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Purpose: While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills., Methods: This was a descriptive retrospective cohort study conducted in the MSF-OCB surgical programmes in the Democratic Republic of Congo (DRC), Afghanistan, and Haiti. Routine programme data on surgical procedures were aggregated and analysed through summary statistics., Results: In the emergency post-earthquake response in Haiti, 81% of open fracture cases were treated by amputation. In a non-emergency project in a conflict setting in DRC, relying on non-specialist surgeons receiving on-site supervision and training by experienced orthopaedic surgeons, amputation rates among open fractures decreased by 100 to 21% over seven years of operations. In two trauma centres in Afghanistan (national surgical staff supported from the outset by expatriate orthopaedic surgeons) and Haiti (national musculoskeletal surgeons trained in external fixation), amputation rates among long bone open fracture cases were stable at 20% and <10%, respectively., Conclusions: Introduction of and training on the proper use of external fixators reduced the amputation rate for open fractures and consequently increased the limb salvage rates in humanitarian contexts where surgical care was provided.

Background: Major peripheral vascular trauma is managed by several surgical specialties. The impact of surgical specialty training and certification on outcome has not been evaluated. We hypothesized that general surgeons without specialty training in vascular surgery would have outcomes equivalent to surgeons with vascular training in the management of extremity arterial injuries requiring interposition grafting., Methods: We performed a multicenter, retrospective study of patients undergoing interposition grafting for peripheral vascular injury between 1995 and 2010. Specialty was defined by training and certification. Outcomes were recorded at the time of discharge from the index hospitalization. Factors affecting limb salvage were determined using logistic regression., Results: From the 11 participating centers, 615 patients were identified. General surgeons performed 69.9%, cardiac/vascular surgeons performed 27.3%, and surgeons of other specialties performed 2.8% of the grafts. There were 32 amputations (5.2%). Outcomes did not differ by institution. Factors associated with amputation were blunt mechanism, older age, female sex, hospital length of stay, and Injury Severity Score (ISS). There was no significant difference in limb salvage among specialty groups (general surgeons, 94%; cardiac/vascular, 95%; other, 100%)., Conclusion: Limb salvage following major peripheral vascular injury is independent of surgeon specialty training. The majority of complex repairs are performed by general surgeons., Level of Evidence: Therapeutic/care management, level III.

Background: This historical perspective highlights some of the pioneers, milestones, teams, and system changes that have had a major impact on the management of the diabetic foot during the past 100 years. In 1934, American diabetologist Elliott P. Joslin noted that mortality from diabetic coma had fallen from 60% to 5% after the introduction of insulin, yet deaths from diabetic gangrene of the lower extremity had risen significantly. He believed that diabetic gangrene was preventable. His remedy was a team approach that included foot care, diet, exercise, prompt treatment of foot infections, and specialized surgical care., Results: The history of a team approach to management of the diabetic foot chronicles the rise of a new health profession, Podiatric Medicine and Surgery, as well as the emergence of the specialty of Vascular Surgery. The partnership between the diabetologist, vascular surgeon, and podiatrist is a natural one. The complementary skills and knowledge of each can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot care programs have been shown to increase quality of care and reduce amputation rates by 36% to 86%. The development of distal revascularization techniques to restore pulsatile blood flow to the foot has also been a major advancement., Conclusion: Diabetic foot patients are among the most complex and vulnerable of all patient populations. Specialized diabetic foot clinics of the 21st century should be multidisciplinary and equipped to coordinate diagnosis, off-loading, and preventive care; perform revascularization procedures; aggressively treat infections; and manage medical comorbidities., (Copyright © 2010 Society for Vascular Surgery and the American Podiatric Medical Association. All rights reserved.)

Introduction: The management of complex extremity injury, which may require assessment of limb viability and performance of amputation, is a challenge to those involved in its emergent and definitive care. Concern exists regarding the exposure of orthopaedic trainees to such cases due both to changes in training and centralisation of trauma services., Subjects and Methods: This is a web-based observational study by survey, investigating the confidence and perceived adequacy of training of UK orthopaedic specialist trainees in the assessment of limb viability and amputation surgery. 222 responses from 888 trainees were required to achieve a < 5% error rate with 90% confidence; 232 surveys were completed., Results: Trainee confidence in dealing with the assessment of limb viability is high despite infrequent exposure to cases. The majority of trainees perceive their training in limb viability assessment as adequate. For performance of amputation, exposure is minimal, confidence is lower and 36% of trainees regard their training as inadequate., Conclusions: Limb viability assessment is an area in which trainees feel confident and well trained. There is, however, a perceived training inadequacy in amputation surgery and a corresponding lack of confidence for many trainees, irrespective of training year. This is the first study to offer an insight into specific training experiences of junior orthopaedic surgeons at a national level and it should drive the development of opportunities for trainees to develop skills in amputation surgery.

The Amputierten-Initiative e.V. [Amputees' initiative] was founded in Berlin as a self-help group of amputee patients in 1991. Since then, its aim has been to prevent amputations by education, to give patients sociomedical advice before and after inevitable amputations and to refer them to problem-oriented angiologists, vascular surgeons, pain therapists, orthopaedists, orthopaedic technologists, and rehabilitation centres. Because of this activity, the Amputierten-Initiative has become a member of many scientific societies, taken part in research projects and received personal and institutional honours. The acceptance and necessity of the Amputierten-Initiative and the need for its work become manifest in the rising number of its members.

Objective: We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures., Methods: We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH., Results: Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss., Conclusions: Technical modifications in endoscopic saphenous vein harvest techniques facilitate their use in lower extremity limb salvage procedures. Vascular surgeons should become familiar with these techniques to minimize vein harvest wound complications and extend the options for limb salvage conduits, including use of both the ipsilateral and contralateral saphenous vein and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.

Background: Antegrade femoral access is fraught by technical challenges and steeper learning curve, in comparison with retrograde contralateral femoral access. We appraised learning curve, complications, and technical aspects inherent in the adoption of antegrade approach., Methods: Consecutive cases in which antegrade access was attempted by a cardiologist experienced in retrograde access, but inexperienced in antegrade, under supervision of an operator with anterograde expertise, were collected. The primary end-point was the occurrence of antegrade access failure or local complications. Major complications were defined as those life-threatening, requiring transfusion, percutaneous, or surgical repair., Results: Anterograde access was attempted in 120 patients. The primary end-point occurred in 14 (11.6%) cases, but according to the learning curve, in 12 (20%) for first 60 cases vs 2 (3.3%) for the last 60 cases (P = 0.008). Access failure in the hands of the in-training operator was similarly found in all cases but one during the first 60 cases. No major complications occurred, while minor complications were found in 9 (7.5%) patients, again with all but two of them occurring in the first 60 cases. These included peri-adventitial extravasation in 8 patients (6.7%), and perforation of a small branch in one (0.8%); all these complications were conservatively and successfully managed. Obesity was the only significant predictor of access failure/complication (P = 0.004)., Conclusions: This work, the first to report on the learning curve of the antegrade approach, supports the feasibility and safety of this access site even for an in-training operator, if supervised. A minimum caseload of 60 procedures is likely needed to master this technique.

Management of complex tissue injuries and provision of replantation services calls for the availability of a dedicated team with high skill levels and good infrastructure. Centres of excellence which provide consistent good care exist in many parts of the world, but large populations are still left uncovered. In the developed world, the reduced exposure to such injuries, lesser training opportunities and poor reimbursement for the efforts put in are the problems. In the developing countries, lack of awareness of the possibilities, inadequate transport systems and infrastructure are the problems. In both systems the cornerstone for improvement will be the availability of well trained surgeons who will deliver consistent good results. Public education and developing a team around the surgeon will improve the results in developing countries. Collaboration with good units with high volume load in the developing countries will be beneficial for training and maintainance of the required skill levels in the developed world.

Objectives: femorodistal bypass operation is one of three index procedures for vascular training in the U.K. Our aim is to determine the suitability of femorodistal bypass to be considered as an index procedure in the era of increasing utilisation of percutaneous transluminal angioplasty (PTA)., Design: a retrospective analysis of prospectively collected data., Patients and Methods: a total of 526 patients with 608 chronic critically ischaemic limbs admitted to the vascular unit, at the Royal United Hospital, Bath, between January 1994 and December 1999 was included in the study., Results: revascularisation either by PTA, bypass surgery or a combination of both was attempted in 524 limbs (86%). Crural procedures were carried out on 71 limbs (14% of revascularised limbs). Primary crural procedures included 34 PTAs as a sole treatment (48%), and 37 femorodistal bypass operations (52%)., Conclusions: during a 6-year period only 37 primary femorodistal bypass operations were performed in a unit which aggressively treats CLI. PTA is the initial step and increasingly the sole treatment for critical limb ischaemia (CLI), including distal lesions. We question the rationale of including an uncommon operation as a vascular training index procedure.