Femoral-Femoral Bypass for Limb Salvage to Correct Common Iliac Occlusion after Lower Extremity Trauma

Background Roadway injuries are a leading cause of lower extremity vascular trauma. Treating these injuries involves controlling life-threatening hemorrhage and restoring distal perfusion. Materials and Methods We describe a unique presentation of chronic iliac artery occlusion in the setting of blunt trauma requiring extra-anatomic bypass for maximal limb salvage. Results A 50-year-old male presented after a pedestrian versus auto accident. He had mangled bilateral lower extremities and was taken emergently for lower extremity amputations. He was found to have chronic left common iliac occlusion and a femoral-femoral bypass was performed to assist with healing his left below-the-knee amputation Discussion Lack of adequate perfusion can cause poor outcomes in limb salvage. This case demonstrated that lower extremity trauma can be complicated by chronic vascular disease. Reperfusion and adequate wound healing can be accomplished by using bypass grafting after more traditional reperfusion techniques fail.

Should I Stay or Should I Go? Identifying Intrinsic and Extrinsic Factors in the Decision to Return to Duty Following Lower Extremity Injury

ABSTRACT Introduction Rehabilitation research of wounded service members (SMs) commonly focuses on physical ability to return to duty (RTD) as a measure of successful recovery. However, numerous factors or barriers may influence a SM’s ability and/or desire to RTD after lower extremity musculoskeletal trauma. SMs themselves as well as the clinical care team that works with them daily, often for years at a time, both offer unique perspectives on the influential factors that weigh into decisions to RTD. The purpose of this study was to identify the intrinsic and extrinsic factors patients and clinicians recognized as influencing the decision to RTD after severe lower extremity trauma. Materials and Methods Thirty-two SMs with severe lower extremity trauma (amputation and lower limb salvage) and 30 providers with at least 2 years’ experience caring for SMs with similar injuries participated separately in either a SM or provider/clinician focus group. Open-ended questions on factors influencing RTD and other rehabilitation success were discussed. Data analysis consisted of qualitative transcription and participatory active sorting, followed by thematic coding and grouping of qualitative data. Results Individual (health condition, personal traits, and career consideration), interpersonal (clinician’s impact, family influence, and peer influence), health care system (systems of care, transdisciplinary rehabilitation, and innovation availability), and institutional (policy, benefits, and unit/commander) themes emerged amongst SM patients and clinicians. Expected frequently occurring themes common to both groups were the influence of the team and family unit, as well as career trajectory options after a severe injury. An unexpected theme was acknowledgment of and dissatisfaction with the recent dismantling of institutional systems that support wounded SMs. Patients placed less emphasis on severity of injury and greater emphasis on system and policy barriers than did clinicians. Conclusions Characterization and classification of these clinician and SM-identified factors that influence the decision to RTD after severe lower extremity trauma is expected to improve the efficacy of future rehabilitation efforts and clinical practice guidelines by providing the clinical team the knowledge necessary to recognize modifiable barriers to patient success. A better understanding of factors influencing RTD decision-making may support policies for mitigating RTD barriers, better monitoring of the changing landscape of RTD after lower extremity trauma, improving systems of health care, and/or reducing turnover and facilitating force readiness.