Prognostic Factors of Leg Amputation in Patients With Vascular Injury: A Systematic Review

Predictive Factors for Failure of Limb Salvage in Blunt Leg Trauma Associated with Vascular Injuries

Introduction:

Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization.

Methods:

A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality.

Results:

Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality.

Conclusions:

Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.

Outcomes of Soft Tissue Reconstruction for Traumatic Lower Extremity Fractures with Compromised Vascularity

Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries. A retrospective review of 158 lower extremities with traumatic fractures, including 26 extremities with arterial injuries, was performed to determine the effects of vascular compromise on flap survival, successful limb salvage and complication rates. Patients with arterial injuries had a larger average flap surface area (255.1 vs 144.6 cm2, P = 0.02) and a greater number of operations (4.7 vs 3.8, P = 0.01) than patients without vascular compromise. Patients presenting with vascular injury were also more likely to require fasciotomy [odds ratio (OR): 6.5, confidence interval (CI): 2.3–18.2] and to have a nerve deficit (OR: 16.6, CI: 3.9–70.0), fracture of the distal third of the leg (OR: 2.9, CI: 1.15–7.1) and intracranial hemorrhage (OR: 3.84, CI: 1.1–12.9). After soft tissue reconstruction, patients with arterial injuries had a higher rate of amputation (OR: 8.5, CI: 1.3–53.6) and flap failure requiring a return to the operating room (OR: 4.5, CI: 1.5–13.2). Arterial injury did not correlate with infection or overall complication rate. In conclusion, arterial injuries resulted in significant complications for patients with lower extremity fractures requiring flap coverage, although limb salvage was still effective in most cases.

Gustilo type IIIC open tibia fractures with vascular repair: minimum 2-year follow-up

PURPOSE

Salvage or amputation for grade 3C open fracture of tibia is not well responded question universally because of surgical innovations, cultural believes, difficulties in estimate the outcome, coasts, and different results in the literature. The aim of this study was to evaluate the surgical outcomes of Gustilo grade 3C open tibia fractures with at least two years follow-up in non-military adults.

METHODS

Twenty-two non-military patients with a mean age of 31.1 were operated with grade 3c open fractures at tibia level in last 10 years in our clinic. We evaluated them retrospectively and asked about their daily life, pain, and if present, about the wish for secondary amputation. We also asked if they would prefer a first day amputation rather than their present status.

RESULTS

Mean operation time after the injury was 13 h. Seven patients had nerve injury. Mean operation number was 3.5. Eight patients (%36) (all due to circulatory problem) had to have amputation. All patients treated with temporary unilateral external fixation than converted to circular external fixators when soft tissue healing was completed. Two patients were reoperated because of deformity. Four patients needed revision surgery because of non-union. At long term follow, we had osteomyelitis in one patient.

CONCLUSIONS

Scoring systems and the ischemic time are not the only predictors of amputation. The decision of the treatment mode should be made by the patient and the care team after discussing the options and outcomes rather than relying on a scoring system.