In comparison to published reference values, the TBI in young, healthy individuals is significantly higher. Whereas no gender difference existed, greater variability of the TBI was observed in women. Further studies are recommended to determine if the threshold for diagnosis of peripheral arterial disease based on TBI should be raised.
A pulseless limb is considered a hard sign of vascular injury after penetrating trauma in the civilian population. However, the reliability of this finding has never been examined in combat trauma. The purpose of this study was to examine the reliability of the pulseless limb in the combat trauma population. Methods: The Joint Theater Trauma Registry (JTTR) identified all patients who presented to a military treatment facility in Kandahar, Afghanistan, with a penetrating extremity injury during a 2-year period. Patients with pulseless limbs were followed up, and the results of the subsequent computed tomographic angiogram (CTA) or angiogram recorded. Patient demographics and injury patterns were examined. Standard statistical analysis was performed. Results: From 2011 to 2012, 638 patients were treated for penetrating extremity injuries. The mechanisms of injury were explosions (62%), firearms (20%), or other etiology (18%). Of the 566 patients with complete records, 436 (77%) presented with palpable pulses, 119 (21%) presented with a pulseless limb, and 11 (2%) presented with other hard signs of vascular injury. Forty-two patients (35%) with a pulseless limb underwent an immediate CTA (83%) or angiogram (17%) that identified no vascular injury. Twenty-six of those patients (62%) sustained an injury from an explosion, 14 (33%) from a gunshot wound, and two (5%) from other causes. Patients with an abnormal pulse examination and normal CTA/angiogram were compared with all other patients after a penetrating injury. There was a significantly higher chance of a pulseless limb as a result of a gunshot injury, but not an explosion or other mechanism of injury (P < .0005). Patient variables and risk factors were analyzed. Acidosis (P < .0005), gunshot wounds (P ¼ .025), and battle injuries (P ¼ .031) were associated with an abnormal pulse examination and normal CTA or angiogram. Conclusions: Unlike previous studies, our results demonstrate that a pulseless limb poorly predicts a vascular injury in this population. Acidosis, a surrogate for under-resuscitation after penetrating injuries, may contribute to the decreased accuracy of the physical examination in combat warriors. Future studies must continue to focus on improved algorithms for accurate diagnosis of extremity vascular injuries in this population.
Between 2005 and 2013, nine patients (3%) with malignant lower extremity STS underwent surgical resection with vascular reconstruction. Of these, 6 (67%) underwent resection of femoral and popliteal vessels with subsequent femoropopliteal bypass, 1 (11%) underwent resection of femoral vessels with iliac-SFA bypass, 1 (11%) underwent transection of the femoral and popliteal vessels with reanastomosis, and 1 (11%) underwent resection of the superficial femoral vessels with superficial femoral artery-distal superficial femoral artery bypass. All bypasses were performed using saphenous vein from the contralateral leg. Four patients (44%) returned to the operating room for wound complications requiring incision and drainage. Three (33%) required plastic surgery each for one of the following: VRAM flap, split-thickness skin graft, and pedicle gracilis flap. Functional activity was assessed using the criterion 1 of the Musculoskeletal Tumor Society (MSTS) functional assessment forms preoperatively and at follow-up at 6 months and 1 year. A score of 5 indicates no functional restrictions, whereas a score of 0 indicates total disability. The mean MSTS scores preoperatively and at 6 months and 1 year were 4.1, 3.6, and 3.8, respectively, for the vascular reconstruction group, and 4.2, 4.3, and 4.3, respectively, for the limb-sparing surgery without vascular reconstruction group. Conclusions: The need for vascular reconstruction during limbsparing surgery for lower extremity malignant STS is rare in a high-volume sarcoma center. Wound morbidity is high, and these patients frequently require plastic surgery to achieve wound healing. Postoperative functional status as assessed by the MSTS is acceptable but may be lower than in patients not requiring vascular reconstruction.
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