Fasciotomy Rates Research Articles

Could fasciotomy prevent amputation in patients with electrical burn injuries? Insights from a cross-sectional study in Indonesia.

The amputation rate resulting from electrical burn injuries remains high, yet no study has investigated whether early fasciotomy may reduce the amputation rate. The aim of this study was to analyze the success rate of fasciotomy in preventing amputation and determine the optimal timing for fasciotomy in electrical burn injuries. This study was conducted at Dr. Soetomo Hospital from January 2020 to July 2023. Total sampling was employed to recruit the patients. Clinical data, voltage characteristics, burn location, affected total body surface area, burn depth, hospital arrival time, and time interval from incident to fasciotomy were assessed. Chi-squared test was used to assess factors associated with the fasciotomy incidence and factors associated with amputation after fasciotomy. A total of 45 patients were included, of which 97.8% were male, with a mean age of 37.60 years old. Approximately 73% of patients had full-thickness burn injuries, with the left upper extremity being the most affected (80%). There are seven patients (15.6%) had fasciotomy and five (11.1%) patients had an amputation. Our data indicated a significant association between voltage characteristics and fasciotomy incidence (p=0.034). Additionally, our data indicated that earlier arrival to the hospital (p=0.002) and timely fasciotomy conducted upon arrival (p<0.001) were associated with a reduced rate of amputation. This study highlights that prompt arrival to the hospital and early fasciotomy may prevent amputation in patients with electrical burn injuries.

Multilevel thrombotic or embolic burden and its role in sex-related outcomes in acute limb ischemia

ObjectiveThe impact of sex upon outcomes in acute limb ischemia (ALI) remains disputed. We aim to quantify the effect of sex upon amputation-free survival (AFS) after a percutaneous-first approach for ALI. MethodsThis was a two-center retrospective review of ALI managed via a percutaneous-first approach. Demographics, comorbidities, and clinical characteristics were analyzed. The Kaplan-Meier and Cox regression were used to estimate AFS, limb salvage, and overall survival. ResultsOver 9 years, 170 patients (n = 87, 51% males; median age, 67 [interquartile range (IQR), 59-77 years) presented with ALI. Rutherford classification was I in 56 (33%); IIa in 85 (50%); IIb in 20 (12%), and III in 9 (5%). Thirty-day mortality, major amputation rate, and fasciotomy rates were 8% (n = 13); 6.5% (n = 11), and 4.7% (n = 8), respectively. Among revascularized limbs, 92% were patent at 30 days. Length of stay was 7 days (IQR, 3-11 days). Complications included 13 bleeding episodes (8%), four cases of atrial fibrillation (2%), and three re-thrombosis/clot extension events (1.7%). No differences were noted in complication rates when stratified by sex. Females were older than males (median age, 70 [IQR, 62-79] vs 65 [IQR, 56-76 years]; P = .02) and more likely to present with atrial fibrillation (20.5% vs 8%; P = .02) and hyperlipidemia (72% vs 57%; P = .04). Females also more frequently presented with multi-level thrombotic/embolic burden compared with males (56% vs 43%; P = .03) and required both aspiration thrombectomy and thrombolysis (27% vs 14%; P = .02). Kaplan-Meier estimated median AFS, limb salvage, and overall survival were 425 days (IQR, 140-824 days); 314 days (IQR, 72-727 days); and 342 days (IQR, 112-762 days). When stratified by sex, females had worse survival (median, 270 days [IQR, 92-636 days] vs 406 days [IQR, 140-937 days]; P = .005) and limb salvage (median, 241 days [IQR, 88-636 days] vs 363 days [IQR, 49-822 days]; P = .04) compared with males. Univariate Cox regression showed female sex (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.04-2.05; P = .03), multi-level thrombotic/embolic burden (HR, 1.64; 95% CI, 1.17-2.31; P = .004), and Rutherford class (HR, 1.37; 95% CI, 1.08-1.73; P = .009) predicted major amputation/death. By multivariable Cox regression, multi-level thrombotic/embolic burden (HR, 1.54; 95% CI, 1.09-2.17; P = .01), Rutherford class (HR, 1.34; 95% CI, 1.07-1.69; P = .01), and female sex (HR, 1.45; 95% CI, 1.03-2.05; P = .03) were each independently predictive of major amputation/death. ConclusionsA percutaneous-first strategy is safe and efficacious in the overall ALI population. Similar to prior works, female vs male patients with ALI in our cohort have higher rates of mortality and major amputation. In our multivariable model, multi-level thrombotic/embolic burden was independently associated with a greater than 45% increased hazard of major amputation/death at last follow-up. Further prospective analysis is warranted to elucidate the underlying factors contributing to the higher prevalence of multi-level thrombotic/embolic burden in female patients with ALI, and to further define the optimal percutaneous-first approach for ALI in consideration of patient sex and extent of clot burden.

Management of Pediatric Lower Extremity Vascular Trauma: Adult vs Pediatric Level I Trauma Centers [RETRACTED

Pediatric lower extremity vascular injury (PLEVI) is uncommon. Though epidemiologic studies exist, the availability of granular data is sparse. Additionally, few studies compare the management between adult (ATC) and pediatric (PTC) trauma centers. The objective of this study was to analyze the surgical management of PLEVIs between a Level I ATC and a Level 1 PTCs in our metropolitan area. We performed a retrospective review of all PLEVIs (age < 18 years) managed surgically between 01/2009-12/2022. Demographics, clinical and outcome data were obtained and compared between centers. Primary outcomes included amputation and fasciotomy rates. Secondary outcomes included type of vessel repair, mortality, and intensive care unit (ICU) and hospital length of stay. Seventy-nine patients were identified, 41 at the ATC and 38 at the PTC totaling 111 vessels injured. Overall, 84.8% were male. ATC patients were older (median 16.0 vs 12.5) and almost exclusively (97.6% vs 29.0%) gunshot wounds. There was no difference in ISS. The popliteal artery was the most injured vessel, ATC (50%) and PTC (40%). Vascular surgeons managed 50% of injuries at ATC vs 60.5% of injuries at the PTC (p = 0.35). Rates of arterial or venous repair, ligation, or grafting were not significantly different. Amputations were uncommon at both centers and not significantly different. Seventeen patients (44.7%) required fasciotomies at the PTC vs 21 (51.2%) at the ATC (p = 0.56). There was no significant difference in mortality, ICU, or hospital length of stay. PLEVI have acceptable outcomes (low amputation and/or fasciotomy rates, low mortality) and are managed uniformly between ATCs and PTCs. This data adds important context to the management of PLEVI. Retrospective Chart Review, Level IV.

More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury.

Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.

Resuscitative Endovascular Balloon Occlusion of the Aorta is Associatedwith Increased Risk of Extremity Compartment Syndrome.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a temporizing procedure to control intra-abdominal or pelvic bleeding. Theoretically, occlusion of the aorta and the resulting ischemia-reperfusion of the lower extremities may increase the risk of extremity compartment syndrome (CS). To date, no study has addressed systematically the incidence and risk factors of CS following REBOA intervention. The purpose of this study was to address this knowledge gap. Adult trauma patients from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2016-2019) were included. Patients who received REBOA within 4h of admission were compared to patients without REBOA after propensity score matching for demographics, vital signs on admission, comorbidities, injury severity of different body regions, pelvic and lower extremity fractures, vascular trauma to the lower extremities, fixation for fractures, angioembolization (AE) for pelvis, preperitoneal pelvic packing (PPP), laparotomy, and venous thromboembolism (VTE) prophylaxis. The primary outcomes were rates of lower extremity CS and fasciotomy and acute kidney injury (AKI). Secondary outcomes included mortality. There were 534 patients who received REBOA matched with 1043 patients without REBOA. Overall, patients in the REBOA group had significantly higher rates of CS than no REBOA patients [5.4% vs 1.1%, p < 0.001, OR: 5.39]. The risk of CS remained significantly higher in the subgroups of patients with or without pelvic or lower extremity fractures, as well as in the subgroup of patients with associated extremity vascular injury [11.2% vs 1.5%, p < 0.001, OR: 8.12].The fasciotomy and AKI rates were significantly higher in the REBOA group (5.8% vs 1.2%, p < 0.001 and 12.9% vs 7.4%, p< 0.001 respectively). REBOA use is associated with a higher risk of lower extremity CS, fasciotomy and AKI, especially in patients with associated lower extremity vascular injuries. These complications should be taken into account when considering REBOA use, and close observation for this complication should always be part of the routine monitoring.

Predictors of Foot Acute Compartment Syndrome: Big Data analysis

Acute compartment syndrome (ACS) in the foot is a challenging diagnosis and can lead to significant disabilities to patients. The present study aims to investigate the incidence, risk factors, demographics and association in the analysis of acute compartment syndrome (ACS) of the foot. We performed a retrospective review of the Trauma Quality Programs data from the American College of Surgeons including 70,525 patients who sustained a fracture of the foot from 2015 to 2018 (4 calendar years). Fasciotomies were performed in 0.7% of all foot fractures. Open fractures, crush injuries and multiple foot fractures were the strongest predictors of fasciotomies, with odds ratios of 2.38, 2.38 and 2.33 respectively. Being a male was associated with an increased likelihood of fasciotomies of 64% (p < .0001 O.R.=[1.42-1.90]), while a dislocation in the foot increased likelihood of fasciotomies by 48% (p= .0008O.R.=[1.18-1.86]).Trauma centre level III had higher rate of fasciotomy than Tertiary Trauma centers. Multiple other factors were addressed while controlling for cofounders. This big data analysis provided information not previously reported on the risk factors, demographics, and clinical association of ACS in the foot.

Clinical versus Instrumented Reliability of Diagnosis of Acute Compartmental Syndrome in Tibial Fractures

Abstract Background: Acute compartment syndrome of the leg may be a devastating complication of a tibial fracture. Metic-ulous and repeated examinations of the patient who has such a fracture are needed to ensure the diagnosis of acute com-partment syndrome (ACS). A.C.S. remains challenging in many patients although the 5 Ps of compartment syndrome; pain, pallor, paralysis, pulselessness, and paresthesia. Aim of Study: To measure intra-compartmental pressure in different compartments in the lower leg in tibial fractures and to correlate it with common clinical findings found in acute compartment syndrome in trial to early detect acute compartment syndrome and to decrease its devastating com-plications and rate of fasciotomy. Patients and Methods: This study was conducted on 100 patients referred to the Emergency department having Tibial fracture predisposed to have acute compartment syndrome by measuring intra-compartmental pressure instrumentally using stryker intra-compartmental pressure monitoring system and correlated with clinical picture and detect the percentage of patients need fasciotomy. Results: The Stryker intra compartmental monitoring system (STIC catheter) has accuracy and easy to measure intra-compartmental pressure and helps us to early detect A.C.S. in the lower leg also to decrease rate of fasciotomy and complications but it is expensive and needs proper training to use it. Conclusion: The patient who undergoes fasciotomy re-quires a physical therapy program to regain function. Postop-erative care and rehabilitation are just as important as the procedure itself.

Predictors for the need for fasciotomy after arterial vascular trauma of the lower extremity

IntroductionCompartment syndrome of the lower extremity following arterial vascular trauma can cause irreversible damage to muscle as well as nerve tissue leading to long-term functional impairment of the extremity or worse limb loss. Prompt diagnosis and treatment of compartment syndrome is mandatory to preserve muscle tissue and prevent limb loss. The aim of the study was to analyze the fasciotomy rate of our patient cohort and to perform a predictors analysis for the need of fasciotomy. Material and MethodsIn a retrospective study all patients treated for arterial vascular trauma since 1990 were identified. Demographics, clinical data and outcome were analysed. After separation in a fasciotomy and non-fasciotomy group, a Bayes Network was used to arrive at a predictor ranking for the need of fasciotomy via a gain ratio feature evaluation. ResultsIn the period of 28 years, 88 (73.9%) of a total of 119 patients, predominantly male (80.7%) and aged under 40 years (37.5 ± 17.5), required fasciotomy after arterial vascular trauma. Patients of the fasciotomy group presented at higher Rutherford categories (grade III 34.1% vs. 9.7%, p = 0.005), varied in terms of the type of arterial vascular injury (dissection 25% vs. 61.3%, p <0.001, occlusion 15.9% vs. 0%, p = 0.011) and showed prolonged hospitalization (35.17 ± 29.3 vs. 21.48±25.4, p = 0.002). Ischaemia duration exceeding 2.5 h followed by the Rutherford grade IIa and greater, the site (popliteal artery segment 3), type (transection and occlusion), and mechanism of vascular trauma (work related accident over traffic and sports accidents), as well as the male gender presented as strong predictors for fasciotomy. ConclusionsArterial vascular trauma requiring fasciotomy for compartment syndrome accounted for 73.9% of all cases. Immediate diagnosis and treatment is mandatory to prevent long-term functional impairment or limb loss. The above mentioned predictors should help identifying patients at risk for developing a compartment syndrome to provide best possible treatment.

Endovascular repair is a feasible option for superficial femoral artery injuries: a comparative effectiveness analysis.

To compare outcomes between open (OR) and endovascular repair following superficial femoral artery (SFA) injuries. This is a cross-sectional study querying the 2012-2014 National Inpatient Sample for SFA injuries. Patients were grouped into OR and stent-graft placement (SGP). Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), fasciotomy and amputation rate, and cost. Wilcoxon rank-sum, Kruskal-Wallis, Chi-squared test with Bonferroni adjustment were used as appropriate; p < 0.05 was significant. 255 Patients were identified. Mean age was 34.6years and majority were males. OR was performed in 82.7%. Overall mortality rate was 3.7%. Median HLOS was 8days. Fasciotomies were performed in 31% and lower limb amputations in 3.7%. Males more often underwent OR (89.0% vs. 73.1%, p < 0.01). SGP patients were significantly older (44.9 vs. 32.5years; p < 0.01), and with Medicare insurance (20.5% vs. 6.5%; p < 0.01. Mortality, HLOS, and hospitalization cost were not significantly different. OR patients had higher rate of fasciotomy (35.4% vs. 15.4%; p < 0.01). Endovascular management is not inferior to OR following SFA injuries and both carry a low amputation rate. OR is associated with a higher fasciotomy rate. Endovascular repair should be considered when technically feasible.

Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners.

Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running. Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy. Case series. Level 4. Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy. A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively. Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery. Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients

BackgroundPopliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes. MethodsPatients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement. ResultsOverall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality. ConclusionsLigation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.

Impact of inferior vena cava ligation on mortality in trauma patients

ObjectiveInferior vena cava (IVC) injuries are potentially lethal and require prompt intervention. Repair of complex IVC injuries may require the use of a prosthetic graft or a complicated panel or spiral vein graft reconstruction to avoid the need for ligation. Collateral venous drainage may be sufficient to allow acceptable results from IVC ligation; however, previous studies have suffered from low numbers and have differing results. The aims of this study were to assess the outcomes of isolated IVC injuries overall and to compare IVC ligation with repair. MethodsPatients in the National Trauma Data Bank from 2007 to 2014 with an IVC injury were evaluated. Isolated IVC injury was defined as patients with nonvascular Abbreviated Injury Scale scores <4 and no other named vascular injury. The primary outcome was mortality; secondary outcomes were in-hospital amputation-free survival, major lower extremity amputation, lower extremity compartment syndrome, acute kidney injury (AKI), deep venous thrombosis (DVT), and pulmonary embolism (PE). ResultsOverall, 1075 (0.018%) patients had IVC injuries and 443 met inclusion criteria. On univariate analysis, in comparing IVC ligation and primary repair, ligation was not associated with mortality (23% vs 16%; P = .102) but was associated with blunt mechanism (22% vs 11%; P = .009), higher fasciotomy rate (11% vs 0%; P < .001), trend toward lower in-hospital amputation-free survival (76% vs 84.4%, P = .056), and higher rates of AKI (9% vs 4%; P = .060) and PE (3% vs 1%, P = .087). Similarly, major lower extremity amputation, compartment syndrome, and DVT were not different between groups. IVC ligation was not independently associated with mortality (adjusted odds ratio [AOR], 1.54; P = .197), in-hospital amputation-free survival (AOR, 0.61; P = .141), major amputation (AOR, Inf; P = .99), lower extremity compartment syndrome (AOR, 0.82; P = .827), or PE (AOR, 6.72; P = .052), but it was independently associated with fasciotomy (AOR, 31.4; P = .002), AKI (AOR, 2.7; P = .048), and DVT (AOR, 2.3; P = .021). ConclusionsIVC ligation was not independently associated with mortality or lower extremity amputation, but it was associated with AKI and need for fasciotomy.

Fasciotomy for Lateral Lower-leg Chronic Exertional Compartment Syndrome.

Exercise-induced lower leg pain may be caused by chronic exertional compartment syndrome (CECS). Anterior or deep posterior compartments are usually affected. Knowledge about CECS of the lateral compartment (lat-CECS) is limited and outcome after fasciotomy is unknown. The purpose of this study is to report on success rates of fasciotomy in patients with lat-CECS. Surgical success rates in patients with lat-CECS diagnosed with a dynamic intracompartmental pressure (ICP) measurement were studied using a questionnaire (success: excellent or good as judged by the patient; unsuccessful: moderate, fair or poor). We conducted ICP measurements in 247 patients for suspected lat-CECS, of whom 78 were positively diagnosed. Following exclusion (n=11), 30 of the eligible 67 patients completed the questionnaire. Bilateral (70%, n=21/30) exertional pain (97%, n=29) and a feeling of tightness (93%, n=28) were the most frequently reported symptoms. Four years after fasciotomy, severity and frequency of symptoms had dropped significantly. Long-term surgical success was reported by 33% (n=10; excellent n=4, good n=6). Seventy-three percent (n=22) had resumed sports activities (9 same level, 13 lower level). In conclusion, a fasciotomy for lat-CECS was successful in the long term in just one of three operated patients in this retrospective study.

Outcomes Comparison Between Ligation and Repair after Major Lower Extremity Venous Injury

The necessity of repair remains controversial after major lower extremity venous injuries (MLEVIs). Ligation may cause venous hypertension which should be managed with fasciotomies. Previous studies have shown that fasciotomy rate is not affected by the type of management of MLEVIs. The aim of this study was to examine the rate of fasciotomy, amputation, and other complications from a difference between ligation and repair of MLEVIs. The National Trauma Data Bank (NTDB) for 2010-2014 was reviewed. Eligiblepatients were restricted to MLEVI patients who underwent surgical ligation or repair. Data on demographics, rate of fasciotomy, secondary amputation, and other complications were collected. Comparative analysis between ligation and repair on demographics, complications, and outcomes was performed using multivariate logistic regression models. A total of 2120 patients were identified in NTDB and 1029 (48.5%) underwent ligation while 1091 (51.5%) underwent repair. The overall rate of fasciotomy and secondary amputation was 38.9% (n=824) and 4.8% (n=101), respectively. Patients in the ligation group had a higher proportion of university hospital setting and penetrating injury. Otherwise, there was no significant difference in other characteristics between the 2 groups. Patients in the ligation group had significantly higher rates of fasciotomy and secondary amputation and longer hospital length of stay (LOS) than those in the repair group (44.6% vs. 33.5%, risk ratio [RR] 1.33, 6.1% vs. 3.4%, RR 1.81, 11 [6-20] vs. 9 [5-17], respectively). Otherwise, there was no significant difference in all other complications and in-hospital mortality between 2 groups. The fasciotomy rate was surprisingly high and affected by venous ligation in patients with MLEVIs. Considering the overall physiological condition, trauma surgeons should perform venous repair aggressively and prepare judiciously for fasciotomy after surgery. Avoiding venous ligation and maintaining venous outflow may contribute to not only reducing the need for fasciotomy and LOS but also saving limbs.

Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years.

Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. IV, retrospective observational study.

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury

ObjectiveThe incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries. MethodsPatients in the National Trauma Data Bank (NTDB; 2007-2012) with at least one iliac vascular injury were analyzed. Isolated iliac vessels were defined as cases with Abbreviated Injury Scale severity score of greater than 3 for extraabdominal injuries and an Organ Injury Scale grade of greater than 3 for intraabdominal injuries. ResultsOverall, 6262 iliac vascular injuries (2809 penetrating, 3453 blunt) were identified in 271,076 patients with abdominal trauma (2.3%). There were 3379 patients (1841 penetrating, 1538 blunt) with isolated iliac vascular injuries (1.2%) and 557 patients (514 penetrating, 43 blunt) with combined iliac artery and vein injuries (0.2%). The 30-day mortality rate was 16.5% for isolated iliac vein injury, 19.3% for isolated iliac artery injury, and 48.7% for combined isolated iliac artery and vein injury. The 30-day mortality rate was 23.4% for isolated iliac vascular injuries compared with 39.0% for nonisolated iliac vascular injuries (P < .001). Patients with isolated iliac vein injuries had morbidity rates of deep venous thrombosis (repair, 14.6%; ligation, 14.1%; P = .875), pulmonary embolism (repair, 1.8%; ligation, 0.5%; P = .38), fasciotomy (repair, 9.3%; ligation, 14.6%; P = .094), amputation (repair, 1.8%; ligation, 2.6%; P = .738), acute kidney injury (repair, 5.8%; ligation, 4.7%; P = .627). Multivariate logistic regression demonstrated that ligation of isolated iliac vein injuries had an odds ratio of 2.2 for mortality compared with repair (95% confidence interval, 1.08-4.66). ConclusionsIsolated iliac vascular injuries are associated with a high incidence of mortality, especially for combined venous and arterial injury, but mortality is significantly lower than in patients with nonisolated iliac vascular injuries. In patients with isolated iliac vein injuries, mortality was higher in patients who underwent ligation compared with repair; however, the rates of deep venous thrombosis, pulmonary embolism, fasciotomy, amputation, and acute kidney injury were not different between the treatment groups. These data lend credence to the assessment that repair of iliac vein injuries is preferable to ligation whenever feasible.

A true silent compartment syndrome in a competent sensate patient: Case report

A true silent compartment syndrome in a competent sensate patient: Case report

Predictors of secondary amputation in patients with grade IIIC lower limb injuries: A retrospective analysis of 35 patients.

The aim of this study was to identify risk factors for failure of limb salvage surgery in grade IIIC lower extremity injuries.A single-institution, retrospective review was performed of all patients with grade IIIC lower limb injuries presenting from January 2009 to April 2014. We gathered the data on each patient who underwent limb salvage and analyzed the final outcome for these patients (limb salvage vs secondary amputation).Grade IIIC lower limb injuries were identified in 41 patients. Primary amputation was performed in 6 patients (15%) as the initial procedure. Thirty-five patients (85%) underwent vascular reconstruction and other surgical procedures to salvage the limb. Limb salvage was successful in 23 patients (66%); 12 patients (34%) ultimately underwent secondary amputation. The median time from injury to secondary amputation was 22.5 days (range 4–380 days). The mean Mangled Extremity Severity Score (MESS) was 7.2 ± 1.5 (range 5–10). The MESS was significantly higher in the secondary amputation group compared with the limb salvage group. Additionally, statistical testing revealed that the limb ischemia time, complex fractures, rate of fasciotomy, and number of vascular reconstruction were significantly higher in the secondary amputation group. Muscle necrosis and extensive soft tissue defect were the main reasons for secondary amputation.The findings indicate that MESS of 7 or greater, complex fractures, limb ischemia time equal to or greater than 6 hours, and osteofascial compartment syndrome were associated with an increased risk of delayed amputation. The MESS is highly prognostic but not perfect; decision-making in patients with an MESS of 7 or greater should be re-evaluated for clinical use.

Arterial duplex for diagnosis of peripheral arterial emboli

Whether duplex ultrasound (DUS) imaging alone can be used to successfully plan revascularization for peripheral arterial embolism (PAE) is unknown. This study evaluated the utility of DUS imaging alone for the diagnosis and treatment of PAE. Patients with cardiogenic PAE to the lower or upper extremities during a 20-year period were retrospectively evaluated. Patients with visceral or cerebral PAE were excluded. Diagnosis by DUS imaging alone was compared with contrast angiography (CA) or computed tomography angiography (CTA). Patient demographics, use of intraoperative CA, need for reintervention, length of revascularization procedure, and rate of fasciotomy and amputation were compared. Mean peak systolic velocity (PSV; cm/s) measured at the proximal, middle, and distal segment of each artery from the common femoral to the distal tibial arteries was also compared with surgical outcomes. We identified 203 extremities in 182 patients with PAE. Preoperative imaging was obtained in 89%, including DUS imaging alone (44%), CA (37%), and CTA (7%). DUS imaging was used more frequently than CA or CTA in women, older patients, patients with congestive heart failure, upper extremity PAE, and patients on antiplatelet agents preoperatively. Use of intraoperative CA, need for reintervention, rate of fasciotomy and limb loss, and hospital length of stay were similar between the two groups. No upper extremities required amputation. Patients with lower extremity emboli who underwent fasciotomy had lower mean PSVs than those free from fasciotomy at the popliteal (4± 6cm/s vs 31± 62cm/s; P= .03), anterior tibial (1± 3cm/s vs 10± 16cm/s; P= .004), and posterior tibial (2± 3cm/s vs 9± 15cm/s; P= .03) arteries. The 30-day mortality for the series was 25% with a median follow-up of 7.4months. The only predictor of 30-day mortality on multivariate analysis was tobacco use (odds ratio, 3.1; 95% confidence interval, 1.4-7.0). Surgical outcomes and survival for patients evaluated by preoperative DUS imaging alone for PAE areequivalent to patients evaluated with CA or CTA. PSVs in the tibiopopliteal arteries may predict the need for fasciotomy. Preoperative DUS imaging alone is sufficient for operative planning in patients with symptoms suggestive ofPAE.

U.S. Military Experience From 2001 to 2010 With Extremity Fasciotomy in War Surgery.

After trauma, compartment syndrome of the extremities is a common, disabling, and-if managed suboptimally-lethal problem. Its treatment by surgical fasciotomy continues to be useful but controversial. The purpose of this survey is to measure survival and fasciotomy in a large trauma system to characterize trends and to determine if fasciotomy is associated with improved survival. We retrospectively surveyed data from a military trauma registry for U.S. casualties from 2001 to 2010. Casualties had extremity injury or extremity fasciotomy. We associated survival and fasciotomy. Of 17,166 casualties in the total study, 19% (3,313) had fasciotomy and 2.8% (481) had compartment syndrome. Annual fasciotomy rates started at 0% (2001) and rose to 26% (2010). For all casualties, the survival rate initially was high (100%) but decreased steadily until its nadir (96.4%) in 2005. Thereafter, it increased to make a V-shaped trend with reversal occurring after fielding two interventions within the trauma system specifically for casualties at risk for fasciotomy-tourniquet use and a fasciotomy education program. Over a decade of war, the survival rate of extremity injured casualties was associated with two trauma system interventions-tourniquet usage and a fasciotomy education program. The current example of measuring implementation of initiatives may be useful as a model for future attempted improvements in health care.