SLR - July 2010 - Judianne Walker

Lower Extremity Arterial Injury Patterns and Reconstructive Outcomes in Patients with Sever Lower Extremity Trauma: A 26-Year Review

Reference: 
Haddock et al, Journal of the American College of Surgeons, Vol. 210, No. 1, January 2010

Scientific Literature Reviews

Reviewed by:  Judianne Walker, DPM
Residency Program: Maricopa Medical Center PM&S 36, Phoenix, AZ

Podiatric Relevance:
When presented with Gustilo IIIB and IIIC open fractures the use of angiography, whether traditional CTA or MRA, should be liberally performed.  The use of angiography is paramount in determining not only the extent of vascular damage, but also the caliber of available vessels that can be used as recipient arteries for a flap.  It is essential to have a multidisciplinary surgical plan of care to improve limb salvage and surgical outcomes.  The objective of this study was to evaluate the arterial injury patterns in Gustilo IIIB and IIIC injuries, and to gain insight on vascular injury patterns and surgical outcomes.

Methods:
This is a retrospective analysis of all free flaps performed for Gustilo IIIB and IIIC lower extremity fractures. Data for 222 free flaps on 191 patients was gathered. Only patients requiring free flap reconstruction after lower extremity trauma resulting from Gustilo IIIB and IIIC type fractures were included in the data set. 

Results: 
Patients who had imaging modalities were most commonly found to have solitary anterior tibial injuries (19.7%), and had injuries to both anterior tibial and peroneal arteries (7.3%). Of the 191 microvascular reconstructions, 57.2% used the posterior tibial as the recipient vessel of choice, 26.6% used the anterior tibial, and 3.6% used the peroneal. The type of flap varied, however, the most common flap used for reconstruction was a latissimus dorsi flap.  27% of patients suffered long term morbidity after microvascular reconstruction requiring multiple procedures.

Conclusions:
Vascular injury involving the anterior tibial artery was the most common vascular injury encountered. The posterior tibial artery was most likely spared and therefore used as the recipient artery for free flap repair. A multidisciplinary approach is paramount in early treatment and in minimizing long term morbidity associated with high grade lower extremity injuries.

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