Emergency Amputation Research Articles

Secondary amputation of the limb after primary surgery of open fractures of the lower limb

Les auteurs rapportent les complications survenues au cours de la prise en charge des fractures ouvertes de membres inférieurs, observées ces dernières années dans leur pratique et qui ont abouti à des amputations secondaires, tout en analysant les différents facteurs de risque et les déficits éventuels dans la prise en charge qui ont pu être à l'origine de cette évolution. Il s'agissait d'une étude rétrospective s'étendant sur une période de 06 ans ( Janvier 2006 - Janvier 2012). Elle concernait des patients ayant présenté une fracture ouverte de membre inférieur traité initialement dans notre institution et dont les suites se sont compliquées et ont nécessité une amputation. Tout patient dont l'amputation avait été réalisée d'emblée après l'examen à l'entrée aux urgences était exclu. Egalement tout patient traité dans un autre hôpital avant d'être admis chez nous était exclu de l'étude, même si une amputation secondaire avait été réalisée dans notre institution. Nous avons récolté les différentes données en analysant les dossiers de patients (examens cliniques et complémentaires, comptes rendus opératoires). Nous avons évalué notre prise en charge en fonction des différents guidelines et recommandations retrouvés dans la littérature. Ces complications ont été observées chez neuf patients sur les 306 fractures ouvertes de membre inférieur prises en charge sur la même période (Janvier 2006 - Janvier 2012), soit 2,9 . L'âge moyen était de 42,6(26-57) ans, la totalité des patients était de sexe masculin. Nous avons enregistré 1 cas de fracture du fémur, 7 cas de fracture des 2 os de la jambe et 1 cas d'écrasement du pied. Il s'agissait de fracture ouverte dont 1 cas de type 1; 3 cas de type II et 5 cas de type III selon la classification de Gustilo et Anderson. 5 cas d'amputations à la cuisse ont été réalisées et 4 cas d'amputation au tiers supérieur de la jambe. Les différentes complications ayant motivées ces amputations étaient des infections osseuses ou des gangrènes de parties molles d'origine ischémique ou infectieuse. Les patients n'avaient pas de tares favorisantes telle que le diabète et n'étaient pas tabagiques chroniques. Nous n'avons pas constaté de décès. Les fractures ouvertes méritent une attention particulière du chirurgien tant au point de vu diagnostic des complications immédiates que thérapeutique afin de réduire l'incidence des amputations post chirurgie primaire donnant l'impression au patient d'avoir été initialement mal opéré. Une attention particulière doit être portée au degré de contamination initiale et à la présence d'un germe virulent sur le lieu du traumatisme, pouvant motiver des attitudes particulières lors de la prise en charge primaire.

Management of an Entrapped Patient with a Field Amputation

BackgroundEmergency surgical amputations are rare and resource-intensive lifesaving interventions. Most emergency medical services (EMS) lack a formal protocol to manage these high-risk but low-occurrence events. There has been limited attention in the EMS community to address this issue. Without a literature-based approach, the EMS community has been offered little guidance on managing surgical field amputations. Case ReportA 38-year-old man was terminally entrapped below the waist in an industrial auger. As a last resort, the decision to initiate a field amputation was made. We outline an adaptive strategy to address the circumstances surrounding this entrapment scenario. Why Should an Emergency Physician Be Aware of This?A carefully preplanned protocol may lead to increased overall survivability for entrapped patients requiring emergent field amputation. Based on the lessons learned from the outcome of this case, previous cases, and a literature review, we have devised a simplified planning tool in the form of a “LIMB” mnemonic to aid EMS services in developing their own traumatic amputation protocol (TAP). “LIMB” is an acronym for: Lists of resources and equipment, Initiate TAP checklist, Manage the extrication, and Bring the patient in. The LIMB mnemonic may also be used as a checklist to assist EMS personnel in performing a field amputation. We offer rescuers a starting point to develop their own TAP capable of being executed in their own rescue environment.

受傷初日に両下肢切断術を施行した高齢者の広範囲火焔熱傷の1救命例(A case of survival of elderly patient with extensive flame burn after amputation of bilateral lower limbs on the first day)

症例は81歳の男性で，田んぼでの野焼き中に衣服へ着火して受傷し，当院へ搬送された。腹部から両下肢にかけて皮膚の著明な炭化を認め，両膝より遠位では熱傷が筋層に達していた。深達性II度熱傷7%，III度熱傷46%で熱傷予後指数（prognostic burn index: PBI）は130.5であり，予測される死亡率は98%以上であった。検査所見では血清CPK値の上昇，急性腎傷害，高カリウム血症を認めた。受傷から約4時間後，股関節から10cmの部位での両下肢切断術を施行し，ICUへ入室した。4日目に昇圧剤を終了，7日目に抜管，人工呼吸器離脱に至った。分層植皮術を繰り返し，119日目の転院時には車椅子で自走可能な状態であった。高齢者の広範囲火焔熱傷に対する受傷初日の四肢切断術がその後の集中治療管理や手術戦略に寄与し，救命し得た。過去に熱損傷での両下肢切断術を受傷初日にしたとする症例報告はなく，その臨床経過について詳述した。 An 81–year–old man who suffered a flame burn during burning on the soil presented to our hospital. His skin from the abdomen to bilateral lower limbs seemed to be carbonized. The burn depth extended to the muscles on the distal area from the knees. Because 7% of his body surface area was covered in deep dermal burn (DDB) and 46% was covered in deep burn (DB), his prognostic burn index was 130.5, so mortality was estimated more than 98%. Laboratory test results were consistent with elevation of serum CPK and revealed acute kidney injury and hyperkalemia. Four hours after the accident, an emergency amputation of the bilateral limbs at an area 10cm distal from his hip was performed, and he was admitted to the intensive care unit. Vasopressor was discontinued on day 4, and he was extubated and weaned from the ventilator on day 7. After several split thickness skin graft and debridement, on day 119 he could use a wheelchair at the time of his transfer. In the case of an elderly patient with an extensive flame burn, performing amputation on day 1 may affect subsequent critical care and operative strategy, and in this case, the patient survived. This is a detailed first report of bilateral limb amputation for thermal injury on day 1. 熱傷患者の予後予測の手段として熱傷指数（burn index: BI）や熱傷予後指数（prognostic burn index: PBI）がある。PBI 85以上では有意に死亡率が上昇し 1，とくにPBI 130以上では死亡率98%を超え，救命困難とされる 2。また，熱傷では四肢の切断に至ることがあるが，その適応や時期について未だ議論が残る。今回我々は，受傷初日の両下肢切断術が救命に寄与したと考えられる高齢者の広範囲火焔熱傷の1例を経験したため報告する。 なお倫理委員会の承認を要する内容はなく，本人の同意を得たうえで匿名化した。 患 者：81歳の男性 主 訴：腹部・腰部より尾側の熱傷 既往歴：高血圧症 現病歴：田んぼの野焼きをしていたところ着衣に火がつき，受傷から約1時間後に当院へ救急搬送された。 入院時現症：呼吸数40/分，SpO2 97%（酸素15L/min，リザーバーマスク），脈拍121/分・整，血圧175/131mmHg，意識 Glasgow coma scale 14点（E3V5M6）であった。血液検査所見ではCPK 22,221IU/L，AST 396IU/Lと筋原性酵素の上昇を認め，Cre 1.23mg/dL，K 6.6mEq/L，base excess –6.9mmol/Lと急性腎傷害，高カリウム血症，代謝性アシドーシスを呈した（Table 1）。鼻腔の煤と鼻毛の焦げを認め，腹部から両下肢にかけて皮膚が炭化しており，両足背動脈は触知不能であった。深達性II度熱傷7%，III度熱傷46%，熱傷面積（total body surface area， %TBSA）53，BI 49.5，PBI 130.5であった（Fig. 1）。 Physical examination on the first day. 7% of his body surface area was covered in DDB and 46% was covered in DB. DDB: deep dermal burn, DB: deep burn 入院後経過：両膝より遠位では炭化が筋層にまで達していたため，今後歩行などの荷重に耐えられるまでの機能回復は見込めないと予想された。また，PBI 130.5から予測される救命率は1%程度と推定されるものの上半身の損傷が比較的軽微であり，下肢切断による大幅な熱傷面積の減少が達成できれば予測値よりも救命率を向上できる可能性も考えられた。以上をふまえ，本人・家族に対して一般的な熱傷治療戦略では救命の可能性が極めて低いこと，下肢機能の回復が望めず遅かれ早かれ切断術に至る可能性が極めて高いこと，緊急での両下肢切断により救命率が向上する可能性があること，長期の集中治療管理や人工肛門造設術を要して日常生活動作の著しい低下を伴うこと，緩和医療への移行という選択肢もあることを説明し，両者ともに積極的治療を望まれた。 術式決定に際しては機能的予後の見込めない患肢救済よりも救命を最優先とし，熱傷面積を可能な限り軽減できるよう大腿近位での切断を想定した。また，軟骨面などに感染が生じた際に治療に難渋することが予想され，股関節離断は回避する方針とした。 気管支鏡検査で気道熱傷を否定した後に気管挿管を実施し，Parklandの公式に則った大量輸液（4×62.4kg×53%：13.2×103mL/day）と高カリウム血症の是正を行いながら，受傷から約4時間後に緊急で両下肢切断術を施行した。 手術所見：大腿部は熱傷の深達度が脂肪組織に留まっていたが，切断高位は両股関節から10cmの部位で離断し，その時点で残存する %TBSAは21，III度熱傷は14%となった。断端皮膚の著しい炭化により一期的な創閉鎖を見込めず骨を筋で被覆し，最後に下腹部から両大腿の断端まで焼痂切開を加えた。術中に血色素尿が出現し，ハプトグロビン製剤4,000単位を投与した。術中出血量は浸出液も含めて1,966mLであり，赤血球濃厚液8単位，新鮮凍結血漿10単位の投与，ノルアドレナリン0.09μg/kg/minの開始下にICUに入院となった。 超早期での手術侵襲もあり，受傷24時間での総輸液量は19.4×103mLに達した。受傷から22時間後より0.5mL/kg/hr，30時間後には1mL/kg/hrの尿量が安定して得られた。4日目に腹部，背部，陰茎，陰嚢に対する分層植皮術を行い，同日昇圧剤を終了して7日目に抜管，人工呼吸器離脱に至った（Fig. 2）。10日目に臀部，両大腿部背側，14日目に腹部，両大腿部腹側に対する分層植皮術，21日目に大腿断端の縫縮術をそれぞれ実施した。栄養療法に関しては，入院初日から乳性ペプチド含有の消化体栄養剤による経腸栄養と便失禁管理システムでの排便管理を行っていたが，プレアルブミン値の改善が得られず，低栄養状態による人工肛門の脱落が懸念された。さらに，本患者の最適人工肛門設置位置である左上腹部の健常皮膚領域は狭く，また同部位の上皮化遅延も重なり，人工肛門造設は53日目となった。その後59日目に会陰部，肛門部に分層植皮術を行った。119日目の転院時には車椅子で自走可能であり，熱傷創は全上皮化して完全創閉鎖を得た（Fig. 3）。受傷より301日経過した現在，精神的問題もなく家族の支えのもと自宅で生活している。 Clinical course from admission. Physical examination on day 89. 熱傷の四肢切断術は古くから行われており，1961年に膝上での両下肢切断術の救命例が報告 3されている。また，熱傷に対する四肢切断術が救命率の向上に寄与したとする報告 4, 5も散見される。熱傷における四肢切断術の頻度は1.5–5.8%と報告 6, 7, 8されているが，自験例のように火焔熱傷といった熱損傷での切断は電撃傷の場合よりも圧倒的に少ない 6。また，熱傷での四肢切断術の適応については，患肢の不可逆的な機能喪失，生命を脅かす感染症といった病態が挙げられ 5, 9，横紋筋融解に起因する全身性病態の併発や易出血性などの要素も加味して主観的に判断されている 5, 8。これらいずれの病態も基本的には入院後一定期間を経て判明するものである。しかし，自験例では少なくとも膝下は不可逆的な機能喪失が強く予想され，かつ急性腎傷害，高カリウム血症といった全身性病態も伴ったことから，初日の段階で四肢切断術の適応と判断した。その切断高位についてはリハビリテーションの見地からも判断されるべきである 8が，救命を第一目標とし，大腿部のうち可能な範囲で近位を選択した。 熱傷における四肢切断術の時期についても定まった見解はない。Parshleyら 10は，電撃傷に対する入院当日の四肢切断術は全身状態への忍容性も十分見込まれ，著明な改善が得られることがあるとしている。またYowlerら 4は，深達度の高い熱傷に対する度重なるデブリドマンが結果的に患肢を無機能にさせ，患肢の不適切な温存がかえって創感染のリスクを高めるとし，電撃傷以外の熱損傷での四肢切断術は受傷から平均18.4日と電撃傷よりも遅い傾向にあったと報告した。これは，電撃傷に比してそれ以外の熱損傷では受傷早期の組織損傷が浅い場合が多いことも関与していると思われる。このように，とくに電撃傷以外の熱損傷における受傷早期の四肢切断術は稀と考えられるが，自験例では患肢の筋を含めた深達度の経過を待たずに初日に施行した。Sotoら 8による原著論文の中で受傷初日に四肢切断術がなされた電撃傷以外の熱損傷症例を含んでいるものの年齢や熱傷面積，転帰などの情報は得ることができず，我々が渉猟した限りでは臨床経過について詳述した報告は見当たらなかった。当初のPBIから推定される死亡率98%以上の重症例に対し，入院後の治療経過で難渋しなかったことは特筆に値する。 Mackieら 11は，気道熱傷がなく人工呼吸管理を要した62例（平均42.2歳，%TBSA 47.4）での人工呼吸器離脱に平均18日を要したとし，受傷から3，7日目までの累積水分出納バランスについてもそれぞれ+23.1×103mL，+34.2×103mLであったとしている。自験例では受傷24時間での総輸液量はParklandの公式よりも多かったが，累積水分出納バランスは受傷から3日目で+16.8×103mL，7日目で+14.5×103mLと著明に少なく，人工呼吸器離脱も7日間と比較的短期間であった。これらの理由として，下肢の切断が炎症を来した異常な血管床を減少させ，利尿期を含めた輸液管理を容易にしたことが一因として考えられた。またその背景として，熱傷が広範囲であるほど炎症反応も強くなる 12が，近位かつ初日の切断が全身の炎症性サイトカインを軽減し，血管透過性亢進の制御に有利に作用した可能性が考えられる。さらに，四肢切断術を要した患者の受傷1，2日目の血清CPK値は要さなかった患者に比して有意に高かったとする報告 6や，切断によりミオグロビンによる急性腎傷害を軽減できるとした報告 10もある。自験例は来院時点で既に著明な筋原性酵素の上昇と急性腎傷害，代謝性アシドーシスといった横紋筋融解症様の病態を来していたが，受傷2日目にはCPK 6,382IU/Lと速やかに減少しており，これらのことからも受傷後数日経過した時期ではなく初日こそ四肢切断術のタイミングとして適切と考えられる。また，重症熱傷において壊死した開放創は容易に菌の侵入門戸となり 5，熱傷面積の増加に伴い感染の確率が上がるとする報告 13もあるが，自験例では昇圧剤を要するような重篤な感染は併発しなかった。この要因として，広範囲熱傷に対して早期手術といった迅速な創閉鎖が求められる 14ように，初日のより近位での切断が熱傷創を，ひいては創感染の機会を大幅に減少させたことが挙げられる。さらに，受傷早期の手術は入院後の手術戦略にも好影響をもたらしたと考えられる。高齢者では頭部をはじめとした採皮による出血が増加して全身状態の悪化を来すことがあるが，今回入院直後から32%にも及ぶ熱傷面積の減少が達成できたため，残る未上皮化創は21%に留まった。大小含め計7回の分層植皮術で一度も頭部からの採皮を行わずに済んでおり，この点においてもより早期かつ近位での切断は合理的と言える。 最後に，自験例は救肢の観点だけで考えれば皮弁を用いて膝下も含めて温存できたかもしれない。また自験例の転帰が良好であったことは受傷前の栄養状態や気道熱傷がなかったことも影響している可能性も否定できない。仮に自験例をふまえての提言をするのであれば，下肢を含む重症の広範囲熱傷の場合，例えばその指標として死亡率が50%を超えるとされる %TBSA 50以上，BI 40以上，PBI 100以上 2などの症例では，年齢，全身状態，上半身の熱傷の程度，下肢の機能的予後から総合判断して受傷初日の下肢切断術を考慮してもよいと思われる。現段階では %TBSA，PBIといった重症度と関連づけて四肢切断術を論じた報告は少なく，とくに重症の熱損傷について知見の蓄積が望まれる。 高齢者の広範囲火焔熱傷に対する受傷初日の四肢切断術がその後の集中治療管理や手術戦略に寄与し，救命し得たと考えられた。過去に熱損傷での両下肢切断術を受傷初日に行ったとする症例報告はないため，その臨床経過について詳述した。 本報告において利益相反はない。

Man or machine? An experimental study of prehospital emergency amputation

ObjectivePrehospital emergency amputation is a rare procedure, which may be necessary to free a time-critical patient from entrapment. This study aimed to evaluate four techniques of cadaveric lower limb prehospital...

Negative pressure wound therapy for high-risk wounds in lower extremity revascularization: study protocol for a randomized controlled trial.

BackgroundRates of surgical site infections (SSIs) following groin incision for femoral artery exposure are much higher than expected of a clean operation. The morbidity and mortality is high, particularly with the use of prosthetic grafts. The vascular surgery population is at an increased risk of SSIs related to peripheral vascular disease (PVD), diabetes, obesity, previous surgery and presence of tissue loss. Negative pressure wound therapy (NPWT) dressings have been used on primarily closed incisions to reduce surgical site infections in other surgical disciplines. We have not come across any randomized controlled trials to support the prophylactic use of negative pressure wound therapy in high-risk vascular patients undergoing lower limb revascularization.Methods/designIn this single-center, prospective randomized controlled trial, patients scheduled for a lower limb revascularization requiring open femoral artery exposure who are at a high risk (BMI > 30 kg/m2, previous femoral cutdown or Rutherford V or VI category for chronic limb ischemia) will be eligible for the study. A total of 108 groin incisions will be randomized to the use of a negative pressure wound device or standard adhesive gauze dressing. Patients will be followed in hospital and reassessed within the first 30 days postoperatively. The primary outcome is SSI within the first 30 days of surgery and will be determined using the intention-to-treat principle. Secondary outcomes include length of stay, emergency room visits, reoperation, amputation and mortality. A cost analysis will be performed.DiscussionThe trial is expected to define the role of NPWT in SSI prophylaxis for lower limb revascularization in high-risk vascular patients. The results of the study will be used to inform current best practice for perioperative care and the minimization of SSIs.Trial registrationNCT02084017, March 2014

Surgery and Obstetric Care are Highly Cost-Effective Interventions in a Sub-Saharan African District Hospital: A Three-Month Single-Institution Study of Surgical Costs and Outcomes.

The Lancet recently sponsored a commission examining the role of surgery in global health. There is a paucity of published information on the cost-effectiveness of surgery in low- and middle-income countries, a key metric in the prioritisation of limited resources. All patients undergoing emergency laparotomy, elective and emergency inguinal hernia repair, elective and emergency caesarean section, amputation, fracture manipulation, or fracture fixation over a 3 months period in a single district African hospital were assessed. World Health Organisation global burden of disease (GBD) methodology was used to calculate the disability-adjusted life years (DALYs) saved for each patient (using global and local life expectancy). Fully loaded costs were calculated for each patient’s care and providing the overall surgical service. Cost-effectiveness was calculated in year 2012 US$ per DALY saved for each procedure and overall. A total of 428 patients were included, with an overall cost-effectiveness of $10.70 per DALY averted. The cost-effectiveness of individual procedures (global life expectancy) was: Amputation—$17.66; Emergency caesarean section—$7.42; Elective caesarean section—$20.50; Emergency laparotomy—$8.62; Elective hernia repair—$15.26; Emergency hernia repair—$4.36; Fracture/dislocation reduction—$69.03; Fracture/dislocation fixation—$225.89. Surgery is a highly cost-effective healthcare measure in the setting of an African district hospital. The presented outcomes demonstrate that surgery is on a par with better-recognised and funded interventions such as HIV anti-retrovirals, malaria prevention and diarrhoea treatment. There are recognised limitations with the GBD methodology used here; however, this remains the best way to investigate the cost-effectiveness of health interventions. This study provides useful information on an, at present, under-studied field.

Severe leg trauma in a resource-poor environment: indications for amputation in emergencies

Although the development of multitissue limb reconstruction has reduced the role of post-traumatic primary amputation of the leg, some patients should nonetheless undergo emergency amputations. In developing countries, the socioeconomic context associated with the limited health care supply compromises still further the prognosis of preservation efforts. The decision criteria for surgery are thus different in these settings. The choice of emergency leg amputation or attempted preservation in developing countries depends on the epidemiology of severe leg trauma, the local and general prognosis, and the practice conditions. Three factors must be combined before limb preservationcan be attempted: adequate local and general adequate wound elements, an available, experienced surgeon with a competent care structure, and a favorable social context.

Application of homemade stump wound fixed sets for amputees

Objective To discuss the clinical effect of homemade stump wound fixed sets for amputees. Methods From January 2010 to November 2013 we treated sixty eight cases of patients with smashed wound, who received emergency amputation surgery.We randomly selected thirty five cases of using homemade stump wound fixed sets as experimental group, and chosenthirty three cases of using the U-shaped plaster dressingmethodto dress outside wound as control group, comparing two groups with postoperative wound drainage, local swelling, stump skin pressure sores, wound infection, joint function close to the situation. Results In the experimental group, the infection rate was 5.71%, skin necrosis rate 8.57%, incidence of swelling 28.57%,while those rate in the control group were 18.18%,15.15% and 54.55% respectively, the differences were statistically signifcant （χ2 =3.81,3.34,4.79, respectively;P〈0.05）.In the experimental group, the wound drainage averaged （46.8.0 ±12.35） ml, and the activities degrees of neighboring joint was （145.68 ±13.20）°;meanwhile in the control group the wound drainage averaged （89.81 ±10.61）ml, and the activities degrees of neighboring joint was （112.46 ±9.21）°, the differences were statistically significant （t=24.721,11.330,P〈0.05）.Conclusions It is a commendable approach to promote homemade stump wound fixed sets for amputees, because it can significantly reduce postoperative bleeding, promote swelling, reduce skin pressure sores, and can contribute the function exerciseof the neighboring jointearlier. Key words: Innovation to promote; Wound fixed sets; Amputation

Endovascular Recanalization of Native Chronic Total Occlusions in Patients with Failed Lower-Extremity Bypass Grafts

PurposeTo investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts. Materials and MethodsRetrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication. ResultsThe mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively. ConclusionsEndovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.

The Shortfall in Long-term Survival of Patients with Repaired Thoracic or Abdominal Aortic Aneurysms: Retrospective Case–Control Analysis of Hospital Episode Statistics

To report the contemporary life expectancy of patients undergoing abdominal (AAA) or thoracic aortic aneurysm (TAA) repair in England, relative to a healthy control population. A retrospective observational case-control study was carried out of Hospital Episode Statistics (HES) data, an administrative dataset covering the entire English National Health Service. Patients undergoing elective repair of an abdominal or thoracic aortic aneurysm in an English NHS hospital between April 2006 and March 2011 were included. Outcome measures were 5-year all-cause mortality (in- and out-of-hospital) and adverse cardiovascular events (myocardial infarction, stroke, emergency amputation or limb revascularisation). 19,505 AAA and 730 TAA repairs were identified, with 75,260 and 2,721 control participants, respectively, and 27.5 (1.0-60.0) months' median (range) follow-up. Five-year survival was 67.4% for AAA against 81.1% for control participants, and 65.3% for TAA against 89.1% for control participants (p < .001). Freedom from adverse cardiovascular events was 86.1% for AAA against 93% for control participants and 89.1% for TAA against 94.4% for control participants (p < .001). Long-term survival remains poor after aneurysm repair and adverse cardiovascular events are common relative to the wider population. Further research is required to characterise and optimise cardiovascular risk prevention in patients with aortic aneurysms.

Cryoamputation as a Lifesaving Intervention: A Case Report, Description of Technique, and Review of the Literature.

Emergency amputation of ischemic or infected limbs in critically ill patients is associated with substantial morbidity and mortality. Cryoamputation involves a physiologic amputation, effectively isolating the offending limb without actual amputation, as a lifesaving, temporizing measure in the subset of patients who cannot undergo a surgical amputation1,2. A physiologic amputation should be considered in disaster scenarios or with those patients who are experiencing systemic toxicity from the offending limb but whose current condition or extraneous circumstances do not permit a surgical amputation. Cryoamputation involves the application of an occlusive tourniquet to isolate the affected extremity, with subsequent cooling with use of dry ice (frozen carbon dioxide), common ice, or special cooling systems. This allows for patients to be medically optimized prior to undergoing a formal amputation. This approach may be valuable even in situations when long-term survival is not anticipated. The benefit of this technique is that it allows a high-risk emergency amputation to be performed in an elective fashion after medical optimization. We present a case of cryoamputation and review the literature on this subject. We are not aware of any prior report of this technique in the orthopaedic literature. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. The Orthopaedic Surgery Service was emergently consulted by the Vascular Surgery Service to assist with bilateral transfemoral amputation. A fifty-six-year-old man with a history of multiple bypass procedures presented with acute-on-chronic worsening of severe peripheral vascular disease in the setting of a hypercoagulable state. At the time of our initial consultation, the patient had bilateral lower limbs that were cool to the touch and insensate to the level of the proximal part of the thigh. The case was complicated by prior bilateral total hip arthroplasty with prosthesis …

8:24 AM Abstract No. 15 - Limb salvage after endovascular recanalization of native arterial occlusions in patients with failed lower extremity bypass grafts

Purpose Failed lower extremity bypass in patients with critical limb ischemia carries a high rate of amputation. Percutaneous revascularization of the native arterial occlusion can be performed as an alternative to redo bypass in patients who are poor surgical candidates. We set forth to investigate the feasibility, safety, and outcome of endovascular recanalization of chronic native occlusions in patients with failed bypass grafts. Materials and Methods We performed a retrospective review of 15 patients with failed lower extremity bypass who underwent recanalization of their native arterial occlusions between February 2009 and August 2012. Demographic, clinical, procedural and follow-up data were collected. Technical success was defined as the ability to recanalize the occlusion and restore flow with Results Fifteen lower extremities were treated in 15 patients (7 male) with a mean age of 68 years. The mean patency of the failed bypass grafts (53% venous, 47% prosthetic) was 23.4 months. All patients had TASC C or D lesions of the native circulation. Technical success of the endovascular procedure was achieved in all but one patient (93%) with the majority undergoing subintimal recanalization. Retrograde recanalization was required in 3 patients using a transpedal or transgraft approach. Stents were placed in all patients. The mean ABIs before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 13.8 months. The mean time to PTA failure was 6.1 months. Primary patency at 3, 6 and 12 months was 78%, 47%, and 16%. Successful secondary procedures were performed in 5 patients to recanalize restenotic or reoccluded lesions with secondary patency at 3, 6 and 12 months of 85%, 46%, and 17%. Limb salvage at 6, 12 and 24 months was 93%, 93%, and 62%. Amputation-free survival at 6, 12 and 24 months was 85%, 85% and 57%. Conclusion Endovascular recanalization of native arterial occlusions in patients with failed lower extremity bypass grafts is technically feasible, safe and results in acceptable limb salvage.

Spontaneous gas gangrene in a patient with Crohn’s disease

SummaryBackground:Spontaneous gas gangrene is necrosis of muscles in the absence of trauma, causing an acutely painful and potentially fatal condition. However, the occurrence of this condition in Crohn’s disease has been very rarely documented.Case Report:In this extremely rare case we describe an occurrence of spontaneous gas gangrene, in a known case of Crohn’s disease. The patient presented with fever and pain in the left arm and abdomen. After admission and initial management with antibiotics, the patient developed crepitus in the arm and myonecrosis necessitating a fasciotomy and later an emergency amputation of his left upper limb.The pathogenesis of gas gangrene in inflammatory bowel disease is not fully understood. Management includes aggressive antibiotic administration followed by amputation of the non-salvageable limb.Conclusions:A high index of suspicion of such rare complications is a must and surgical intervention is life saving; however, the efficacy of anti-gas gangrene serum is controversial. We recommend use of a multipronged approach in such cases with high mortality rates.

Amputation of a lower extremity after severe trauma

Serious lower extremity injuries sometimes warrant emergency amputation. The goal of amputation in polytrauma patients is to increase chances of survival, while the goal of amputation in a single limb injury is to prevent further complications, e.g., infection, septic shock. Rescue from life-threatening lower extremity bleeding in a critically injured patient. Severe injury of a lower extremity: crushed, burned, frozen, advanced infection. Patient refusal. Supine position, determination of resection border, skin incision, identification of nerves and blood vessels, osteotomy, vessel ligation, separation of blood vessels and nerves, final removal of tissue with amputation knife, disposal of amputated extremity, skin closure. Wound care, careful compression wraps beginning on postoperative day7, early prosthesis fitting, mental health care consultation. From January 2008 until October 2010, 115lower extremities were amputated at the BG Trauma Clinic in Ludwigshafen, Germany. A total of 42amputations were posttraumatic and were performed in the clinic for trauma surgery and orthopedics. There were a total of 18foot and toe amputations, 16lower leg amputations, 5knee amputations, and 3above knee amputations. Comparison of the groups is difficult due to the varying mechanisms of injury and locations of amputation. Therapeutic decisions regarding emergency amputation are made with careful consideration of the patient.

‘Time critical’ rapid amputation using fire service hydraulic cutting equipment

Introduction Entrapped trauma victims require extrication, which, on rare occasions, may involve amputation of a limb. Standard extrication techniques sometimes fail or may be impossible, leading to the death of the entrapped victim. We propose that the use of fire service hydraulic cutting equipment can be used effectively to urgently amputate a limb, where conventional techniques are unusable. Method The study aims to determine: (i) the potential use of this equipment to achieve expeditious life-saving amputations and (ii) the effect the fire service hydraulic cutting equipment has on the bony and surrounding soft tissues. Initially a porcine limb was used followed by fresh-frozen cadaveric lower limbs. We recorded the time, number of cuts, proximal fracture propagation and quality of bone cut when performing amputations at five levels. Results The experiment confirms that faster guillotine amputations in human cadaveric lower limb specimens can be achieved by using fire service hydraulic cutting equipment. Overall, the average time to complete an amputation in these ideal experimental circumstances at all five levels was quicker using the hydraulic cutting equipment. Either one or two cutting actions were required to achieve the amputation using fire service hydraulic cutting equipment. The degree and proximal extent of the comminution were greater using the fire service hydraulic cutting equipment. Conclusion If circumstances and time constrains allow, a conventional amputation technique carried out by a trained medical practitioner would be preferable to the use of the fire service hydraulic cutting equipment. However, we feel that this technique could be used to perform emergent amputation under trained medical supervision, if it is felt that a standard amputation technique would take too long or the environment is too restrictive to perform a standard amputation safely.

Replantation of Above-Knee Amputation: A Surviving but Dysfunctional Case Needing Secondary Amputation

Above-knee amputations are rare injuries that need emergent replantation or primary amputation. Although survival could be achieved in selective cases, postoperative function of the affected limb is usually unsatisfactory and a late amputation has to be performed for poor prognosis or severe complications. Experience of the surgical team may play an important role in primary decision making, which leads us to report one case of above-knee replantation with poor postoperative function and needing a late amputation. Scoring systems, expected results based on our case, and a brief review of literature concerning above-knee replantations are discussed.

Healthcare does not simply equate to hospitals

Imperial College, London, UK Email: p.howitt@imperial.ac.uk The future of healthcare is not, principally, about the hospital. The future is with primary healthcare in the management of chronic disease or, even better, in public health and a drive to reduce the incidence of those diseases. Suzanne Robertson-Malt’s excellent editorial in this edition of Avicenna, sets out the challenge clearly. The Gulf Cooperation Council (GCC) countries rightly aspire to world-class healthcare, but they are in danger of becoming the world leaders in a less desirable area--the prevalence of chronic disease. It may seem strange for one of the authors, as a colorectal surgeon, to be emphasising the importance of primary healthcare and prevention. Yet the evidence is clear that the burden of disease across the world is shifting to chronic disease. Already the majority of global deaths--60% in 2005-are caused by chronic disease [1]. Amongst the relatively affluent GCC states this figure rises further; in Oman, for instance, 75% of deaths are due to non-communicable diseases [2]. Nor is it just deaths that will be driven by chronic disease. It is projected that the two leading contributors to disability-adjusted life years (DALYs) in 2020 will be chronic diseases (heart disease and depression) [3]. Chronic disease should be prevented where possible and managed effectively in the community when it does occur. Hospital treatment of chronic disease--such as emergency amputations carried out on diabetic patients--must be the last resort. However, currently there is a danger that the development of GCC healthcare repeats the experience of Europe, North America and Australasia, where spending has been focussed where it has least impact on the health of the population, as illustrated in Fig. 1. There is no reason why the GCC countries need to repeat the mistakes of Western healthcare systems. Yet to avoid them, there needs to be a fundamental reprioritisation of investment so that healthcare spending is not focused on the construction of huge hospitals. Money would be better spent on state of the art primary care facilities close to where people live. These new facilities need to be staffed by dedicated primary care physicians. Family medicine physicians in the US and General Practitioners in the UK are highly respected doctors whose specialism is recognised. They are also well rewarded financially---In 2007/08 the mean income for a general practitioner in the UK was just under UKP 100,000 compared with a newly qualified hospital consultant who earned just over UKP 70,000 [4]. The status and financial rewards help to ensure that some of the very best medical students go into primary care. Alongside the establishment of an effective primary care system, it is vital that public health and disease prevention are well resourced. Increasing exercise, decreasing obesity, eating a healthy diet and stopping smoking are lifestyle changes that reduce people’s risks of a multitude of chronic disease. The World Health Organisation estimates that if these lifestyle issues were addressed, 80% of heart disease, stroke and type 2 diabetes could be prevented [5]. If lifestyles can be influenced and if primary care can be fully established, then GCC countries will have a sustainable health system. This is not a threat to hospitals, but an opportunity. Instead of dealing with patients who do not need to be there--such as the majority of the 1,500 attendees at Hamad General Hospital’s Emergency Department in Doha--they will be freed up to focus on providing the specialist care to those most in need; the road traffic accident victim suffering multiple trauma or the stroke patient needing rapid CT scan and thrombolysis.

Under pressure: new team training now under way

You enter theatre in a rush after being severely delayed in traffic; a patient well known to you from clinic is prepped and in need of an emergency amputation of the left leg. However, the consent form says right leg; the registrar who took it has finished his or her night shift and is unable to confirm whether this is a clerical mistake; the anaesthetist is unwilling to proceed without further corroboration; and the clock is ticking. What do you do next? This is just one of the scenarios presented to participants in a new course starting in 2010.

Upper Extremity Amputations After Motor Vehicle Rollovers

The upper extremity is vulnerable to injury during a rollover motor vehicle crash (MVC). There is some concern that positioning one's arm on a vehicle door/window eliminates the benefit of maintaining containment within a protective structure. Mangled extremities with associated vascular injuries have an amputation rate exceeding 40%. The primary goal was to describe the care process and outcome of patients requiring an emergent upper extremity amputation after a rollover MVC. All patients requiring an upper extremity amputation after a rollover MVC (2000-2008) were included. Patient demographics, injuries, and outcomes were analyzed. Seventeen patients required an upper extremity amputation after a rollover MVC (mean injury severity score = 23; hemodynamic instability at presentation = 29%). Injuries occurred on the side ipsilateral to the occupant vehicle position in 88% of cases. Most (76%) amputations occurred between May 1 and August 1 of their respective years, with 11 (65%) in the past 24 months. All amputations except one (replantation attempt) were completed within 24 hours. Concurrent operative procedures were performed in six (35%) patients, including three diagnostic peritoneal lavages, two laparotomies (splenectomies), one craniotomy, and one thoracotomy (atrial rupture). Mortality (12%) was a direct result of traumatic brain injuries. Temporary intravascular shunts were used before amputation in four (24%) patients. The majority (65%) of amputations were above the elbow joint. Blunt mangled upper extremities requiring completion amputations are most often caused by MVC rollovers. The risk of this injury is strongly associated with summer days and seems to be increasing in frequency.

Ipsilateral fractures of tibia and femur or floating knee

Ipsilateral fractures of the femur and the tibia are relatively uncommon lesions, with critical consequences to the knee. We report a series of 18 ipsilateral fractures of the femur and the tibia treated at the Department of orthopaedics, CHU Hassan II of Fez, over an eight-year period (1996-2004). Various surgical procedures were used, in particular, intramedullary nailing. After an average follow-up of 2.5 years, we re-examined the 18 patients. The functional results were evaluated using the Schiedts' criteria, and we had seven excellent results (38.9%), six good (33.4%), and five bad (27.8%). There was one major lesion of the popliteal artery that led to an emergency amputation, two cases of osteitis, one septic non-union, one case of late deep sepsis, one insignificant shortening of 2 cm, two cases of varus, three cases of stiffness, and one ankylosis of the knee. Through this work we will try to show the repercussions of this type of fracture of the knee and to evaluate our therapeutic choices.