Amputation and the assessment of limb viability: perceptions of two hundred and thirty two orthopaedic trainees

Variability in Experience Performing Lower Extremity Amputations Between Surgical Residents: An Examination Of ACGME Case Logs

BACKGROUND

There is a wide array of indications for lower extremity amputation (LEA) and inherent variability in operative experiences between surgical residents. Significant variation in resident surgical experience performing LEAs is possible.

OBJECTIVE

To identify inter- and intra-specialty trends and variability in LEA experience in graduating orthopedic surgery, general surgery, and vascular surgery residents from 2007-2017.

METHODS

Publicly available ACGME case log data for above knee amputation, below knee amputation, and transmetatarsal/ digital amputation procedures from accredited orthopaedic surgery, general surgery, traditional (5+2) vascular surgery and integrated (0+5) vascular surgery residencies was reviewed from 2007-2017. Linear regression analysis was used to identify temporal trends, with statistical significance set at p<0.05.

RESULTS

From 2007-2017, the mean number of total LEA, AKA, and BKA performed by graduating orthopaedic surgery residents did not change significantly. The mean number of total LEAs logged by graduating general surgery and integrated (0+5) vascular surgery residents did not change significantly over time (p=0.98, p=0.23, respectively). The mean number of total LEAs logged by traditional (5+2) vascular surgery residents increased from 16.0 to 32.6 (p<0.01). As study year increased, graduating integrated (0+5) and traditional (5+2) vascular surgery residents logged more LEAs relative to graduating orthopaedic surgery and general surgery residents (p<0.01).

CONCLUSIONS

There is significant variation in resident experience in LEAs between surgical specialties. Integrated vascular surgery residents logged the most LEAs, followed by traditional vascular surgery residents, orthopaedic surgery residents, and general surgery residents. Experience of orthopaedic surgery residents in LEAs has been relatively stable over time.Level of Evidence: IV.

Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali

INTRODUCTION

On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces.

METHODS

All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded.

RESULTS

268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest.

CONCLUSION

this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.

French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery

INTRODUCTION

In 2009, the French took command of the Medical Hospital (MH) or Role 3 Hospital at KaIA (Kabul International Airport) within the framework of its role in the military mission Operation Pamir in Afghanistan. The goal of this study was to analyze the volume of orthopedic surgical activity for the last four years, to identify its specificities and to improve training of military orthopedic surgeons.

HYPOTHESIS

Orthopedic surgery is the most important activity in the field and surgeons must adapt to situations and injuries that are different from those encountered in France.

PATIENTS AND METHODS

All patients operated on between July 2009 and June 2013 were prospectively included in an electronic database. The analysis included the number of surgical acts and patients, the types of injuries and the surgical procedures.

RESULTS

Forty-three percent (n=1875) of 4318 procedures involved orthopedic surgery. Half of these were emergencies. French military personnel represented 17% of the patients, local civilians 47% and children 17%. Half of the procedures involved the soft tissues, 20% were for bone fixation and 10% for surgery of the hand. The rate of amputation was 6%. The diversity of the surgical acts was high ranging from emergency surgery to surgical reconstruction.

DISCUSSION

The activity of this Role 3 facility is comparable to that of other Role 3 facilities in Afghanistan, with an important percentage of acts involving medical assistance to the local population and scheduled surgeries as well as primary and/or secondary management of the wounded. The diversity of surgical acts confirms the challenge of training military orthopedic surgeons within the context of the hyperspecialization of the civilian sector. Specific training has been organized in France by the École du Val de Grâce. Specific continuing education is also necessary.

LEVEL OF EVIDENCE

IV (retrospective review).

Delayed amputation following trauma increases residual lower limb infection

INTRODUCTION

Residual limb infection following amputation is a devastating complication, resulting in delayed rehabilitation, repeat surgery, prolonged hospitalisation and poor functional outcome. The aim of this study was to identify variables predicting residual limb infection following non-salvageable lower limb trauma.

METHODS

All cases of non-salvageable lower limb trauma presenting to a specialist centre over 5 years were evaluated from a prospective database and clinical and management variables correlated with the development of deep infection.

RESULTS

Forty patients requiring 42 amputations were identified with a mean age of 49 years (±19.9, 1SD). Amputations were performed for 21 Gustilo IIIB injuries, 12 multi-planar degloving injuries, seven IIIC injuries and one open Schatzker 6 fracture. One limb was traumatically amputated at the scene and surgically revised. Amputation level was transtibial in 32, through-knee in one and transfemoral in nine. Median time from injury to amputation was 4 days (range 0-30 days). Amputation following only one debridement and within 5 days resulted in significantly fewer stump infections (p = 0.026 and p = 0.03, respectively, Fisher's exact test). The cumulative probability of infection-free residual limb closure declined steadily from day 5. Multivariate analyses revealed that neither the nature of the injury nor pre-injury patient morbidity independently influenced residual limb infection.

CONCLUSION

Avoiding residual limb infection is critically dependent on prompt amputation of non-salvageable limbs.