Browsing by Subject "Lower Extremity"
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Item Deep Venous Thrombosis and Pulmonary Embolism after Lower Extremity Amputation in Patients with Diabetes(2018-01-23) Gallaway, Kathryn E.; Ahn, Junho; Raspovic, Katherine M.; Wukich, Dane K.This study aims to identify risk factors for deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients with diabetes mellitus (DM) undergoing a lower extremity amputation (LEA). A retrospective analysis of 36,445 LEA cases from the American College of Surgeons-National Surgical Quality Improvement Program (ACSNSQIP) database was performed. 23,380 patients with DM and 13,065 patients without DM were evaluated to determine whether DM is correlated with an increased risk of DVT and PE. Specific risk factors for DVT and PE in this population were also evaluated. The incidence of DVT in post-LEA patients with DM was 0.94% compared to 1.36% in patients without DM (p=0.0002). The incidence of PE in patients with DM was 0.37% compared to 0.54% in patients without DM (p<0.0001). Although statistically significant, this small increase in DVT/PE risk appears to be driven by a higher proportion of "completely dependent" patients without DM (p<0.0001). Patients with "completely dependent" pre-op functional status were 2.59 times more likely to develop a DVT (95% CI: 1.81-3.70) and 3.36 times more likely to experience a PE (95% CI: 1.97-5.72), while "independent" patients were significantly less likely to experience either complication. Level of amputation (LOA) was also associated with an increased risk of DVT and PE. Patients who underwent a below knee amputation (BKA) were 2.12 times more likely to experience a DVT/PE (95% CI: 1.40-3.12) and patients with an above knee amputation (AKA) were 1.82 times more likely to experience a DVT/PE (95% CI: 1.40-3.21). Patients who underwent a transmetatarsal amputation (TMA) were significantly less likely to experience either complication. Other statistically significant risk factors identified in this study include prior myocardial infarction, ASA classification of III-V, and female sex. Patients with a history of dialysis within 2 weeks of surgery had an increased risk of DVT (OR: 1.52, 95% CI: 1.15-2.02); however, no increased risk of DVT/PE in patients with Chronic Kidney Disease (CKD) stage III-V was found (OR: 1.19, 95% CI: 0.97, 1.45). Although DM is not associated with increased risk of DVT/PE, LOA is a significant predictor of DVT/PE risk. Diabetics with peripheral neuropathy may delay seeking treatment due to lack of pain, potentially resulting in higher LOA. Physicians should emphasize rapid evaluation and management of pressure sores to minimize LOA. Prophylactic antithrombotic protocols should also be considered for patients undergoing a high level amputation and for patients with comorbid risk factors such as cardiovascular disease or dependent functional status.Item How Do Open Distal Tibia Fractures Differ from Open Tibial Shaft Fractures?(2018-01-23) Nguyen, Ivy; Ho, Christine AnnPURPOSE: The purpose of this study was to compare a cohort of open distal tibia fractures to open tibial shaft fractures in regards to injury severity, method of fixation, and outcomes. METHODS: This is a retrospective review of 49 open distal tibia fractures (group D) with a mean age of 8.7years and 56 open tibia shaft fractures (group S) with a mean age of 8.6years, treated from 2007-May2017 at a single level 1 pediatric trauma center. Mann Whitney test was used to compare means between groups. RESULTS: Extremely high energy trauma (ATV, GSW, vehicular collision, lawnmower, crush, fall >8 feet) was the mechanism of injury in 90% (44/49) in group D and 77% (43/56) in group S (p=0.119). Mean AIS lower extremity scores were significantly higher in group S compared to group D (2.74 vs 2.55, p=0.043), as were mean Injury Severity Scores (13.10 vs 9.36, p=0.053). There were more Gustilo type II fractures in group S (42% vs. 35%), and more Gustilo type III fractures in group D (51% vs 39%) which trended towards significance (p=0.0622). 88% (43/49) of open distal tibia fractures had ipsilateral fibular involvement, compared to 71% (40/56) of open tibial shaft fractures (p=0.054). Tibial fixation methods were statistically different between the 2 groups (Table 1, p=0.0377), but incidence of fibular fixation was not statistically different (group D-12% vs group S-5%, p=0.4348). While surgical time and fluoroscopy times were not significantly different between the two groups, group D had longer mean length of hospitalization (8.44vs6.36 days, p=0.006), mean duration of immobilization (135vs100 days, p=0.033), and longer mean time to full weight bearing (77vs40 days, p=0.006). Rate of hardware removal (group D-49%, group S-52%) and radiographic angulation at final follow-up were not statistically significantly different between the two groups (p>0.05). Mean time to union was prolonged for both groups (178 days group D-178 days, group S-139 days, p=0.231). CONCLUSIONS: Open distal tibia fractures are significant for extremely high energy of injury. Alternate methods of fixation for open distal tibia fractures such as external fixation, K wires, and ORIF are more likely to be utilized than flexible intramedullary nailing. Open distal tibia fractures have longer hospital stays, immobilization, and time to full weightbearing but radiographic outcomes and time to union are comparable. SIGNIFICANCE: This study increases awareness of the difference in injury severity, fixation methods, and clinical course between open distal tibia and open tibial shaft fractures.Item [News](1984-09-14) Rutherford, SusanItem Prescription Trends During Lower Extremity Peripheral Artery Endovascular Interventions: Insights from the XPLAD Registry(2016-01-19) Kocak, Denizen; Planchard, Kyle; Das, Thomas M.; Mohammad, Atif; Armstrong, Ehrin J.; Shammas, Nicholas W.; Gigliotti, Osvaldo; Klein, Andrew; Brilakis, Emmanouil S.; Banerjee, SubhashDespite peripheral arterial intervention procedures (PAI) becoming the most utilized treatment in the symptomatic peripheral artery disease patient population, adherence to guideline management therapy (GMT) has not been well described. PAIs (n=1532) registered in the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) from 13 U.S. centers between 2005 and 2013 were evaluated for adherence to GMT at discharge post-PAI, which is comprised of antiplatelet therapy (APT), lipid-lowering therapy (LLT), and renin-angiotensin pathway inhibitors (RAI) including angiotensin receptor blockers (ARB) and angiotensin converting enzyme inhibitors (ACEI). In addition, a subset of patients (n=365) were tracked over a three year period and adherence to GMT and adverse events were analyzed in SAS using a Cox proportional hazard ratio adjusted for baseline characteristics. Analysis of 1532 PAI in the study periods (n=55 in 2005-2007, n=314 in 2008-2010, and n=1,163 in 2011-2013) demonstrates an exponential rise in PAIs, consistent with national U.S. trends. This rise in PAI was not accompanied with an equally robust adherence to GMT. Excluding the limited number of patients enrolled from 2005-2007, the period between 2008 and 2013 demonstrates suboptimal adherence to GMT across all therapy groups. APT prescriptions fell from 90% to 77%, between 2008-2010 and 2011-2013 (p<0.001), and dual-APT prescriptions remained consistently low during the periods (53% vs. 48%). Consistent with the overall trend of falling adherence to GMT between 2008-2010 and 2011-2013 (55% vs. 42%; p<0.001), individual prescriptions of LLT and RAI were also significantly lower (83% vs. 66% for LLT; p<0.001 and 62% vs. 49% for RAI; p<0.001), respectively. Analysis of prescription therapy course in a subset (n=365) patients over time showed a statistically significant drops in APT (95.9% vs. 83.8%; p<0.0001) and dual-APT (74.8% vs. 31.1%; p<0.0001) therapy at one year post-PAI and a significant decrease in dual-APT therapy between one and two years post-PAI (31.1% vs. 18.9%; p=.001) (Figure 3). Cox proportional analysis in these patients showed that APT and dual-APT prescription both significantly decreased the risk of Major Adverse Cardiovascular Events (MACE) but had little effect on Major Adverse Limb Events (MALE) (Figures 1 & 2).