Objective To investigate the clinical effect of the one-stage arteriovenous shunt on the extensive arterial ischemic disease of the lower extremities. Methods The one-stage arteriovenous shunts in the lower extremities were applied to 90 patients with extensive arterial ischemic diseases, including arterial occlusive disease (AODs,62 patients) and thromboangiitis obliterans (TAOs,28 patients). By the retrospective analysis on the clinical materials and the follow-up of the postoperative patients, the immediate and the longterm surgical outcomes were summarized. Results During the hospitalization, 88 patients achieved a remarkable surgical effectiveness, with an immediate surgical effectiveness rate of 97.7% (88/90), but 2 patients failed in the operation and had to undergo amputation of the lower limb. Of the 72 patients who were followed up for 0.5-5 years after the arteriovenous shunt operation, 64 could have a sufficient blood supply to the lower extremities, with a longterm effectiveness rate of 88.9% (64/72); however, 8 patients had to undergo transplantation of the greater omentum or amputation of the lower limb. Conclusion The one-stage arteriovenous shunt performedon the lower extremities for an extensive arterial ischemic disease is a simpler and more effective surgical protocol for reconstruction of the circulation of the patient who is not suitable for the operation of arterial bypass.
ObjectiveTo evaluate the value of clinical application of determination of lower venous pressure in the diagnosis and treatment of deep venous thrombosis (DVT). MethodsThe 90 patients with DVT of unilateral lower limb who were admitted by using color Doppler or deep veins of lower limb angiography in our hospital during the period of 2013 July to 2014 June were selected and as the research object (case group), 37 cases were male, 53 cases were female; the age was 18-84 years old, mean age was 59.48 years old. According to the development of disease, 90 cases were divided into acute 30 cases, subacute 30 cases, and chronic 30 cases; and according to the pathological types were divided into the central type in 30 cases, 30 cases of peripheral type, and 30 cases of mixed type. At the same time the without lower extremity DVT volunteers of 20 cases were selected as normal control group, including male 9 cases, female 11 cases; age was 21-65 years old, average age was 38.7 years old. The static venous pressure (P0), dynamic venous pressure (P00), and decreased pressure ratio (Pd) of double lower limbs of participants in 2 groups were determinated and comparative analyzed. ResultsThe P0 and P00 of patients with different development of disease and pathological types of the case group were higher than those of the normal control group (P < 0.01), and the Pd was lower than that of the normal control group (P < 0.01). In case group, the P0 and P00 of acute phase were higher than those of the normal control group (P < 0.01), the P0 of central type was higher than that of the peripheral type and mixed type (P < 0.01), and the Pd central type was lower than that of mixed type (P < 0.01). The above 3 indexes' differences of double lower limbs in the normal control group had no statistical significance (P > 0.01). In case group, the P0 and P00 of ipsilateral limb in different development of disease and pathological types were higher than those of the healthy limb, and the Pd were lower than that of the healthy limb (P < 0.01). ConclusionsLower extremity venous pressure measurements can be used in clinical detection for early lower limb DVT, and can be used as the objective index of clinical evaluation curative effect for the treatment of DVT. It is a simple and practical clinical detection method.
ObjectiveTo study the effectiveness of Keystone flap in the repair of soft tissue defect of lower extremity.MethodsThe clinical data of 27 cases with soft tissue defects of lower extremity treated by Keystone flap between January 2018 and June 2020 were retrospectively analyzed. There were 18 males and 9 females, with an average age of 43.9 years (range, 8-63 years). The cause of soft tissue defects included skin tumor in 3 cases, ulcer in 2 cases, soft-tissue infection in 8 cases, trauma in 7 cases, and donor site defect after free or pedicled flap transplantation in 7 cases. Defect size ranged from 2.0 cm×1.5 cm to 15.0 cm×9.5 cm. The types of Keystone flaps included type Ⅰ in 2 cases, type Ⅱa in 16 cases, type Ⅱb in 1 case, type Ⅲ in 6 cases, and Moncrieff modified type in 2 cases. The area of flap ranged from 3.0 cm×1.5 cm to 20.0 cm×10.0 cm. The donor site was directly sutured (26 cases) or repaired with skin grafting (1 case).ResultsThe operation time was 45-100 minutes, with an average of 67.5 minutes; the hospitalization stay was 3-12 days, with an average of 8.5 days. Postoperative incision dehiscence occurred in 1 case, and flap marginal necrosis occurred in 2 cases, all of which were completely healed after dressing change; 1 case of incision was swollen and congested with tension blisters, which resolved spontaneously at 7 days after operation. The other flaps and the skin grafting survived and healed successfully, the wounds of recipient and donor sites healed by first intention. The healing time was 2-3 weeks (mean, 2.2 weeks). No pain occurred in all patients. All 27 cases were followed up 3-26 months (mean, 11.5 months). No obvious scar contracture and bloated skin flap were found. The texture and color of the skin in the recipient area were similar to those of the surrounding tissues and feel existed.ConclusionThe Keystone flap is a feasible and efficient way to repair soft tissue defect of lower extremity. Furthermore, the skin color and texture is similar to the surrounding tissue after healing.
ObjectiveTo summarize the progress of perioperative pain management in patients with lower limb vascular diseases. MethodRetrieved the literature about pain management in patients with lower limb vascular diseases both at home and abroad in recent years and reviewed the literature. ResultsLower limb vascular diseases were very common in elderly patients. Whether it was limb ischemic pain or surgery-related pain, it often increased the stress response and activation of the autonomic system, which was not conducive to the recovery of the disease. Good analgesic management was important for these patients. Perioperative pain management could be performed by intravenous analgesics, oral analgesics, local anesthesia, neuraxial anesthesia and peripheral nerve block. Acute and chronic pain should be actively managed during perioperative period. Pre-emptive analgesic strategies could be implemented in patients with severe peripheral vascular disease. ConclusionsGood perioperative analgesia management is necessary. Pain management which employes one or more analgesic methods is important in maximizing pain relief, function, and quality of life for this patient group.
Objective To compare the effectiveness of lower extremity axial distractor (LEAD) and traction table assisted closed reduction and intramedullary nail fixation in treatment of femoral subtrochanteric fracture. Methods The clinical data of 117 patients with subtrochanteric fracture of femur treated by closed reduction and intramedullary nail fixation between May 2012 and May 2022 who met the selection criteria were retrospectively analyzed. According to the auxiliary reduction tools used during operation, the patients were divided into LEAD group (62 cases with LEAD reduction) and traction table group (55 cases with traction table reduction). There was no significant difference in baseline data, such as gender, age, injured side, cause of injury, fracture Seinsheimer classification, time from injury to operation, and preoperative visual analogue scale (VAS) score, between the two groups (P>0.05). Total incision length, operation time, intraoperative blood loss, fluoroscopy frequency, closed reduction rate, fracture reduction quality, fracture healing time, weight-bearing activity time, and incidence of complications, as well as hip flexion and extension range of motion (ROM), Harris score, and VAS score at 1 month and 6 months after operation and last follow-up were recorded and compared between the two groups. Results There were 14 cases in the LEAD group from closed reduction to limited open reduction, and 43 cases in the traction table group. The incisions in the LEAD group healed by first intention, and no complication such as nerve and vascular injury occurred during operation. In the traction table group, 3 cases had perineal crush injury, which recovered spontaneously in 1 week. The total incision length, operation time, intraoperative blood loss, fluoroscopy frequency, and closed reduction rate in the LEAD group were significantly better than those in the traction table group (P<0.05). There was no significant difference in the quality of fracture reduction between the two groups (P>0.05). Patients in both groups were followed up 12-44 months, with an average of 15.8 months. In the LEAD group, 1 patient had delayed fracture union at 6 months after operation, 1 patient had nonunion at 3 years after operation, and 1 patient had incision sinus pus flow at 10 months after operation. In the traction table group, there was 1 patient with fracture nonunion at 15 months after operation. X-ray films of the other patients in the two groups showed that the internal fixator was fixed firmly without loosening and the fractures healed. There was no significant difference in fracture healing time, weight bearing activity time, incidence of complications, and postoperative hip flexion and extension ROM, Harris score, and VAS score at different time points between the two groups (P>0.05). ConclusionFor femoral subtrochanteric fracture treated by close reduction and intramedullary nail fixation, compared with traction table, LEAD assisted fracture reduction can significantly shorten the operation time, reduce intraoperative blood loss and fluoroscopy frequency, reduce incision length, effectively improve the success rate of closed reduction, and avoid complications related to traction table reduction. It provides a new method for good reduction of femoral subtrochanteric fracture.
Objective To investigate the short-term result of catheter directed thrombolysis (CDT) in treatment of acute deep venous thrombosis (DVT) in lower extremity. Methods A total of 289 cases of acute DVT in lower extremity who got treatment in Nanjing Drum Tower Hospital Group Suqian City People’s Hospital and Xuzhou Central Hospital from March 2013 to December 2014 were enrolled prospectively, and of them, 125 cases of system thrombolysis (ST) group underwent ST, 164 cases of CDT group underwent inferior vena cava filter placement (IVCF)+CDT. Clinical effect was compared between the 2 groups. Results Clinical symptoms of all cases were obviously relieved, and limb swelling was significantly reduced. Of the CDT group, 73 cases presented iliac vein compression syndrome (IVCS), and 43 cases of them underwent the percutaneous transluminal angioplasty and stent implantation. In CDT group, there was 1 case complicated by catheter displacement, 10 cases suffered from puncture site ecchymosis, 3 cases suffered from hematuria. In ST group, there was 1 case suffered from pulmonary embolism (PE), 14 cases suffered from bleeding gums, 22 cases suffered from hematuria, 3 cases suffered from skin and mucosa petechia, and 2 cases suffered from melena (didn’t need transfusion). The morbidity of ST group was higher than that of CDT group (P=0.002). There were 18 cases suffered from recurrence in ST group, 15 cases suffered from recurrence in CDT group, but there was no significant difference in the recurrence rate between the 2 groups (P=0.786). In addition, the dosage of urokinase, thrombolysis time, blood vessel patency score, thigh circumference after treatment, and calf circumference after treatment in ST group were all higher than those of CDT group (P<0.050), but the Villalta score in ST group was lower than that of CDT group (P<0.001). There was no significant difference in hospital stay (P=0.383). Conclusion For acute DVT in lower extremity, CDT has a superior short-term outcome with safety and feasibility.
Objective To discuss the reconstructive method of the bone defect after resection of the upper extremity bone tumor and to assess the outcome of the autograft to reconstruct the bone defect after the bone tumor resection. Methods From August 1998 to March 2004,16 patients aged 7~45 years suffering from bone tumor of the upper extremity were treated with the wide resection of the bone tumor and the reconstruction of the bone defect by the autograft. The following diagnoses were confirmed by pathological examination:Ewing’s sarcoma and osteosarcoma of theproximal humerus in 1 patient each; Ewing’s sarcoma of the distal humerus in 2 patients;giant cell tumor in 8 patients, highgrade chondrosarcoma in 2, malignant fibrohistiocytoma in 1; and osteosarcoma in 1 of the distal radius. Substitution of the proximal humerus with the clavicle was performed in 2 patients, andthedistal humerus with the fibula in other 2 patients. Of the 12 patients with tumor in the distal radius, 1 was reconstructed with autograft of the iliac bone and 11 with autograft with the fibula. The functional outcome was evaluated by the MSTS score. Results The follow-up for 36 and 12 months respectively revealed that in the 2 patients undergoing the autograft with the clavicle in the proximal humerus, good shoulder functions of flexion and extension were obtained although the function of abduction was poor, with the MSTS scores of 23 and 22 respectively. In the 2 patients undergoing the autograft with the fibular in the distal humerus, good elbow function and bone union were observed according to the followup for 3 and 4 months respectively, with the MSTS scores of 24 and 19 respectively. Of the 12 patients undergoing the autograft in the distal radius, 11 had an excellent or good function with no complication, with the average MSTS score of 22.6 (ranging from 18 to 27), accordingto the follow-up for 6-75 months; only 1 had no bone union 10 months after operation and lost the follow-up afterwards. Conclusion Reconstruction ofthe bone defect with the autograft after the wide resection of the upper extremity bone tumor is an ideal and reliable method for some suitable patients, especially for some children.
Objective To discuss the advantages and disadvantages of flaps in therepairment of soft tissue defects in upper extremity. Methods Based on the 2 609 cases of flaps in 2 512 patients from 1995 to 2004,the advantages and disadvantages of different sort of flaps, outcomes of treatment and indications of different soft of flaps were analyzed retrospectively. In the series, 2 089 pieces of the traditional flaps of different sorts were applied in 1 992 patients, 474 piecesof the axial flaps of different sorts were applied in 474 patients, different sorts of free flaps were used in 46 patients. Results Follow-ups were done for 1 month to 9 years (2.7 months in average). 2 531 flaps survived (97.01%); complete necrosis occurred in 10 flaps(0.38%); partial necrosis occurred in 68 flaps(2.61%). Of the 2 089 traditional flaps, 46 had partial necrosis(2.2%); 687 needed flap revisions(32.9%). Of the 474 axial flaps, 28 had complete or partial necrosis(5.9%); 82 needed revisions(17.3%). Of the 46 free flaps, 4 had complete or partial necrosis(8.7%) and nearly all the anterolateral flpas of thighs needed revisions.Conclusion Traditional flaps had the advantages of easy manipulation and the highest survival rate, however, also had the disadvantages of poor texture and many timesof operations. The flap with a pedicle had the advantage of good texture, consistent artery, free-range arc, however, the venous congestion was its disadvantage, which impaired the survival of the reverse flap. Free flap had the advantage ofgood texture and abandant donor site, but complicate manipulation was its shortage. Axial Flap with a pedicle is the optional choicefor repairing soft tissue defects in upper extremity.
Objective To investigate the effectiveness and safety of low molecular weight heparin combined with aspirin for perioperative prophylactic anticoagulation in patients with lower extremity fracture after splenectomy. MethodsThe clinical data of 50 patients with splenic rupture combined with lower extremity fracture between January 2009 and June 2022 were retrospectively analyzed. All patients were given enoxaparin sodium at 48 hours after splenectomy, and stopped at 24 hours before fracture surgery. After fracture surgery, the patients were divided into aspirin group (group A, 15 cases), low molecular weight heparin group (group B, 16 cases), and low molecular weight heparin combined with aspirin group (group C, 19 cases) according to different anticoagulation regimens. The treatment course was 28 days. There was no significant difference in gender, age, body mass index, cause of injury, fracture site, time from injury to operation, complications, and other general data between groups (P>0.05). The occurrence of venous thromboembolism (VTE) was observed; hemoglobin (Hb), platelet (PLT), D-D dimer, and fibrinogen degradation product (FDP) were recorded before operation and at 1, 3, and 7 days after operation, and the effect of anticoagulation regimen on coagulation function was observed. The incidences of wound complications and bleeding related complications were recorded, and the total perioperative blood loss, hidden blood loss, and overt blood loss were calculated. Results The incidences of VTE in groups A, B, and C were 13.33% (2/15), 12.50% (2/16), and 5.26% (1/19), respectively, and there was no significant difference between groups (χ2=0.770, P=0.680). There was no portal vein thrombosis and no VTE-related death in the 3 groups. There was no significant difference in the levels of Hb, PLT, D-D dimer, and FDP between groups before and after operation (P>0.05); and there was no significant difference in total perioperative blood loss, hidden blood loss, and overt blood loss between groups (P>0.05). No local skin necrosis was found in all patients. In group A, 1 case occurred redness and swelling of incision; in group B, 1 case had incision discharge, redness, and swelling, and 1 case had fat liquefaction; in group C, 1 case had repeated incision exudation accompanied by local tissue redness and swelling, and 1 case had local hematoma. The incidences of adverse incision in groups A, B, and C were 6.66% (1/15), 12.50% (2/16), and 11.76% (2/19), respectively, with no significant difference (χ2=0.302, P=0.860). There were 4 cases of bleeding related complications, including 1 case of incision ecchymosis in groups A and B respectively, with the incidence of 6.66% and 6.25%, respectively; there was 1 case of incision hematoma and 1 case of bleeding in group C, with the incidence of 11.76%; showing no significant difference in the incidence of bleeding related complications between groups (χ2=0.268, P=0.875). Conclusion Perioperative combined use of low molecular weight heparin and aspirin for prevention of anticoagulation in patients with splenic rupture and lower extremity fracture can effectively prevent the occurrence of VTE without increasing the incidence of complications, which is an effective and safe treatment method. However, whether the incidence of VTE can be reduced needs to be further studied by expanding the sample size.
In order to summarize the experience in the treatment of ischemic necrosis of lower extremities resulted from thrombotic occluded angittis, 15 cases were reported, which were treated by primary arterization in situ of V. Saphena magna. With a period of follow-up, 4-26 months on the average, it was found that symptoms in 14 cases were much allayed obviously, except 1 case with little relief. It suggested that primary arterization in situ of V. saphena magna could improve the circulation of the ischemic extremity rapidly without any influence of venous reflux.