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Wed Aug 9 18:10:53 BST 2006

 Karim--
There is nothing clear cut about this, I am sorry if that impression was given.  The difference between the two in a contaminated field that makes synthetic better than autogenous vein is that when infected the vein disintegrates with the "blowout" and life threatening hemorrhage--syntheitcs do not as a rule do this, but leak slowly as in this case which can more easily be taken care of by measures as in this case--this is why you see false aneurysms around infected grafts which you do not see with vein anastomoses, as anyone who does vascular surgery can attest--in fact there appears no difference in the vulnerability to infection between the two.  The difference is how they act when infected.  These differential properties are well documented in the literature, refs can be found in Chapter 43 of TRAUMA 5th edition.  This is why synthetics are best to use in infected fields IF you must, as certainly you try not to put any anastomosis in such a field if it can be avoided--and the assumption is if you must do this that whatever you put there is purely temporary--something else must eventually be done to get out of that field
ERF

-----Original Message-----
From: karimbrohi at gmail.com
To: trauma-list at trauma.org
Sent: Wed, 9 Aug 2006 5:48 AM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

I've been following this peripherally but I'd agree that if the is 
neurological function in the limb and future soft tissue cover is possible 
then amputation is not the way to go at this stage (you'd probably be 
looking at a hindquarter after all with very poor chance of 
rehabilitation.) Some pictures would be helpful but there are several 
vascular reconstructive options including obturator bypass to the distal 
SFA/popliteal. 

The blow-outs *must* be due to infection and the stents will *probably* only 
temporise this (although there may not be a rush to intervene if things are 
controlled at present. 

I personally remain unclear about the role of synthetic vs autogenous graft 
in these wounds. I have searched the literature and do not find the clear 
cut evidence that Ken & Rick have quoted. There are some retrospective 
studies in the mid 80s - early 90s but I can't see anything definitive - or 
even very conclusive. If you have the actual references that people believe 
definitively prove this I'd love to read them. 

Regardless of vein being a *dead collagen tube*, there is no doubt it has 
different properties to synthetic graft. Which is more appropriate for 
trauma - proximal or distal, infected or non-infected I believe is not yet 
proven by the type of study one would like to see. 

Karim 

On 08/08/06, docrickfry at aol.com <docrickfry at aol.com> wrote: 
> 
> I agree with this and am very sensitive about removing a doomed limb at 
> the earliest time, but right now we are just days, not weeks and months, 
> into it, and there is really no indication of inevitable doom just yet. The 
> LEAP study published in several installments in the NEJM has clearly shown 
> that some of the old maxims guiding the need for early amputation have 
> fallen by the wayside as data drives by--i.e. loss of plantar sensation, 
> Gustilo III-C injuries, severe venous insufficiency, etc etc have all shown 
> surprisingly good salvage of reasonably functional limbs with present 
> technology. In view of the patient's wishes to continue, and no overriding 
> reason to amputate at present, I think it is reasonable to give the wounds a 
> chance to heal and attempt an extra-anatomic bypass within a few days if at 
> all feasible. 
> ERF 
> 
> 
> -----Original Message----- 
> From: rgross at harthosp.org 
> To: trauma-list at trauma.org 
> Sent: Tue, 8 Aug 2006 3:50 PM 
> Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous" 
> 
> 
> Ken, 
> While the leg might be viable, is it or might it still be FUNCTIONAL. 
> As I try to envision the destruction to the groin and upper thigh as 
> described, a wonder if there will be any FUNCTION or if he will instead 
> be dragging a viable, non-functional appendage, much as a sailboat would 
> drag her anchor in a storm....... 
> My guess is, knowing Dr. Mattox, that the leg will not be functional, 
> and the debate now raging is more (understandably) emotional than 
> ethical, or scientific. 
> Amputation now will enable emotional and physical rehab in the very near 
> future. Delay, with months of futile surgical heroism will delay and 
> perhaps eliminate eventual emotional rehab, regardless of the physical 
> outcome. 
> I will shut up now. 
> Ron 
> 
> >>> <KMATTOX at aol.com> 08/08/06 3:25 PM >>> 
> 
> In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time, 
> sohailmuzammil at hotmail.com writes: 
> 
> The time has come to counsel the patient and 
> amputate (or ablate as Dr. Mattox puts it). 
> 
> Regards 
> S Muzammil, FRCS 
> 
> 
> 
> This suggestion was also mentioned in our group, by me. It has caused 
> a 
> great deal of ethical, moral, and scientific polarization. The leg is 
> still 
> viable. The man is a construction worker and wants to keep his leg. 
> 
> 
> k 
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SGW to Femoral triangle - Synthetic vs "autogenous"