The objective of this review is to develop a more reliable overall assesment of the injury and clinical factors predictive of secondary amputation in patients with traumatic lower limb vascular injuries.

Information sources:

a) Electronic Databases: MEDLINE, EMBASE, CINAHL

b) Manual search of relevant reference lists

Limits:

a) Date: 01/01/2000 - 01/06/2012

b) Human

c) Language: English

Include:

Cohort studies, observational studies, case series with greater than 5 patients; systematic reviews.

Exclude:

Case series with 5 or less patients; case reports; narrative/expert reviews, letters and editorials.

Trauma is the leading cause of death and disability in societies' young and most active members. Severe lower limb injuries, including limb amputations, are an important source of this disability. Secondary amputations are amputations performed after an initial attempt to salvage the limb.

Inclusion:

a) Adult patients (>16 years), AND

b) Acute traumatic injury, AND

c) Lower limb major vascular injury (external iliac to tibial vessels), AND

d) Attempted surgical repair using standard vascular surgery techniques.

Exclusions:

a) Children

b) Not an acute traumatic injury: iatrogenic injuries, pathological changes following spinal injury, longstanding complications of traumatic vascular injuries, peripheral vascular disease.

c) Non-surgical management: Injuries treated conservatively or with interventional radiology techniques, injuries treated with experimental or non-standard surgical techniques.

Prognostic factors related to secondary amputation:

a) Injury related factors: Mechanism of injury (blunt/penetrating); anatomical segment of vessel injured; associated vein/bone/soft tissue injury; associated shock.

b) Treatment related factors: ischaemic time; surgical procedure; prophylactic faciotomy; temporary shunt.

c) Complications: Infection; graft failure.

Comparator will be lower limb vascular injuries requiring surgical repair where the prognostic factor is not present.

Primary outcomes

Secondary amputation. Defined as an amputation performed after a surgical attempt at vascular repair (salvage) has occurred.

Outcome is occurrence of secondary amputation (binary), regardless of time.

Secondary outcomes

None

Two independent reviewers will screen all citations for possible relevance. All identified citations from either reviewer will be assessed for inclusion eligibility. Both reviewers will then independently apply inclusion/exclusion criteria; discrepancies will be resolved by discussion and consensus.

Quality assessment:

Key components of study design and reporting related to the study question (population, prognostic factors, outcome, study design) will be appraised. This will include an assessment of the description of the study population, prognostic factors and outcome; definitions used; length of follow-up, standard treatment, study design, level of care and year of study.

Performance bias will be assessed by subgroup analysis (Level of care; Military vs. Civilian).

Measurement bias will be assessed based on the outcome definition.

a) Descriptive summary of the included studies' key characteristics.

b) Collate and summarise the observed effects (Qualitative). Where possible, an odds ratio (95% CI) will be calculated in individual studies as a measure of the strength of the relationship between the prognostic factor and outcome. If sufficient similar studies are available, a meta-analysis of studies with available/calculated odds ratios will be performed using a random-effect model.

c) If there is a sufficient pool of data on individual patients, a multiple regression analysis will be performed to control for confounding.

d) Statistical heterogeneity will be calculated using the chi-squared test and I-squared index.

Military vs. Civilian outcomes.

Level 1 trauma unit (or equivalent) vs. other hospitals outcomes

Zane Perkins

Trauma Clinical and Academic Unit

The Royal London Hospital

Whitechapel Road,

London,

E1 1BB

zaneperkins@gmail.com

Trauma Sciences. Queen Mary, University of London

http://www.smd.qmul.ac.uk/research/neuro/traumascience/index.html

Mr Zane Perkins, Trauma Sciences. Queen Mary, University of London
Dr Simon Glasgow, Trauma Sciences. Queen Mary, University of London
Mr Nigel Tai, Trauma Sciences, Queen Mary, University of London

01 March 2012

31 October 2012

Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London.

Academic Department of Military Surgery & Trauma (ADMST)

None known

English

England

Subject indexing assigned by CRD

Amputation; Blood Vessels; Humans; Lower Extremity; Prognosis; Vascular Surgical Procedures

30 July 2012

31 July 2012