SGW to Femoral triangle - Synthetic vs "autogenous"

[Karim Brohi]

I've been following this peripherally but I'd agree that if the is
neurological function in the limb and future soft tissue cover is possible
then amputation is not the way to go at this stage (you'd probably be
looking at a hindquarter after all with very poor chance of
rehabilitation.)  Some pictures would be helpful but there are several
vascular reconstructive options including obturator bypass to the distal
SFA/popliteal.

The blow-outs *must* be due to infection and the stents will *probably* only
temporise this (although there may not be a rush to intervene if things are
controlled at present.

I personally remain unclear about the role of synthetic vs autogenous graft
in these wounds.  I have searched the literature and do not find the clear
cut evidence that Ken & Rick have quoted.  There are some retrospective
studies in the mid 80s - early 90s but I can't see anything definitive - or
even very conclusive.  If you have the actual references that people believe
definitively prove this I'd love to read them.

Regardless of vein being a *dead collagen tube*, there is no doubt it has
different properties to synthetic graft.  Which is more appropriate for
trauma - proximal or distal, infected or non-infected I believe is not yet
proven by the type of study one would like to see.

Karim




On 08/08/06, docrickfry at aol.com <docrickfry at aol.com> wrote:
>
> I agree with this and am very sensitive about removing a doomed limb at
> the earliest time, but right now we are just days, not weeks and months,
> into it, and there is really no indication of inevitable doom just yet.  The
> LEAP study published in several installments in the NEJM has clearly shown
> that some of the old maxims guiding the need for early amputation have
> fallen by the wayside as data drives by--i.e. loss of plantar sensation,
> Gustilo III-C injuries, severe venous insufficiency, etc etc have all shown
> surprisingly good salvage of reasonably functional limbs with present
> technology.  In view of the patient's wishes to continue, and no overriding
> reason to amputate at present, I think it is reasonable to give the wounds a
> chance to heal and attempt an extra-anatomic bypass within a few days if at
> all feasible.
> ERF
>
>
> -----Original Message-----
> From: rgross at harthosp.org
> To: trauma-list at trauma.org
> Sent: Tue, 8 Aug 2006 3:50 PM
> Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
>
>
> Ken,
> While the leg might be viable, is it or might it still be FUNCTIONAL.
> As I try to envision the destruction to the groin and upper thigh as
> described, a wonder if there will be any FUNCTION or if he will instead
> be dragging a viable, non-functional appendage, much as a sailboat would
> drag her anchor in a storm.......
> My guess is, knowing Dr. Mattox, that the leg will not be functional,
> and the debate now raging is more (understandably) emotional than
> ethical, or scientific.
> Amputation now will enable emotional and physical rehab in the very near
> future.  Delay, with months of futile surgical heroism will delay and
> perhaps eliminate eventual emotional rehab, regardless of the physical
> outcome.
> I will shut up now.
> Ron
>
> >>> <KMATTOX at aol.com> 08/08/06 3:25 PM >>>
>
> In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,
> sohailmuzammil at hotmail.com writes:
>
> The time  has come to counsel the patient and
> amputate (or ablate as Dr. Mattox puts  it).
>
> Regards
> S Muzammil, FRCS
>
>
>
> This suggestion was also mentioned in our group, by me.   It has  caused
> a
> great deal of ethical, moral, and scientific polarization.    The leg is
> still
> viable.   The man is a construction worker and wants  to keep his leg.
>
>
> k
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