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.     

The indications for major limb amputations: 8 years retrospective study in a private orthopaedic and trauma centre in the south-east Nigeria

BackgroundMajor limb amputation is a common orthopaedic trauma procedure and it is indicated mainly for traumatic gangrene and for trauma related limb conditions. The loss of a limb is devastating to the patient even when it is done to save life. The aims of the study are to highlight the indications for major limb amputations and to find out if there are any concurrent pattern changes.Patients and methodsThis is a retrospective study analysing medical records of all the patients, who had major limb amputations over a period of 8 years, between October 2007 and September 2015 in a private orthopaedic and trauma centre in the south-east sub-region of Nigeria.ResultsTraumatic gangrene was the commonest indication for amputation n = 30 (44.7%), followed by diabetic gangrene n = 15 (22.3%), and then traditional bone setters’ gangrene n = 10 (14.9%). These were trailed by mangled extremity, malignant conditions of the limb and polydactyl in that order of decreasing frequency.ConclusionTraumatic gangrene and other trauma related limb conditions are the leading indications for amputation in this study despite some recent reports stating otherwise. Trauma is largely preventable and so there is a need for continued intensification of the public campaign on road use as a means of preventing severe limb injuries and thus reducing consequent need for amputations.     

The Influence of Socio-economic Deprivation on Rates of Major Lower Limb Amputation Secondary to Peripheral Arterial Disease

ObjectivesTo investigate a hypothesised link between socio-economic deprivation and rates of major lower limb amputation within the catchment of a district general hospital in the United Kingdom.DesignAn analysis of a demographic database collated using patients identified by the OPCS codes for lower limb amputations.MaterialsAll patients undergoing a lower limb amputation as a result of peripheral vascular disease, as identified by ICD-10 code, between January 2003 and January 2009 were included in the study.MethodsA case–control study was undertaken, comparing the Index of Multiple Deprivation 2007 (IMD) scores of major lower limb amputees, to those of the catchment population. Multivariate analysis was not undertaken.ResultsA total of 327 patients underwent 445 lower limb amputations during the 6-year period. A comparative plot of cumulative frequency of IMD score in the catchment and amputation groups indicates greater numbers of major amputations in more deprived postcodes (P = 0.004). The catchment population was further divided into population-matched deprivation quintiles. A significant increase in the number of amputations occurred in the two most deprived quintiles (OR (95%CI) = 1.654 (1.121–2.440), P = 0.011)ConclusionsThis study indicates a positive association between increasing social deprivation and rates of lower limb amputation. If the most deprived quintiles are combined, this increase in amputation rates is approximately 65%. This inequity should be further investigated, and consideration given to targeted care within areas of greater social deprivation.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Systemic anticoagulation in the setting of vascular extremity trauma

IntroductionThere is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities.MethodsWe analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data.ResultsBetween February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4–91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p = 0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p = 0.002). Patients treated with ISA also stayed longer in the ICU (median 3 days vs. 1 day, p = 0.001) and hospital (median 9.5 days vs. 6 days, p = 0.01).DiscussionIn this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries.     

Historia natural del paciente sometido a una amputación infracondílea: análisis de la supervivencia y protetización durante 2 décadas

IntroductionThis study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation.MethodsRetrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996-2005 and 2006-2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis.Results133 BKA were performed from 1996-2005 and 106 from 2006-2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic + infection, 52.6%), with no differences found between periods. Survival: mortality within one month = 9.2%, one year = 31.9%, 2 years = 43.8% and 5 years = 63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods.ConclusionsIn the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival were not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.     

The weight of obesity in patients with lower extremity vascular injuries

ObjectiveClinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI.MethodsAll adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI) > 30. Obese and non-obese patient groups were compared for surgical management and outcome.ResultsA total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n = 47; non-obese n = 68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different.ConclusionsWhile obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI > 30. However, patients with a BMI > 40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.     

Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical

Introduction and objectiveMinimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality.Material and methodA retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n = 191) and laparoscopic radical cystectomy (LRC) (n = 74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival.Results90.9% were males with a median age of 65 years and a median follow-up period of 65.5 (IQR 27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P = .0001), a longer time between TUR and cystectomy (P = .04), a lower rate of intraoperative transfusion (P = .0001), a lower pT stage (P = .002) and a lower incidence of infection associated with surgical wounds (P = .04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P = .007). Open approach to cystectomy multiplied the risk of mortality by 3.27.ConclusionsIn our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.     

Radical Prostatectomy or Observation for Clinically Localized Prostate Cancer: Extended Follow-up of the Prostate Cancer Intervention Versus Observation Trial (PIVOT)

BackgroundVery long-term mortality in men with early prostate cancer treated with surgery versus observation is uncertain.ObjectiveTo determine long-term effects of surgery versus observation on all-cause mortality for men with early prostate cancer.Design, setting, and participantsThis study evaluated long-term follow-up of a randomized trial conducted at the US Department of Veterans Affairs and National Cancer Institute sites. The participants were men (n = 731) ≤75 yr of age with localized prostate cancer, prostate-specific antigen (PSA) <50 ng/ml, life expectancy ≥10 yr, and medically fit for surgery.InterventionRadical prostatectomy versus observation.Outcome measurements and statistical analysisAll-cause mortality was assessed in the entire cohort and patient and tumor subgroups. Intention-to-treat analysis was conducted using Kaplan-Meier methods with log-rank tests and Cox proportional hazard models; cumulative mortality incidence, between-group differences, and relative risks were also assessed at predefined time periods.Results and limitationsDuring 22.1 yr (median follow-up for survivors = 18.6 yr; interquartile range: 16.6–20.0), 515 men died; 246 of 346 men (68%) were assigned to surgery versus 269 of 367 (73%) assigned to observation (hazard ratio 0.84 [95% confidence interval {CI}: 0.70–1.00]; p =  0.044 [absolute risk reduction = 5.7 percentage points, 95% CI: –0.89 to 12%]; relative risk: 0.92 [95% CI: 0.84–1.01]). The restricted mean survival in the surgical group was 13.6 yr (95% CI: 12.9–14.3) versus 12.6 yr (95% CI: 11.8–13.3) in the observation group; a mean of 1 life-year was gained with surgery. Results did not significantly vary by patient or tumor characteristics, although differences were larger favoring surgery among men aged <65 yr, of white race, and having better health status, fewer comorbidities, ≥34% positive prostate biopsy cores, and intermediate-risk disease. Results were not adjusted for multiple comparisons, and we could not assess outcomes other than all-cause mortality.ConclusionsSurgery was associated with small very long-term reductions in all-cause mortality and increases in years of life gained. Absolute effects did not vary markedly by patient characteristics. Absolute effects and mean survival were much smaller in men with low-risk disease, but were greater in men with intermediate-risk disease although not in men with high-risk disease.Patient summaryIn this randomized study, we evaluated death from any cause in men with early prostate cancer treated with either surgery or observation. Overall, surgery may provide small very long-term reductions in death from any cause and increases in years of life gained. Absolute effects were much smaller in men with low-risk disease, but were greater in men with intermediate-risk disease although not in men with high-risk disease. Strategies are needed to identify men needing and benefitting from surgery while reducing ineffective treatment and overtreatment.     

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis

IntroductionOutcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections.MethodsRetrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients’ age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann–Whitney U test for continuous variables.ResultsA total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p = 0.369), major complications (RATS: 9% vs VATS: 9.2%; p = 0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p = 1; pneumonia RATS:0%, VATS:4.6%, p = 0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p = 0.718) and reoperation (RATS: 3%, VATS: 1.5%, p = 1) were comparable between both groups. The median length of stay was 3 days in both groups (p = 0.101).ConclusionsA RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.     

Outcomes of partial and total calcanectomies for the treatment of diabetic heel ulcers complicated with osteomyelitis. A systematic review and meta-analysis

BackgroundInfected diabetic foot ulcers (DFU) complicated with calcaneal osteomyelitis are a real challenge for limb preservation. Very few alternatives to amputation are available, mainly the resection of a part or the totality of the calcaneal bone. Calcanectomies were advanced as limb-sparing procedures in patients with heel osteomyelitis. However, there is a lack of pooled quantitative evidence on their efficacy and complications.ObjectivesThe present systematic review and meta-analysis was conducted to determine the primary outcome of healing rates following partial (PC) and total calcanectomies (TC) in treating calcaneal osteomyelitis due to diabetic heel ulcers. Additionally, secondary outcomes such as secondary TC following PC, secondary below knee amputation (BKA), mortality and the change in the ambulation status were analyzed.MethodsMedline, Scopus, Web of science, Cochrane Library and Google Scholar were searched since inception. All types of study design were included. Single case report studies and studies reporting osteomyelitis due to other etiologies than DFU were excluded.ResultsTwenty studies met the inclusion criteria comprising 295 patients with 300 calcanectomies (270 PC and 30 TC). With a mean follow-up period of 29.3 ± 17.7 months, the weighted results were as follows: a) the osteomyelitis healing rate was of 80% (95% CI = 0.728 to 0.861, I² = 48.3%), b) the rate of secondary total calcanectomy was of 5.4% (95% CI = 0.022 to 0.097, I² = 7.5%), c) the rate of secondary BKA was of 17.1% (95% CI = 0.111 to 0.241, I² = 50.6%) with no difference between subgroups of TC and PC, and d) the combined mortality rate of both calcanectomies was of 13.4% (95% CI = 0.064 to 0.224, I² = 73.6%); however, significant higher mortality was found following TC compared to PC (p < 0.0001).ConclusionPartial and total calcanectomies were found to yield very good healing rates with acceptable complication frequencies. When compared to the reported outcomes of below and above-knee amputations in the literature, calcanectomies could be fairly considered as good alternatives to above ankle amputations.     

Long Non-coding RNA LINC-PINT and LINC00599 Polymorphisms are Associated With High-altitude Pulmonary Edema in Chinese

BackgroundHigh-altitude pulmonary edema (HAPE) is a kind of non-cardiogenic edema with high incidence and life-threatening. This study was designed to explore the association of LINC-PINT and LINC00599 polymorphisms with HAPE susceptibility.MethodsThis study included 244 HAPE patients and 243 age-, sex-matched healthy controls from the Chinese population. The genotypes of polymorphisms were detected using the Agena MassARRAY. The relationship between polymorphisms and HAPE risk was evaluated using a χ² test with an odds ratio (OR) and 95% confidence intervals (CIs) in multiple genetic models.ResultsWe observe a significant association between the rs157928 and decreased HAPE risk in genotype model (OR = 0.65, 95% CI = 0.43–0.98, p = 0.038). The subgroup analysis results indicated that rs2272026 was associated with a decreased risk of HAPE in younger patients with age ≤32 (codominant model: p = 0.006; recessive model: p = 0.005 additive model: p = 0.018; and allele model: p = 0.012; rs72625676, codominant model: p = 0.038; recessive model: p = 0.037). Among patients older than 32 years, there was a significantly increased risk of HAPE associated with the rs2272026 and rs1962430 (rs2272026: genotype model: p = 0.049; recessive model: p = 0.029; rs1962430: genotype model: p = 0.024; recessive model: p = 0.020). Nevertheless, rs157928 had relationship with significantly reducing the risk of HAPE in the genotype model (p = 0.018).ConclusionOur study suggests that LINC-PINT and LINC00599 polymorphisms are associated with HAPE susceptibility in Chinese population.     

Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation

BackgroundAfter major upper extremity traumatic amputation, replantation is attempted based upon the assumption that outcomes for a replanted limb exceed those for revision amputation with prosthetic rehabilitation. While some reports have examined functional differences between these patients, it is increasingly apparent that patient perceptions are also critical determinants of success. Currently, little patient-reported outcomes data exists to support surgical decision-making in the setting of major upper extremity traumatic amputation. Therefore, the purpose of this study is to directly compare patient-reported outcomes after replantation versus prosthetic rehabilitation.MethodsAt three tertiary care centers, patients with a history of traumatic unilateral upper extremity amputation at or between the radiocarpal and elbow joints were identified. Patients who underwent either successful replantation or revision amputation with prosthetic rehabilitation were contacted. Patient-reported health status was evaluated with both DASH and MHQ instruments. Intergroup comparisons were performed for aggregate DASH score, aggregate MHQ score on the injured side, and each MHQ domain.ResultsNine patients with successful replantation and 22 amputees who underwent prosthetic rehabilitation were enrolled. Aggregate MHQ score for the affected extremity was significantly higher for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p < 0.05). Among the MHQ domains, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p = 0.03), ADLs (28.3 vs. 6.0, p = 0.03), and patient satisfaction (46.0 vs. 24.4, p = 0.03). Additionally, Replantation patients had a lower mean DASH score (24.6 vs. 39.8, p = 0.08).ConclusionsPatients in this study who experienced major upper extremity traumatic amputation reported more favorable patient-reported outcomes after successful replantation compared to revision amputation with prosthetic rehabilitation.     

An Emergency EVAR Service Reduces Mortality in Ruptured Abdominal Aortic Aneurysms

ObjectivesThe aim of this study was to compare all in-hospital mortality for ruptured abdominal aortic aneurysms (rAAAs) before and after the establishment of an emergency EVAR (eEVAR) service.Design and methodsAn eEVAR service was established in January 2006, since when all patients presenting with rAAAs have been considered for endovascular repair. Data for all rAAAs presenting between January 2006 and December 2007 was prospectively collected (Group 1). This patient group was compared to those presenting with rAAA between January 2003 and December 2005 when eEVAR was not offered at our institution (Group 2). These records had also been collected prospectively and submitted to the National Vascular Database (NVD).ResultsA total of 50 rAAAs (17 eEVAR, 29 open repairs, 4 palliated) presented after the introduction of eEVAR (Group 1) and 71 in the historical Group 2 of which 54 underwent open repair and 17 were palliated. The total in-hospital mortality was significantly lower in Group 1 20% (eEVAR (n = 1), 6%: Open (n = 5), 17%: palliated (n = 4), 100%) when compared to Group 2 54% (Open (n = 21), 39%: palliated (n = 17), 100%) (p = 0.000001). Furthermore similar significant differences were seen in 30-day operative mortalities between the two groups 13% in Group 1 versus 39% in Group 2 (p = 0.0003). In addition the proportion of patients who were palliated has significantly decreased (8% Group 1 versus 24% Group 2, p = 0.01).ConclusionsThe establishment of an eEVAR service has significantly reduced in-hospital mortality for patients presenting with ruptured abdominal aortic aneurysms.     

A 20-year Experience with Portal and Superior Mesenteric Venous Injuries: Has Anything Changed?

ObjectivesTo identify predictive factors causing mortality in patients with injuries to the portal (PV) and superior mesenteric veins (SMV).DesignRetrospective analysis of prospectively collected data.Materials and methodsAdults admitted with blunt or penetrating PV and SMV injuries at an academic level I trauma center during a 20-year period.ResultsOf 26,387 major trauma victims admitted from 1987 through 2006, 26 sustained PV or SMV injuries (PV = 15, SMV = 11). Mechanism of injury was penetrating in 19 (73%) and 20 were in shock. Active hemorrhage occurred in 21. Most patients had associated injuries (2.9 ± 1.8/patient). Mean Injury Severity Score (ISS) was 27.8 ± 16.8. All PV injuries underwent suture repair and 27% of SMV injuries were ligated. Overall mortality was 46% (PV = 47%, SMV = 45%). Stab wounds had a lower mortality (31%) compared to gunshot wounds (67%) and blunt injuries (57%). Nonsurvivors had a higher ISS (35.8 vs. 20.9; p = 0.02), more associated injuries (3.7 vs. 2.2; p = 0.02), were older, and had active hemorrhage. Active hemorrhage (p = 0.04) was independently related to death while shock on admission (odds ratio = 6.1, p = 0.61) trended toward higher mortality.ConclusionDespite improvements in trauma care, mortality of PV and SMV injuries remains high. Shock, active hemorrhage, and associated injuries were predictive of increased mortality.     

The impact of serum albumin and serum protein levels on POSSUM score of patients with proximal femur fractures

BackgroundPOSSUM was developed to predict risk-adjusted mortality and morbidity rates for surgical procedures. We evaluated the impact of serum albumin and serum protein levels on POSSUM scores.MethodsMedical files of 2269 patients operated for proximal femur fractures were reviewed. Preoperative serum albumin levels were available for 387 patients (mean 35.1 g/l, range 22–49) and serum protein levels for 279 patients (mean 61.6 g/l, range 40–86).ResultsSerum albumin and protein levels were inversely associated with mortality in multivariate models (albumin, OR = 0.89, p = 0.009; protein, OR = 0.92, p = 0.009) and in composite outcome models as well (albumin, OR = 0.955, p = 0.219, protein, OR = 0.94, p = 0.014). The area under the curve (AUC) for POSSUM prediction of mortality (n = 1770) was 0.632 (95% CI: 0.580–0.684, p < 0.001). The AUC for a model including serum protein levels was 0.742 (95% CI: 0.649–0.834, p < 0.001). Hospitalisation time was longer for patients with lower serum proteins levels (p = 0.045), with an inverse correlation (Pearson correlation −0.164, p = 0.011).ConclusionsLower preoperative serum albumin and serum protein levels were associated with increased risk for mortality, increased hospitalisation time and poorer outcomes in patients operated for proximal femoral fractures. Including those values to POSSUM scores would increase their predictive power.     

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate.MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation.ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02).ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries.Type of study/level of evidenceTherapeutic III.     

Are bilateral tibial shaft fractures associated with an increased risk for adverse outcome?

IntroductionLong bone fractures are assumed to be an independent risk factor for systemic complications and death after trauma. Multiple studies have identified an increased risk for mortality and morbidity in patients with bilateral femoral fractures. Data about bilateral tibial shaft fractures is rare. The aim of our study was to analyze if patients with bilateral tibial shaft fractures are at higher risk for systemic complications.MethodsWe performed a retrospective analysis of the TraumaRegister DGU^® from 1993 to 2008. Inclusion criteria were unilateral or bilateral tibial shaft fractures and an age ≥16. Additionally to the overall collective we analyzed different subgroups (divided into different injury severities and treatment periods).Results1899 patients with unilateral and 175 patients with bilateral tibial shaft fractures were included. Age, gender and mean ISS (25.8 vs. 26.2, p = 0.51) in the two groups were comparable. Regarding the entire study population, patients with bilateral tibial shaft fractures showed no significant higher incidence of respiratory organ failure (29.5% vs. 23.1%, p = 0.076) or mortality (20.0% vs. 16.3%, p = 0.203). However, subgroup analysis showed a significant higher rate of pulmonary organ failure for bilateral tibial shaft fractures as compared to unilateral tibial shaft fractures in the group ISS < 25 (20.7% vs. 11.7%, p = 0.023). Multivariate regression analysis identified the additional tibial shaft fracture as an independent risk factor for pulmonary organ failure (OR = 1.56) but not for mortality.DiscussionThe additional tibial shaft fracture is an independent risk factor for pulmonary organ failure but not for multiple organ failure or mortality. The impact of the additional tibial shaft fracture is especially pronounced in less severely injured patients (ISS < 25). These findings are comparable to results of bilateral femoral fracture studies and we therefore suggest to treat patients with bilateral tibial shaft fractures with the same caution as those with bilateral femoral fractures.     

Epidemiologic data of trauma-related lower limb amputees: A single center 10-year experience

ObjectiveThe aim of this study is three fold: 1) to introduce epidemiologic data of patients with trauma-related amputations as a 10-year experience of a rehabitation center; 2) to determine comorbidities and secondary conditions of lower limb loss; 3) to determine the rehospitalization reasons for lower limb amputee patients.Materials and methodsThis retrospective study was conducted in a tertiary rehabilitation center in Turkey. Clinical and demographic data of amputees including sex, age, employment status, time since amputation, time after amputation to first hospitalization, length of hospitalization, how many times the patient was hospitalized, reason for hospitalization, stump complications, comorbid conditions, amputation level and K classifacation were documented.ResultsThree hundred ninetynine patients with a mean age of 23,48 ± 6,04 (4–74) years were included in this study. Mean duration after amputation was 119,71 ± 68,86 months. Patients were 3,43 ± 2,53 times hospitalized. Landmine explosion was the most common etiology of amputation with 370 patients (92.7%). Below knee amputation was the most common amputation level with 230 (50,77%) amputations. 399 patients were hospitalized 1369 times and the most common hospitalization reason were stump complications (356 times, 26,00%). Spur formation (202 times) was the most common stump complications. Pyscologic disorders were the most common comorbidity with 68 patient (37,56%).ConclusionPatients with traumatic limb amputations are likely to experience several complications and comorbidities. Prevention of secondary conditions affecting those living with the loss of a limb is an important part of amputee rehabilitation and may prevent rehospitalization.     

The effect of aortic stenosis on elderly hip fracture outcomes: A case control study

IntroductionAortic stenosis (AS) is an established predictor of perioperative complications following both cardiac and non-cardiac surgery. The purpose of this study was to evaluate the risk of mortality and perioperative complications among surgically treated hip fractures in elderly patients with moderate or severe AS compared to those without AS (negative controls).Materials and methodsA retrospective case-controlled review (1:2) of elderly (≥65 years) surgically treated hip fractures from 2011 to 2015 with moderate/severe AS (according to American Heart Association criteria) was conducted. Postoperative complication rates, 30 days and 1 year mortality were reviewed.ResultsModerate/severe AS was identified in 65 hip fracture cases and compared to 129 negative controls. AS cases were significantly older with higher rates of coronary artery disease and atrial fibrillation (p < 0.05). Rates of any 30-day perioperative complication (74% vs. 37%, p < 0.001) and severe non-cardiac 30-day perioperative complication (52% vs. 26%, p = 0.002) were significantly higher among AS cases compared to controls. Kaplan Meier estimates of 30-day mortality (14.7% vs. 4.2%, p < 0.001) and 1-year mortality (46.8% vs. 14.1%, p < 0.001) were significantly higher in AS cases compared to controls. Multivariate analysis of severe 30-day postoperative complications identified moderate/severe AS (OR 4.02, p = 0.001), pulmonary disease (OR 7.36, p = 0.002) and renal disease (OR 3.27, p = 0.04) as independent predictors. Moderate/severe AS (OR 3.38, p = 0.03), atrial fibrillation (OR 3.73, p = 0.03) and renal disease (OR 4.44, p = 0.02) were independent predictors of 30-day mortality. Moderate/severe AS (OR 5.79, p < 0.001) and renal disease (OR 3.39, p = 0.02) were independent predictors of 1-year mortality.ConclusionAortic stenosis is associated with a significantly increased risk of perioperative complications, 30-day mortality and 1-year mortality in elderly patients undergoing surgical treatment of hip fractures.