Betty Leclerc

Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years

BACKGROUND Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. HYPOTHESIS The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. MATERIAL AND METHODS A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. RESULTS The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. DISCUSSION Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. LEVEL OF EVIDENCE IV, retrospective observational study.

How to identify patients at risk of abdominal compartment syndrome after surgical repair of ruptured abdominal aortic aneurysms in the operating room: A pilot study

Objectives Abdominal compartment syndrome (ACS) is poorly identified in surgery for ruptured abdominal aortic aneurysm and an early management is crucial. The aim of this study was to validate how many risk factors were needed to predict ACS. Secondary objectives were to assess its prevalence and the 30-day mortality. Methods All patients operated for ruptured abdominal aortic aneurysm during 5 years were included. An independent committee performed a retrospective diagnosis of ACS. Eight criteria were selected from the literature, and corresponded to pre- and intraoperative period: anemia (hemoglobin lower than 10 g/dL), prolonged shock (systolic blood pressure <90 mmHg more than 18 min), preoperative cardiac arrest, obesity (body mass index > 30), massive fluid resuscitation (≥3500 mL per hour for at least 1 h) and transfusions (>10 units packed blood red cell since the beginning of the treatment), severe hypothermia (≤33℃), acidosis (pH < 7.2). Sensitivity and specificity were assessed for each number of criteria. Results Eight patients were ACS+ and 28 ACS-, with three criteria for ACS+ and 1.5 for ACS- (p = 0.002). Three criteria among the eight selected criteria have the best cutoff for sensitivity and specificity (75% and 82%) with a positive predictive value of 54% and a negative predictive value of 92%. The prevalence of ACS was 17%. The 30-day mortality in ACS+ tended to be higher than in ACS- (p = 0.108). Conclusion The present results suggest that patients with an ACS seemed to have higher mortality and the threshold of three factors among eight specific factors is enough to predict this.

Axillary artery transection and bilateral pulmonary embolism after anterior shoulder dislocation: case report

Introduction: Anterior shoulder dislocation can be associated with vascular and neurological complications. However, axillary artery injury associated with shoulder dislocation is rare and extremely rare without bone fracture. An early diagnosis of these complications allows predicting long-term functional outcomes. Methods: This article reports the case of a 66-year-old patient who presented an anterior shoulder dislocation after a ski fall without any neurological dysfunction or pulse deficit. Results: The first reduction attempts were unsuccessful and during the new attempt, we observed a hematoma. A CT scan showed a disruption of the axillary artery and a bilateral pulmonary embolism. Conclusion: Neurovascular injury must be systematically sought before and after reduction, and a multidisciplinary approach is always necessary.