Patterns of presentation and outcome in critical limb ischemia

The threatened limb due to peripheral occlusive arterial disease, embolism or trauma requires early recognition and urgent treatment if the limb is to be saved. To determine the pattern of presentation and outcome of surgery in cases of critical limb ischemia. Descriptive study. This study was conducted at surgical ward, Combined Military Hospital, Rawalpindi, from Dec 2006 to Dec 2007. A sample size of 30 patients was taken by convenience sampling. Informed written consent was obtained from all patients. Patients suffering from rest pain with ischemia features, trophic lesions, extensive gangrene, ulcers and demonstrable presence of occlusive arterial disease were included in the study. Moribund patients, extensive cardiopulmonary disease or advanced malignancy were not included in the study. Thirty patients were included in the study. The mean age was 56 +/- 13. There were 28 males [93.3%] and 2 females [6.7%]. They were all married and belonged to middle and low middle social economic class. Out of 30, there were 2 [6.7%] cases of trauma while 28 [93.3%] had peripheral vascular involvement secondary to thromboembolism. Vessels involved were femoral artery in 9 [30%] cases, popliteal artery in 18 [60%] cases and brachial artery in 2 [6.7%] cases. Rest pain was present as a primary feature in all the patients [100%], while tissue loss or gangrene was seen in 22 [73.33%] cases. A total of 14 [46.7%] amputations, 6 [20%] bypass procedures, 4 [13.3%] lumbar sympathectomies, and 2 [6.7%] embolectomies, were carried out, whereas 4 [13.3%] patients were managed conservatively. Of the patients having rest pain 46.7% were amputated, whereas of patients having ischemic tissue loss 73.3% were amputated. 13 patients who underwent primary amputation had ankle brachial pressure index [ABPI less than 0.4 [86.7%]. ABPI was more than 0.4 in 4 [13.3%] patients whereas it was less than 0.4 in 26 [86.7%] patients. Overall, critical leg ischemia has a very poor prognosis. If surgical, or endovascular, improvement of the blood supply to the leg is not provided in due course; half of the legs will be amputated within a year. One of the main goals of vascular surgery is to prevent major amputations

Analysis of causes and treatment modality in non-union of long bones diaphyseal fractures

The purpose of this study was to analyze the causes of nonunion leading to modification in treatment modalities in long bones diaphyseal fractures. Descriptive Study. Combined Military Hospital Quetta, Combined Military Hospital Sialkot, Pakistan, from 5th Sep 2005 to 26th Dec 2008. Non-healing long bones diaphyseal fractures > 6 months were included with exclusion of pathological fractures, delayed union < 6 months. Patients general profile and fracture details with non-union causes were recorded. Old failed surgery with re-do surgical intervention was analyzed. Infected cases were treated with removal of implant, thorough debridment, appropriate antibiotics followed by delayed stabilization while non-infected cases with stable fixation and bone grafting. Out of fifty six patients, tibial fractures were maximum 17[30.4%], femur 16[28.6%], radius ulna 15[26.6%], and humerus 8[14.3%]. Most patients were young 37[66.07%] and male 48[85.7%]. Road traffic accident caused 43[76.8%] fractures. Causes of non-union were high energy trauma 37[66%], insufficient stabilization 31[55.4%], followed by smoking, soft tissue interposition, poor nutrition, NSAIDs, broken implants, infection, intact fellow bone, multiple segment fracture, repeated manipulation, chronic illness and neurovascular impairment in descending order. Plates failed more than K nails. Complications like superficial and deep infection, neuroprexia and delayed healing settled with bone healing in mean time 4.76 months. Nonunion of long bones diaphyseal fractures can be prevented by avoiding causative agents, early intervention, tissue protection and stable fixation. Interlock nailing is best for femur, good for tibia, may be useful in humerus but not suitable for radius and ulna. Bone graft accelerates healing process. Early re do surgery must be considered because of manageable rate of complications