TO ASSESS THE INCIDENCE OF DVT AMONG PATIENTS OF LOWER LIMB SURGERIES /LOWER LIMB TRAUMA ADMITTED TO ST. STEPHEN?S HOSPITAL

Background: This study therefore aimed to assess the incidence of DVT among patients of lower limb surgeries /lower limb trauma admitted to St. Stephen?s hospital Methods: The prospective study was conducted at St Stephen?s hospital from Jan 2019 to December 2019 for duration of 1 year, and 104 patients were part of the study. Results: The overall prevalence of DVT in our study was found to be 2.8%. Out of 3 DVT cases 2 were found in males (3.4%) and 1 was a female (2.1%). Conclusion: There is comparable incidence of DVT in our patients as compared to the incidence found in world literature. There is a need to institute DVT prophylaxis in patients undergoing major lower limb surgeries. Keywords: DVT, Lower limb, Trauma

Free gracilis end-to-side microanastomosis to a peronea arteria magna: a case report

Background Complex orthoplastic lower limb trauma in individuals with multiple injuries requires considerable resources and interdisciplinary collaboration for good outcomes. We present the first reported end-to-side free flap microanastomosis for lower limb trauma reconstruction involving a peronea arteria magna without radiographic collaterals. Case presentation A 55-year-old Caucasian gentleman involved in road traffic collision sustained an open tibial fracture on the anteromedial distal third of the left lower leg with local degloving and a subtotal right foot and ankle degloving. Both injuries were reconstructed with free tissue transfer. A left lower limb peronea arteria magna successfully received a free gracilis muscle flap by end-to-side microanastomosis and perfusion of the foot was preserved. This rare anatomical variant and its anatomy is reviewed, as well as a description of the suggested preoperative planning and technique for reconstruction. Conclusions Successful free flap reconstruction may be performed to a lower limb with a peronea arteria magna recipient as the lone vessel supplying the foot in trauma, although preoperative counseling of the risks, benefits, and options are essential. Level of evidence Level V, case report

Principles of acute management of lower limb trauma

The morbidity of lower limb trauma can be significant and a combination of orthopaedic and plastic surgery expertise is required from the initial assessment through to completion of treatment for these complex injuries. Guidelines have been established in the United Kingdom that address assessment, timing of treatment, and the management of soft tissue and skeletal components of injury. This chapter outlines these principles of treatment.

Lower limb trauma outcome measuresLimb salvage and amputation

The management of lower limb-threatening injuries is complex. Advances over the last few decades have provided the ability to salvage complex limb trauma but also have raised concerns that successful complex salvage surgery may not result in overall benefit for the patient. Surgical factors such as bony union, flap success, and a lack of complications are important but are not the sole factors upon which one can guide the patient toward their decision. The patient needs to know how the different treatments may affect their recovery, rehabilitation, return to work, and outcome. This chapter examines the indications and evidence for amputation and salvage by considering the importance of patient and injury-specific factors, biological and physiological variables, quality of life, patient satisfaction, and cost to the individual, hospital, and healthcare provider.

Classification of lower limb trauma

Accurate, simple, and reproducible classification of lower limb injuries facilitates communication between healthcare professionals, allows application of a standard treatment algorithm, and provides a platform for conducting detailed audit. The Gustilo and Anderson grading is widely used and is relatively simple but has poor inter-rater reliability and is best applied after wound excision. Other more comprehensive classifications (such as the AO system) are best used for audit and in outcomes databases.

Quantitative analysis of intermuscular septa in the leg: implications for trauma surgery

BackgroundCompartment syndrome is the excess swelling within an inelastic compartment leading to excessive compartment pressure. Lower limb trauma has a high risk of compartment syndrome, which is typically mitigated using a two-incision fasciotomy. Our previous findings showed surgeons sometimes perform incomplete fasciotomies due to misidentifying the septum between the lateral and superficial posterior compartments as the septum between the anterior and lateral compartments. We conjectured this may be due to variability in the septal position between individuals leading to misinterpretation of the septal identity.MethodsA retrospective analysis was performed using CT angiograms to analyze septal position between the anterior and lateral compartments of the leg of 100 patients randomly selected from the University of Maryland Shock Trauma Center database.ResultsAnalysis of septal position showed that (1) as the septum progresses distally down the leg, the relative septum position shifts anteriorly; and that (2) there was considerable variability in the intermuscular septum position between individuals even when accounting for the anterior to posterior progression of septal position.DiscussionThis variability could lead to erroneous septal identification in individuals with a very anteriorly located septum during a leg fasciotomy with the classic initial incision being insufficiently anterior. We propose making the lateral initial incision ‘two finger breadths posterior the tibia’ rather than the traditional ‘one finger breadth anterior’ to the fibula. This moves the initial incision slightly anteriorly, uses the more readily palpable tibia, and makes the medial and lateral incisions symmetrical at ‘two finger breadths’ from the tibia, simplifying the procedure.Level of evidenceLevel 3.

Risk and Prognostic Factors of Replantation Failure in Patients With Severe Traumatic Major Limb Mutilation: a Retrospective Cohort Study

Background: Traumatic mutilation of major limbs can result in limb loss, motor disability, or even death. Despite advancements in treatment, replantation failure could result in additional financial burden and severe psychosocial pressure on patients. Here, we determine the risk and prognostic factors of replantation failure in patients with traumatic major limb mutilation.Methods: In this retrospective cohort study, severed adult inpatients with traumatic major limb mutilation who underwent replantation from three hospitals in the Suzhou Ruixing Medical Group were included. Data obtained from electronic medical records were used to analyze predictors and risk factors for replantation failure.Results: From the 66 patients included, replantation failure occurred in 48 patients (72.7%). The area under the curve of the joint prediction of lactic acid on admission, 72 h cumulative fluid balance, and albumin level immediately postoperatively was 0.838 (95% CI, 0.722-0.954; P < 0.001) with a sensitivity of 89.7% and a specificity of 69.2%. Lower limb trauma (OR 8.65, 95%CI 1.64-45.56, P = 0.011), mangled extremity severity scores (OR 2.24, 95%CI 1.25-4.01, P = 0.007), and first 72 h cumulative fluid balance > 4885.6 ml (OR 10.25, 95%CI 1.37-76.93, P = 0.024) were independent risk factors for replantation failure.Conclusions: Lower limb trauma, mangled extremity severity scores, and cumulative water balance were associated with replantation failure. This implies that fluid management is necessary for major limb salvage. More studies are needed to explore the predictive power of indicators related to tissue oxygenation and wound healing for replantation failure.

Thromboembolic risk stratification by TRiP(cast) score to rationalise thromboprophylaxis in patients with lower leg trauma requiring immobilisation: a study protocol of the casting stepped-wedge cluster randomised trial

IntroductionPatients with lower limb trauma requiring orthopaedic immobilisation may be at risk of venous thromboembolism but opinions differ about who may benefit from thromboprophylactic anticoagulant treatment.The aim of this CASTING study is to demonstrate the safety of thromboprophylaxis based on the Thrombosis Risk Prediction for patients with cast immobilisation (TRiP(cast) score with regards to the 3-month incidence of symptomatic venous thromboembolism events in low-risk patients not receiving thromboprophylaxis, as well as the usefulness of this strategy on the rate of patients receiving anticoagulant treatment in comparison to current practice.Methods and analysisCASTING will be a stepped-wedge cluster randomised controlled clinical trial, performed in 15 emergency departments in France and Belgium. With their informed consent, outpatients admitted to one of the participating emergency departments for a lower limb trauma requiring orthopaedic immobilisation without surgery will be included. All centres will begin the trial with the ‘observational period’ and, every 2 weeks, 1 centre will be randomly assigned to switch to the ‘interventional period’ and to apply the TRiP(cast) score, in which only patients with a score ≥7 will receive thromboprophylactic anticoagulant treatment. The primary endpoint is the rate of clinical thromboembolic events within 90 days following the inclusion of low-risk patients not receiving thromboprophylaxis.Ethics and disseminationThe protocol has been approved by the Comité de Protection des Personnes Sud I (Ethics Review ID-RCB: 2019-A01829-48) for France and the Comité d’éthique hôpital-facultaire Saint Luc (N° B403201941338) for Belgium. It is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences.Trial registration numberNCT04064489.