Stephen L. Hill

The effects of peripheral vascular disease with osteomyelitis in the diabetic foot

BACKGROUND Osteomyelitis in the diabetic foot is a difficult problem with multiple etiologies. The effects of peripheral vascular disease, neuropathy, and repetitive trauma all interact to produce complex lesions with exposed bone, surrounding cellulitis, and gangrenous changes. METHODS We performed a retrospective study over a 14-year period at a community hospital looking at osteomyelitis in the diabetic foot. We looked at the contributing factors, organisms involved, most common locations, physical findings, and surgical procedures necessary to treat this condition. The purpose of the study was to determine the incidence and effect of peripheral vascular disease in diabetic patients with foot ulcers. RESULTS There were a total of 150 patients requiring 278 hospitalizations over the 14-year period who represented 14% of all diabetic admissions. A total of 438 surgical procedures were necessary in these patients, with the most common being debridement (39%) and toe amputation (19%). There were 6 deaths (4%) in this series, and leg amputation was necessary in 21 patients (14%). A vascular bypass was necessary for healing and limb salvage in 36 patients (24%). Most of the bypasses (85%) were with autogenous tissue to the distal leg in order to limit the extent of amputation and to preserve a functional limb. CONCLUSION Ischemia is often a contributing factor in the diabetic foot ulcer that must be recognized and treated to avoid prolonged hospitalization, spreading infection, and unnecessary amputation.

Heparin, deep venous thrombosis, and trauma patients☆

One hundred consecutive patients with multiple trauma, who were admitted to a level I trauma center with an injury severity score of 10 or greater, were studied prospectively. A duplex scan was used to evaluate each patient initially and at set intervals during the hospitalization for the presence of deep vein thrombosis (DVT). The prophylactic regimen for DVT in this study was 5,000 U of subcutaneous heparin every 12 hours. This was used in 50 patients at the discretion of the attending physician, while the remaining 50 patients received no DVT prophylaxis. Fourteen of 50 patients (28%) who were receiving heparin developed DVT, while only 1 patient (2%) of the 50 who did not receive heparin developed DVT. The use of heparin did not provide any significant protection in the susceptible trauma patient. It is believed that those patients with minimal lower extremity injuries, lower injury severity scores, and a shorter period of immobilization do not require any form of DVT prophylaxis. However, those patients at increased risk for DVT are better served with either increased doses of heparin or alternative forms of DVT prophylaxis.

The origin of lower extremity deep vein thrombi in acute venous thrombosis

BACKGROUND: It has been taught that most deep venous thromboses (DVT) begin in the deep veins of the calf and propagate proximally. The duplex ultrasound scan, with its noninvasive characteristics and accuracy, has brought this premise into question. The purpose of this study was to determine the pattern and distribution of acute DVT as well as the different types of thrombi. METHODS: We performed a retrospective review of all duplex scans ordered for a diagnosis of acute lower extremite DVT at a 200-bed hospital over a 5-year period. RESULTS: There were 3,585 examinations performed on 2,654 patients. There were 461 patients (17.4%) with a venous thrombosis. Four types of venous thrombosis were identified: an isolated thrombosis in one venous segment (34%), a thrombosis extending over two or more contiguous segments (52%), multiple thromboses in noncontiguous segments (8%), and bilateral thrombi in different locations (6%). CONCLUSION: Calf vein thrombi represented 24% of all DVT. Thrombi in the major veins of the thigh and popliteal space without calf involvement were present in 49% of all DVT. The data in this paper indicate that most significant deep venous thromboses do not begin in the calf but instead arise in the proximal thigh or groin.

Massive venous thrombosis of the extremities

Massive venous thromboses of the extremities, although uncommon, are responsible for many of the long-term sequelae associated with venous disease. The charts of all patients with a diagnosis of iliofemoral venous thrombosis or subclavian vein thrombosis over a 6-year period were reviewed. There were 59 patients with iliofemoral venous thrombosis and 18 patients with subclavian vein thrombosis. Iliofemoral venous thromboses were three times more common, showed the classic leftsided predominance, and were more likely to be idiopathic. Subclavian vein thromboses showed no side or sex predilection and were due to anatomic abnormalities, intravenous lines, or radiation. Iliofemoral venous thrombosis showed poor response to lytic therapy, whereas subclavian vein thromboses were effectively lysed in those patients in whom it could be used. Massive venous thromboses of the extremities, although similar in presentation, have different characteristics depending upon the extremity affected. The cause, frequency, and response to treatment differ, which could ultimately influence outcome and the severity of postphlebitic symptoms.

Selective use of the duplex scan in diagnosis of deep venous thrombosis

BACKGROUND The introduction of managed care, with its emphasis on cost containment, makes it of paramount importance that all tests ordered be specific, selective, and appropriate. METHOD The data concerning patients who underwent a duplex scan to determine the presence of deep venous thrombosis (DVT) over a 68-month period, were reviewed in order to determine if the test was ordered appropriately. The symptoms that prompted the test, type of physician ordering the test, and demographic data for both the patients who tested positive and negative were tabulated. RESULTS A total of 2,841 duplex scans were ordered over a 68-month period for presumptive diagnosis of DVT of an extremity. A total of 524 (18%) scans were positive for thrombosis; however, 27% (144) of these were superficial or a small isolated thrombus in the calf or forearm. Thus, only 380 studies, or 13% of the total scans ordered, were positive for a major DVT requiring treatment. The only symptoms consistently found in the positive group were pain, edema, dyspnea, and a history of DVT. Of the types of physicians ordering the test, emergency department physicians were least specific, with only 12% of the scans ordered being positive for DVT; surgeons were more selective and had a 19% positive rate, while internal medicine physicians had a 20% positive rate. CONCLUSION The duplex scan allows the physician the ability to easily diagnose venous thrombosis, but its indications need to be more carefully guided by history, physical examination, risk factors, and logic to enhance its use and effectiveness. This study analyzes the risk factors and symptoms involved in order to assist the clinician in determining when the duplex scan is indicated.

Early diagnosis of iliofemoral venous thrombosis by Doppler examination

The diagnosis of iliofemoral venous thrombosis prior to its progression to phlegmasia cerulea dolens can be difficult and, at times, confusing. The Doppler ultrasound examination in experienced hands can be extremely reliable and rapid in diagnosing the condition. During an 18 month period, we used the Doppler examination to diagnose iliofemoral venous thrombosis in 21 patients, 15 of whom had corroboration by venogram. The key to successful treatment and avoidance of significant complications was early and accurate diagnosis by the Doppler examination. No patient underwent operation or progressed to venous gangrene. Six were treated with streptokinase and the rest, with intravenous heparin, leg elevation, and stockings. We believe that iliofemoral venous thrombosis is a much more common disease than previously recognized and should be vigorously diagnosed and treated when a patient presents with a symptomatic extremity. The Doppler ultrasound examination represents a rapid, reliable alternative to the venogram in the early diagnosis of iliofemoral venous thrombosis.

DEEP VENOUS THROMBOSIS IN THE TRAUMA PATIENT

The incidence of deep venous thrombosis (DVT) in the trauma population and those risk factors which affect its development remain an enigma. We prospectively studied 100 trauma patients admitted to a Level I trauma center with duplex scans throughout their hospitalization. Fifteen patients (15%) developed DVT. The remaining 85 patients (85%) had no evidence of DVT during their hospitalization. The two groups were similar in sex ratio, Glasgow coma scale, trauma score, and type of injury. Fourteen patients (93%) with DVT had been given prophylactic treatment with 5,000 units of Heparin subcutaneously q12h, and 36 patients (42%) without DVT were similarly treated. The data in this study describe the incidence of DVT (15%) in the trauma population and those patients at most risk for its development. Patients admitted with high Injury Severity Scores and extremity injuries are at most risk for development of DVT.

The peroneal artery in limb salvage

In many patients the progression of atherosclerosis in the lower extremities can be insidious, only becoming manifest with gangrene or an ischemic ulcer. The authors have found, in reviewing their patients with end-stage limb salvage procedures, that the peroneal artery can offer a good bypass vessel in a difficult situation. Over a five-year period they isolated 32 in situ operations performed for gangrene, rest pain, or ischemic ulcers. This represented 8.9% of the 466 vascular operations performed during this time. Of these end-stage cases, 34% (11 limbs, 9 patients) were salvaged by a femoral-peroneal in situ bypass graft. Ankle/arm index preoperatively ranged from 0.0 to .5, the average being .27. In the 11 limbs, all bypasses were immediate successes with the relief of rest pain, the return of adequate circulation, and the improvement of ankle/arm index to an average of .79. Six remained patent until the patient’s death. Three are still patent (one year, two years, and four and a half years, respectively) and 2 occluded, necessitating amputation at four months and seven months postoperatively. Therefore, in 9 of 11 limbs (81%) the purpose of salvage was achieved.The peroneal artery, although a difficult vessel to locate and dissect out, represents a viable option for limb salvage. It does not need to be exposed from the lateral approach and does not require resection of the fibula. It should be approached medially. The peroneal artery, if approached properly and used effectively will often provide the vascular surgeon with an adequate vessel to salvage limbs with end-stage vascular disease.