assessment and Interventions for Vascular Injuries Associated With Fractures. J Am Acad Orthop Surg 2022; 30:387-394. [PMID: 35050940 DOI: 10.5435/jaaos-d-21-00660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/23/2021] [Indexed: 02/01/2023] Open
Abstract
Vascular injuries associated with fractures are limb-threatening injuries with notable morbidity. The prompt and thorough evaluation of these patients is imperative to diagnose vascular injuries, and coordinated multidisciplinary care is needed to provide optimal outcomes. The initial assessment includes a detailed physical examination assessing for hard and soft signs of arterial injury, and the arterial pressure index can be used to reliably identify vascular compromise and the need for additional assessment or intervention. Advanced imaging in the form of CT angiography is highly sensitive in additional characterization of the potential injury and can be obtained in an expedient manner. The optimal treatment of fractures with vascular injuries includes providing skeletal stability and confirming or reestablishing adequate distal perfusion as soon as possible. Options for vascular intervention include observation, ligation, direct arterial repair, vascular bypass grafting, endovascular intervention, and staged temporary shunting, followed by bypass grafting. Although the optimal sequence of surgical intervention remains an incompletely answered question, the orthopaedic role in the care of patients with these injuries is to provide mechanical stability to the injured limb to protect the vascular repair and surrounding soft-tissue envelope.
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26
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WINGKAR CC, KAUSHIK T. Management of distal femoral and popliteal artery injuries: a retrospective study. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05236-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis. J Orthop Trauma 2021; 35:512-516. [PMID: 33512862 DOI: 10.1097/bot.0000000000002067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN Retrospective. SETTING Nine trauma centers. PATIENTS This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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28
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Al-Zoubi NA, Shatnawi NJ, Khader Y, Heis M, Aleshawi AJ. Predictive Factors for Failure of Limb Salvage in Blunt Leg Trauma Associated with Vascular Injuries. J Emerg Trauma Shock 2021; 14:80-85. [PMID: 34321805 PMCID: PMC8312914 DOI: 10.4103/jets.jets_37_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 02/02/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization. Methods: A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality. Results: Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality. Conclusions: Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.
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Affiliation(s)
- Nabil A Al-Zoubi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Nawaf J Shatnawi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Yousef Khader
- Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
| | - Mowafeq Heis
- Department of Radiology, Jordan University of Science and Technology, Irbid, Jordan
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Altoijry A, Lindsay TF, Johnston KW, Mamdani M, Al-Omran M. Vascular injury-related in-hospital mortality in Ontario between 1991 and 2009. J Int Med Res 2021; 49:300060520987728. [PMID: 33512260 PMCID: PMC7871087 DOI: 10.1177/0300060520987728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Trauma-related vascular injuries are major contributors to morbidity and mortality worldwide. We conducted a retrospective, population-based, cross-sectional study to examine temporal trends and factors associated with traumatic vascular injury-related in-hospital mortality in Ontario, Canada from 1991 to 2009. METHODS We obtained data on Ontario hospital admissions for traumatic vascular injury, including injury mechanism and body region; and patient age, sex, socioeconomic status, and residence from the Canadian Institute for Health Information Discharge Abstract Database and Registered Persons Database from fiscal years 1991 to 2009. We performed time series analysis of vascular injury-related in-hospital mortality rates and multivariable logistic regression analysis to identify significant mortality-associated factors. RESULTS The overall in-hospital mortality rate for trauma-related vascular injury was 5.5%. A slight but non-significant decline in mortality occurred over time. The likelihood of vascular injury-related in-hospital mortality was significantly higher for patients involved in transport-related accidents (odds ratio [OR[=2.21, 95% confidence interval [CI], 1.76-2.76), age ≥65 years (OR = 4.34, 95% CI, 2.25-8.38), or with thoracic (OR = 2.24, 95% CI, 1.56-3.20) or abdominal (OR = 2.45, 95% CI, 1.75-3.42) injuries. CONCLUSIONS In-hospital mortality from traumatic vascular injury in Ontario was low and stable from 1991 to 2009.
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Affiliation(s)
- Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Thomas F Lindsay
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - K Wayne Johnston
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohammed Al-Omran
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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30
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Bunn C, Kulshrestha S, Di Chiaro B, Maduekwe U, Abdelsattar ZM, Baker MS, Luchette FA, Agnew S. A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury. J Am Coll Surg 2021; 233:120-129.e5. [PMID: 33887482 DOI: 10.1016/j.jamcollsurg.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/24/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs). STUDY DESIGN We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication. RESULTS There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching. CONCLUSIONS In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.
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Affiliation(s)
- Corinne Bunn
- Department of Surgery, Loyola University Chicago, Maywood; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood.
| | - Sujay Kulshrestha
- Department of Surgery, Loyola University Chicago, Maywood; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood
| | - Bianca Di Chiaro
- Department of Plastic and Reconstructive Surgery, Loyola University Chicago, Maywood
| | - Uma Maduekwe
- Department of Plastic and Reconstructive Surgery, Loyola University Chicago, Maywood; Department of Plastic and Reconstructive Surgery, John Hopkins, Baltimore, MD
| | - Zaid M Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| | - Marshall S Baker
- Department of Surgery, Loyola University Chicago, Maywood; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Chicago, Maywood; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| | - Sonya Agnew
- Department of Plastic and Reconstructive Surgery, Loyola University Chicago, Maywood; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
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Herrera MA, Millán M, Del Valle AM, Betancourt-Cajiao M, Caicedo Y, Caicedo I, Gallego LM, Rivera D, Parra MW, Ordoñez CA. Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses. Colomb Med (Cali) 2021; 52:e4074735. [PMID: 34188323 PMCID: PMC8216047 DOI: 10.25100/cm.v52i2.4735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient’s life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.
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Affiliation(s)
- Mario Alain Herrera
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | | | | | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Isabella Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | | | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg 2021; 89:1183-1196. [PMID: 33230048 DOI: 10.1097/ta.0000000000002967] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.
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33
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Jiang C, Chen Z, Zhao Y, Zhang WW, Zeng Q, Li F. Four-year outcomes following endovascular repair in patients with traumatic isolated popliteal artery injuries. J Vasc Surg 2021; 73:2064-2070. [PMID: 33340706 DOI: 10.1016/j.jvs.2020.12.050] [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: 07/02/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The effectiveness of endovascular treatment for popliteal arterial injury has not been well-documented. This study was aimed to investigate the midterm outcomes of endovascular repair of traumatic isolated popliteal arterial injury. METHODS Medical records of the patients who underwent endovascular repair for traumatic popliteal arterial injuries from January 2012 to February 2020 were reviewed retrospectively. Clinical data including patient demographics, Injury Severity Score, type of injury, classification of acute limb ischemia, concomitant extremity fracture, runoff vessel status, complications, time of endovascular procedure, time interval from injury to blood flow restoration, length of hospital stay, reintervention, and follow-up were collected and analyzed. RESULTS Endovascular repair was performed in 46 patients with traumatic popliteal arterial injuries. The mean Injury Severity Score was 15.8 ± 6.2. The overall limb salvage rate was 89.1%. There were 10 penetrating and 36 blunt injuries (78.3%). The initial angiographic findings revealed occlusion in 34 patients (73.9%), pseudoaneurysm in 2 (4.4%), active extravasation in 9 (19.5%), and arteriovenous fistulas in 1 (2.2%). Technical success was achieved in all 46 patients, via antegrade access in 24 patients (52.2%) and concurrent retrograde access in 22 (47.8%). The mean time interval from popliteal artery injury to blood flow restoration was 10.6 ± 4.9 hours and mean operative time was of 54.9 ± 10.0 minutes. The mean follow-up was 36.1 ± 14.5 months. The primary patency rate was 75.3% at 12 months, 61.9% at 24 months, and 55.7% at 48 months. The secondary patency rate was 92.2% at 12 and 24 months and 85.2% at 48 months. A Cox multivariate analysis revealed that single vessel runoff was an independent risk factor for primary patency loss. CONCLUSIONS Endovascular repair of an isolated popliteal artery injury may be a safe and effective alternative treatment in select patients, with acceptable midterm outcomes. Single vessel runoff was an independent risk factor for primary patency loss.
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Affiliation(s)
- Chuli Jiang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington and Puget Sound VA Health Care System, Seattle, Wash
| | - Qiu Zeng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fenghe Li
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Watras JB, Collins DT, Newcomb A, Liu C, Griffen MM. Effect of Obesity on Early, In-Hospital Amputation Risk Following Popliteal Artery Injury Using an Analysis of the National Trauma Data Bank. Am Surg 2021; 88:1111-1117. [PMID: 33522836 DOI: 10.1177/0003134820988819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Popliteal artery injury is associated with a high risk of limb loss; identifying factors associated with increased morbidity and mortality is hampered by its rare occurrence and confounding factors. Anecdotal observations suggest delay in diagnosis of obese patients may be associated with amputation. We aimed to determine whether there is an increased risk of early amputation and if diagnosis is delayed in obese patients with popliteal artery injuries. METHODS We conducted a retrospective cohort study using National Trauma Data Bank (NTDB) data from 2013 to 2017. We extracted those sustaining popliteal artery injury, assigning obesity class based on body mass index. We included select demographic and clinical variables, using time to imaging as a surrogate for time to diagnosis. Statistical models were used to calculate the impact of obesity on amputation rates and time to diagnosis. RESULTS We identified 4803 popliteal artery injuries in the data set; 3289 met inclusion criteria. We calculated an 8.5% overall amputation rate, which was not significantly different between obese (N = 1305; 39.7%) and nonobese (N = 1984; 60.3%) patients. Statistical analysis identified peripheral vascular disease, diabetes, and smoking as risk factors for amputation. Time to imaging was similar for obese and nonobese patients. CONCLUSIONS AND RELEVANCE Analysis of NTDB data suggests that obesity is associated with neither increased early amputation rate nor longer time to imaging in patients with popliteal artery injury. However, our study suggests that underlying comorbidities of peripheral vascular disease and diabetes are associated with an increased risk for amputation in these patients.
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Affiliation(s)
- Jill B Watras
- Trauma Services, Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA.,Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Devon T Collins
- Department of Global and Community Health, College of Health and Human Services, 3298George Mason University, Fairfax, VA, USA.,Inova Heart and Vascular Institute, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Anna Newcomb
- Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Chang Liu
- Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Margaret M Griffen
- Trauma Services, Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
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Kochuba M, Rozycki GF, Feliciano D. Outcome after ligation of major veins for trauma. J Trauma Acute Care Surg 2021; 90:e40-e49. [PMID: 33502152 DOI: 10.1097/ta.0000000000003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Kochuba
- From the Division of Acute Care Surgery, Department of Surgery, UF Health Jacksonville Medical Center (M.K.), University of Florida-Jacksonville, Jacksonville, Florida; Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University School of Medicine (G.F.R.), Johns Hopkins University; and Division of Surgical Critical Care, Department of Shock Trauma Center, Shock Trauma Center (D.F.), University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
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Yu L, Deng L, Zhu S, Deng K, Yu G, Zhu C, Qi B, Pan Z. Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites. Med Sci Monit 2021; 27:e927652. [PMID: 33431786 PMCID: PMC7812700 DOI: 10.12659/msm.927652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity. Materal/Methods From January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed. Results External iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery. Conclusions Although limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon’s best efforts.
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Affiliation(s)
- Li Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Linglong Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Shaobo Zhu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Kai Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Guorong Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Chunquan Zhu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Baiwen Qi
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Zhenyu Pan
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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Mundy LR, Truong T, Shammas RL, Cunningham D, Hollenbeck ST, Pomann GM, Gage MJ. Amputation Rates in More Than 175,000 Open Tibia Fractures in the United States. Orthopedics 2021; 44:48-53. [PMID: 33284985 DOI: 10.3928/01477447-20201202-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/06/2019] [Indexed: 02/03/2023]
Abstract
Open tibia fractures are often associated with considerable soft tissue injuries. Management of open tibia fractures can be challenging, and some patients require amputation. The patient and treatment factors have not been described on a population level in the United States. A retrospective analysis was completed using the 2000 to 2011 Nationwide Inpatient Sample. Amputation rates during the index hospitalization after open tibia fracture were computed based on injury, patient, and hospital characteristics in patients 18 years or older. The overall amputation rate in open tibia fractures during the index hospitalization was 2.2% (n=3769). Patients with midshaft tibia fractures comprised the largest portion of patients undergoing amputation (46.8% of total amputations) compared with distal tibia (34.0%) and proximal tibia (19.3%) fractures. Patients with no neurovascular injury comprised the largest portion of patients undergoing amputation (85.9%), followed by isolated arterial injury (11.1%), combined neurovascular injury (1.9%), and isolated nerve injury (1.1%). Amputation rates were significantly increased for midshaft tibia fractures with neurovascular injury (odds ratio, 12.39; 95% CI, 5.52-27.83) and distal tibia fractures with neurovascular injury (odds ratio, 5.45; 95% CI, 1.73-17.19) compared with tibia fractures with no neurovascular injury while controlling for confounders. On the basis of a review of the Nationwide In-patient Sample during the past decade, the authors have shown that the early amputation rate in open tibia fractures for all-comers is 2.2%. Rates of amputation varied based on fracture site, associated neurovascular injury, medical comorbidities, and hospital location. [Orthopedics. 2021;44(1):48-53.].
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Ratnayake A, Ranatunga PEKB, Worlton TJ. Letter Regarding: A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status. J Surg Res 2020; 259:569-571. [PMID: 33213834 DOI: 10.1016/j.jss.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Amila Ratnayake
- Department of Surgery, Military Hospital Narahenpita, Colombo, Sri Lanka; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Prasad E K B Ranatunga
- Department of Surgery, Clinical Informatics Research Unit, University of Southampton, Southampton, UK
| | - Tamara J Worlton
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.
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Response Regarding: A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status. J Surg Res 2020; 259:572-573. [PMID: 33187672 DOI: 10.1016/j.jss.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Siracuse JJ, Farber A, Cheng TW, Jones DW, Kalesan B. Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma. J Vasc Surg 2020; 72:1298-1304.e1. [DOI: 10.1016/j.jvs.2019.12.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022]
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Hemingway J, Adjei E, Desikan S, Gross J, Tran N, Singh N, Starnes B, Quiroga E. Re-evaluating the safety and effectiveness of the 0.9 ankle-brachial index threshold in penetrating lower extremity trauma. J Vasc Surg 2020; 72:1305-1311.e1. [DOI: 10.1016/j.jvs.2020.01.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 01/20/2020] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma. METHODS Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors. RESULTS During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p < 0.001). Endovascular management increased in frequency during the course of the study, from 0% during the first decade to 5.1 and 11.1% during the second and third decade, respectively (p = 0.005). Mortality was 9.8%, and limb loss (in cases with injury of the aorta or limb arteries, n = 259) was 6.2%. Independent predictors of mortality included increased age (odds ratio, 95% confidence interval [OR, 95% CI] 1.05 (1.02-1.07), p < 0.001), blunt trauma (OR [95% CI] 4.8 (1.9-12.2), p = 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.25 (1.1-1.4), p = 0.001). Independent predictors of limb loss included the first half of the study period (OR [95% CI] 3.9 (1.1-14.1), p = 0.04), lower extremity arterial trauma (vs upper extremity, aortic, common or external iliac artery trauma, OR [95% CI] 8.3 (1.9-35.7), p = 0.004), bone fracture (OR [95% CI] 16.9 (4.7-62.5), p < 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.16 (1.02-1.33), p = 0.024). CONCLUSION Increasingly iatrogenic in cause and managed by endovascular methods, arterial trauma remains a problem associated with significant mortality and limb loss. Identification of unfavourable outcome predictors may help clinicians involved with arterial trauma to escalate the level of care.
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A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status. J Surg Res 2020; 257:363-369. [PMID: 32892132 DOI: 10.1016/j.jss.2020.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/06/2020] [Accepted: 08/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Popliteal artery injuries are the second most common arterial injuries below the inguinal ligament. We aimed to compare outcomes in patients with popliteal injuries by hospital teaching status utilizing the National Trauma Data Bank Research Data Set (NTDB-RDS) 2013-2016. METHODS Four-year retrospective study using the NTDB-RDS, evaluating popliteal vascular injuries. Patients were divided by popliteal injury type and teaching status into; nonteaching hospital (NTH), community teaching (CTH), or University teaching (UTH). Demographics and outcome measures were compared between groups. Risk-adjusted mortality odds ratios (ORs) were calculated. Significance was defined as P < 0.05. RESULTS 3,577,168 patients were in the NTDB-RDS, with 1120 having a popliteal injury, (incidence = 0.03%). There was no significant difference in the amputation rate between patients treated in NTHs, CTHs, or UTHs (P > 0.05). There was no significant difference in the raw mortality rate between patients treated in NTHs, CTHs, or UTHs. After adjusting for confounders; compared to NTH, the odds ratio for mortality for popliteal artery injuries in the CTH group was significantly higher (OR: 15.95, 95% CI: 1.19-213.84), and for the UTH group the mortality was also significantly higher (OR: 5.74, 95% CI: 0.45-72.95). CONCLUSIONS The incidence of popliteal vascular injuries was 0.03% for 2013-2016. Patients with popliteal artery injuries treated at community teaching hospitals have a 16 times higher risk of mortality and at university teaching hospitals have a 5.7 times higher risk of mortality than patients treated at nonteaching hospitals.
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Futchko J, Parsikia A, Berezin N, Shah A, Stone ME, McNelis J, Rivera A. A propensity-matched analysis of contemporary outcomes of blunt popliteal artery injury. J Vasc Surg 2020; 72:189-197. [DOI: 10.1016/j.jvs.2019.09.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/19/2019] [Indexed: 12/31/2022]
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Rehman ZU. Outcomes of Popliteal Artery Injuries Repair: Autologous Vein versus Prosthetic Interposition Grafts. Ann Vasc Surg 2020; 69:141-145. [PMID: 32505682 DOI: 10.1016/j.avsg.2020.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 05/21/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study is to compare wound infection, graft infection, and secondary amputation rates in patients who had popliteal artery injury repair with interposition vein versus prosthetic grafts. METHODS This retrospective comparative study included all adult patients (>18 years) who had interposition grafting for popliteal artery injuries between January 2008 and August 2018 at a university hospital. Patients were divided into 2 groups. Popliteal arteries were repaired with venous graft in Group "A" and with prosthetic graft in Group "B." The outcome measures were wound infection, graft infection, and secondary amputation rates. RESULTS Forty patients fulfilled the inclusion criteria. Twenty-two patients had arterial repair with venous while 18 with polytetrafluoroethylene grafts. All were male with median age of 32 (interquartile range [IQR] 19.5) years. Both groups were comparable in terms of median age (32.5 [19] vs. 30.5 [23]), Mangled Extremity Severity Score (6 [5] vs. 7 [7]), median hospital stay (7 [5] vs. 7 [9] days), and perioperative complications (2/22 vs. 3/18). In Group "A," no patient had graft infection or secondary amputation while in Group "B," 1 patient had secondary amputation and another had graft infection (P > 0.99). CONCLUSIONS There is no statistical difference in secondary amputation rate, wound infection, or graft infection in patients undergoing popliteal artery repair with interposition vein versus prosthetic grafts in trauma setting.
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Affiliation(s)
- Zia Ur Rehman
- Section of Vascular Surgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
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Predictors and timing of amputations in military lower extremity trauma with arterial injury. J Trauma Acute Care Surg 2020; 87:S172-S177. [PMID: 31246923 DOI: 10.1097/ta.0000000000002185] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Military lower extremity arterial injuries present threats to life and limb. These injuries are common and limb salvage is a trauma system priority. Understanding the timing and predictors of amputation through the phases of casualty evacuation can help inform future limb salvage efforts. This study characterizes limbs undergoing amputation at different operationally relevant time points. METHODS A retrospective cohort study of casualties with lower extremity arterial injuries undergoing initial vascular limb salvage in Iraq and Afghanistan was undertaken. Amputations were grouped as having been performed early (in theater at Role 2 or 3) or late (after evacuation to Role 4 or 5). Further distinction was made between late and delayed (after discharge from initial hospitalization) amputations. RESULTS Four hundred fifty-five casualties met inclusion criteria with 103 amputations (23%). Twenty-one (20%) were performed in theater and 82 (80%) were performed following overseas evacuation. Twenty-one (26% of late amputations) were delayed, a median of 359 days from injury (interquartile range, 176-582). Most amputations were performed in the first 4 days following injury. Amputation incidence was highest in popliteal injuries (28%). Overall, amputation was predicted by higher incidence of blast mechanism and fracture and greater limb and casualty injury severity. Early amputations had higher limb injury severity than late amputations. Delayed amputations had greater incidence of motor and sensory loss and contracture than early amputations. CONCLUSION Casualty and limb injury severity predict predictors and timing of amputation in military lower extremity arterial injury. Amputation following overseas evacuation was more common than in-theater amputation, and functional loss is associated with delayed amputation. Future limb salvage efforts should focus on postevacuation and rehabilitative care. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Prieto JM, Van Gent JM, Calvo RY, Checchi KD, Wessels LE, Sise CB, Sise MJ, Bansal V, Ignacio RC. Evaluating surgical outcomes in pediatric extremity vascular trauma. J Pediatr Surg 2020; 55:319-323. [PMID: 31761459 DOI: 10.1016/j.jpedsurg.2019.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the epidemiology and management of pediatric vascular extremity trauma to assess injury patterns and other factors that may contribute to poor outcomes. METHODS Using the California Office of Statewide Health Planning and Development discharge database, we identified pediatric patients with extremity arterial trauma admitted to acute-care hospitals from 2007 to 2014. Demographics, management patterns, and outcomes were collected and analyzed. RESULTS A total of 775 patients were treated for an extremity arterial injury. Overall, 40% were admitted to pediatric trauma centers and 39% to adult trauma centers. Management was predominantly by open surgical repair. Injury to the common femoral artery was associated with mortality (Hazard Ratio 3.9; 95% CI 1.1-14.5; p < 0.05). Popliteal artery injuries (Odds Ratio [OR] 4.8; 95% CI 1.2-19.9; p < 0.05) and anterior tibial artery injuries (OR 7.1; 95% CI 1.4-37.3; p < 0.05) had an increased risk of amputation. There was no difference in amputation or mortality rates by hospital category. CONCLUSIONS Pediatric extremity arterial injuries are rare. In California, outcomes are similar by hospital type. Common femoral artery injuries are associated with an increased risk of mortality, while popliteal and anterior tibial artery injuries are associated with an increased risk of amputation. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- James M Prieto
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA; Division of Pediatric Surgery, Rady Children's Hospital, 3020 Children's Way, MC 5136, San Diego, CA 92123, USA
| | - Jan Michael Van Gent
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - Richard Y Calvo
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - Kyle D Checchi
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - Lyndsey E Wessels
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - C Beth Sise
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - Michael J Sise
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - Vishal Bansal
- Trauma Service (MER62), Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA 92103, USA
| | - Romeo C Ignacio
- Division of Pediatric Surgery, Rady Children's Hospital, 3020 Children's Way, MC 5136, San Diego, CA 92123, USA.
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Maithel S, Fujitani RM, Grigorian A, Kabutey NK, Gambhir S, Sheehan BM, Nahmias J. Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma. Ann Vasc Surg 2020; 66:242-249. [PMID: 31978483 DOI: 10.1016/j.avsg.2020.01.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
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Affiliation(s)
- Shelley Maithel
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA.
| | - Roy M Fujitani
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
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Hemingway J, Adjei E, Desikan S, Gross J, Tran N, Singh N, Starnes B, Quiroga E. Lowering the Ankle–Brachial Index Threshold in Blunt Lower Extremity Trauma May Prevent Unnecessary Imaging. Ann Vasc Surg 2020; 62:106-113. [DOI: 10.1016/j.avsg.2019.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/08/2019] [Accepted: 05/23/2019] [Indexed: 12/11/2022]
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Guice JL, Gifford SM, Hata K, Shi X, Propper BW, Kauvar DS. Analysis of Limb Outcomes by Management of Concomitant Vein Injury in Military Popliteal Artery Trauma. Ann Vasc Surg 2020; 62:51-56. [DOI: 10.1016/j.avsg.2019.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/15/2019] [Accepted: 05/25/2019] [Indexed: 11/15/2022]
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