Upper extremity vascular injuries: Etiology, management and outcome.

BACKGROUND: Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population. They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations. Their management is challenging since they can lead to disabilities with major socioeconomic effects. AIM: To analyze data about the mechanism of injury, the management algorithm and functional outcomes of vascular injuries of the upper extremity. METHODS: One hundred and fifteen patients (96 males and 19 females) with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted. Mean patients' age was 33.7 years and the mean follow up time was 7.4 years. Patients with Mangled Extremity Severity Score ≥ 7 and Injury Severity Score ≥ 20, previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded, from the study. RESULTS: A penetrating trauma was the most common cause of injury. The radial artery was the artery injured in most of the cases (37.4%) followed by the ulnar (29.5%), the brachial (12.1%) and the axillary (6%). A simultaneous injury of both of the forearm's arteries was in 15.6% of the cases. In 93% of the cases there were other concomitant musculoskeletal injuries of the extremity. Tendon lacerations were the most common, followed by nerve injuries. The postoperative functional scores (full Disabilities of the Arm, Shoulder, and Hand and VAS) had very satisfactory values. CONCLUSION: Although vascular injuries of the upper extremity are rare, they may occur in the context of major combined musculoskeletal trauma. Although a multidisciplinary approach is essential to optimize outcome, the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma, excluding isolated vascular injuries, ensures shorter operative times and better functional outcomes.

Appraisal of the Clinical Practice Guidelines for the Use of Antithrombotic Therapy in Elective Spinal Procedures: Do We AGREE (II)?

The perioperative management of patients medicated with antithrombotic agents who require elective spinal surgery is extremely challenging because of the increased risk of surgical bleeding and the concurrent need to minimize the thromboembolic risk. The aims of the present systematic review are to: (1) identify clinical practice guidelines (CPGs) and recommendations (CPRs) on this topic and (2) assess their methodological quality and reporting clarity. An electronic systematic search of the English Medical Literature up to January 31, 2021 was conducted using PubMed, Google Scholar, and Scopus. Two raters assessed the methodological quality and reporting clarity of the gathered CPGs and CPRs using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The agreement between the two raters was assessed using Cohen's kappa. Of the initially gathered 38 CPGs and CPRs, 16 fulfilled our eligibility criteria and were evaluated using the AGREE II instrument. The reports published by "Narouze 2018" and "Fleisher 2014" were scored as being of "high-quality" and having an adequate interrater agreement (Cohen's kappa ≥0.60). Overall, the AGREE II domains of "clarity of presentation" and "scope and purpose" yielded the highest scores (100%), whereas the domain "stakeholder involvement" scored the lowest score (48.5%). The perioperative management of antiplatelet and anticoagulant agents in elective spine surgery may be challenging. Because of the lack of high-quality data in this field, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.

Venous thromboembolism and major adverse cardiovascular events in patients with hip fractures suffering from SARS-CoV-2 infection: a systematic review.

INTRODUCTION: Hip fractures represent 1 of the most common injuries in older adults. They are associated with increased perioperative morbidity and mortality. Additionally, current research suggests that SARS-COV-2 infection may worsen the prognosis of the hip fracture patients who undergo hip fixation. The aims of the present study were: (1) to determine the rate of specific adverse events including VTE (venous thromboembolism) and major adverse cardiovascular events (MACEs) in patients with hip fracture and concomitant SARS-CoV-2 infection undergoing surgery; and (2) to examine if the aforementioned population is at increased risk for VTE and MACEs, when compared to SARS-CoV-2 free patients with hip fracture. METHODS: PubMed, EMBASE, Cochrane, Web of Science, Google scholar and medRxiv were searched from March 2020 to January 2021 for English language studies with patients suffering from hip fractures and SARS-COV-2 -CoV-2. 2 researchers were involved in the data extraction and the quality assessment of the studies respectively. RESULTS: The literature search yielded a total of 1256 articles of which 14 were included in the systematic review and 7 in the meta-analysis respectively. The estimated pooled rate for VTE and MACE were 4.3% and 6.3% respectively. Patients with hip fracture and concomitant SARS-CoV-2 infection who undergo surgery are at increased risk for VTE, when compared to SARS-CoV-2 free patients (odds ratio 2.8 [95% CI, 1.1-7.1]). These patients are also at increased risk for MACE postoperatively as indicated by the odds ratio 2.4 (95% CI, 1.0-5.8). The quality of the studies was moderate. CONCLUSIONS: Although there is a lack of high-quality data it seems that patients with hip fractures and concomitant SARS-CoV-2 infection are facing a 2.8 and 2.4 times increased risk for VTE and MACE.

The effect of type 2 diabetes mellitus on perioperative neurocognitive disorders in patients undergoing elective noncardiac surgery under general anesthesia. A prospective cohort study.

Background and Aims: Preliminary evidence suggests a possible relationship between type 2 diabetes mellitus (T2DM) and perioperative neurocognitive disorders (NCD). We sought to investigate whether patients with T2DM, undergoing elective noncardiac surgery under general anesthesia, are at increased risk of perioperative NCD. Material and Methods: A prospective cohort study was designed. One-hundred and forty-four patients with T2DM and 144 healthy controls were recruited. Controls were matched for sex, age, type of operation, and educational background. Postoperative delirium (POD), delayed neurocognitive recovery and postoperative NCD were evaluated. Results: Two hundred twenty-eight patients were analyzed. Compared to controls, patients with T2DM were diagnosed with higher rates of NCD preoperatively (n = 96 vs. n = 26, P < 0.05) and higher POD up to 4 days postoperatively (n = 204 vs. n = 68, P < 0.05). Increased rates of delayed neurocognitive recovery and postoperative NCD were recorded in patients with T2DM up to 9 months postoperatively (n = 473 vs. n = 192, P < 0.05). Insulin-dependent patients had higher rates of POD on the second (n = 38 vs. n = 24, P < 0.05) and third day (n = 27 vs. n = 16, P < 0.05) when compared to noninsulin-dependent patients. Logistic multivariable analysis revealed that patients with T2DM are at increased risk for postoperative cognitive disorders. Conclusion: Patients with type 2 diabetes mellitus appear to be at a higher risk of perioperative NCDs up to 9 months after elective noncardiac surgery under general anesthesia.

A Missed Bilateral, Acute Anterior Exertional Compartment Syndrome of the Leg.

A 26-year-old male athlete presented to our hospital with bilateral leg pain after intense training. He had a history of transient numbness and pain with rigorous exercise but this time pain persisted and drop foot developed. Unfortunately, the diagnosis of acute exertional compartment syndrome was delayed due to late presentation of the patient in our department. He underwent three consecutive surgeries for decompression and debridement. At 13 months follow-up, he is ambulatory with bilateral ankle-foot orthosis. This case presents a bilateral, acute anterior exertional compartment syndrome of the leg and highlights the need for high clinical suspicion and early treatment of the acute exertional compartment syndrome.