OBJECTIVES: The nature of vascular trauma varies greatly between continents and across time. The aim of this study was to prospectively analyse the demographics, pathology, management and clinical outcomes of vascular injuries in two urban Malaysian hospitals and review of international literature on vascular trauma. From this information, preliminary management and preventive implications will be described.
METHODS: Eighty-four consecutive cases of trauma requiring vascular surgery were prospectively analysed over three years at Hospital Kuala Lumpur and Hospital Pulau Pinang, Malaysia. Extensive patient demographic and injury data, including the mechanism of injury, associated injuries, angiographic findings, operative details and post-operative complications, were systematically gathered.
RESULTS: Most vascular injuries were incurred by males (76/84), with 37% (28/76) of them aged between 21 and 30 years. Malays were most frequently injured (n = 36) followed by Chinese and Indians. Road traffic accidents (n = 49) substantially outnumbered all other causes of injury. Lower limb injuries (n = 57) occurred more than twice as often as upper limb injuries (n = 27). Complete arterial transections (n = 43) and intimal injuries (n = 27) were more common than arterial lacerations (n = 10) and pseudoaneurysms (n = 4). The most frequently damaged vessels were the popliteal/tibioperoneal trunk (n = 33). All patients received urgent Doppler ultrasound assessment and, where possible, ankle-brachial systolic index measurement. Of all patients, 40 received an angiogram, haemodynamic instability making this investigation impractical in others. Primary arterial repair was the most frequently employed surgical procedure (n = 54) followed by autogenous reverse long saphenous vein (LSV) interposition graft (n = 14), embolectomy (n = 5) and PTFE interposition graft (n = 3). The most common post-operative complication was wound infection (n = 11). Amputation, as a last resort, was required in 13 cases following either primary or autogenous reverse LSV repair complicated by sepsis or critical ischaemia.
CONCLUSIONS: Vascular trauma, especially in conjunction with severe soft tissue, nerve or orthopaedic injury carries colossal physical, psychological, financial and social costs. Associated nerve and venous injury portended poor outcome in this study. Whilst orthopaedic trauma was a common association, the concurrence of occult vascular trauma and soft tissue injury without fracture emphasises the crucial importance of thorough and rapid clinical vascular assessment, investigation and surgical intervention. Fasciotomy, especially for the lower limb, is important for the prevention of compartment syndrome and its, limb-threatening sequelae. Primary preventive road safety promotion and interventions, with attention to high-risk groups (young males and motorcyclists), is urgently required.
INTRODUCTION:
Many conditions, including benign and malignant tumours, peripheral vascular diseases and open fracture grade 3C, have been successfully treated with limb sparing procedures. However, the same could not be said for treatment of limb infection, especially late stage diabetic foot complications.
METHODS:
This is a retrospective review of patients who underwent operations at our hospital from July 2003 to June 2005. All patients who underwent various types of limbs amputations were included. The cohort was divided according to the diagnosis leading to the amputation and the level of amputation. The number and levels of amputation were then compared with the various causes leading to the amputation.
RESULTS:
There were 203 patients who underwent amputation during the period of study. 135 (66.5 percent) of the patients were diabetic and amputations performed were related to diabetic foot conditions. 68 (33.5 percent) patients were not known to have diabetes mellitus. Among nondiabetic patients, 54 (26.6 percent) amputations were due to trauma, 11 (5.4 percent) were related to musculoskeletal tumours and 3 (1.5 percent) were due to peripheral vascular disease. Among diabetic patients, 23 (17 percent) patients underwent above knee amputation, 44 (33 percent) patients underwent below knee amputation, and 68 (50 percent) patients underwent local foot amputation. 80 of 135 (59.3 percent) patients, who underwent amputation due to diabetic complications, were less than 60 years old.
CONCLUSION:
Good diabetic control and detection of early diabetic foot complications will reduce the number of patients undergoing limb amputation as well as the number of amputees. Since the incidence of lower limb amputation is due mainly to poor diabetic control, it is important to protect this group of patients from a probable avoidable amputation.
The effects of Seal-In X5 and Dermo liner (Össur) on suspension and patient's comfort in lower limb amputees are unclear. In this report, we consider the case of a 51-yr-old woman with bilateral transtibial amputation whose lower limbs were amputated because of peripheral vascular disease. The subject had bony and painful residual limbs, especially at the distal ends. Two prostheses that used Seal-In X5 liners and a pair of prostheses with Dermo liners were fabricated, and the subject wore each for a period of 2 wks. Once the 2 wks had passed, the pistoning within the socket was assessed and the patient was questioned as to her satisfaction with both liners. This study revealed that Seal-In X5 liner decreased the residual limb pain experienced by the patient and that 1-2 mm less pistoning occurred within the socket compared with the Dermo liner. However, the patient needed to put in extra effort for donning and doffing the prosthesis. Despite this, it is clear that the Seal-In X5 liner offers a viable alternative for individuals with transtibial amputations who do not have enough soft tissue around the bone, especially at the end of the residual limb.