Limb-threatening Complications Research Articles

Heparin-Induced Thrombocytopenia (HIT) in Postoperative Cardiac Surgery: Case Report

Heparin-induced thrombocytopenia (HIT) is a life- and limb-threatening complication of heparin exposure. Unfractionated heparin (UFH) and low molecular weight heparins (LMWHs) are drugs that are widely used in patients undergoing cardiac surgery and that have made it possible to avoid and treat countless venous and arterial thrombotic problems. However, its use is also associated with a paradoxical reaction that leads to a potentially very serious prothrombotic state, which annually causes numerous amputations or fatal outcomes. Although the number of amputations per HIT is not known, recent studies describe an incidence of approximately 3-4%. Therefore, below, we present a woman undergoing cardiac surgery that begins in the post-surgical period with thrombocytopenia associated with arterial thrombosis, complicated by limb amputation due to HIT.

Incidence of Peripheral Vascular Malformations of Limbs in SMS Hospital Jaipur

Peripheral vascular malformations (PVMs) include a wide spectrum of diseases that can produce potentially life- or limb-threatening complications. The International Society for the Study of Vascular Anomalies (ISSVA) Classification System categorized vascular anomalies into two basic types, the vaso proliferative or vascular neoplasms and developmental vascular abnormalities.
 Method: A retrospective, cross-sectional study was conducted for the period of 2 year. All patients under surgery OPD with a Peripheral limb vascular anomaly excluding upper limbs and lower limbs were taken into the study and investigated and followed up for at least 6 months.
 Result: In this study, out of 38 patients 26 patients (12 (44%) males and 14 (56%) females) were diagnosed withvascular malformation of upper and lower limbs. It is observed that low flow lesions are more common in both upper and lower limbs. Male patients with these lesions tend to present much later in life than female patients.
 Conclusion: AVMs show variance in site and type based on gender. Male patients were more likely present with high-flow AVMs in lower limbs whereas female patients typically presented with low-flow AVMs on the upper extremities.
 Keywords: Peripheral limb vascular malformations, varicose veins, AVM.

Surgical Duration Is Independently Associated with an Increased Risk of Surgical Site Infection and May Not Be Mitigated by Prolonged Antibiotics: A Secondary Analysis of the PARITY Trial of Infection After Lower-Extremity Endoprosthetic Reconstruction for Bone Tumors.

Infection after tumor resection and endoprosthetic reconstruction is a potentially limb-threatening complication. The duration of surgery has been shown to be a risk factor for infection, but the ability of an extended duration of postoperative prophylactic antibiotics to potentially minimize that risk has not been specifically studied. The objective of this study was to determine whether extended postoperative antibiotic therapy protects against surgical site infection (SSI) in the setting of prolonged surgical duration in patients undergoing endoprosthetic reconstruction after tumor resection. This study was a planned secondary analysis of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial data set. Patients in the PARITY trial were randomized to receive 24 hours or 5 days of postoperative prophylactic antibiotics. The current study assessed the risk of SSI in those cohorts on the basis of surgical duration. A multivariable regression model was used to examine the adjusted effects of the duration of surgery on SSI, after controlling for other significant risk factors and potential confounders. All 604 patients who had been included in the final data analysis in the PARITY trial were also included in this secondary analysis. Those who sustained an SSI had a greater mean duration of surgery (6.2 hours) compared with those who did not sustain an SSI (4.9 hours, p < 0.0001). There was no specific time point at which the risk of infection significantly increased. Extended postoperative prophylactic antibiotic therapy did not appear to mitigate the risk of SSI even in patients with prolonged surgical duration. Increased surgical duration was an independent risk factor for SSI in orthopaedic patients undergoing endoprosthetic reconstruction after tumor resection. However, surgical duration is multifactorial and is influenced by several variables. For example, there may be protective features of flap coverage that increase surgical duration while paradoxically decreasing the risk of SSI. Extended postoperative antibiotic therapy did not mitigate the risk of infection in this cohort, and other risk mitigation strategies will need to be considered in future studies. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevalence and predictors of lower extremity atherosclerotic disease amongst high-risk patients using ankle brachial index

IntroductionThe prevalence of lower extremity artery disease (LEAD) continues to increase worldwide. This is expected to translate into logarithmic rise in lower-limb amputations especially in the developing world. Majority of patients suffering from LEAD remain asymptomatic until late and are vulnerable to limb-threatening complications unless actively screened and treated. MethodsThis was a prospective, single-center, observational study to determine the prevalence and predictors of LEAD. Patients with known atherosclerotic vascular disease (but not known LEAD) or those at risk were enrolled. All underwent ankle brachial index (ABI) measurement as per the standard protocol. A threshold of ABI ≤0.90 was taken to diagnose LEAD. ResultsA total of 1000 patients were enrolled. The mean age of the group was 61.4 ± 10.0 years and the prevalence of LEAD was 10.2%. Amongst those who had LEAD, the majority of patients (69.6%) had no symptoms. The prevalence of LEAD in diabetic population in our study was 13.2% and it was 30.9% in coronary artery disease patients . Factors independently linked to LEAD on regression analysis included advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. ConclusionsThe vast majority of patients suffering from LEAD are asymptomatic. Early diagnoses and institution of appropriate medical and physical therapy can prevent excess morbidity and mortality due to LEAD. Factors independently linked to LEAD are advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. The presence of either of these should signal undertaking of appropriate steps to unmask underlying LEAD.

Hemoglobin A1C in Charcot: Can It Predict a BKA?

Category: Diabetes; Ankle; Trauma; Other Introduction/Purpose: Charcot Foot is a serious and potentially limb-threatening complication of longstanding diabetes, peripheral neuropathy, and trauma. One of the many challenges that surgeons face when treating the Charcot Foot is predicting long-term outcomes. Therefore, the purpose of this study was to determine if hemoglobin A1C level was associated with an increased risk of BKA in Charcot Foot patients. Methods: Following institutional board approval, all patients from 2015-2021 with a diagnosis of Charcot Foot were queried using hospital electronic medical records. Patients were separated into two groups. Group A consisted of patients with a diagnosis of Charcot and a hemoglobin A1C3 6.5%, while group B consisted of patients with a diagnosis of Charcot and hemoglobin A1C &lt; 6.5%. Statistical analysis was then performed to determine the relative risk of a BKA in patients exposed to a hemoglobin A1C3 6.5%, compared to those with a hemoglobin A1C &lt; 6.5%. Only patients with a documented A1C around the time of diagnosis were included. Results: From 2015 to 2021, 80 patients were diagnosed with Charcot Foot. Of these patients, 59 met our inclusion criteria. Of the 59 patients, 20.3% (12/59) went on to require a BKA and 79.6% (47/59) did not. In our cohort, 54.2% of patients had a hemoglobin A1C3 6.5% and 45.8% (27/59) had a hemoglobin A1C &lt; 6.5%. The relative risk of BKA in patients with an A1C3 6.5% was 2.5 (95% CI: 0.76-8.4; p=0.13). Conclusion: Charcot Foot is a debilitating and potentially limb-threatening complication. While our results suggest an associated increased risk of BKA in patients with an A1C3 6.5%, there was no statistical significance found. As such, further investigation is needed.

Acute Carpal Tunnel syndrome from post-traumatic pseudoaneurysm of the radial artery

Introduction: Pseudoaneurysms are a well described complication of peripheral arteries. They often develop post-traumatically and/or iatrogenically. Prompt recognition with appropriate management is paramount in preventing limb-threatening complications.

Ultrasonographic features of diabetic foot osteomyelitis: a case series.

Osteomyelitis is a limb-threatening complication of diabetic foot ulcers. Early identification of the disease is key to ensuring successful prognosis. In this study, we describe ultrasonographic features for the identification of osteomyelitis. Patients were screened through clinical, ultrasonographic and probe-to-bone tests. Ultrasonographic features in three patients that could be used to identify diabetic foot osteomyelitis included periosteal reaction, periosteal elevation, cortical erosions and presence of sequestrum, all of which were confirmed by a plain X-ray. An ultrasonographic examination could be used for the early detection of osteomyelitis, which could help clinicians devise prompt treatment strategies.

Acute limb ischaemia: not an uncommon complication of COVID-19 infection.

A new variant of coronavirus (2019-nCoV) causing acute respiratory distress in humans was identified for the first time in 2019, in Wuhan, China. One of the many complications of infection with this coronavirus is hypercoagulopathy, resulting in acute thrombosis; often leading to acute limb ischaemia. Herein, we report 20 cases of COVID-19 with peripheral arterial thrombosis involving either upper or lower limbs. Some patients underwent vascular procedures and most had to undergo amputation at some level. All the cases (n=20) were referred to us during the 8-month period June 2020 to March 2021. The most common age group was between 51 and 60 years, of whom 80% were males; all the patients had diabetes. The right lower limb was most affected (50%); 15 patients underwent embolectomy. Twenty-five per cent of patients presented with wet gangrene. One patient with upper limb thrombosis recovered after embolectomy and did not require any amputation. Eighty-five per cent of patients underwent some form of amputation and the mortality rate was 10%. Arterial thrombosis is one complication patients may develop during COVID-19 illness, which may affect the outcome. Patients with comorbid conditions like diabetes are at higher risk of developing arterial thrombosis during COVID-19 infection. Susceptibility to coagulopathy may continue even after patient discharge and it is important that both patients and treating physicians are aware of this limb-threatening complication and seek early medical attention.

The charcot joint osteoarthropathy: a case report

The Charcot Joint Osteoarthropathy also referred as Charcot foot syndrome is a serious lower limb-threatening complication of diabetes. A patient was diagnosed with Charcot joint osteoarthropathy (COA) and found to have uncontrolled Diabetes Mellitus since more than 10 years. This case is crucial considering that Diabetes mellitus is a common case that we encounter, but the consequences of not being controlled can lead to serious complications. Accurate diagnosis is not always easy and can be a considerable clinical challenge. It needs to be differentiated from other conditions that has similar symptoms. Early diagnosis and initiation of treatment is crucial to avoid devastating and permanent complications.

Novel Application of 18F-NaF PET/CT Imaging for Evaluation of Active Bone Remodeling in Diabetic Patients With Charcot Neuropathy: A Proof-of-Concept Report.

Charcot neuropathic osteoarthropathy (CN) is a serious and potentially limb-threatening complication for patients with diabetes mellitus and peripheral arterial disease. In recent decades, nuclear medicine-based approaches have been used for non-invasive detection of CN; however, to date, a positron emission tomography (PET) radionuclide specifically focused on targeted imaging of active bone remodeling has not been explored or validated for patients with CN. The radionuclide 18F-sodium fluoride (NaF) has historically been used as a bone imaging probe due to its high sensitivity for targeting hydroxyapatite and bone turnover, but has not been applied in the context of CN. Therefore, the present study focused on novel application of 18F-NaF PET/computed tomography (CT) imaging to three clinical cases of CN to evaluate active bone remodeling at various time courses of CN. PET/CT imaging in all 3 cases demonstrated focal uptake of 18F-NaF in the bones of the feet afflicted with CN, with bone retention of 18F-NaF persisting for up to 5 years following surgical reconstruction of the foot in two cases. On a group level, 18F-NaF bone uptake in the CN foot was significantly higher compared to the healthy, non-CN foot (p = 0.039). 18F-NaF PET/CT imaging may provide a non-invasive tool for monitoring active bone remodeling in the setting of CN, thereby offering novel opportunities for tracking disease progression and improving treatment and surgical intervention.

Delayed vascular complication after total hip replacement

Vascular injuries following an arthroplasty are a nightmare for both patient and surgeon. When the presentation is delayed and atypical, it is of major concern. We present a case of late presentation of pseudoaneurysm of common femoral artery left hip following total hip replacement. A 54-year-old male presented with complaints of weakness and numbness left knee, following total hip arthroplasty, which was performed 4 months earlier at an outside institution for secondary osteoarthritis of the left hip. on evaluation was found to have pseudoaneurysm of Femoral artery. Due to the co morbid condition of the patient (CKD, DM, Obsity) elevated creatinine values non surgical method of embolization of the pseudoaneurysm via one coil and Gelfoam was deferred and was decided to manage the psuedoaneurysm surgically with repair and PTFE graft. High suspicion in the setting of unresolving postoperative pain, paralysis, or need for blood transfusions may allow for earlier diagnosis and avoidance of serious limb-threatening complications. Care during the procedure for accurate retractor placement and careful manipulation may help avoid serious complications.

Treatment of FRI after intramedullary nailing of tibia fractures: assessment of nail retention and nail removal

Objectives: Fracture related infection (FRI) is a severe, potentially limb-threatening complication after fracture fixation. Dilemma exists with regard to removing or retaining implants while treating the infection. The purpose of this study was to compare primary bone union and infection clearance in patients who had an infection following intramedullary nailing of the tibia treated either by retaining the implant or by removing the implant. &#x0D; &#x0D; Methods: Patients from two level-I trauma centers were identified through billing registries and retrospectively reviewed between January 2013 and December 2020. We identified 44 patients who had a diagnosis of FRI within 90 days of their initial fixation and returned to the OR for operative treatment of the infection. The incidences of both primary union and infection clearance were calculated for both groups and multiple parameters that may be associated with success or failure were assessed. &#x0D; &#x0D; Results: Four patients did not have complete records and were excluded. Of the remaining patients, 20 (50%) achieved infection clearance. Twenty-three (59%) patients achieved primary union whereas 16 (41%) had a primary outcome of either delayed union, nonunion, or amputation (one additional patient excluded as healing status unknown). Further analysis showed no significant difference (X2 (39) = 1.13, p &lt; .29) in infection clearance between patients treated with nail retention (64%) versus nail removal (68%). No significant difference was seen in primary bone union (X2 (39) = 3.24, p &lt; .07) with 36% of patients treated with nail retention and 68% of patients treated with nail removal reaching primary union; however, this does trend toward an association. Fewer surgeries performed for infection and complication after initial fixation was positively associated with infection clearance (p &lt; .04, M=4.6, SD=2.13, df=39) and primary union (p &lt; .001, M=4, SD=2, df=38). &#x0D; &#x0D; Conclusion: Infection clearance seems similarly possible with both nail retention and nail removal strategies, with fewer number of surgeries performed for infection and complication improving the likelihood of infection clearance and bone union. This may suggest that more severe FRI’s are less likely to unite and clear infection. Nail removal may play a role in increasing primary bone union; however, a larger sample size is needed for more definitive assessment.

Topical ozonated virgin coconut oil improves wound healing and increases HSP90α, VEGF-A, EGF, bFGF, and CD34 in diabetic ulcer mouse model of wound healing

Background: Diabetes is a disease that affects people worldwide, including in Indonesia. The prevalence of diabetes in Indonesia is increasing from year to year. One of the most devastating complications of diabetes mellitus is diabetic ulcers, which is a limb-threatening complication. Over the past few decades, ozone generated using plasma medical technology has been investigated as an agent that helps wound healing. This study aims to evaluate the effects of topical ozonated virgin coconut oil (VCO) in a diabetic wound mouse model. Methods: This study was an experimental study with a post-test control design. An ulcer wound model was made in 50 diabetic male Wistar mice, divided into five groups, and a control group of 10 non-diabetic mice. The control groups were given conventional therapy only and the treatment groups were also given topical ozonated VCO with different flow durations (0 min, 90 min, 7 h, 14 h). Macroscopic appearance and wound contraction were observed. HSP90β, VEGF-A, EGF, bFGF, and CD34 levels were measured from the immunostained slices of wound margins. Results: The reduction of wound length was proportionally related to the duration of ozone flow. Ozonated VCO with a longer duration of ozone flow healed the wound more quickly and had the shortest wound length. VCO with ozone flow for 14 hours (16837.10 µm) had the biggest reduction in wound length compared to other groups. The wounds treated with ozonated VCO showed an increase in HSP90β, VEGF-A, EGF, bFGF, and CD34 levels that correlated to improved wound healing. A longer period of treatment resulted in higher levels of wound healing biomarkers compared to shorter therapeutic durations. Conclusions: Topical ozonated VCO improved the wound healing process in a diabetic ulcer mouse model by improving macroscopic wound appearance and increasing levels of wound healing biomarkers.

Topical ozonated virgin coconut oil improves wound healing and increases HSP90α, VEGF-A, EGF, bFGF and CD34 in diabetic ulcer mouse model of wound healing

Background: Diabetes is a disease that affects people worldwide, including in Indonesia. The prevalence of diabetes in Indonesia is increasing from year to year. One of the most devastating complications of diabetes mellitus is diabetic ulcers, which is a limb-threatening complication. Over the past few decades, ozone generated using plasma medical technology has been investigated as an agent that helps wound healing. This study aims to evaluate the effects of topical ozonated virgin coconut oil (VCO) in a diabetic wound mouse model. Methods: This study was an experimental study with a post-test control design. An ulcer wound model was made in 50 diabetic male Wistar mice, divided into five groups, and a control group of 10 non-diabetic mice. The control groups were given conventional therapy only and the treatment groups were also given topical ozonated VCO with different flow durations (0 min, 90 min, 7 h, 14 h). Macroscopic appearance and wound contraction were observed. HSP90β, VEGF-A, EGF, bFGF and CD34 levels were measured from the immunostained slices of wound margins. Results: The reduction of wound length was proportionally related to the duration of ozone flow. Ozonated VCO with a longer duration of ozone flow healed the wound more quickly and had the shortest wound length. VCO with ozone flow for 14 hours (16837.10 µm) had the biggest reduction in wound length compared to other groups. The wounds treated with ozonated VCO showed an increase in HSP90β, VEGF-A, EGF, bFGF and CD34 levels that correlated to improved wound healing. A longer period of treatment resulted in higher levels of wound healing biomarkers compared to shorter therapeutic durations. Conclusions: Topical ozonated VCO improved the wound healing process in a diabetic ulcer mouse model by improving macroscopic wound appearance and increasing levels of wound healing biomarkers.

Acute Compartment Syndrome Following Heart Transplant

Purpose Acute compartment syndrome (ACS) is a rare limb-threatening complication following cardiac transplantation that could negatively impact on post-op rehabilitation. Methods A retrospective chart review was performed for heart transplantation at our institution between 2009-2019. Clinical characteristics of ACS were identified. Results 5 cases of lower limb ACS were observed out of 144 cardiac transplant patients (3.47%). Patients age ranged between 18 and 65, all males. Two had complex congenital heart disease, 1 ischaemic cardiomyopathy and 2 dilated cardiomyopathies. None of them had diabetes. ACS was diagnosed between 1 and 84 hours postoperatively. Doppler ultrasound of the lower limb arteries showed significant stenosis in proximal arteries in two of them and small caliber arteries in the other two. ACS occurred on the side of arteriovenous femoral cannulation. All patients had prior history of arteriovenous femoral cannulation for cardiopulmonary bypass to the same vessel. Cardiopulmonary bypass time and cross clamp time were between 245-330 minutes (mean:283.7 minutes) and 49-125 minutes (mean: 173.2 minutes) respectively. Interestingly, mean cross clamp time was 31.5 minutes shorter in patients with ACS, compared to those without ACS. All patients had factors leading to prolonged surgery including difficulty in establishing hemostasis, previous adhesions and post-op RV dysfunction. 3 patients received temporary mechanical circulatory support immediately post-transplant, including Intra Aortic Balloon Pump or Venoarterial Extracorporeal Membrane Oxygenation. Posterior compartment was the most common compartment involved. All but one underwent fasciotomy. On average ACS increased the hospital length of stay by 16 days. Functional capacity was significantly impaired at 3 months after the diagnosis with variable improvement at 6 months. ACS resulted in permanent disability in 3 patients. Conclusion ACS is a rare complication post heart transplantation with prolonged hospital stay and long-term debilitation. High index of suspicion in high risk patients, early diagnosis and timely treatment with fasciotomy could prevent from subsequent disability and limb loss.

A novel case of a pseudoaneurysm due to thermal injury from a cement hip spacer

Vascular injuries sustained during total hip replacements are associated with life- and limb-threatening complications. In the present report, we have described a novel vascular injury of an external iliac artery pseudoaneurysm repaired with an interposition vein graft. The vascular injury had been caused by heat from the curing process of a nearby cement hip spacer. During the curing process of bone cement, in vivo temperatures of ≤70°C can be reached, with such temperatures creating the potential for vascular injury. This case highlights the importance of limiting the exposure of surrounding neurovascular structures to bone cement to reduce the risk of thermal injury.

A Comparison of the Epidemiology, Clinical Features, and Treatment of Acute Osteomyelitis in Hospitalized Children in Latvia and Norway.

Background and objectives: Paediatric acute osteomyelitis (AO) may result in major life-threatening and limb-threatening complications if not recognized and treated early. The management of AO may depend on local microbial prevalence and virulence factors. This study compares the approach to paediatric AO in hospitals in two countries—Latvia and Norway. Materials and Methods: The study includes patients with AO hospitalized in the paediatric department in the Norwegian hospital Sørlandet Sykehus Kristiansand (SSK), in the period between the 1st of January 2012 and the 31st of December 2019. The results from SSK are compared to the results of a published study of AO in patients hospitalized at the Children’s Clinical University Hospital (CCUH) in Riga, Latvia. Results: The most isolated pathogen from cultures in both hospitals was S. aureus (methicillin-sensitive). The lower extremity was the most affected body part (75% in CCUH, 95% in SSK), the main clinical symptom was pain (CCUH 92%, SSK 96.6%). Deep culture aspiration was most often taken intraoperatively in CCUH (76.6%) and percutaneously in SSK (44.8%). Oxacillin was the most applied antibiotic in CCUH (89.4%), and Cloxacillin in SSK (84.6%). Combined treatment with anti-Staphylococcal penicillins and Clindamycin was administered in 25.5% and 33.8% of CCUH and SSK patients, respectively. The median duration of the intravenous antibacterial treatment in CCUH and SSK was 15 and 10 days, respectively, and a switch to oral therapy was mainly made at discharge in both hospitals. The median total duration of antibiotic treatment was 25 days in CCUH and 35 days in SSK. 75% of CCUH and 10.3% of SSK patients were treated surgically. Complications were seen in 47% of patients in CCUH and in 38% in SSK. Conclusions: The transition to oral antibacterial treatment in both hospitals was delayed, which suggests a lack of criteria for discontinuation of intravenous therapy and could potentially contribute to longer hospitalization, higher cost of treatment and risk of complications. The use of more invasive techniques for deep culturing and significantly more common surgical interventions could possibly be linked to a higher complication rate in AO patients treated at the Latvian hospital.

Clinical validation of immunoassay HemosIL® AcuStar HIT-IgG (PF4-H) in the diagnosis of Heparin-induced thrombocytopenia

Heparin induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. The misdiagnosis of this disease can have major consequences on the patients. The objective of this study was to evaluate a diagnostic strategy that combines the 4Ts score with the result of HemosIL® AcuStar HIT-IgG (PF4-H) to confirm the diagnosis of HIT. Citrated plasmas from 1300 patients with suspicion of HIT were analyzed with a fully automated quantitative chemiluminescent immunoassay (HemosIL® AcuStar HIT-IgG (PF4/H)). If the IgG anti-PF4/H antibodies were positive (cut-off, 1 U/mL), HIT diagnosis was confirmed using functional tests. In total, 1300 samples of consecutive patients were enrolled, 94 (7.2%) of which gave positive results in HemosIL® AcuStar-IgG. HIT was diagnosed in 65 out of these patients, corresponding to a prevalence of 5%. Using ROC curve analysis, patients were divided into three groups according to their titer of antibodies. Higher values of the IgG (PF4-H) were associated with increased probability of HIT, and the diagnostic specificity was greatly increased using the combination of a 4Ts score > 3 and a positive titer ≥ 3.25 U/mL. Importantly, the diagnostic specificity is 100% when the titer is > 12.40 U/mL. We demonstrated that higher values of Anti PF4/H Antibodies were associated with a high probability of having HIT. A titer of HemosIL® IgG (PF4-H) > 12.40 U/mL has a specificity of 100% which should no require a functional test to confirm the diagnosis of HIT.

Tibial Plateau Fracture: Anatomy, Diagnosis and Management.

Tibial plateau fractures are peri-articular knee fractures of the proximal tibia. The presentation is dependent on the mechanism of injury. The tibial plateau is the bony platform of the distal half of the knee joint, and is made up of a medial and lateral condyle separated by the intercondylar eminence. The presentation of tibial plateau fractures can vary greatly as a result of the bimodal mechanism of injury and patient characteristics. The patient should be assessed for life- and limb-threatening injuries in accordance with British Orthopaedic Association Standards of Trauma guidelines. Imaging is undertaken to understand configuration of the fracture, which is classified by the Schatzker classification. Definitive management of the fracture depends on the severity, ranging from conservative to surgical management. Surgery is required for more severe tibial plateau fractures to restore articular congruity, mechanical alignment, ligamentous stability and to permit early mobilisation. Medium-term functional outcome after tibial plateau fractures is generally excellent when anatomy and stability is restored. At least half of patients return to their original level of physical activity. Surgical management of tibial plateau fractures is not without complication. Risk factors include postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment and articular incongruity. Tibial plateau fractures account for 1% of all fractures, and typically occur either as a fragility fracture or secondary to a high-energy impact. These latter injuries are associated with extensive soft tissue injury, life- and limb-threatening complications and long-term sequelae. While outcomes are generally good, severe injuries are at higher risk of infection and post-traumatic arthritis requiring knee arthroplasty. This article considers the anatomy, diagnosis and evidence-based management strategies for tibial plateau fracture.

A CASE OF PHLEGMASIA CERULEA DOLENS AND MAY-THURNER SYNDROME IN A YOUNG MALE WITH TRIPLE-POSITIVE ANTIPHOSPHOLIPID ANTIBODY SYNDROME

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Phlegmasia cerulea dolens (PCD) is an uncommon form of deep vein thrombosis (DVT) typically presenting with acute limb swelling, pain, and cyanosis. Diagnosis of PCD should be made promptly as these patients may develop limb-threatening complications such as gangrene and compartment syndrome. We describe a young male presenting with his first episode of provoked venous thromboembolism (VTE) as PCD complicated with May-Thurner syndrome (MTS) and Antiphospholipid antibody syndrome (APS). CASE PRESENTATION: A 37-year-old obese male with type 2 diabetes, hypertension, and hyperlipidemia was directly admitted to the medicine floor with extensive left lower extremity DVT (including ileofemoral vein thrombosis) found on outpatient duplex ultrasonography. At initial hospitalization, he was tachycardic but without respiratory distress or hemodynamic instability. His left lower extremity was tender and edematous with cyanosis. Diagnosis of PCD was made and patient was treated with subcutaneous enoxaparin. He received catheter-directed thrombolysis for PCD with alteplase and heparin infusion. During left leg venogram, he was discovered to have MTS, and subsequently underwent stent placement of left common iliac vein, external iliac vein, and common femoral vein. After stent placement, patient received bridging to warfarin with enoxaparin and was discharged home two days later. Patient’s family history was significant for Systemic Lupus Erythematosus. During hospitalization, his antibody testing revealed positivity for anti-cardiolipin, anti-beta-2 glycoprotein antibodies in addition to positive functional lupus anticoagulant assay. Positivity confirmed with repeat testing of anti-cardiolipin antibodies and lupus anticoagulant assay at 15 weeks after hospitalization - confirming the diagnosis of triple-positive APS. DISCUSSION: Treatment of PCD is anticoagulation therapy with adjunctive catheter-directed thrombolysis. Outcomes comparing additional catheter-directed thrombolysis versus anticoagulation alone have shown that combination treatment reduces the incidence of post-thrombotic syndrome in patients with acute iliofemoral DVT. Recognition of DVT associated with MTS is important as treatment includes stent placement to maintain venous outflow. Recognition of triple-positive APS is an indication for extended anticoagulation as this portends a high risk of recurrent VTE. Patient was discharged with warfarin therapy because the use of direct oral anticoagulation in patients with APS remains controversial. Recent studies showed increased risk of recurrent thrombosis, particularly in patients with APS who are triple-positive. CONCLUSIONS: We reported a case, 37 year old male with phlegmasia cerulea dolens and May-Thurner syndrome resulting from triple-positive antiphospholipid antibody syndrome. Reference #1: Casey ET, Murad MH, Zumaeta-garcia M, et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg. 2012;55(5):1463-73 Reference #2: Haig Y, Enden T, Grøtta O, et al. Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (CaVenT): 5-year follow-up results of an open-label, randomised controlled trial. Lancet Haematol. 2016;3(2):e64-71 Reference #3: Dufrost V, Risse J, Reshetnyak T, et al. Increased risk of thrombosis in antiphospholipid syndrome patients treated with direct oral anticoagulants. Results from an international patient-level data meta-analysis. Autoimmun Rev. 2018;17(10):1011-1021 DISCLOSURES: No relevant relationships by Waqas Adeel, source=Web Response No relevant relationships by Robert Decker, source=Admin input No relevant relationships by Shuisen Li, source=Web Response No relevant relationships by Preysi Patel, source=Web Response No relevant relationships by Chun Siu, source=Web Response