Below-knee amputations as a result of land-mine injuries: comparison of primary closure versus delayed primary closure.

BACKGROUND: Antipersonnel land mines are designed to maim by mutilating the lower extremities, and these injuries are at higher risk for infection than injuries from other weapon systems. METHODS: The results of 474 unilateral traumatic below-knee amputations as a result of land-mine injuries were reviewed. If the delay in evacuation between the injury and arrival to the battle field hospital was less than 6 hours, 392 amputation stumps (group I) were closed primarily after meticulous debridement. Open amputation was performed after debridement in the remaining 82 amputation stumps (group II), because there was a suspicion of ineffective debridement, although they were evacuated in less than 6 hours or delay was more than 6 hours. RESULTS: Eleven patients in group I (2.8%) were reoperated because of wound sepsis of the stump. Wound sepsis was not encountered in group II. A total of 87.4% of stumps in group I and 81.2% of stumps in group II had healed without a problem. No gas gangrene or tetanus was encountered in any cases. CONCLUSION: Our results reveal that primary closure may be done in traumatic below-knee amputations caused by land-mine injuries with an acceptable infection rate, if the evacuation time is less than 6 hours, and if there is meticulous debridement.     

Bilateral lower limb amputations as a result of landmine injuries.

Landmine explosions cause most of the war injuries in the battlefield. Amputations resulting from severe injuries reveal serious problems despite the improvements in surgery. Bilateral lower limb amputations have more impact than unilateral on social life. Some 29 cases with lower limb amputations due to landmine injuries were treated in the Department of Orthopaedics and Traumatology, Gülhane Military Medical Academy between January 1992 and December 1996. Amputation levels were as follows: 1 case had hip disarticulation and a trans-femoral amputation, 6 had bilateral trans-femoral amputations, 6 had trans-femoral and trans-tibial amputations, 12 had bilateral trans-tibial amputations, 1 had trans-femoral and Chopart amputations and the remaining 3 cases had trans-tibial and Chopart amputations. The initial treatment was done for all cases in the first 6-8 hours after injury at the field hospitals. Aggressive debridement, excision and primary closure were performed. None of the stumps required reamputations and/or revision. No case had gas gangrene or tetanus. Postoperative, pre-prosthetic training programme which ranged between 30-120 days with an average 48 days; and prosthesis fitting and adequate post-prosthetic training programme which ranged 32-126 (average 94) days was applied. All the cases were followed-up with a mean of 38.5 months (14-72 months). Nine (9) cases (31%) returned to their previous occupation, while 20 (69%) cases had to change their jobs.     

Study of clinical pattern of limb loss in electrical burn injuries

Introduction: Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries. Material and methods: The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes. Results: Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment. Conclusion: Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.     

Primary closure of below-knee amputation stumps: A prospective study of sixty-two cases

Between January 1, 1985, and December 31, 1988, we prospectively studied the outcome of 62 consecutive below-knee amputations with primary closure in 56 patients. There were 35 men and 21 women; mean age was 70 years. Above-knee amputation was performed for occlusion of the profunda femoris artery, acute thrombosis of a popliteal aneurysm with inadequate sural artery vascularity, intractable knee flexion contracture, suspended ischemia, and occasionally, when ischemia was found intraoperatively to extend proximally during below-knee amputation. Bedridden patients deemed unfit for prosthetic devices were also candidates for above-knee amputation. Fifty-four lower extremities (87%) were gangrenous and rest pain was present in eight patients (13%). Twenty-nine limbs (47%) were amputated primarily, 33 (53%) after failure of one or more revascularization procedures. Six patients had bilateral amputation. Forty patients (71%) were diabetic. Mean hospital stay was five days. Fifteen patients (27%) died during a mean follow-up period of 29 months. Eleven stumps (17.5%) required reoperation: five for postoperative infection, four for wound breakdown after a fall, and two for secondary abscess. Three secondary above-knee amputations (5%) were necessary. Of 44 below-knee amputations in diabetic patients, one had to be revised at the level of the thigh. Of 33 amputations after revascularization failure, one secondary above-knee amputation was necessary. Restoration of preischemic status was achieved after a mean of 58 days. Upon patient discharge from a rehabilitation center, 44 stumps (81%) were suitable to be fitted with prostheses. Compared with the open-stump technique, primary closure of below-knee amputation stumps reduces healing time without an increased reoperation rate. Hospitalization is short and reestablishment of patient autonomy is rapid.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Strasbourg, France, June 23–27, 1989.     

Combined orthopedic and vascular injury in the lower extremities: indications for amputation

A retrospective review was undertaken to determine risk factors associated with amputation after open fractures of the lower extremity that were complicated by vascular injury. During an 11-year period ending in December 1987, we observed open fractures in 31 patients and injuries to the popliteal artery in 16 patients, to the tibial arteries in eight patients, to the femoral artery in five patients, and to the dorsal artery of the foot in two patients. Vascular repair was accomplished in 25 patients; 12 patients had primary end-to-end anastomosis, 12 patients had reverse saphenous vein grafts, and one patient had a bovine graft. Of these 25 patients, five patients required amputation because of infection and three patients required amputation because of continued ischemia. Three patients with irreparable damage had immediate amputation, and three patients without distal ischemia had vessel ligation only. The risk factors associated with amputation were shock on admission (10 of 19 patients [p less than 0.02]) and a crushed extremity (10 of 18 patients [p less than 0.01]). The overall amputation rate, which included three immediate amputations and eight late amputations, was 35.2%. The data suggest that limb salvage is possible in two thirds of patients with combined orthopedic and vascular injuries of the lower extremity, but a history of shock or crush injury with vascular compromise is an unfavorable prognostic sign.     

Complications and revision amputation following trauma-related lower limb loss

IntroductionTrauma-related amputations are a common cause of limb loss in the United States. Despite the military and public health impact of trauma-related amputations, distributions of various lower limb amputations and the relative frequency of complications and revision amputations have not been well described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of trauma-related lower extremity amputations among civilians in U.S. trauma centers.Materials and methodsWe conducted a secondary data analysis of the 2011–2012 NTDB research data sets, using means and frequencies to characterize the patient population and describe the distribution of major lower extremity amputations. Multivariable regression models were fit to identify predictors of major post-surgical complications, revision amputation, length of hospitalization, and in-hospital mortality.ResultsA total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4% were male and 67.6% were white. The three most frequent definitive amputations preformed included trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for all amputees was 22.7 days. Patients with at least one revision amputation stayed in the hospital approximately 5.5 days longer than patients not needing a revision amputation. 1204 patients (41.8%) required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical complication. African Americans experienced a 49% higher major post-surgical complication incidence and stayed, on average, 2.5 days longer in the hospital compared to whites. Injury severity score, age, hospital teaching status, presence of a crush injury, fracture location, presence of compartment syndrome, and experiencing a major post-surgical complication were all significant predictors of revision amputation.ConclusionWe report a high rate of complications and revision amputations among trauma-related lower limb amputees, and identify predictors of surgical outcomes that have not been described in the literature including African American race. Compartment syndrome is a significant predictor of major post-surgical complications, revision amputation, and length of hospitalization.     

Infrapopliteal arterial injury: prompt revascularization affords optimal limb salvage.

Sixty-nine limbs with infrapopliteal arterial injuries were evaluated in 68 patients. Thirty-five (50%) cases were complicated by acute limb-threatening ischemia. Management consisted of revascularization (26 limbs), ligation (15 limbs), fasciotomy only (2 limbs), observation (18 limbs), and primary amputation (8 limbs). Penetrating injuries (n = 35) had a 33% incidence of ischemia and a reduced frequency of associated injury. One delayed amputation (3%) was required. In contrast, blunt injuries (n = 34) had a 68% incidence of ischemia and a greater frequency of associated injury. There were 20 amputations in the blunt group, including eight primary amputations performed in limbs with profound ischemia, complex open fractures, severe soft-tissue damage, and neural injury. Observation or ligation of single arterial injuries resulted in no early amputations. Associated local injuries in both groups included fracture or ligamentous disruption (64%), severe soft-tissue damage (32%), and nerve dysfunction (36%). In both groups, 15 of 35 ischemic limbs were salvaged by prompt revascularization (11 penetrating and four blunt injuries). Aggressive revascularization with autogenous repair or bypass is recommended for management of penetrating trauma. Though a good outcome will be achieved in some patients with combined blunt trauma and infrapopliteal arterial injury, the probability of delayed amputation and prolonged disability must be consciously integrated into the decision to pursue limb salvage. The prognosis for blunt injury complicated by arterial ischemia is poor; thus the severity of associated local and remote injuries will affect the results of revascularization program.     

Why were limbs amputated? An evaluation of 216 surgical specimens from Chiang Mai University Hospital,Thailand

Introduction: Limb loss has a devastating effect on patients. To know the underlying causes of limb amputation would be helpful in planning public health strategies in the country. The objectives of this study are (1) to identify the primary causes and the feature of limb amputations in the setting of a university hospital, and (2) to study the time trends of the causes of limb amputation over a period of 5 years. Materials and methods: The clinical and pathological data from 216 amputated limbs submitted to the Pathology Department of Chiang Mai University Hospital from 2000 to 2004 were reviewed. Results: Of these, 188 cases were first time amputations, and 28 cases were repeat amputations. The 188 first amputated specimens included 23 upper limbs (12%) and 165 lower limbs (88%), from 115 male (61%) and 73 female (39%) patients. Dysvascular (46%), tumor-related (36%), and infection-related (10%) amputations were the three most common scenarios. The rate of amputation was high in 2004 (32%) owing to an unexpected increase in the numbers of dysvascular amputation. Atherosclerosis accounted for at least 52% of dysvascular amputations. The leading cause of tumor-related amputations was sarcoma (72%), almost half of which were osteosarcomas. The major cause of lower limb amputation was dysvascular (51%) whereas that of upper limb amputation was tumor related (61%). Subgroup analysis of the major limb amputations revealed that 44% were tumor related, 39% were dysvascular, and 8% were infection-related causes. The proportion of major limb losses in the tumor-related group (87%, 59/68) was significantly higher than those in the dysvascular group (62%, 53/86) (P=0.001). In addition, the proportion of upper limb losses in the tumor-related group (21%, 14/68) was significantly greater than those in the dysvascular group (2%, 2/86), (P<0.001). The causes of 28 repeat amputations were similar, i.e., dysvascular (61%), tumor related (29%), and infectious related (7%). Conclusion: (1) Atherosclerosis, a potentially preventable disease is responsible for the great proportion of limb losses in Northern Thailand; (2) the numbers of dysvascular amputation seem to be increasing; (3) tumor, especially sarcoma, is the most common cause of major limb amputations as well as upper limb loss.     

The burden of post-traumatic amputations in a developing country – An epidemiological study from a level I trauma centre

BackgroundWith the rapidly growing population and expanding vehicle density on the roads, there has been an upsurge in road accidents in developing countries. Knowledge about the causes and patterns of trauma-related amputations helps in the formulation of strategies for limb savage, timely management, and effective rehabilitation.ObjectiveTo study the epidemiology, demographic profile, and outcomes of post-trauma amputations at a level I tertiary care centre in North India.MethodsRetrospective evaluation of the amputee data from 1st January 2018 to 31st December 2019, focusing on demographic details, injury mechanisms, surgical delays, hospital stay, and complications.ResultsA total of 17,445 trauma cases were seen in our trauma centre during the study period. Of these, 442 patients (2.5%) underwent major limb amputation. The hospital-based prevalence of traumatic limb amputation was 2.5%. The mean age of the amputees was 35.6years (range 1–75), and the majority were males (n = 369, 83.5%). The lower to upper limb involvement ratio was 3:1 (n = 338:105). A road traffic accident was the most common mode of injury (77.4%), followed by machine-cut injuries (16.1%). On-site traumatic amputation was seen in 23.1% (n = 102), while 43.5% had a mangled limb amputated in the hospital (mean MESS score 9.53). Overall, 27% of cases had a vascular injury after trauma, ultimately ending in limb amputation. The in-hospital mortality was 2% (n = 9/442). 43.7% of patients with a single limb amputation were discharged within 48 h. Extended hospital stay was noted in cases with associated fractures in the other limbs (28.5%), head or facial injury (9.9%), and with or without a combination of chest, abdomen, pelvic, or spine injury (7.2%).ConclusionA 2.5% incidence of post-trauma amputation reflects on the severity of injury related to road and industrial accidents which predominantly affect the lower limbs at the peak of productive work life. In the absence of national amputation registries, the results underscore the need to focus on road safety protocols, patient transfer methods, and the up-gradation of local hospitals.     

The medical and economic impact of severely injured lower extremities

Modern methods of open fracture management, skeletal fixation, and soft-tissue and bone reconstruction have dramatically improved the potential for limb salvage. The absence of adequate objective parameters on which to base the decision for salvage results in delayed amputations in many cases. The present study was undertaken to review the medical and economic impact of delayed versus primary amputations following severe open fractures of the tibia. From January 1980 to August 1986, 263 patients with grade III open tibia fractures were treated at a major trauma center: 43 ultimately had amputations. This group included 38 males and five females with an average age of 31 years (range, 15-73). All patients were taken to the operating suite for consideration of limb salvage procedures including debridement, fasciotomy, revascularization, or rigid fixation. The standard subjective criteria including color, consistency, bleeding, and contractility were used to determine muscle viability at the time of debridement. If substantial muscle mass was found to be nonviable then amputation was considered. Fourteen (32.6%) of the patients had primary amputations. They averaged 22.3 days hospitalization, 1.6 surgical procedures to the involved lower extremity, and $28,964 hospital costs (range, $5,344-$81,282). The 29 patients with delayed amputations had an average of 53.4 days hospitalization, 6.9 surgical procedures, and $53,462 hospital costs (range, $14,574-$102,434). Six (20.7%) of the delayed amputation patients developed sepsis secondary to their involved lower extremity and died; no patient in the primary amputation group developed sepsis or died.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral thumb amputation

Seventy-one patients with thumb amputations, 45 complete and 26 incomplete nonviable, have been treated at the Microsurgical Unit of the Department of Orthopaedic Surgery at the University of Ioannina Medical School over the past 15 years. Of these thumb amputations, which included crush, avulsion, and guillotine injuries, three cases involved amputation of both thumbs. The three patients with complete bilateral thumb amputations are presented. Because of the importance of the thumb, microsurgical replantation efforts were made which proved successful for two of the patients. Replantation efforts in the third patient, who had severe crush injuries of both thumbs, were not successful. Bilateral thumb amputation is a serious and disabling injury. When replantation is attempted by a team of surgeons well trained in microsurgery, the final result can be impressive, with exceptionally good function of the replanted thumbs. © 1994 Wiley-Liss, Inc.     

The status of lower-limb amputation in Bangladesh: A 6-year review

We conducted a review of 450 single lower-limb amputations performed in our hospital in Bangladesh between July 1982 and June 1987. The incidence of amputation in the specific area of 1 000 000 inhabitants covered by the hospital was 0.75/10³ per year. The indications for amputation were: limb ischemia in 366 patients (81%), traumatic crush injury in 45 (10%), diabetes-associated complications in 20 (5%), severe limb infection in 10 (2%), and neoplasm growth in 10 (2%). The ratio of above-knee (AK) to below-knee (BK) amputation was 1∶65, and 36 patients (8%) required reamputation, 22 of whom had undergone BK amputation previously. Thus, the number of patients with a final amputation at AK level was 302 (67%). The operative mortality was 21% and the uncomplicated primary wound healing rate was 89% within the survivors. Among the 355 patients who survived the amputation, 265 (75%) were given a prosthesis, 50 (14%) refused a prosthesis, and the remaining 40 (11%) were unfit for a prosthesis. Rehabilitation was successful in 44% of the AK and 86% of the BK amputees. In conclusion, when amputation is inevitable, maximum consideration should be given to the type of surgery performed to avoid rehabilitation failure.     

Farm-related limb amputations in children

The purpose of this study was to review results for children sustaining traumatic farm-related limb amputations. Farm machinery accidents were responsible for 12 limb amputations among 260 consecutive childhood traumatic amputations. All amputations resulted in open, grade III-C fractures. Treatment consisted of operative debridement, antibiotics, possible replantation, and delayed wound closure. Mean follow-up was 8 years (range 1-20). Wound closure was achieved at a mean of 22 days (range 2-88) after an average of seven operative procedures (range, 2-11 operations). Skin grafting was necessary for 9 of the 12 limbs. Blood replacement was necessary for all but one patient. Initial wound cultures revealed polymicrobial contamination in all patients. Clinical infections developed exclusively and in all (6/6) patients who underwent attempted replantation. Replantation was considered in all cases and was attempted for six limbs but was successful in only two patients. Failure of replantation in four limbs was due to vascular insufficiency and infection. The surviving replanted limbs have continued to grow and have regained protective sensation. Prosthetic use ranges from excellent to intermittent among the 10 patients with permanent amputation. Farm-related limb amputations are among the most severe orthopaedic injuries sustained by children. Despite massive contamination, infection occurred only in replanted limbs. Because of the mutilating nature of these amputations, less than 20% can be successfully replanted.     

Management of Upper Extremity Vascular Injury: Outcome Related to the Mangled Extremity Severity Score

Background  The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower extremity injury as well as for amputation prediction after upper extremity injury. A MESS of ≥7 has been utilized as a cutoff point for amputation prediction. In this study, we examined the result of upper extremity vascular injurty (UEVI) management in terms of the amputation rate as related to the MESS. Methods  During January 2002 to July 2007, we reviewed patients with UEVIs at our institution. Data collections included demographic data, mechanism of injuries, injury severity score (ISS), ischemic time, MESS, pathology of UEVI, operative management, and amputation rate. Decisions to amputate the injured limbs at our institution were made individually by clinically assessing limb viability (i.e., color and capillary refill of skin; color, consistency, and contractility of muscles) regardless of the MESS. The outcome was analyzed in terms of the amputation rate related to the MESS. Results  There were 52 patients with UEVIs in this study: 25 (48%) suffered blunt injuries and 27 (52%) suffered penetrating injuries. The age ranged from 15 to 59 years (mean 28.7 years). The mean ischemia time was 10.07 h. The mean ISS was 17.52. There were 12 patients (23%) with subclavian artery injuries, 3 patients (5.76%) with axillary artery injuries, 18 patients (34.61%) with brachial artery injuries, and 19 patients (36.54%) with radial artery and/or ulnar artery injuries. Primary repairs were performed in 45 patients (86.54%), with ligations in 3 patients (5.77%). An endovascular stent-graft was used in one patient (1.92%). Primary amputations were performed in three patients (5.77%). Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (secondary amputation rate 8.16%). All amputation patients suffered blunt injuries and had a MESS of ≥7 (range 7–11). The overall amputation rate in this study was 13.46% (7/52 patients). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. There were no amputations in 33 patients who had a MESS of <7. We could avoid amputation in 12 of 19 patients who had a MESS ≥7. There were no mortalities among 52 UEVI patients. Conclusions  MESS, an outcome score used to grade the severity of extremity injuries, correlates well with the risk of amputation. Nevertheless, a MESS of ≥7 does not always mandate amputation. On the other hand, the MESS is a better predictor for patients who do not require amputation when the score is <7. The decisions to amputate in patients should be made individually based on clinical signs and an intraoperative finding of irreversible limb ischemia.     

Civil and war peripheral arterial trauma: review of risk factors associated with limb loss

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.     

Acute bilateral leg amputation following combat injury in UK servicemen

Background

This study aims to characterise the injuries and surgical management of British servicemen sustaining bilateral lower limb amputations.

Methods

The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained between March 2004 and March 2010. Amputations were excluded if they occurred more than 7 days after injury or if they were at the ankle or more distal.

Results

There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All casualties were men with a mean age of 25.1 years (SD 4.3): all were injured in Afghanistan by Improvised Explosive Devices (IEDs). Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score (NISS) was 48.2 (SD 13.2): four patients had a maximum score of 75. The mean TRISS probability of survival was 60% (SD 39.4), with 18 having a survival probability of less than 50% i.e. unexpected survivors. The most common amputation pattern was bilateral trans-femoral (TF) amputations, which was seen in 25 patients (58%). Nine patients also lost an upper limb (triple amputation): no patients survived loss of all four limbs. In retained upper limbs extensive injuries to the hands and forearms were common, including loss of digits. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD 41.7). The maximum transfusion was 12 units of platelets, 94 packed red cells, 8 cryoprecipitate, 76 units of fresh frozen plasma and 3 units of fresh whole blood, a total of 193 units of blood products.

Conclusions

Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.     

Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul

Purpose

Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed.

Methods

This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation.

Results

Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4 months (range 1–28 months). In the DPC group, secondary closure was performed with a mean time of 18.7 days (range 4–45 days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p = 0.1). Forty-three patients were not prosthetic fitted at the last follow-up.

Conclusion

This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.     

Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss

PURPOSE: We sought to analyze the results of lower limb arterial injury (LLAI) management in a busy metropolitan vascular unit and to identify risk factors associated with limb loss.Patients and Methods: Between 1987 and 1997, prospectively collected data on 550 patients with 641 lower limb arterial injuries were analyzed. RESULTS: The mechanism of LLAI was gunshot wounds in 46.1%, blunt in 19%, stabbing in 11.8%, and shotgun in 9.1%. The most frequently injured vessel was the superficial femoral artery (37.2%), followed by the popliteal (30.7%), crural (11%), common femoral (8.7%), and deep femoral (5.3%) arteries. In 3.4% of cases, there was a combined injury on either side of the knee (ipsilaterally). Associated injuries included bony injury in 35.1% of cases, nerve injury in 7.6%, and remote affecting the head, chest, or abdomen in 3.6%. Surgery was carried out on 96.2% of cases with a limb salvage rate of 83.8% and a survival of 98.5%. In spite of a rising trend in LLAI, our total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant (P <.01) independent risk factors for amputation were occluded graft (odds ratio [OR] 16.7), combined above- and below-knee injury (OR 4.4), tense compartment (OR 4.2), arterial transsection (OR 2.8), and associated compound fracture (OR 2.7). CONCLUSION: LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputations, whereas high-velocity firearm injuries are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization.     

Latissimus dorsi flap coverage of soft tissue defect following below-knee amputation: emphasis on flap design and recipient vessels

High-energy trauma to the lower extremity often results in amputation of the limb. For maximal preservation of limb length during amputation, free tissue transfer is often necessary. In this study, we report our experience of stump coverage using latissimus dorsi musculocutaneous flaps with an emphasis on flap design and recipient vessels. Between January 2005 and September 2010, twelve patients with severe traumatic injuries to the lower leg underwent below-knee amputations with stump coverage using latissimus dorsi free flaps. The primary and secondary cases were approached differently regarding the flap design and recipient vessels. All flaps survived completely. There were 8 primary cases and 4 secondary cases. In the primary cases, the anterior tibial artery was used as the recipient vessel in 6 cases, and in 2 cases, the descending geniculate artery was used. In the secondary cases, the descending geniculate artery was used in all cases. There were two cases of ulceration on the grafted non-weight-bearing site, but after the usage of collagen–elastin artificial dermis, no ulcerations were seen. The latissimus dorsi musculocutaneous flap is the most feasible option for coverage of amputation stumps. In flap design, the width of the skin paddle must match the anteroposterior diameter of the defect at the stump. The latissimus dorsi muscle must sufficiently wrap the bony stump for padding. We recommend using the anterior tibial artery as a recipient vessel in primary cases, and the descending geniculate artery in secondary cases.