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Thu Aug 10 00:06:13 BST 2006

As Leo Getz was so fond of saying, "OK, OK, OK".....

I keep on hearing about the extravagant vascular repairs and heroic
reconstructions that so many who are so expert in vascular surgery have
proposed.  We have also been hearing of techniques to control lymphedema
in the salvaged limb.   All of the discussions have been very
enlightening and thought-provoking, and I certainly have learned a bit
on this one; I will defer to guys like Eric and Ken for any vascular
procedure - 'cause they are certainly well known as "the gurus". 
However, I STILL have not heard from Ken exactly what has been left with
respect to the gentleman's thigh musculature, and exactly what sort of
functional outcome the physiatrists are predicting with best case
scenario muscle mass they are going to have to work with, let alone the
worst case scenario where much more debridement is going to be needed. 
Yes, the vascular repairs can be done, and the nerve might be intact,
but sans photos and/or a clear description, we still do not know if
there is enough functional muscle to enable the man to eventually use
his saved leg.  

Ken?????

Best to all, especially to your 3 unfortunate patients,
Ron
>>> "Mark Hamilton" <vascular at ekit.com> 8/9/2006 4:39 PM >>>
Thanks Karim,

I too have had a bit of a look for the references that KM and ERF have
suggested are out there, and most of them are from late 70's early
80's, and
as you say, mainly retrospective.  I also concur that vein has
different
properties to PTFE, else why would we preferentially use it for
CABG/Fem-pop/AV Fistula etc.  

I guess it gives me scope for a randomised prospective trial.....might
have
to be on sheep in NZ though as we don't have very many GSW here ! :-)

As for this guys limb....I'd try and preserve it.  I suspect the
blowouts
are sepsis related and that the groin is going to remain a no go zone
for
any form of reconstruction for some time. Obturator bypass or ax-pop
would
be reasonable alternatives then debride the groin to billy-oh, VAC and
wait.
The venous issue remains a problem....in the long term it will probably
be
ok if not reconstructed, however in the short term and reconstruction
is
going to be made very hard work by oedema etc with the likelihood of
wound
complications in this as well (all the more reason to use autogenous I
would
have thought).  Profore bandaging may be useful here in the short term
(but
it does take a skilled person to apply it).

Mark

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Karim Brohi
Sent: Wednesday, 9 August 2006 9:48 p.m.
To: Trauma &amp, Critical Care mailing list
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"