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Orthopaedic Patients with Lower Limb Vascular Injuries
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Vascular injuries in lower limbs are rare but serious events. If not detected and managed correctly and timely they can lead to permanent functional impairment and even limb loss. The increasing number of orthopaedic interventions, worldwide, makes awareness of this problem among orthopaedic surgeons important.

The overall aim of this thesis was to describe lower limb orthopaedic injuries with associated concomitant arterial injuries, especially to the popliteal artery. Epidemiology, mechanisms of injury, management, outcomes and the patient perspective were all addressed. The research questions were generated from clinical praxis. 

Vascular injuries are rare events, but by using as the National Patient (NPR) and National Vascular registries (Swedvasc) a relatively speaking large cohort was studied. Deep interviews with qualitative study method were used to investigate the patients’ perspective.

In papers I and II iatrogenic popliteal artery injuries (PAI) in knee-replacements, and in non-knee-replacements, were investigated. The number of knee arthroplasties in Sweden increased 1987-2008, but not the frequency of iatrogenic PAI. The most common mechanism of injury was sharp, directly to the artery. One third of the injuries resulted in pseudo-aneurysms. This was an unexpected and important finding, since these patients were often diagnosed late, resulting in poor outcome.

Paper III. The interviewed patients narrated substantial functional, cosmetic and psychological impairments,4-17 years after their accidents, yet they described their lives as “normal”. Patients with saved limbs reported a need for better interpersonal support in their rehabilitation and adaptation back to “normal” life.

Paper IV. Popliteal artery injury is feared in knee dislocations and fractures. The proportion incidence of vascular injury was previously reported to be 2-60%. In this large population-based study, the incidence proportion in knee dislocations was 3.4-8.2%, depending on the definition of dislocation/ligamentous injury. In knee fractures the incidence proportion was lower, only 0.2%. The dominating cause of arterial injury in knee dislocations was fall, in knee fractures it was motor vehicle accidents. Amputation- free survival after arterial injury was inferior in knee fractures compared with knee dislocations.

In conclusion, PAI is a serious injury but on sequences can be limited by awareness and timely action.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. , 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1234
National Category
Surgery Orthopedics
Research subject
Orthopaedics; Surgery
Identifiers
URN: urn:nbn:se:uu:diva-296141ISBN: 978-91-554-9611-1OAI: oai:DiVA.org:uu-296141DiVA: diva2:936373
Public defence
2016-09-23, Gustavianum, Akademigatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-08-18 Created: 2016-06-13 Last updated: 2016-08-25
List of papers
1. Popliteal artery injury in knee arthroplasty: a population based, nationwide study
Open this publication in new window or tab >>Popliteal artery injury in knee arthroplasty: a population based, nationwide study
(English)In: Journal of Bone and Joint Surgery, ISSN 0301-620XArticle in journal (Other academic) Submitted
Abstract [en]

Popliteal artery injury (PAI) is a feared but rare complication during knee arthroplasty (KA). The aim was to study PAI during KA: Type of injury, treatment and outcome.

Thirty-two cases were identified in the national Swedish vascular registry (Swedvasc) and the Swedish Patient Insurance databases. Prospective data from the registries was supplemented with case-records, including long-term follow-up.

Twenty-five injuries (78%) were due to penetrating, seven to blunt trauma. Three different presentations of injury were identified: Bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Five (16%) cases were during revision KA. Twelve injuries (38%) were detected intraoperatively, eight (25%) within 24 hours (range 3-24) and twelve (38%) >24 hours postoperatively (range 2-90), 28 (88%) were treated with open surgery. Patency at 30 days was 97% (one amputation). Twenty-five (78%) patients had residual symptoms at the end of follow-up (median 546 days, range: 24-1251). Six of the seven patients with complete recovery had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital.

Outcome after popliteal artery injury during KA is often negatively affected by diagnostic and therapeutic delay. Bleeding and pseudoaneurysm were the most common clinical presentations.

Keyword
Vascular injury, popliteal artery, knee arthroplasty, complication, adverse event, pseudoaneurysm
National Category
Orthopedics Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-194380 (URN)
Available from: 2013-02-13 Created: 2013-02-13 Last updated: 2016-08-25Bibliographically approved
2. Iatrogenic popliteal artery injury in non arthroplasty knee surgery
Open this publication in new window or tab >>Iatrogenic popliteal artery injury in non arthroplasty knee surgery
2015 (English)In: The Bone & Joint Journal, ISSN 2049-4394, Vol. 97B, no 2, 192-196 p.Article in journal (Refereed) Published
Abstract [en]

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intraoperatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support.

National Category
Orthopedics
Identifiers
urn:nbn:se:uu:diva-246818 (URN)10.1302/0301-620X.97B2.34353 (DOI)000348613700010 ()25628281 (PubMedID)
Available from: 2015-03-13 Created: 2015-03-10 Last updated: 2016-08-25Bibliographically approved
3. Patients’ experiences of life years after severe civilian lower extremity trauma with vascular injury
Open this publication in new window or tab >>Patients’ experiences of life years after severe civilian lower extremity trauma with vascular injury
(English)Manuscript (preprint) (Other academic)
National Category
Surgery Orthopedics
Identifiers
urn:nbn:se:uu:diva-296032 (URN)
Available from: 2016-06-13 Created: 2016-06-13 Last updated: 2016-06-13
4. Incidence and outcome of popliteal artery injury associated with knee trauma: a nation-wide population-based cohort study
Open this publication in new window or tab >>Incidence and outcome of popliteal artery injury associated with knee trauma: a nation-wide population-based cohort study
(English)Manuscript (preprint) (Other academic)
National Category
Orthopedics Surgery
Identifiers
urn:nbn:se:uu:diva-296034 (URN)
Available from: 2016-06-13 Created: 2016-06-13 Last updated: 2016-08-25

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