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Jha RK, Jayaram PV, Shankaran R, Pillai HJ. Salvage of a severely mangled limb following traumatic injury. BMJ Case Rep 2023; 16:e254629. [PMID: 37321642 PMCID: PMC10277066 DOI: 10.1136/bcr-2023-254629] [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] [Indexed: 06/17/2023] Open
Abstract
Management of a severely damaged extremity poses a dilemma-whether to perform a primary amputation or attempt limb salvage. A multitude of factors-such as the extent of neurovascular injury, limb ischaemia time, severity of bone and soft tissue loss, physiological reserve of the patient and availability of surgical expertise and resources-influence this decision. The Mangled Extremity Severity Score (MESS) was developed as a predictor of the need for limb amputation, and a MESS of 7 or more is considered a predictor of primary amputation. Here we describe a case where a man in his 20s sustained traumatic avulsion of his right ankle with severe neurovascular damage and multiple tendon injuries onboard a ship at high sea. Despite a MESS of 10, limb ischaemia time of more than 10 hours and injuries to all three extremity vessels (anterior tibial, posterior tibial and peroneal arteries), limb salvage was successfully carried out at a level-II trauma centre.
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Affiliation(s)
- Rakesh Kumar Jha
- Department of Surgery, Indian Naval Hospital Ship Asvini, Mumbai, Maharashtra, India
| | - Prasad Vijay Jayaram
- Department of Surgery, Indian Naval Hospital Ship Asvini, Mumbai, Maharashtra, India
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Copeland LA, Pugh MJ, Bollinger MJ, Wang CP, Amuan ME, Rivera JC, Shireman PK. The VA vascular injury study: A glimpse at quality of care in Veterans with traumatic vascular injury repair. Injury 2022; 53:1947-1953. [PMID: 35422314 DOI: 10.1016/j.injury.2022.04.002] [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: 03/14/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The high number of limb injuries among Post-9/11 Veterans and their long-term care pose significant challenges to clinicians. Current follow-up for extremity arterial vascular injury (EVI) is based on guideline-concordant care for treatment of peripheral vascular disease (GCC-PVD), including anticoagulant/antiplatelet or statin therapy and duplex ultrasound. No best practices exist for arterial EVI. Our goal was to determine correlates of GCC-PVD and other care among Post-9/11 Veterans with combat-related arterial EVI. MATERIALS AND METHODS We identified Post-9/11 Veterans with arterial EVI who underwent initial limb salvage repair or ligation (e.g., for single-vessel injury) attempt per DoD Trauma Registry validated by chart abstraction. Veterans Health Administration (VHA) data characterized the cohort in the first five years of VHA care. Models predicted (a) GCC-PVD, (b) pain clinic use, (c) mental/behavioral health care, (d) long-term opioid use, and (e) time to complication, controlling for injury severity and type, mental health parameters, and demographics. RESULTS The 490-Veteran cohort with validated arterial injury was 77% White averaging 25.2 years at injury (range: 18-56). Mechanism of injury was primarily explosive (63%). Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%). Approximately 25% received at least one component of VHA GCC-PVD including 8% arterial ultrasounds, 5% statins, and 11% anticoagulants/antiplatelets; 77% had mental/behavioral healthcare. GCC-PVD, as well as PTSD and substance use disorders, were associated with receipt of mental/behavioral health care. Complications affected 46% of the cohort and were more common among those prescribed 90+ days of opioids or receiving GCC-PVD. CONCLUSION Despite injury severity (40% moderate/severe), only 25% of cohort patients received VHA GCC-PVD, and nearly half had complications from their arterial injury. Receiving GCC-PVD appeared to potentiate receiving care for mental and behavioral disorders. IMPACT The treatment gap in Veterans with arterial EVI may be due to lack of appropriate guidelines, lack of vascular specialists in VHA or accessing care outside the VHA. Focused study of care options and their outcomes will help define optimal care processes for combat Veterans with arterial EVI.
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Affiliation(s)
- Laurel A Copeland
- Research Service, VA Central Western Massachusetts Healthcare System, 421N Main, Leeds, MA 01053 USA; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation St, Worcester, MA 01655 USA.
| | - Mary Jo Pugh
- VA Salt Lake City Health Care System, 500 Foothill Blvd, Salt Lake City, UT 84148 USA; Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132 USA
| | - Mary J Bollinger
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Dr, North Little Rock, AR 72114 USA; Department of Psychiatry, University of Arkansas for Medical Sciences, 4301W Markham St, Little Rock, AR 72205 USA
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229 USA; Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
| | - Megan E Amuan
- VA Salt Lake City Health Care System, 500 Foothill Blvd, Salt Lake City, UT 84148 USA
| | - Jessica C Rivera
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234 USA; Louisiana State University Health Science Center - New Orleans Department of Orthopaedic Surgery, New Orleans, LA USA
| | - Paula K Shireman
- Geriatric Research, Education & Clinical Center, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229 USA; Department of Surgery, University of Texas Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA; Departments of Primary Care & Population Health and Medical Physiology, College of Medicine, Texas A&M Health, 2900 E 29th St, Bryan, TX 77802 USA
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Laverty RB, Brock SG, Walters TJ, Kauvar DS. Outcomes of Arterial Grafts for the Reconstruction of Military Lower Extremity Arterial Injuries. Ann Vasc Surg 2021; 76:59-65. [PMID: 33831531 DOI: 10.1016/j.avsg.2021.03.006] [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: 01/07/2021] [Revised: 03/02/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Lower extremity (LE) arterial injuries are common in military casualties and limb salvage is a primary goal. Bypass grafts are the most common reconstructions; however, their specific outcomes are largely unreported. We sought to describe the outcomes of LE arterial grafts among combat casualties and their association with limb loss. METHODS Retrospective cohort study of 2004-2012 Iraq/Afghanistan casualties with LE arterial injury undergoing bypass graft from a database containing follow-up until amputation, death, or military discharge. Primary outcome was composite graft complications (GC-thrombosis, stenosis, pseudoaneurysm, blowout, and/or arteriovenous fistula). RESULTS Two hundred and twenty-two grafts were included (99 femoral, 73 popliteal, 48 tibial). 56 (26%) had at least one GC; thrombosis was most common in femoral, stenosis most common in popliteal and tibial. GC was not associated with graft level but was associated with synthetic conduit (P = 0.01) and trended towards an association with multiple-level arterial injuries (P = 0.07). Four of eight (50%) synthetic grafts had amputations, all within 72h. Two of the eight synthetic grafts thrombosed, and both limbs were amputated. There were 52 total amputations. Amputation was performed in 13 (23%) of limbs with a GC and 24% of those without (P = 0.93) Overall, 24 (11%) of grafts thrombosed, 16 within 48h and 13 (25%) in limbs undergoing amputation (P = 0.001 for association of thrombosis with amputation). CONCLUSION GC are common among LE bypass grafts in combat casualties but are not associated with limb loss. Thrombosis is predominantly early and is associated with amputation. Closer attention to ensuring early patency may improve limb salvage.
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Affiliation(s)
- Robert B Laverty
- Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | | | - Thomas J Walters
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; Department of Surgery, Uniformed Services University, Bethesda, Maryland.
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