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Byline: Staff WritersToronto, Canada (SPX) Jan 03, 2019, 2019 A unique collaboration between University of British Columbia (UBC) zoologists and U of T Engineering's aviation expert Professor Philippe Lavoie provides [...]

Complications related to intraaortic balloon counterpulsation pumping (IABP) remain a problem despite the development of small caliber balloon catheter shafts and introducer sheaths. The authors report their experience in counterpulsation-related [...]

BACKGROUND: Extremity soft tissue infections from group A, [Beta]-hemolytic streptococcus frequently culminate in amputation. This study compares our protocol for limb salvage with expected results. METHODS: Patients with extremity streptococcal gangrene treated from 1989 to 1995 were reviewed. The management protocol mandated immediate, radical excision of involved skin and subcutaneous tissue, with preservation of fascia. Patients were managed in the burn unit, and wounds were covered with split-thickness skin grafts. Amputation rate and mortality were measured. RESULTS: Fourteen cases of extremity streptococcal gangrene were identified. Delay to surgical referral was 5 days. Eleven (79%) patients were septic. Ten (71%) were managed with a single debridement before grafting. Limb salvage was 93% (13 of 14). One patient (7%) died on day 150 from acute myelogenous leukemia. CONCLUSIONS: Delay in referral of extremity streptococcal gangrene is common, contributing to a high incidence of sepsis. Our management protocol of a single, radical debridement with preservation of fascia maximizes limb salvage and survival. Am J Surg. 1998;175:213-217. [C] 1998 by Excerpta Medica, Inc.

BACKGROUND: The role of scoring systems as predictors of amputation and functional outcome in severe blunt extremity trauma was examined. METHODS: All severe extremity injuries treated over a 10-year period were scored retrospectively using four scoring systems: Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and Limb Salvage Index (LSI). RESULTS: Twenty-three-upper (UK) and 51 lower extremity (LE) injuries were evaluated. Sensitivity and specificity, respectively, were MESI 100% and 50%, MESS 79% and 83%, PSI 96% and 50%, and LSI 83% and 83%. For each system, there were no differences between patients with good and poor functional outcomes. CONCLUSION: All of the scoring systems were able to identify the majority of patients who required amputation. However, prediction in individual patients was problematic. None of the scoring systems were able to predict functional outcome.

Evaluation of a multi-dimensional treatment approach for extremity sarcoma (cancer of an arm or leg) in 60 patients at three different research institutions is presented. Patients underwent extensive examination prior to surgery, including chest X-ray, chest CT scan (an X-ray of structures inside the chest), an extremity CT scan, and an arteriogram (injection of dye into an artery under X-ray guidance to enable visualization of the vessel). Biopsies of the affected area were performed and doxorubicin hydrochloride was administered directly into the vessels feeding the tumors in these patients. The chemotherapy lasted three days. Patients also received radiation therapy at different dose levels, depending on the institution where they received treatment. Seventeen tumors were in the upper extremity and 43 in the lower. Appropriate limb-salvage surgery was performed, and 31 patients received postoperative chemotherapy. Median follow-up time was 56 months. Results showed an overall survival at 60 months of 58 percent of the patients, with disease-free survival for 47 percent. Between 35 and 60 months, the recurrence rate was 52 percent. The variables with the greatest prognostic importance were the grade (severity) of disease, its size, and patient age (for patients with high-grade tumors), with younger patients surviving longer. It appears that therapy using a combination of approaches can result in excellent control of disease, good limb function, and reasonable survival in patients after limb salvage surgery. (Consumer Summary produced by Reliance Medical Information, Inc.)

In situ bypass surgery using the saphenous vein in the leg is a standard treatment for ischemia (loss of blood supply) caused by blockage of the femoral artery in the lower extremity. In this technique, blood from the artery is rerouted through a section of the adjacent vein without removing the section of the vein, and returned to the artery at a point past the diseased artery. It has become the preferred method of reconstructing arteries in the lower limbs. Restoring blood flow to the area and salvaging the limb have been successful, but there are nevertheless complications associated with this procedure. Clinicians believe that wound complications occur more frequently than reported, with wound infection and necrosis (tissue death) being two of these complications. A chart review was initiated of all patients undergoing reconstruction of an artery in the lower extremity performed over a five-year period, to determine the factors associated with development of wound complications. There was a 17 percent incidence of wound complications. Four factors were identified as increasing the risk of wound complications: bypass graft of the dorsalis pedis artery; the use of the true in situ method; presence of a limb ulcer, primarily of the foot; and chronic steroid therapy. Diabetes mellitus alone did not place the patient at risk of wound complications; however, it does contribute to delayed wound healing. Careful surgical procedure and reduction of risk factors can minimize the possibility of wound complications in a majority of patients undergoing lower extremity arterial reconstruction. (Consumer Summary produced by Reliance Medical Information, Inc.)

Treatment of penetrating trauma near major blood vessels of the extremities without evidence of vascular injury remains controversial. A total of 254 patients with 318 penetrating wounds to their extremities were evaluated. Several major arteries in the area of the penetrating wound were at risk of injury, yet there was only a 10 percent incidence of injury to a major artery in this study. Vascular injuries frequently require prompt surgical exploration and repair. When there is no clear evidence of vascular injury, management of the penetrating trauma in proximity to major extremity arteries is less clearly defined. Arteriography, radiographic visualization of arteries, is useful to detect vascular injuries and is used before exploratory surgery is initiated. The location and mechanism of the injury to the extremity have some predictive value for identifying the presence of injury to a major artery. Shotgun wounds and any penetrating wound of the chest cavity should be routinely evaluated using arteriography. The physical exam is still the most reliable, safe, and practical management of penetrating trauma in proximity to a major artery. (Consumer Summary produced by Reliance Medical Information, Inc.)

Surgical procedures are always associated with some risks; however, it has been generally accepted that a recent acute myocardial infarction (MI; heart attack) is a contraindication for any type of major surgery. There are three situations that are believed to warrant emergency surgery: repetitive transient ischemic attacks (''ministrokes''), lower extremity disease with systemic toxicity, and limb-threatening ischemia (loss of blood supply). Patients with recent myocardial infarctions who underwent emergent vascular surgery were evaluated to determine the rate of cardiac complications. Several standard scales were used to determine cardiac risks factors, including the Goldman scale. Surgery was performed on 30 patients within six weeks of an acute MI. Preoperative complications were often responsible for the development of severe peripheral vascular disease, specifically, an occlusion (blockage). The most frequent procedures performed were bypass grafting of blood vessels in the extremities and thromboembolectomy, removal of an embolism blocking a blood vessel. Surgery was delayed as long as possible in all patients to allow for maximal recovery of the heart muscle following the MI. There were a total of four postoperative deaths, two which were believed to be directly related to the original MI. The surgical procedures performed were all outside the chest cavity; nevertheless, improvements in anesthetic and perioperative management may also be factors in the overall low rate of cardiac complications of 17 percent. This rate was compared with the predictions based on use of the Goldman scale and the actual results were considerably better than expected. It is not absolutely necessary to wait up to six months after an MI before operating. Under certain circumstances aggressive early surgical intervention is justified for procedures outside the chest cavity or involving the extremities. (Consumer Summary produced by Reliance Medical Information, Inc.)

Summary points At the Red Cross Children's Hospital in Cape Town it was decided, on ethical grounds, against novel limb allografts for two patients--one with no hands and one with [...]

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A recent study investigated and demonstrated the clinical utility of using the McKenzie classification categories for patients with extremity problems, according to The McKenzie Institute. The recent study, 'A Survey [...]

This sensation usually comes on when you put pressure on a nerve--say, by crossing your legs tightly or falling asleep with one arm under you--cutting off signals to the brain [...]