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Background: Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery, resulting in neurogenic (NTOS), venous (VTOS), and arterial (ATOS) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of paraclavicular surgical decompression for TOS., Methods: A prospective analysis of patients who underwent surgical decompression for TOS at a newly established center was performed. Diagnosis of TOS was based on clinical history, a physical examination, and additional diagnostic studies. The indication for surgery in patients diagnosed with NTOS was the presence of persistent symptoms after a trial of physical therapy. Primary outcomes were assessed according to Derkash's classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and duration of hospital stay., Results: Between August 2004 and June 2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 men) with TOS. The mean age was 36.5 years (range: 15-68). Bilateral decompression was performed on 4 patients. The types were NTOS (n = 19; 48%), VTOS (n = 16; 40%), and ATOS (n = 5; 12%). In addition to pain, the most common presenting symptom was numbness in NTOS, swelling in VTOS, and coolness in ATOS. A history of trauma was present in 22.2%. Two patients suffered from recurrent symptoms after previous transaxillary first rib resection for VTOS at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and first rib resection. The first rib resection was partial, through a supraclavicular only approach in NTOS and ATOS patients (60%) or complete, through a supra- and infraclavicular approach for VTOS patients (40%). Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow-up. Two patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths. Complications included pleural effusion requiring evacuation (n = 4), neuropraxia (n = 1), and lymph leak (n = 1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean duration of hospital stay was 4.4 days. The mean follow-up was 10.3 months., Conclusions: In our experience, surgical paraclavicular decompression can provide safe and effective relief of NTOS, VTOS, and ATOS symptoms. Functional outcomes were excellent or good in the majority of patients, with minimal complications., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Significantly reduced amputation rates for traumatic popliteal artery injuries have been achieved with improved revascularization and resuscitative techniques. Predictive scores have failed to accurately predict outcomes in patients who sustain popliteal artery damage. This study aimed to identify predictors of limb salvage in a civilian cohort after popliteal artery trauma., Methods: A single-institution, retrospective review was performed of all patients with popliteal artery trauma presenting between January 2002 and June 2009. Data were compiled using the institutional trauma registry, with demographics, mechanism of injury, associated injury, fasciotomy, Mangled Extremity Severity Score (MESS), and Injury Severity Score (ISS) all documented. Statistical analysis included descriptive statistics, univariate analysis, and multiple exact logistic regression., Results: Seventy traumatic popliteal artery injuries were identified in 68 patients with a mean age of 33 years (range: 5-88 years). The majority of patients were male (n = 57; 81%), and 73% sustained blunt injury. Associated venous injury was present in 16 (23%) cases. Associated orthopedic injuries included 19 (27%) dislocations and 49 (70%) fractures. The median MESS was 5 (range: 2-9) and the median ISS was 9 (range: 4-41). Revascularization was performed in 62 cases (89%). Twenty-three percent of patients had compartment syndrome and 56% underwent fasciotomy. Fifteen (21%) patients required amputation, 11% of which were primary and 10% secondary. Variables associated with amputation included ISS >10 compared to ISS <9 (odds ratio [OR]: 7.4; P < 0.045), blunt injury (OR: 10.7; P = 0.009), MESS >7 (OR: 2.4; P < 0.0001), and fractures (OR: 0.13; P < 0.045). In a multiple exact logistic regression analysis, a MESS >7 (P < 0.05) was the only significant predictor of amputation., Conclusion: Patients with traumatic popliteal artery injury are at high risk for amputation. Blunt injury, fractures, ISS >9, and MESS >7 were associated with an increased odds of amputation. Although in our data, MESS was the strongest predictor of amputation, we recognize that MESS was previously invalidated as a scoring system. New methods to determine limb viability in the mangled extremity are needed., (Copyright © 2014 Elsevier Inc. All rights reserved.)