SLR - September 2022 - Husang Lee, DPM
Reference: Lewis RH Jr, Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg. 2022 Jan 1;92(1):21-27.Level of evidence: Prognostic study, Level IV.
Scientific Literature Review
Reviewed By: Husang Lee, DPM
Residency Program: Saint Vincent Hospital, Worcester, MA
Podiatric Relevance: Simple, communited, and complex fractures in the metatarsals, tibia, and fibula with associated major vascular injury should be all approached with the best surgical outcome in mind. To reduce extremity amputations and minimize graft complications, it is pertinent to account for all factors. Surgical timing of long bone fractures with associated major vascular injury is debated with some advocating for temporary fracture fixation before vascular repair to minimize graft complications as opposed to immediate vascular repair to minimize ischemia. This study reviews 104 patients and compared Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST).
Methods: A level IV prognostic and retrospective study at a single level 1 trauma center with 104 patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity, which was categorized as rhabdomyolysis, acute kidney injury, graft failure, and extremity amputation, along with in-hospital mortality was also compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST).
Results: One hundred four patients were identified: 19 PRE and 85 POST. Both groups were found to be similar with respect to sex, mechanism of injury, ISS, intraoperative heparin administration, initial base excess, and admission systolic blood pressure. The PRE group had fewer penetrating injuries (32 percent vs. 60 percent, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). There was no difference in mortality p > 0.99. However, the 2 deaths were both POST. There were more vascular-related complications in the PRE group in regards to rhabdomyolysis (42 percent vs. 19 percent, p = 0.029), graft failure (26 percent vs. 8 percent, p = 0.026), and amputation (37 percent vs. 13 percent, p = 0.013). Utilizing multivariable logistic regression, it was noted that PRE fracture fixation as the only independent predictor of graft failure (odds ratio, 3.98; 95 percent confidence interval, 1.11–14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95 percent confidence interval, 1.272–12.111; p = 0.017).
Conclusions: Fracture fixation PRE revascularization is associated with increased vascular-related morbidity. It also is the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. Delaying temporary or definitive fracture fixation until POST with either a temporary shunt or definitive repair should be the standard to minimize the risk subsequent extremity amputations and graft failure.