Management Algorithm of External Fixation in Lower Leg Arterial Injury for Limb Salvages

Purpose: The purpose of this study was to review the roles of using external fixation to rescue the patients who sustained arterial injuries in the lower legs.Methods: Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery.Results:80 patients (90 legs) maintained a successful lower leg salvage. The patients were followed up for an average of 15.5±5.5 months. 6 patients (8 pins) experienced pin-tract infection, pins loosening happened in 2 patients (4 pins), 7 patients (7 legs) developed wound superficial infection, 3 patients (3 legs) with a deep infection developed osteomyelitis, 16 patients (17 legs) suffered the bone nonunion or bone defect. The average healing time of fracture was 5.6±4.3months. The maintain of external fixation average time was 5.8±3.6 months. Conclusion: With correctly judging the condition of limb ischemia, mastering reasonably the operation indications, and preventing complications, good clinical effects can be achieved when external fixation is used.Level of evidence: Retrospective cohort, level IV.

Contemporary Management of Axillosubclavian Arterial Injuries Using Data from the AAST PROOVIT Registry

Background: Endovascular repair has emerged as a viable repair option for axillosubclavian arterial injuries in select patients; however, further study of contemporary outcomes is warranted. Methods: The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was used to identify patients with axillo-subclavian arterial injuries from 2013 – 2019. Demographics and outcomes were compared between patients undergoing endovascular repair versus open repair. Results: 167 patients were identified, with intervention required in 107 (64.1%). Among these, 24 patients underwent open damage control surgery (primary amputation = 3, ligation = 17, temporary vascular shunt = 4). The remaining 83 patients (91.6% male; mean age 26.0 ± 16) underwent either endovascular repair (36, 43.4%) or open repair (47, 56.6%). Patients managed with definitive endovascular or open repair had similar demographics and presentation, with the only exception that endovascular repair was more commonly employed for traumatic pseudoaneurysms (p=0.004). Endovascular repair was associated with lower 24-hour transfusion requirements (p=0.012), but otherwise the two groups were similar with regards to in-hospital outcomes. Conclusion: Endovascular repair is now employed in > 40% of axillo-subclavian arterial injuries undergoing repair at initial operation and is associated with lower 24 hour transfusion requirements, but otherwise outcomes are comparable to open repair.

Two Urgency Categories, Same Outcome: No Difference After “Therapeutic” vs. “Prophylactic” Fasciotomy

Objectives Fasciotomy to treat or prevent compartment syndromes in patients with truncal or peripheral arterial injuries is a valuable adjunct. The objective of this study was to document the current incidence, indications, and outcomes of below knee fasciotomy in patients with femoropopliteal arterial injuries. Methods The PROspective Observational Vascular Injury Treatment registry of the American Association for the Surgery of Trauma was utilized to identify patients undergoing two-incision four-compartment fasciotomy of the leg after repair of a femoropopliteal arterial injury. Outcomes after therapeutic versus prophylactic (surgeon label) fasciotomy were compared as was the technique of closure, that is, primary skin closure or application of a split-thickness skin graft (STSG). Results From 2013 to 2018, fasciotomy was performed in 158 patients overall, including 95.6% (151/158) at the initial operation. In the group of 139 patients who survived to discharge, fasciotomies were labeled as therapeutic in 58.3% (81/139) and prophylactic in 41.7% (58/139). There were no significant differences between the therapeutic and prophylactic groups in amputation rates (14.8% vs. 8.6%, P = .919). Primary skin closure was achieved at a median of 5.0 days vs. 11.0 days for STSG ( P = .001). Conclusions Over 55% of patients undergoing repair of an injury to a femoral or popliteal artery have a fasciotomy performed at the same operation. A “therapeutic” indication for fasciotomy continues to be more common than “prophylactic,” while outcomes are identical in both groups.

Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities

Background Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma. Methods All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated. Results During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.