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Sahoko H Little,1,2 Sunil S Menawat,1,3 Michael Worzniak,1 Michael D Fetters2 1Oakwood Annapolis Family Medicine Residency, Wayne, Michigan, USA; 2University of Michigan, Department of Family Medicine, Ann Arbor, Michigan, USA; 3Ghent Family Medicine Residency, Eastern Virginia Medical School, Norfolk, Virginia, USA Abstract: Primary care physicians often care for patients with chronic wounds, and they can best serve patients if they have knowledge and proficient skills in chronic wound care, including sharp debridement. The Oakwood Annapolis Family Medicine Residency in Michigan, USA developed a Wound Care Service, incorporating wound care training during the surgical rotation. Effectiveness of the wound care training was evaluated through pre- and posttesting of residents, to assess changes in knowledge and comfort in treating chronic wounds. The results demonstrate significant improvement in residents’ knowledge and comfort in wound care. This innovation demonstrates the feasibility of educating residents in chronic wound care through hands-on experience. Keywords: wound care education, primary care, residency education, surgery rotation, curriculum development

Purpose: The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency., Methods: Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996., Results: SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120)., Conclusions: The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Purpose: This study was undertaken to define the surgical anatomy of the medial perforating veins (PVs) of the leg and to provide information on how to gain access to all medial PVs from the superficial posterior compartment during a subfascial endoscopic procedure., Methods: The venous anatomy of 40 limbs (from 23 cadavers) were studied. Medial PVs located between the ankle and the tibial tuberosity were dissected. None of the subjects had pathologic evidence of venous disease. Each PV's type (direct or indirect), size (< 1 mm, 1 to 2 mm, > 2 mm), location (distances from ankle [D1], and tibia [D2]), and accessibility from the superficial posterior compartment were recorded., Results: Five hundred fifty-two PVs were identified (mean, 13.8; range, 7 to 22). Two hundred eighty-seven PVs (52%) directly connected the superficial with the deep systems, 228 (41%) were indirect muscle perforators, and 37 PVs (7%) were undetermined. One hundred thirty-seven PVs (25%) were > 2 mm. Sixty-three percent of PVs were accessible from the superficial posterior compartment. In the distal half of the leg, two groups of direct PVs could be identified (Cockett II: D1, 7 to 9 cm; Cockett III: D1, 10 to 12 cm). In the proximal half of the leg, paratibial direct PVs (D2 < or = 1 cm) were found clustered in three groups (D1, 18 to 22 cm; D1, 23 to 27 cm; D1, 28 to 32 cm)., Conclusions: Our study confirmed the presence of the Cockett II and III PVs and three groups of proximal paratibial PVs, including the "24-cm" perforators. Two thirds of the medial direct PVs are accessible for endoscopic division from the superficial posterior compartment. To divide paratibial PVs, however, incision of the paratibial deep fascia is frequently required.

Purpose: To study the hemodynamic effects of an arteriovenous fistula (AVF) used as an adjunct to venous reconstructions and to determine the optimal size for such a fistula., Methods: A model of limb circulation with an AVF (in vitro system) was constructed with silicon elastic tubes and 40% glycerin solution as the fluid medium. Pulsatile arterial flow and venous return was maintained with a roller pump and a centrifugal assist device. Flows and pressures were measured for three different fistula diameters (3, 4, and 5 mm). A canine model of venous hypertension with outflow obstruction was constructed in 15 adult mongrel dogs. After 7 to 13 days an externally supported 8-mm expanded polytetrafluoroethylene femorocaval graft was implanted with a distal AVF (3 mm, n = 5; 4 mm, n = 5; 5 mm, n = 5). Arterial and venous flows and venous pressures were measured proximal and distal to the fistula before and after exercise., Results: In the in vitro system, flows through the venous graft increased with increasing fistula size, but venous return decreased progressively, increasing the distal venous pressure. In the canine model, flow in the venous graft increased with each AVF (p < 0.01). Only the 3-mm AVF resulted in decreased distal femoral vein pressure (p < 0.01), orthograde flow, and improved venous return with exercise., Conclusion: AVFs increased flow through the femorocaval grafts, yet they impeded venous return. The ideal AVF-to-graft ratio used in our study was 0.375, because it increased graft flow, permitted forward flow in the femoral vein while reducing pressure, and improved venous return with exercise.

Background: Significant changes occurred over a 4.5-year period in the causes, diagnosis, and treatment of arterial injuries associated with skeletal fractures of the extremities., Study Design: The trauma registry data of 1,091 consecutive patients with fractures, dislocations, or both, were reviewed for the diagnosis of associated arterial injury documented by arteriography or an exploratory operation. The decision to perform a vascular repair was based solely on the presence of definitive signs of arterial injury found during physical examination., Results: Arterial injuries occurred in 41 patients (3.8 percent). Of these, 29 (71 percent) had penetrating injuries, and 12 (29 percent) had blunt trauma. Twenty-six patients (63 percent) had definitive signs of arterial injury and all required arterial repairs. Only three patients (7.3 percent), all with blunt injuries, required amputations because of massive soft tissue trauma. Fifteen patients had intimal flaps, irregularities, or localized narrowings shown on the arteriogram. No patient's condition had deteriorated by the time of a repeat arteriogram (n = 6) or physical examination (n = 9), and no injury required delayed repair (mean follow-up of 6.5 months). No patient without definitive signs of vascular injury at the time of initial examination required surgical repair., Conclusions: Arterial injuries associated with fractures increasingly result from penetrating trauma and carry a much lower risk of amputation than injuries from blunt trauma. Physical examination can accurately detect 100 percent of the arterial injuries requiring repair. Minimal arterial abnormalities seen on arteriograms may be safely followed up by observation.

Background: Optimal management of patients with Zone II penetrating neck trauma for vascular injury remains controversial. Retrospective studies have demonstrated that physical examination alone may be as accurate as arteriography in detecting significant cervical vascular injuries requiring operative repair. This study was undertaken to evaluate prospectively the safety and accuracy of physical examination in determining the management of patients with penetrating Zone II neck trauma., Study Design: During a 22 month period, 66 consecutive patients presented to our Level I trauma center with penetrating neck trauma. Determination of the vascular status of these patients was based on physical examination alone if the injury was located in Zone II and there was no definite sign of vascular injury. Patients were observed for at least 23 hours. Patients admitted during the first year of the study underwent ultrasound examination of the carotid artery within 48 hours to assess for injuries., Results: Thirty-six patients met admission criteria. Two patients had large lacerations requiring operative debridement and closure. Six patients underwent arteriography because of the proximity of the vertebral arteries to the injury tract, the trajectory also included Zone I or III, or there were equivocal signs of vascular injury. Each arteriogram was negative. Of the remaining 28 patients, none had any evidence of a vascular injury during hospitalization or follow-up period (mean of 1.8 months). Eighteen of the 28 patients had carotid ultrasounds, none of which showed injuries requiring operative intervention., Conclusions: Patients with Zone II penetrating neck injuries and no definite signs of vascular injury can be safely and accurately managed on the basis of physical examination alone. Arteriography or ultrasonography are not needed to identify vascular injuries.

Vascular injury has been reported in up to one third of patients with posterior knee dislocations, which has led to the routine use of arteriograms in the management of these injuries. Recent studies have shown physical examination (PE) is reliable in detecting significant vascular injuries requiring surgery from other mechanisms. We hypothesized that PE would be similarly sufficient to assess popliteal injury in patients with posterior knee dislocations. To test this, we reviewed the records of all 37 patients with 38 such injuries at our institution over the past 5 years. The average age was 29.5 years, and 31 patients (81.5%) had other associated injuries. All dislocations were the result of blunt trauma. Two patients (5.3%) had hard signs (distal ischemia and no pulses) that clearly indicated vascular injury. Total occlusions of the popliteal artery were seen on arteriograms in both cases and these were successfully treated surgically with reversed saphenous vein bypass grafts. The remaining 36 dislocations manifested no hard signs of vascular injury (absent pulses, distal ischemia, active bleeding, bruit/thrill). Nineteen patients (50.0%) had normal vascular examination results, did not receive arteriograms, and had no adverse sequelae, with a mean follow-up of 9.3 months (range 1 day-43 months). Sixteen patients with 17 dislocations (44.7%) underwent arteriography and the findings appeared normal in ten extremities; nine of these extremities had normal pulses and one had a diminished but palpable pulse. A minimal injury (intimal defect, 3; narrowing, 4) was demonstrated in seven extremities, five with normal pulses and two with diminished pulses.(ABSTRACT TRUNCATED AT 250 WORDS)

The evaluation and management of potential arterial injuries in penetrating neck trauma are controversial. Routine surgical exploration or arteriography can be very expensive and time-consuming and can overburden available resources if used in all patients. We reviewed the records of 4035 patients seen in our trauma center during a 20-month period and identified a total of 110 patients (2.7%) with penetrating wounds to zone II of the neck; 50 were from gunshot wounds, 43 from stab wounds, 7 from shotgun injuries, and 10 from lacerations. In 42 (39%) patients there was no arteriogram or surgery based on location of the wounds or lack of any physical findings. None of these patients later had any evidence of an arterial injury. Forty-five patients (40%) had arteriograms based on proximity or a "soft" sign of vascular injury, which included evidence of significant bleeding or a stable hematoma. A total of 15 injuries to major arteries were identified: 3 common carotid, 5 internal carotid, and 7 vertebral. One patient died during initial resuscitation, and four patients went directly to surgery with no preoperative arteriogram for active bleeding and expanding hematoma (n = 1), an expanding hematoma (n = 2), and a large, stable hematoma (n = 1). Only one patient (of the 110) had a significant major arterial injury requiring surgery that was not predicted by physical findings. Nine arterial injuries were treated nonoperatively: six vertebral, two common carotid intimal flaps, and one small distal internal carotid pseudoaneurysm (diagnosed late). Three additional minor external carotid artery injuries were observed with no adverse sequelae.(ABSTRACT TRUNCATED AT 250 WORDS)

Marked changes occur in cardiac function during aortic reconstruction. Numerous factors (primarily compliance changes) limit the currently used pressure-based pulmonary artery catheters' ability to reflect these changes accurately. A new pulmonary artery catheter was used in 26 patients undergoing aortic reconstruction (7 patients with abdominal aortic aneurysms and 19 with occlusive disease) that directly measures right ventricular (RV) volumes and ejection fractions. The extent of coronary artery disease (CAD) was evaluated before surgery, and the patients were divided into three classes. The greatest changes in cardiac function were noted immediately after aortic cross-clamping. Cardiac output significantly decreased in patients with mild or moderate CAD (p less than 0.01 and p less than 0.001) but not in patients with no CAD (p less than 0.5). This correlated well with RV end-diastolic volume (RV-EDV) and stroke volume (RV-SV) measurements in the groups with mild (p less than 0.05) and moderate CAD (p less than 0.01) but not in the group with no CAD (p greater than 0.5). Wedge pressure showed poor correlation, with no significant change noted in any group (p greater than 0.5). Measurements taken later in the procedure documented a significant trend toward baseline in mild and moderate groups. At the opening of the second limb of the graft, the compensated values (CO, RV-EDV, and RV-SV) did not change significantly in the groups with mild and no CAD (p greater than 0.2) but approached significance in the group with moderate CAD (p less than 0.08).(ABSTRACT TRUNCATED AT 250 WORDS)