In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations.

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma.

BACKGROUND: Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS: From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS: A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.

Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience.

BACKGROUND: Traumatic popliteal arterial injury (TPAI) is associated with a risk of both limb loss and long-term morbidity due to prolonged ischemia and the often-associated musculoskeletal injuries. Long-term functional outcome following this injury has not been adequately studied. We evaluated patients with TPAI to determine if there was an improvement in functional outcome over time. We hypothesized that both the initial severity of ischemia and the associated injuries limited the ability of patients to improve functional outcome. METHODS: Patients with TPAI for 20 years were identified. All patients had at least a 2-year follow-up. Functional outcomes were measured using the Boston University Activity Measure for Post-Acute Care to assess basic mobility (BM) and daily activity (DA). Multiple linear regression, adjusted for age, severity of injury and shock, operative complexity, associated injuries, ischemic time, and length of follow-up were used to identify predictors of functional outcome after TPAI. RESULTS: A total of 214 patients were identified: 123 penetrating (57%) and 91 blunt (43%). Overall mortality was 1.9% (all in-hospital), and amputation occurred in 10%. Of the 210 survivors, follow-up was obtained in 145 patients (69%). Median follow-up was 9.2 years (interquartile range, 5.7-15.7 years). Mean Activity Measure for Post-Acute Care scores for BM and DA were 78 and 75, respectively, both signifying mild impairment (normal, >84). Multiple linear regression failed to identify increasing length of follow-up as a predictor of improved functional outcomes. Only age, lower extremity fracture, and ischemic time were identified as predictors of decreased BM and DA. CONCLUSION: Increasing age, lower extremity fracture, and prolonged ischemic time worsened long-term functional outcomes. Functional outcome did not improve over time, suggesting that maximal recovery may be achieved within the first 2 years postinjury. Thus, early and effective revascularization remains the only potentially modifiable risk factor for improving functional outcomes following TPAI. LEVEL OF EVIDENCE: Prognostic, level III.

Lower Extremity Burns, Complications, and Outcome.

We have encountered many burn cases with lower extremity burn with adverse outcome. The study was a retrospective cohort study in 2 years, mean (SD) of follow up was 12(7) months. All demographic data, cause burn, time, total burn surface area (TBSA), presence lower extremity burn and its burn surface area (BSA), foot burn, delay in treatment, smoking, infection, morbidity, co-morbid diseases, length of stay (LOS), amputation, mortality, and outcome were gathered from patients' files. Statistical analysis was done with SPSS 21software. We had 14,215 burn patients, of them 995 were admitted according to criteria of ABA. Six hundred and ten (61.3%) were male and 358 (37%) female. Male to female ratio was 1.58:1. The mean age ± SD was 33.64 ±23.45. Mean (SD) of lower extremity BSA was 12.09 ± 9.18%. The patients who had 10 to 19% burn, had 3 times more risk of mortality than patients with 0 to 9% burn (P < .018). And those with 20 to 29% burn had 35 times more risk of mortality comparing to patients with 0 to 9% burn. The difference was significant too. (P < .000). Delay in treatment, presence of co-morbid diseases and diabetes would not do any increase in mortality. The sex, weight, cause of burn, diabetes, and delay in treatment have not any influence on the death risk. But age and lower extremity BSA have influence on the risk of death. According to statistical study: with every 1-year increase in age, death rate increased by 4% (P < .0001). With every 1% increase in lower extremity BSA, death rate increase by 9% (P < .0005) and with every 1 day increase in LOS, the death rate increase by 4%. Statistical study shows lower extremity burn, TBSA, age, and LOS have great influence on the outcome of these patients. Sex, weight, cause of burn, and delay in treatment have not affected the risk of mortality.

Risk factors for death and amputation in acute leg compartment syndrome.

INTRODUCTION: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. METHODS: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. RESULTS: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. CONCLUSIONS: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. LEVEL OF EVIDENCE: Level III Prognostic.

Arterial lesions in osteoarticular trauma of the lower limbs.

OBJECTIVE: To evaluate in-hospital mortality and limb salvage of a series of patients presenting with arterial injury of the lower limbs complicating an osteoarticular trauma, and to determine any preoperative predictive factors of limb salvage. METHODS: Data of consecutive patients treated between 01/2007 and 12/2017 were retrospectively analyzed. Primary outcomes were in-hospital mortality and limb salvage. Multivariate analysis was performed to assess any variable that could affect limb salvage. P values <0.05 were considered statistically significant. RESULTS: The postoperative course, death occurred in 2 patients Lower limb amputation was performed in 13 cases (15.6%). The main factors predicting limb amputation were the timing of staged surgery, in particular when bone stabilization was performed first (P<0.001), and a delay Data concerning 74 patients with 83 traumatized lower limbs were analyzed. Most vascular lesions were located at the popliteal artery (47, 63.5%). Surgical bone stabilization was performed as a first step in 45 patients (60.8% of cases), followed by a delayed arterial repair. The median time to revascularization was 14.3 hours (range from 2 hours to 6 days). In 29 patients (39.2%) vascular repair and bone stabilization were performed simultaneously. During to limb revascularization longer than 6 hours (P<0.001). The location of injury at the popliteal artery (P=0.005), the presence of infection (P<0.001), and the severe ischemic signs at presentation (P=0.001) also were factors associated with amputation. CONCLUSIONS: The timing of staged surgical repair and the revascularization delay were the main predictor factors of limb salvage. KEY WORDS: Osteoarticular trauma, Vascular injury, Limb salvage, Orthopedic trauma.

Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma.

The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.

Tourniquet use is not associated with limb loss following military lower extremity arterial trauma.

BACKGROUND: The effect of battlefield extremity tourniquet (TK) use on limb salvage and long-term complications following vascular repair is unknown. This study explores the influence of TK use on limb outcomes in military lower extremity arterial injury. METHODS: The study database includes cases of lower extremity vascular injury from 2004 to 2012 with data recorded until discharge from military service. We analyzed all limbs with at least one named arterial injury from the femoral to the tibial level. Tourniquet (TK) and no TK (NTK) groups were identified. Univariate analyses were performed with significance set at p ≤ 0.05. RESULTS: A total of 455 cases were included, with 254 (56%) having a TK for a median of 60 minutes (8-270 minutes). Explosive injuries (53%) and gunshot wounds (26%) predominated. No difference between TK and NTK was present in presence of fracture, level of arterial injury, type of arterial repair, or concomitant venous injury. More nerve injuries were present in the TK group, and Abbreviated Injury Scale extremity and Mangled Extremity Severity Score tended toward greater injury severity. Amputation and mortality rates did not differ between groups, but the incidence of severe edema, wound infection, and foot drop was higher in the TK group. Vascular above-knee amputation, arterial repair complication, and severe edema were higher in the TK group also (p = 0.10). Tourniquet duration of 60 minutes or longer was not associated with increased amputations, but more rhabdomyolysis was present. CONCLUSION: Field TK use is associated with wound infection and neurologic compromise but not limb loss. This may be due to a more severe injury profile among TK limbs. Increased TK times may predispose to systemic, but not limb, complications. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

The management of pretibial lacerations.

Introduction Pretibial lacerations are common injuries, often presenting in the elderly and infirm. Unclear management pathways often result in inappropriate care. We identify patient demographics, morbidity risk factors, injury severity and management options. Materials and methods This retrospective study involved analysing databases and hardcopy notes for patients admitted with pretibial lacerations to Addenbrooke's Hospital, January to December 2012. Microsoft Excel and Fishers exact test were used to analyse the data with a P-value of less than 0.05 representative of statistical significance. Information on patient demographics, site of lesion, preoperative symptoms, management, operative details and clinical outcomes were collected. Results A total of 36 patients were identified; the mean age was 79 years (± 16 years, 1 standard deviation) with a three to two female to male preponderance; 57% of injuries were caused by mechanical fall, 33% traumatic blunt impact and 7% road traffic accidents. American Society of Anesthesiologists physical status classification was 43% level III, 40% II, 9% I and 9% IV. Dunkin classification of severity was 33% grade III, 30% grade I, 24% grade IV and 12% grade II. Median inpatient duration was 11 days for surgically managed compared with 15 days for conservatively managed patients. Discussion Pretibial lacerations tend to affect the elderly. Management is compounded by polypharmacy and comorbidities. If inadequately managed, such injuries can adopt characteristics of chronic wounds, with lengthy inpatient stays. Surgical intervention may be appropriate where injuries are severe and the patient stable enough for theatre. Conclusions We believe that surgical management with autologous tissue repair, with minimal delay between presentation and theatre, is warranted for extensive injuries wherever possible, with conservative management used for predominantly less extensive pretibial lacerations.

High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients.

INTRODUCTION: A lower extremity injury can be a devastating event in low-income countries due to limited access to surgical care. Its incidence, treatment patterns, and outcomes, however, have not been well-described. METHODS: We prospectively enrolled all patients admitted with lower extremity trauma to a tertiary hospital in Lilongwe, Malawi between October 2010 and September 2011. Patients with a lower extremity injury but primarily admitted for unrelated reasons were excluded. The outcomes were deaths, complications, and length of hospital stay. RESULTS: Of the 905 patients eligible for analysis, 696 (77%) were males. Most patients had femur fractures (46%), and most were treated non-operatively (70%). Overall mortality rate was 3.9%. For adult patients with femur fractures, mortality was higher in patients treated with traction (9.0%) than for those treated with surgery (1.3%). The total complication rate was 15%, with adjusted odds of developing a complication higher in patients with concurrent head injury (OR = 2.8; 95% CI: 1.3-6.0), and patients who had an operative treatment (OR = 2; 95% CI: 1.2-1.9). The median length of stay was 16 days (IQR: 6-27) and was greatest among patients with femur fractures. CONCLUSION: Lower extremity injuries resulted in substantial mortality and morbidity in this low-income country. Mortality was particularly high among patients with femur fractures who did not have surgery. Modern orthopedic trauma surgery is greatly needed in low-income countries.

Significance of Traumatic Macroamputation in Severely Injured Patients: An Analysis of the Traumaregister DGU®.

Treatment of patients with traumatic macroamputations is challenging. The aim of this study is to analyze the significance of this type of injury in TraumaRegister DGU® (TR-DGU) and to depict the rate of formal surgical ablation of the traumatically induced amputation, epidemiologic data, as well as outcome in severely injured patients with amputations. We acquired data from the TR-DGU of the German Trauma Society (DGU). The inclusion criteria for our study were Injury Severity Score (ISS) greater than 9, macroamputation, and available data about the Abbreviated Injury Scale (AIS) code. A total of 48,908 of 67,425 patients had an ISS greater than 9 and available data about the AIS code. In total, 926 (1.9%) of 48,908 patients had an immediate traumatic macroamputation on-scene. Thereof, 298 patients (32.2%) had a macroamputation of the arms, 605 patients (65.3%) had an amputation of the legs, and 23 patients (2.5%) had both. Among them, 457 patients (49.4%) with a macroamputation had monotrauma. In total, 126 patients (13.6%) underwent replantation and 800 patients (86.4%) underwent formal surgical ablation of the traumatically induced amputation. Seventy-six (23.7%) of 321 patients with upper-extremity amputations and 53 (8.4%) of 628 patients with lower-extremity amputations underwent replantation. Mortality in patients with replantation was lower (5.6% vs. 19.6%, P < 0.001). Standardized mortality rate was lower for patients with replantation (0.71, 95% confidence interval, 0.20-1.21 vs. 0.94, 95% confidence interval, 0.80-1.10; P = 0.26). Glasgow Outcome Scale (GOS) was significantly better for patients with replantation (34.0%; GOS score 5) as compared with patients without replantation (20.7%; GOS score 5; P < 0.001). In borderline patients (defined according to the orthopedic damage control principles), 91.5% received formal surgical ablation of the traumatically induced amputation and 8.5% underwent replantation. The rate of formal surgical ablation of the traumatically induced amputation is higher when principles of damage control surgery are applied. The replantation rate in the upper extremity is higher than in the lower extremity. The less ISS and base excess and the higher blood pressure, hemoglobin value, and thromboplastin time are, the safer the decision for replantation seems to be.

Free tissue transfer for complex reconstruction of the lower extremity: experience of a young microsurgeon.

To examine the limb salvage experience of a young microsurgeon to determine risk factors for complications and demonstrate lessons learned through cases in practice. We performed a retrospective review of lower extremity (LE) reconstruction between 2007 and 2012 performed by the senior author. This analysis focused on medical comorbidities, mechanisms, indications, and perioperative complications. A total of 61 free tissue transfers were performed with a 95% LE salvage rate. The most common donor site was the anterolateral thigh (ALT) (n = 39). Infection (n = 25) and trauma (n = 25) were the most common indications for intervention. A total of 18 complications were reported, with 8 defined as major complications. Total flap loss occurred in three patients. Through increased utilization of the ALT and adherence to lessons learned over time, improvements in outcomes can occur, giving patients the best possible chance at limb salvage.

Indications and complications of major limb amputations in Kano, Nigeria.

OBJECTIVES: To determine the indications and complications of major limb amputations in a Nigerian hospital. DESIGN: A five-year retrospective descriptive study. SETTING: National Orthopaedic Hospital, Dala, Kano, Nigeria. PARTICIPANTS: Patients who had amputations above the wrist or ankle between January 2006 and December 2010. MAIN OUTCOME MEASURES: Indications, complications and mortality. RESULTS: There were 132 unilateral amputations. The patients were mostly males and below the age of 40. Lower limb amputations (74.2%) exceeded upper limb amputations (25.8%). The commonest indication was trauma (42.4%) followed by TBS gangrene (31.8%) and malignant tumours (12.9%). Wound infection, the commonest complication, occurred in patients who had identifiable predisposing factors. The 3 deaths that occurred were in patients who had had traditional bone setter intervention: 2 were due to septicaemia; 1, due to severe tetanus. CONCLUSION: Trauma and traditional bone setter gangrene were the commonest indications. Most of the amputations were avoidable. Institution of preventive measures is imperative. Paying attention to predisposing factors can reduce complications.

Lower extremity vascular injuries: increased mortality for minorities and the uninsured?

BACKGROUND: There is increasing evidence to suggest that racial disparities exist in outcomes for trauma. Minorities and the uninsured have been found to have higher mortality rates for blunt and penetrating trauma. However, mechanisms for these disparities are incompletely understood. Limiting the inquiry to a homogenous group, those with lower extremity vascular injuries (LEVIs), may clarify these disparities. METHODS: The National Trauma Data Bank (NTDB; version 7.0, American College of Surgeons) was used for this study. LEVIs were identified using codes from the International Classification of Diseases, 9th revision. Univariate and multivariate analyses were performed using Stata software (version 11; StataCorp, LP, College Station, TX). RESULTS: Records were reviewed for 4,928 LEVI patients. The mechanism of injury was blunt in 2,452 (49.8%), penetrating in 2,452 (49.8%), and unknown in 24 cases (0.5%). Mortality was similar by mechanism (7.6% overall). Regression analysis using mechanism as a covariate revealed a significantly worse mortality for people of color (POC; odds ratio [OR], 1.45; 95% confidence interval [CI], 1.03-2.02; P = .03) and the uninsured (UN; OR, 1.62; 95% CI, 1.15-2.23; P = .006). However, when separate analyses were performed stratifying by mechanism, no significant mortality disparities were found for blunt trauma (POC OR, 1.28; 95% CI, 0.85-1.96; P = .23; UN OR, 1.33; 95% CI, 0.78-2.22; P = .29), but disparities remained for penetrating trauma (POC OR, 1.81; 95% CI, 0.93-3.57; P = .08; UN OR, 1.85; 95% CI, 1.18-2.94; P = .009). CONCLUSION: For patients with LEVI, mortality disparities based on race or insurance status were only observed for penetrating trauma. It is possible that injury heterogeneity or patient cohort differences may partly explain mortality disparities that have been observed between racial and socioeconomic groups.

The impact of trauma-center care on functional outcomes following major lower-limb trauma.

BACKGROUND: Although studies have shown that treatment at a trauma center reduces a patient's risk of dying following major trauma, important questions remain as to the effect of trauma centers on functional outcomes, especially among patients who have sustained major lower-limb trauma. METHODS: Domain-specific scores on the Medical Outcomes Study Short Form Health Survey (SF-36) supplemented by scores on the mobility subscale of the Musculoskeletal Function Assessment (MFA) and the Revised Center for Epidemiologic Studies Depression Scale (CESD-R) were compared among patients treated in eighteen hospitals with a level-I trauma center and fifty-one hospitals without a trauma center. Included in the study were 1389 adults, eighteen to eighty-four years of age, with at least one lower-limb injury with a score of >/=3 points according to the Abbreviated Injury Scale (AIS). To account for the competing risk of death, we estimated the survivors' average causal effect. Estimates were derived for all patients with a lower-limb injury and separately for a subset of patients without associated injuries of the head or spinal cord. RESULTS: For patients with a lower-limb injury resulting from a high-energy force, care at a trauma center yielded modest but clinically meaningful improvements in physical functioning and overall vitality at one year after the injury. After adjustment for differences in case mix and the competing risk of death, the average differences in the SF-36 physical functioning and vitality scores and the MFA mobility score were 7.82 points (95% confidence interval: 2.65, 12.98), 6.80 points (95% confidence interval: 2.53, 11.07), and 6.31 points (95% confidence interval: 0.25, 12.36), respectively. These results were similar when the analysis was restricted to patients without associated injuries to the head or spine. Treatment at a trauma center resulted in negligible differences in outcome for the subset of patients with injuries resulting from low-energy forces. CONCLUSIONS: This study provides evidence that patients who sustain high-energy lower-limb trauma benefit from treatment at a level-I trauma center.

[Surgical treatment of high-voltage electrical injuries]. / Die chirurgische Behandlung von Hochspannungsverletzungen.

PURPOSE/BACKGROUND: High-voltage burns represent a challenging surgical entity. Compared to conventional burns, these injuries are characterized by an increased morbidity and worse potential for rehabilitation. The aim of the present study was to analyse the management of high-voltage injuries during the early posttraumatic period with special emphasis on the surgical procedures. PATIENTS/MATERIAL AND METHOD: We retrospectively evaluated the medical records of patients with electrical injuries treated from 1995 - 2007. A total of 61 patients (57 men, 4 females, mean age: 34 +/- 13 years) with high-voltage burns was included for analysis. RESULTS: The majority of high-voltage burns was work-related (75 %). The mean total burn area was 35 % of the total body surface, with a mean of 29 % deep burns. An average of 4.8 +/- 4 operations were performed per patient (range: 1 - 23 operations). Surgical procedures included repeated debridement/necrectomy (100 % of all patients), early escharotomy/fasciotomy (47.5 %), and amputations (18 %). 14 patients (23 %) underwent reconstructive surgery using either local or free flaps. The mortality rate was 15 %. CONCLUSION: The surgical management of high-voltage burns is characterised by repetitive debridements and necrectomies. Despite an aggressive approach to remove necrotic tissue, the mortality in this type of injury is considerably high. Limb salvage may be achieved with the use of free microvascular flaps. However, an amputation of necrotic extremities must be considered in the copresence of septic complications.

The use of vacuum assisted closure (VAC) in soft tissue injuries after high energy pelvic trauma.

BACKGROUND: Application of vacuum-assisted closure (VAC) in soft tissue defects after high-energy pelvic trauma is described as a retrospective study in a level one trauma center. MATERIALS AND METHODS: Between 2002 and 2004, 13 patients were treated for severe soft tissue injuries in the pelvic region. All musculoskeletal injuries were treated with multiple irrigation and debridement procedures and broad-spectrum antibiotics. VAC was applied as a temporary coverage for defects and wound conditioning. RESULTS: The injuries included three patients with traumatic hemipelvectomies. Seven patients had pelvic ring fractures with five Morel-Lavallee lesions and two open pelviperineal trauma. One patient suffered from an open iliac crest fracture and a Morel-Lavallee lesion. Two patients sustained near complete pertrochanteric amputations of the lower limb. The average injury severity score was 34.1 +/- 1.4. The application of VAC started in average 3.8 +/- 0.4 days after trauma and was used for 15.5 +/- 1.8 days. The dressing changes were performed in average every 3 days. One patient (8%) with a traumatic hemipelvectomy died in the course of treatment due to septic complications. CONCLUSION: High-energy trauma causing severe soft tissues injuries requires multiple operative debridements to prevent high morbidity and mortality rates. The application of VAC as temporary coverage of large tissue defects in pelvic regions supports wound conditioning and facilitates the definitive wound closure.

Outcomes of a contemporary amputation series.

BACKGROUND: The aim of this study was to determine the outcomes of a contemporary amputation series. METHODS: A retrospective audit of 87 cases of major lower limb amputation from January 2000 to December 2002 from the Department of Vascular Surgery, Royal Perth Hospital, was conducted. RESULTS: The mean age of the study population was 70.1 +/- 14.3 years; the male : female ratio was 3.35:1. Comorbid problems included diabetes (49.4%), smoking (81.6%), hypertension (77.0%), ischaemic heart disease (58.6%), stroke (25.3%), raised creatinine level (34.5%) and chronic airway limitation (25.3%). Preamputation vascular reconstructive procedures were common, 34.5% in a previous admission and 23.0% in the same admission. The main indication was critical limb ischaemia (75.9%) followed by diabetic infection (17.2%). There were 51 below-knee (58.6%), 5 through-knee (5.7%) and 31 above-knee (35.6%.) amputations. The below-knee amputation to above-knee amputation ratio was 1.65:1. The overall wound infection rate was 26.4%; the infection rates for below-knee (29.4%) and above-knee (22.6%) amputation did not differ significantly (P = 0.58). Revision rates were 17.6% for below-knee, 20% for through-knee and none for above-knee amputations. Twenty patients (23.0%) underwent subsequent contralateral amputation. Thirty-nine patients (44.8%) were selected as suitable for a prosthesis by a rehabilitation physician; 31 (79.5%) used the prosthesis both indoors and outdoors and 6 (15.4%) used it indoors only within 3 months. Cumulative mortality at 30 days, 6 months, 12 months and 24 months was 10.1, 28.7, 43.1 and 51.7%, respectively. CONCLUSION: This series agrees with the current published work in finding that patients undergoing major lower limb amputation are older, with a high prevalence of comorbid conditions. Successful prosthesis rehabilitation depends on patient selection and a multidisciplinary approach. Despite a low immediate mortality, the overall long-term results of lower limb amputation remain dismal.

Shank vessel injuries.

The management of lower extremity vascular injuries has undergone dramatic changes over the last century. With the optimal management of femoral and popliteal injuries established, controversy still exists with respect to management of vascular injuries below the popliteal fossa, in the shank arterial vessels. These injuries are uncommon, often limb threatening, and usually require complex management decisions. Incidence of shank vessel injuries, imaging studies required for accurate and expedient diagnosis, determinants influencing the decision for repair or amputation, and details of techniques in surgical intervention are discussed.

The effect of early versus late fasciotomy in the management of extremity trauma.

BACKGROUND: Recent reports have demonstrated an increase in the number of complications associated with delayed timing of fasciotomy for trauma. This study examines the effectiveness of early (less than 12 hours) versus late (more than 12 hours) fasciotomy in the injured extremity. METHODS: This is a retrospective review of 88 patients undergoing fasciotomy for extremity trauma admitted to the University of Cincinnati from January 1990 through December 1995. Records were reviewed for demographics, compartment pressures, time and type of fasciotomy, complications, limb salvage, and mortality. Statistical analysis was determined with chi-squared, multivariant regression analysis, and Student's t test with significance at p less than 0.05. RESULTS: Sixty-one (69%) patients had fasciotomy performed before 12 hours and twenty-seven (31%) after 12 hours. Although the rates of infection differed significantly between the two groups (7.3% for early versus 28% for late), the rates of limb salvage and neurologic sequelae were similar. Age, mechanism, shock, associated injuries, and time to fasciotomy were not predictive of complications. CONCLUSIONS: Fasciotomy for trauma is most efficacious when performed early. However, when performed late, it results in similar rates of limb salvage as compared with early fasciotomy but at the increased risk of infection. These results support aggressive use of fasciotomy in extremity trauma regardless of time of diagnosis.