Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm

• Published in: Journal of plastic, reconstructive & aesthetic surgery reconstructive & aesthetic surgery, 2009-05, Vol.62 (5), p.571-579
• Main Authors: Glass, G.E, Pearse, M.F, Nanchahal, J
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Algorithms; Arteries - injuries; Biological and medical sciences; Blood Vessel Prosthesis Implantation - methods; Child; Child, Preschool; Female; Fracture Fixation - methods; Fractures, Bone - surgery; Gustilo IIIC; Humans; Injuries of the limb. Injuries of the spine; Ischaemia; Ischemia - diagnostic imaging; Ischemia - surgery; Limb salvage; Limb Salvage - methods; Lower Extremity - blood supply; Lower Extremity - injuries; Lower Extremity - surgery; Male; Medical sciences; Middle Aged; Open fracture; Plastic Surgery; Radiography; Shunt; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Traumas. Diseases due to physical agents; Treatment Outcome; Young Adult
• ISSN: 1748-6815; 1878-0539
• DOI: 10.1016/j.bjps.2008.11.117

Summary Background Lower limb fractures with vascular injuries are associated with a high rate of secondary amputation. Reducing ischaemic time is vital for limb salvage. However, the optimal sequence of surgical management remains unclear. We aimed to review the literature to establish an evidence-based management algorithm. Methods All identifiable English language or translated literature related to the surgical sequence of lower limb fractures with vascular injuries was reviewed. Results A total of 101 cases described in 10 publications (median age: 31; range: 2.5–76) were suitable for analysis. The mean MESS was 4.2. The limb-salvage rate with an ischaemic time of less than 6 h was 87%, falling to 61% when ischaemic time exceeded 6 h. A preoperative angiography caused a significant delay. The rate of re-vascularisation within 6 h improved from 46% (33 of 71) to 90% (27 of 30) with the use of a shunt ( p = 0.04), with a mean ischaemic time of 3.8 h (±1.7 h, 1 standard deviation (SD)) versus 7.6 h (±3.8 h, 1 SD) in those re-vascularised using grafts ( p < 0.001). The amputation rate of 27% was reduced to 13% by using shunts. Conclusion Early recognition of vascular injury is vital. Formal angiograms are unnecessary and cause crucial delays. A vascular shunt can significantly reduce ischaemic time, enabling unhurried assessment of the feasibility of limb salvage, debridement of demonstrably non-viable tissue and safe skeletal fixation prior to definitive vascular and soft-tissue repair.