Secondary Amputation Rate Research Articles

Clinical Outcomes following Invasive Treatment of Femoropopliteal Artery Disease: A Retrospective Single-Center Cohort Study

PurposeTo identify predictors of clinical success in invasive treatment for femoropopliteal arterial disease aiding clinical decision-making. Materials and MethodsA retrospective analysis was performed on 676 consecutive patients who underwent a first episode of invasive treatment for femoropopliteal disease, either endovascular therapy (EVT) or femoropopliteal bypass (FPB), between 2004 and 2015. Primary end points were primary and secondary clinical patency and amputation rate. Kaplan–Meier curves were used to evaluate clinical patency. A Cox proportional hazard model explored predictors of primary end points. ResultsMost patients (58%) underwent EVT as primary intervention, while 42% underwent FPB. Median follow-up was 43 months. The only independent predictor for loss of primary clinical patency was critical limb-threatening ischemia (CLTI) (P = .008; hazards ratio [HR], 1.25; 95% CI, 1.07–1.47). Secondary clinical patency was positively associated with FPB surgery (P = .037; HR, 0.66; 95% CI, 0.44–0.97), a higher pre-interventional ankle–brachial index (P = .029; HR, 0.43; 95% CI, 0.20–0.92), more distal runoff vessels (P = .036; HR, 0.77; 95% CI, 0.60–0.98), and the absence of ischemic heart disease (P = .006; HR, 1.69; 95% CI, 1.16–2.47). In patients with CLTI, chronic renal failure predicted loss of primary and secondary clinical patency and increased amputation risk. ConclusionsIn this cohort, CLTI was independently associated with decreased primary clinical patency in invasive treatment for femoropopliteal disease. Secondary clinical patency was positively associated with FPB, higher ankle–brachial index, more runoff vessels, and the absence of ischemic heart disease.

Surgical Management of Diabetic Foot Burns Is Associated With Poor Outcomes: A Systematic Review and Meta-Analysis.

There is no consensus on the optimal management of diabetic foot burn injuries. Here, we systematically identify studies reporting on diabetic foot burns and evaluate outcomes among patients managed operatively vs nonoperatively. PubMed, Embase, and Web of Science were searched. Screening was performed by independent reviewers. Primary research studies with English full texts published between 1980 and 2023 that discussed outcomes of foot burns in adults with diabetes were included and critically appraised using validated tools. Results are presented using descriptive statistics of aggregated data. The search yielded 2402 nonduplicate papers, of which 35 met the inclusion criteria. Nine papers were included for meta-analysis, including 7 retrospective comparative analyses, 1 cross-sectional study, and 1 retrospective chart review. There were 1798 diabetic foot burn patients. The mean age was 58.2 years (SD 4.12), and 73.1% (n = 1314) were male. A total of 15.7% (n = 283) of patients were surgically managed, including debridement (3.7%, n = 66), grafting (8.2%, n = 147), flap (0.2%, n = 3), and primary amputation (7.1%, n = 127). The secondary amputation rate, defined as amputation following initial surgery, was 4.9% (n = 14). The overall amputation rate was 7.8% (n = 141). Other complications included infection (4.0%, n = 72), osteomyelitis (1.9%, n = 34), and graft failure (8.2%, n = 12). One study reported functional status at the last visit. Diabetic foot burns are highly morbid. The surgical management of these complex injuries is high risk, as amputation results in poorer quality of life and functional outcomes.

The Clinical Utility of Lower Extremity Dual-Energy CT Angiography in the Detection of Bone Marrow Edema in Diabetic Patients with Peripheral Artery Disease.

(1) Background: Type 2 diabetes is a major cause of incidences and the progression of peripheral artery disease (PAD). Bone marrow edema (BME) is an important finding suggestive of underlying bone inflammation in non-traumatic diabetic patients with PAD. Our aim was to evaluate the presence, severity, and clinical implications of BME detected by virtual non-calcium application (VNCa) of dual-energy CT angiography (DE-CTA). (2) Methods: A consecutive series of 76 diabetic patients (55 men; mean age 71.6 ± 11.2 yrs) submitted to lower limb DE-CTA for PAD evaluation and revascularization planning, which were retrospectively analyzed. VNCa images were independently and blindly revised for the presence, location, and severity of BME by two radiologists with 10 years of experience. BME and non-BME groups were evaluated in terms of PAD clinical severity and 6-month secondary major amputation rate. (3) Results: BME was present in 17 (22%) cases, while 59 (78%) patients were non-BME. The BME group showed a significantly higher incidence of major amputation (p < 0.001) and a significantly higher number of patients with advanced clinical stages of PAD compared to the non-BME group (p = 0.024). (4) Conclusions: Lower limb DE-CTA with VNCa application is a useful tool in the detection of BME in diabetic patients with PAD, simultaneously enabling the evaluation of the severity and location of the arterial disease for revascularization planning. BME presence could be a marker of clinically severe PAD and a possible risk factor for revascularization failure.

Limb salvage results of Gustilo IIIC fractures of the lower extremity.

This study aims to present our results for limb salvage in Gustilo IIIC open fractures of the femur and tibia. 92 patients with Gustilo IIIC fractures operated in our clinic between January 2000 and March 2016 were retrospectively evaluated. Demographic data, ischemia time, method of arterial repair, means of primary and secondary fixation, time to amputation, complications, and final VAS scores were recorded. The difference between the primary amputation rates of tibia and femur fractures was not statisti- cally significant (18% vs 21%, p>0.05). The difference between the secondary amputation rates of tibia and femur fractures was not significant (16% vs 27%, p>0.05). All secondary amputations were done within the first month during the initial hospital stay. Overall limb salvage rate was 69% for Gustilo IIIC fractures of the femur and 58% for Gustilo IIIC fractures of the tibia. The overall limb salvage rate was not significantly different between the two groups (p>0.05). At the final follow-up, patients in the limb salvage group had average VAS scores of 4.3 (femur) and 4.7 (tibia). The decision between amputation versus limb salvage remains a difficult decision that should be jointly made by the treating physicians and the patient.

Temporal trends in major, minor and recurrent lower extremity amputations in people with and without diabetes in Belgium from 2009 to 2018

AimsThis study assessed temporal trends in the incidence of lower extremity amputations (LEA) in Belgium from 2009 to 2018, and subsequent secondary amputation rates. MethodsNationwide data on LEA were collected. Sex- and age-adjusted annual incidence rates were calculated. Time trends were analysed in negative binomial models. The incidence of secondary interventions, defined as either any ipsilateral reamputation or any contralateral amputation, was studied with death as competing risk. Results41 304 amputations were performed (13 247 major, 28 057 minor). In individuals with diabetes, the amputation rate (first amputation per patient per year) decreased from 143.6/100.000 person-years to 109.7 (IRR 0.97 per year, 95 %CI 0.96–0.98, p < 0.001). The incidence of major LEAs decreased from 56.2 to 30.7 (IRR 0.93, 95 %CI 0.91–0.94, p < 0.001); the incidence of minor amputations showed a non-significant declining trend in women (54.3 to 45.0/100 000 person years, IRR 0.97 per year, 95 %CI 0.96–0.99), while this remained stable in men with diabetes (149.2 to 135.3/100 000 person years, IRR 1.00 per year, 95 %CI 0.98–1.01). In individuals without diabetes, the incidence of major amputation didn’t change significantly, whereas minor amputation incidence increased (8.0 to 10.6, IRR 1.04, 95 %CI 1.03–1.05, p < 0.001). In individuals with diabetes, one-year secondary intervention rates were high (31.3% after minor, 18.4% after major LEA); the incidence of secondary amputations didn’t change. ConclusionsA significant decline in the incidence rate of major LEA was observed in people with diabetes. This decline was not accompanied by a significant rise in minor LEA. The incidence of secondary interventions remained stable.

Lower Extremity Vascular Trauma Assiut University Hospital Experience

Background: There is globally increase incidence in vascular trauma as a result of increase rate of civilian violence and increase rate of road traffic accident. Vascular injury affects young males and associated with high mortality and long-term morbidity. Here, we present our experience as tertiary health centers in the management of this type of injury, also we present our result as regards to primary and secondary amputation rates. The most important factors affecting these rates were ischemia time and condition of surrounding soft tissue. Aims and Objectives: Detect rate of limb salvage after trauma injury in assuit university hospital, and risk factors for limb loss. Materials and Methods: Our study is prospective study of all patients who vascular lower extremity trauma from January 2014 to January 2015 during the period of the study(from January 2014 to January 2015), 135 cases of vascular injury presented to Assiut University Hospital, 87 of them had lower limb vascular injury representing 64.4%. Results: Surgical intervention was done in 82 patients representing 94.3%, endovascular intervention was done in 2 patients representing 2.3, 1 patient had endovascular balloon control then surgical intervention representing 1.15%, and two patients had conservative management representing 2.3%. Conclusion: vascular trauma is prevalent health problem in our locality, which have huge socioeconomic impact in our community as it affects mainly young men. The main controlling factor in secondary amputation rate is ischemia time, infection which accompanies severe soft tissue damage. At the end trauma with vascular injury is considered, a complex process needs urgent intervention with multidisciplinary team in well-equipped facility.

Does preoperative wound infection impact outcomes of lower extremity salvage via microvascular free flap reconstruction? A cohort study

We sought to identify preoperative wound characteristics associated with a higher risk of adverse outcomes in patients undergoing lower extremity (LE) reconstruction with microvascular free flaps. A retrospective review of patients undergoing free flap reconstruction of the LE at a single academic institution between 2010-2021 was conducted. Preoperative wound culture results were classified by Gram stain, aerobe status, multi-drug resistance (MDR), and presence of multiple bacteria. Outcomes studied included flap viability at 60, 120, and 180 days, as well as flap dehiscence, partial and full necrosis, sepsis, and amputation. A total of 218 LE free flap reconstructions were performed during the study period. 152 (69.7%) of patients were male. Rate of secondary amputation following attempted limb salvage was 4.6%. LE reconstructions utilized either fasciocutaneous (79.4%) or muscular flaps (20.6%). The type of free flap used for reconstruction had no effect on reconstructive outcomes or flap viability. Preoperative bacterial wound cultures were obtained in 102 (46.8%) patients; 80 cultures (78.4%) were positive for bacterial growth. Of these, 33 (41.2%) grew Gram-positive bacteria, 14 (17.5%) grew Gram-negative bacteria, and 33 (41.2%) grew multiple organisms. Positive preoperative wound culture was independently associated with flap failure at 120 days ( p = 0.04) when compared to wounds with no infection. Among patients with positive cultures, polymicrobial infection was significantly associated with higher rates of amputation ( p = 0.04) compared to single Gram-positive or Gram-negative infectious agents. Identification and management of positive wound cultures may play an important role in outcomes of microvascular free flap reconstruction. • Positive preoperative wound culture is associated with free flap failure at 120 days. • Positive wound culture is not associated with flap dehiscence or necrosis. • Polymicrobial infection was associated with higher rates of amputation.

Correlation of glycated hemoglobin in lower extremity amputation in diabetes mellitus

Lower extremity amputation (LEA) in patients with diabetes are associated with high postoperative mortality and a high rate of secondary amputation. Glycated Hemoglobin reflects average plasma glucose over the previous 8 to 12 weeks and is an excellent marker for disease control in diabetes. However, a direct link between the level of quality of diabetic care—as measured by hemoglobin A1c—and amputation risk has yet to be documented. In this retrospective time bound study study, we sought to examine the relationship between the use of hemoglobin A1c testing and amputation risk using a hospital database. Diabetic patients registered at our centre who have underwent lower extremity amputation, their HbA1c levels were collected from the Medical records department between 2016-19. A total of 150 patients were included in the study, majority of the cases showed elevated levels of glycated hemoglobin while only 1.3% had normal values. There was a significant association between patients undergoing LEA and their glycated hemoglobin levels (p

Traumatismes artériels des membres supérieurs : particularités de la population en Tunisie et facteurs de risque d’amputation

Aim of the studyThe purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss. MethodsThis was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate. ResultsThe average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma. ConclusionPrompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

Outcomes of Popliteal Artery Injuries Repair: Autologous Vein versus Prosthetic Interposition Grafts

The aim of this study is to compare wound infection, graft infection, and secondary amputation rates in patients who had popliteal artery injury repair with interposition vein versus prosthetic grafts. This retrospective comparative study included all adult patients (>18years) who had interposition grafting for popliteal artery injuries between January 2008 and August 2018 at a university hospital. Patients were divided into 2 groups. Popliteal arteries were repaired with venous graft in Group "A" and with prosthetic graft in Group "B." The outcome measures were wound infection, graft infection, and secondary amputation rates. Forty patients fulfilled the inclusion criteria. Twenty-two patients had arterial repair with venous while 18 with polytetrafluoroethylene grafts. All were male with median age of 32 (interquartile range [IQR] 19.5) years. Both groups were comparable in terms of median age (32.5 [19] vs. 30.5 [23]), Mangled Extremity Severity Score (6 [5] vs. 7 [7]), median hospital stay (7 [5] vs. 7 [9] days), and perioperative complications (2/22 vs. 3/18). In Group "A," no patient had graft infection or secondary amputation while in Group "B," 1 patient had secondary amputation and another had graft infection (P>0.99). There is no statistical difference in secondary amputation rate, wound infection, or graft infection in patients undergoing popliteal artery repair with interposition vein versus prosthetic grafts in trauma setting.

Anastomotic Technique and Preoperative Imaging in Microsurgical Lower-Extremity Reconstruction: A Single-Surgeon Experience.

The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes. A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test. One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62). In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.

The Mangled Extremity Severity Score Fails to be a Good Predictor for Secondary Limb Amputation After Trauma with Vascular Injury in Central Europe.

The Mangled Extremity Severity Score (MESS) was constructed as an objective quantification criterion for limb trauma. A MESS of or greater than 7 was proposed as a cut-off point for primary limb amputation. Opinions concerning the predictive value of the MESS vary broadly in the literature. The aim of this study was to evaluate the applicability of the MESS in a contemporary civilian Central European cohort. All patients treated for extremity injuries with arterial reconstruction at two centres between January 2005 and December 2014 were assessed. The MESS and the amputation rate were determined. Seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. The mean MESS was 4.97 (CI 4.4-5.6). Seventy-three per cent of all patients (52/71) had a MESS < 7 and 27% (19/71) of ≥7. Eight patients (11%) underwent secondary amputation. Patients with a MESS ≥ 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a MESS < 7 (7.7%; 4/52; p = 0.20). The area under the ROC curve was 0.57 (95% CI 0.41; 0.73). Based on these results, the MESS appears to be an inappropriate predictor for amputation in civilian settings in Central Europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft-tissue traumas.

Outcome After Surgical Treatment of Calcaneal Osteomyelitis.

Surgical procedures for calcaneal osteomyelitis are partial calcanectomy (PC), total calcanectomy (TC), and below-knee amputation (BKA). With calcaneal osteomyelitis, limb-saving surgery was described to have secondary BKA rates of 4% to 20%, while secondary amputation rates after BKA are unknown. The aim of this study was to describe and compare overall revision and secondary amputation rates for each surgical option in our institution's cohort and to identify risk factors for secondary amputation. Fifty patients treated between 2002 and 2017 were included. Revisions, secondary amputations, and possible risk factors for secondary amputation and overall revision were statistically analyzed. Minor revisions rates were 57.1% in PCs, 100% in TCs, and 27.8% in BKAs. Secondary amputation was performed in 28.6% of the PCs, in 50% of the TCs, and in 5.6% of the BKAs. No statistically significant differences between overall revision and secondary amputation rates were found. C-reactive protein values greater than 5 mg/L at the index procedure were significantly associated with overall revision while we could not identify risk factors for secondary amputation. This study represents the largest group of patients treated for calcaneal osteomyelitis in the literature. In limb-preserving surgical options, secondary BKA rates are higher than previously known. Primary BKA is a procedure with a low reamputation rate of 5.6%. PC can be considered, with 28.6% needing more proximal amputation. In TC, all patients underwent revision surgery and 50% had to undergo secondary BKA. Therefore, we hesitate to consider total calcanectomy as a surgical option in calcaneal osteomyelitis anymore. Level IV, case series.

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.

Penetrating femoral artery injuries: an urban trauma centre experience.

This study reviews a single centre experience with penetrating femoral artery injuries. The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage. One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01). This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.

Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation

ObjectiveTo elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI). Material and methodsThis retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n=69), in which the limb was salvaged and group II (n=21), in which the patients received amputation. ResultsThe overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of nine or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p=0.042). They were also more likely to be injured as a result of an explosion (p=0.004). Along with the MESS (p<0.001), the duration of ischemia (DoI) (p<0.001) were higher in group II. The rate of bony fracture (p<0.001) and wound infection (p=0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p=0.011), nerve injury (OR: 136.23, p=0.004), DoI (OR: 2.03, p=0.003), vascular ligation (OR: 8.65, p=0.040) and explosive device injury (OR: 10.8, p=0.041) were significant. Although the DoI (p<0.001) and the MESS (p=0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilisation of a TVS did not influence the amputation rate (p=1.0). ConclusionsThe DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS>7 seem to benefit from revascularisation with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.

Management of Vascular Injury during Current Peaceful Yemeni Revolution

To provide a complete review of our experience on the observed vascular injuries patterns during contemporary Yemeni revolution, management strategies used in the care of injuries and to highlight lessons learned from that period. From February 2011 to January 2012, all casualties evaluated at Yemen International Hospital, were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury, associated trauma, type of vascular repair; initial outcome, amputation rate, and complication. Of 2,200 injured patients evacuated from field hospital, vascular injuries occurred in 63 patients, and these patients comprised the study group. Fifty-one (80.9%) patients were wounded by gunshots high velocity, 6 (9.5%) were wounded by gunshots low velocity, and 6 (9.5%) experienced explosive devices injury. Most of injuries 55 (87%) occurred in the extremities 45 (71%) in the lower extremities and 10 (16%) in the upper extremities, 3 (5%) in carotid arteries, 3 (5%) in internal iliac arteries, and 2 (3%) in internal jugular vein. Nearly half 31 (49%) of the patients sustained complex vascular injuries (arterial and venous injuries), isolated arterial injuries 28 (45%), and isolated venous injuries 4 (6%). Twenty (32%) of the patients underwent complete revascularization and 11 (15%) just arterial repair with venous ligation. According arterial management 32 (51%) of patients underwent revascularization with venous graft, 18 (29%) repaired by end-to-end anastomosis, 1 (2%) polytetrafluorethylene, 7 (11%) thrombectomy, and 5 (8%) arterial ligation. Vascular injuries were associated with bony fracture in 33 (52%) of patients. Postoperative wound infection occurred in 9 (14%) patients. Of those, 7 had venous ligation. Secondary amputation and mortality rates during the study period were 3 (5%) and 4 (6%), respectively. This report represents the first analysis of vascular injuries during contemporary Yemeni revolution in Taiz city. Vascular injuries occurred in 3% of revolution-related injured patients. Our secondary amputation rate of extremities was 5%. Management of arterial repair with autologous vein graft remains the treatment of choice. Ligation of venous injured in a watershed area, such an iliofemoral and popliteal vein should be avoided to prevent leg phlegmasia.

Outcomes after Long-Term Follow-Up of Combat-Related Extremity Injuries in a Multidisciplinary Limb Salvage Clinic

Although the incidence of casualties from the Global War on Terror is decreasing, there remains a focus on the long-term sequelae from injuries sustained in the combat. Patients with prior significant limb injuries remain at risk of future complications. This study examines our institution's experience with a multidisciplinary team approach toward this challenging patient population. A retrospective review was performed on all patients treated in a single institution Limb Preservation Clinic over a 2-year period. Those patients who sustained a combat-related injury in theater were examined. Patient demographics, mechanism of injury, amputation rates, time to amputation, and reasons for failure were examined. Ninety-four patients were evaluated in our multidisciplinary Limb Preservation Clinic over a 2-year period. Twenty patients (21%) were seen for combat-related injuries. Sixteen patients were evaluated and treated for chronic complications at a median of 13 months from their injury. All 16 patients were male with a median age of 24 years (range, 20-35). Ten patients sustained injuries secondary to a dismounted improvised explosive device (IED). All 16 patients had extensive soft tissue injuries and associated fractures. Only 2 patients sustained a vascular injury. The median number of prior surgeries to the affected limb was 8 (range, 3-19). The limb salvage rate of 37% was lower than our noncombat cohort (47%). The most common reasons for delayed amputation included chronic pain, osteomyelitis, and soft tissue infections. The high secondary amputation rates seen in this cohort underscores the need for long-term follow-up. Despite successful initial outcomes, many patients eventually progress to limb loss. Patients who sustain a dismounted IED are at greatest risk for a delayed amputation. Identifying and addressing those factors which lead to delayed amputation should be a priority for returning war veterans and focus of future studies.

Surgical treatment of locally aggressive and malignant tumors of the proximal third of the tibia. Oncology results and functional evaluation

IntroductionProximal fibula malignant and locally aggressive benign bone tumors are uncommon and usually treat by surgery. Bloc resection of the knee can compromise knee stability due to the resection of the posterolateral ligament complex. Material and methodsWe analyzed 28 consecutive patients treated for a proximal fibula bone tumor between 1980 and 2006 (osteosarcoma: 9, giant cell tumor: 9, Ewing sarcoma: 8 and chondrosarcoma: 2). Sixty-one percent were male and the median age was 21 years (range: 8–60). The mean follow-up was 86 months. The posterolateral complex was reinserted at tibial metaphyseal level. Patients were evaluated functionally using the Musculoskeletal Tumor Society scale (MSTS). ResultsOverall survival rate was 89%, local recurrence rate was 11%, and secondary amputation rate was 6% at 7 years of median follow-up. The average MSTS score was 93%. Five patients had neurological complications. No patient experienced subjective instability or vascular insufficiency. ConclusionsBloc resection of the proximal fibula for the treatment of aggressive or malignant primary bone tumors allowed us to obtain local tumor control, and overall survival rate for sarcomas of 89% at 7 years. The posterolateral ligament complex tibial reinsertion provided functional knee stability without major functional consequences in the medium term.

Comparison of military and civilian popliteal artery trauma outcomes

Popliteal artery injury has historically led to high amputation rates in both the military and civilian setting. Military and civilian popliteal injury patterns differ in mechanism and severity of injury, prompting us to compare modern management and report differences in outcomes between these two patient groups. We hypothesized that whereas amputation rates may be higher in the military, this would correlate with worse overall injury severity. Military casualties from 2003-2007 with a popliteal artery injury identified from the Joint Theater Trauma Registry were compared retrospectively with civilian patients presenting to a single level I institution from 2002-2009 with popliteal arterial injury. Demographics, mechanism of injury, coinjuries, Injury Severity Score (ISS), Mangled Extremity Severity Scores (MESS), interventions, and secondary amputation rates were reviewed. Descriptive statistics and unpaired t-tests were used to compare data. Statistical significance was P < .05. The study group of 110 patients consisted of 46 (41.8%) military and 64 (58.2%) civilians with 48 and 64 popliteal artery injuries, respectively. The military population was younger (28 vs 35 years; P < .004), entirely male (46 [100%] vs 51 [80%]; P < .0001), and had more penetrating injuries (44 [96%] vs 19 [30%]; P < .0001). ISS (18.7 vs 13.9; P < .005) and MESS (7.3 vs 5.1; P < .0001) were higher in the military group. Limb revascularizations in both military and civilian populations were mostly by autogenous bypass (65% vs 77%) followed by primary repair (26% vs 16%), covered stent (0% vs 6%), or other procedure (ligation and/or thrombectomy) (9% vs 1%). Fasciotomy (20 [42%] vs 37 [58%]; P = .14), compartment syndrome (10 [21%] vs 15 [23%]; P = .84), and concomitant venous repair rates (14 [29%] vs 15 [23%]; P = .42) were not different between cohorts. There was no difference in the fracture rate (26 [54%] vs 41 [64%]; P = .43), but the civilian group had a higher rate of dislocation (1 [2%] vs 19 [30%]; P < .0001). Secondary amputation rates were significantly higher in the military (14 [29%] vs 8 [13%]; P < .03). Although both civilian and military cohorts have high amputation rates for popliteal arterial injury, the rate of amputation appears to be higher in the military and is associated with a penetrating mechanism of injury primarily from improvised explosive devices resulting in a higher MESS and ISS.