Impact of Intraoperative Arteriography on Limb Salvage for Traumatic Popliteal Artery Injury

The Mangled Extremity Severity Score (MESS) does not predict amputation in popliteal artery injury

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.

The mangled extremity: assessment, decision making and outcomes

The management of the mangled extremity continues to pose a significant challenge for ortho- paedic trauma surgeons. This article provides a comprehensive, up-to-date literature review on the assessment of complex limb injuries, and the variables that affect decision-making and outcomes in both limb salvage and amputation. Initial assessment involves using a systematic approach, saving life before limb, with early involvement of the relevant surgical specialities and multidisciplinary team. The decision to attempt limb salvage or perform amputation can be extremely difficult. Scoring systems can be used as a guide but should not be wholly relied upon; instead more emphasis should be placed on the surgeon's experience, extent of soft tissue damage, and patient factors and wishes. Outcomes following amputation versus limb salvage are comparable, with some studies suggesting amputation may be favourable. It is important to advise patients and families on what treatment is in their best interest so they can make an informed decision, and this must utilise a multidisciplinary approach.

Popliteal artery injuries. Less ischemic time may lead to improved outcomes

BACKGROUND

Popliteal artery injuries are rare. They have high amputation rates.

OBJECTIVES

To report our experience, identify predictors of outcome; mechanism of injury (MOI), Mangled Extremity Severity Score (MESS) score and length of ischemic time. We hypothesized that ischemic time as close to six hours results in improved outcomes.

METHODS

Retrospective 132-month study. All popliteal artery injuries. Urban Level I Trauma Center.

OUTCOME MEASURES

MOI, ISS, MESS, ischemic time, risk factors for amputation, role of popliteal venous injuries, and limb salvage.

STATISTICAL ANALYSIS

univariate and multivariate.

RESULTS

76 patients - 59 (76.1%) males and 17 (22.4%) females. MOI: penetrating - 54 (71%). MESS for penetrating injuries - 5.8 ± 1.5, blunt injuries - 5.6 ± 1.8. Admission-perfusion restoration (n = 76) - 5.97 hours (358 minutes). Ischemic time was not predictive of outcome (p = 0.79). Ischemic time penetrating (n = 58) 5.9 hours (354 ± 209 minutes), blunt 6.1 hours (371 ± 201 minutes). Popliteal arterial repairs: RSVG 44 (58%), primary repair 21 (26%), PTFE 3 (4%), vein patch 2 (2%), ligation 2 (3%), exsanguinated 4 (6%). No patients underwent stenting. Popliteal Vein: Repair 19 (65%), ligation 10 (35%). Fasciotomies 45 patients (59%).

OUTCOMES

Limb salvage - 90% (68/76). Adjusted limb salvage excluding intraoperative deaths - 94% (68/72). Selected patient characteristics; MOI: penetrating vs. blunt - age (p <0.0005). Amputated vs. non-amputated patients, age (p < 0.05). ISS (p < 0.005) predicted amputation, MESS (p = 0.98) did not. Mean ischemic time (p = 0.79) did not predict amputation. Relative risk of amputation, MOI - blunt (p = 0.26, RR 4.67, 95% CI: 1.11 - 14.1), popliteal artery ligation (p = 0.06, RR 3.965, 95% CI: 1.11 - 14.1) as predictors of outcome. Combined artery and vein injuries (p = 0.25) did not predict amputation.

CONCLUSIONS

Decreasing ischemic time from arrival to restoration of perfusion may lead to improved outcomes and increased limb salvage. MESS is not predictive for amputation. Blunt MOI is a risk factor for amputation. Maintaining ischemic times as close to six hours as possible may lead to improved outcomes.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.

Comparison of traditional vascular reconstruction with covered stent in the treatment of subclavian artery injury

PURPOSE

To explore the significance of traditional vascular reconstruction and covered stent for limb salvage after subclavian artery injury.

METHODS

Patients with subclavian artery injury admitted to Beijing Jishuitan Hospital from January 2010 to December 2018 were retrospectively analyzed. All the injuries have been confirmed by intraoperative exploration, computed tomography angiography or digital subtraction angiography. Complete or partial amputation injuries were excluded. Mild artery defect or partial intimal damage was treated by interventional implantation, while other patients received open surgeries, including direct suture of small defect less than 2 cm and transplantation with autologous vein or artificial blood when the defect was more than 2 cm. Patients were divided into open surgery group and stent implantation group based on the treatment they received. Patients were followed up at 2 weeks (first stage) and 6 months (second stage) after operation to investigate limb salvage. Student's t-test was used to compare the general data between two groups and Chi-square test to analyze the rate of limb salvage.

RESULTS

Altogether 50 cases of subclavian artery injury were treated, including 36 cases of open surgery and 14 cases of stent implantation. Combination of nerve injury was observed in 27 cases (75.0%) in open surgery group and 12 cases (85.7%) in stent implantation group. Amputation developed in 3 cases with open surgery and 1 case with stent implantation. Consequently the rate of successful limb salvage was respectively 91.7% (33/36) and 92.9% (13/14), revealing no significant difference (p > 0.05).

CONCLUSION

Rapid reconstruction of blood circulation is crucial following subclavian artery injury, no matter what kinds of treatment strategies have been adopted. Interventional stent implantation can achieve a good effect for limb salvage.

Bilateral popliteal artery injury: Lessons learned

Popliteal artery trauma is reported to have the highest rates of limb loss in peripheral vascular injuries. It can be inferred that morbidity associated with bilateral popliteal artery trauma is worse. However, bilateral popliteal artery injuries are sparsely reported in literature and as such management options are not well defined. Despite the paucity of reported cases, a systematic and deliberate approach to these devastating injuries may result in reproducible limb salvage. We hereby use our case report as a provocateur to this conundrum. Consideration should be given to the utilization of surgical shunts or a two-surgical team and limb salvage attempted till proving the neurovascular bundle irreparable. Arterial grafts should be part of the surgeon's armamentarium. In massive hard to control hemorrhage, tourniquets or resuscitative endovascular occlusion devices (REBOA) may prove lifesaving. Larger studies are needed to define contemporary management and derive management guidelines.

Vascular Injury in Orthopedic Trauma

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].

The management of lower extremity multilevel arterial injuries: a 10-year experience

Background

Limb amputation due to lower extremity arterial injury is not uncommon and multilevel arterial injury is even more limb-threatening and easily missed with potentially devastating consequences. There is limited information on multilevel arterial injuries.

Purpose

We undertook a review of our experience to gain insight on multilevel arterial injury patterns associated with lower extremity trauma and to analyze the results of management of such injuries with a special focus on the influence of initial diagnosis on limb salvage.

Patients and Methods

Between August 2002 and September 2012, 38 patients with lower extremity multilevel arterial injuries were reviewed, retrospectively. The injury patterns and amputation rates associated with initial diagnosis or misdiagnosis were analyzed.

Results

According to their injury levels, three multilevel arterial injury patterns were seen in this series: arterial injuries with the involvement of femoral artery and popliteal artery (pattern A), femoral artery and anterior or (and) posterior artery (pattern B), and popliteal artery and anterior or (and) posterior artery (pattern C). The general missed diagnosis rate was 31.6%. Pattern B had a much higher missed diagnosis rate than the other two patterns. The missed diagnosis rate was significantly correlated with the amputation rates (Odds Ratio =10.7, 95% CI: 2.04-56.61). The definite diagnosis rate was only 14.8% using duplex ultrasonography examination.

Conclusions

Diagnosis of pattern B injury is more prone to be missed. DUS has low specificity in the detection of multilevel arterial injuries. Aggressive intraoperative exploration is considered to be valuable in the definitive diagnosis of highly suspected cases when other diagnostic tools are unavailable.

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

Background

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

Methods

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

Results

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

Conclusion

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

Idiopathic popliteal artery pseudoaneurysm: emergency diagnosis and treatment

Pseudoaneurysms or false aneurysms of the popliteal artery are uncommon arterial disorders. These disorders most commonly result from trauma and iatrogenic lesions following orthopedic procedures. The authors report a rare case of popliteal artery pseudoaneurysm in which etiology was unknown. The authors also demonstrate that Doppler ultrasonography may be sufficient for planning vascular surgical procedures and that the open surgical approach is the treatment of choice for cases in which the symptomatic lesion causes local compression.

Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges

The incidence of popliteal vessel injuries is low, even in busy urban trauma centers. As a result of this fact, few trauma centers and trauma surgeons have developed extensive experience in the management of these injuries. Popliteal vessel injuries in both civilian and military arenas incur significant morbidity. These injuries present a difficult challenge, and, although the overall incidence of these injuries remains low, the sequelae can be devastating. Successful outcomes for limb salvage and survival result from early recognition and rapid surgical intervention by a multidisciplinary approach with a great participation of different surgical specialties. From the historical perspective, anatomy, incidence and associated injuries, to the clinical presentation, diagnosis, management, and morbidity and mortality, the aim of this article is to review the various aspects of these complex injuries.

Brachial vessel injuries: high morbidity and low mortality injuries

INTRODUCTION

Reports of arterial injuries from both the civilian and military arenas report the brachial artery as the most frequently injured vessel, accounting for approximately 25-33% of all peripheral arterial injuries. The brachial artery is surrounded by important peripheral nerves -the median, ulnar and radial, and also parallels the humerus and associated veins. Due to its close proximity to these structures, associated nerve and osseous injuries are frequent with residual neuropathy from such nerve injuries, often the main sources of permanent disability.

MATERIALS AND METHODS

Systematic review of the literature, with emphasis in the diagnosis, treatment and outcomes of these injuries, incorporating the authors experience.

CONCLUSIONS

The morbidity and mortality rates associated with brachial artery injuries depend on the cause of the injury itself, which vein or tendon is injured, and whether musculoskeletal and nerve injuries are also present. During the last 20 years, amputation associated with upper extremity arterial injuries has decreased to a rate of 3% because of advances in the treatment of shock, the use of antibiotic therapy, and increased surgical experience.

Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management

PURPOSE

Limb loss following lower extremity arterial injury is not uncommon and has serious implications on the patient's life and functionality. This retrospective study was performed to analyze the results of lower extremity arterial injuries and to identify the risk factors associated with amputation.

METHODS

Between 2002 and 2009, retrospectively collected data on 140 patients with 173 lower extremity arterial injuries were analyzed.

RESULTS

There were 133 males (95%) and 7 females (5%). The mechanism of injuries was gunshot wounds in 56.4% of cases, stab wounds in 30%, and blunt trauma in 13.4%. Associated injuries included vein injury in 45% of cases, nerve injury in 16.4%, and bone fracture in 31.4%. The most frequently injured artery was superficial femoral artery (31.2%). More than 1 artery was injured in 18.6% of patients. Surgery was carried out, with a limb salvage rate of 90.4% and a survival of 97.1%. Amputation was performed in 75% of patients in whom only 1 artery was repaired, although all crural arteries were injured. Multivariate logistic regression analysis showed that significant risk factors of outcome were below-knee multiple arterial injuries (odds ratio [OR] 6.62, P < 0.001), associated 2-bone fractures (OR 2.71, P = 0.003), development of compartment syndrome (OR 1.94, P = 0.042), and great soft tissue disruption (OR 1.74, P = 0.010).

CONCLUSIONS

Limb loss may be decreased by performing prophylactic fasciotomy more often and by repairing at least 2 crural arteries.