The management of open fractures associated with arterial injury requiring vascular repair

Prevention and treatment of osteomyelitis after open tibia fractures

Infection and chronic post-traumatic osteomyelitis of the tibia after open fracture are complex problems that cause significant morbidity and threaten the viability of a limb. Therefore, it is of utmost importance for the orthopaedic surgeon to understand both patient and treatment factors that modify the risk of developing these disastrous complications. Infection risk is largely based on severity of open injury in addition to inherent patient factors. Orthopaedic surgeons can work to mitigate this risk with prompt antibiotic administration, thorough and complete debridement, expedient fracture stabilization, and early wound closure. In the case osteomyelitis does occur, the surgeon should use a systematic multidisciplinary approach for eradication.

The antibiotic bead pouch - a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery

Soft tissue defects resulting from trauma and musculoskeletal infections can complicate surgical treatment. Appropriate temporary coverage of these defects is essential to achieve the best outcomes for necessary plastic soft tissue defect reconstruction. The antibiotic bead pouch technique is a reasonable surgical approach for managing temporary soft tissue defects following adequate surgical debridement. This technique involves the use of small diameter antibiotic-loaded bone cement beads to fill the dead space created by debridement. By applying antibiotics to the bone cement and covering the beads with an artificial skin graft, high local dosages of antibiotics can be achieved, resulting in the creation of a sterile wound that offers the best starting position for soft tissue and bone defect reconstruction. This narrative review describes the rationale for using this technique, including its advantages and disadvantages, as well as pearls and pitfalls associated with its use in daily practice. In addition, the article provides a comprehensive overview of the literature that has been published since the technique was introduced in surgical practice.

Arterial Injury Portends Worse Soft Tissue Outcomes and Delayed Coverage in Open Tibial Fractures

OBJECTIVES

To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome.

DESIGN

Retrospective cohort comparative study.

SETTING

Two academic level one trauma centers.

PATIENTS/PARTICIPANTS

Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up.

INTERVENTION

N/A.

MAIN OUTCOME MEASUREMENTS

Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up.

RESULTS

Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation.

CONCLUSIONS

Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of establishing a level-1 trauma center for lower extremity trauma: a 4-year experience

Purpose

A multidisciplinary approach is essential for trauma patients’ treatment, particularly for cases with open lower extremity fractures, which are considered major traumas requiring a comprehensive approach. Recently, the social demand for severe-trauma centers has increased. This study analyzed the clinical impact of establishing a trauma center for the treatment of open lower extremity fractures.

Methods

A retrospective chart review was conducted for trauma patients admitted to our hospital. Patients were classified into two groups: before (January 2014–December 2015, 178 patients) and after establishment of a Level-1 trauma center (January 2017–December 2018, 125 patients). We included patients with open fracture below the knee level and Gustilo type II/III, but excluded those with life-threatening trauma that affected the treatment choice.

Results

Total 273 patient were included in this study, initial infection was significantly more common and external fixator application significantly less in post-center establishment group. The time to emergency operation decreased significantly from 13.89 ± 17.48 to 11.65 ± 19.33 h post-center setup. By multivariate analysis, the decreased primary amputation and increased limb salvage was attributed to establishment of the trauma center.

Conclusion

With the establishment of the Level-1 trauma center, limbs of patients with open lower extremity fractures could be salvaged, and the need for primary amputation was decreased. Early control of initial open wound infection and minimizing external fixator use allowed early soft tissue reconstruction. The existence of the center ensured a shorter interval to emergency operation and facilitated interdepartmental cooperation, which promoted active limb salvage and contributed to patients’ quality of life.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?

BACKGROUND

This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods.

METHODS

A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed.

RESULTS

In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001).

CONCLUSION

The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.

Medial approach for the treatment of femur fractures in association with vascular injury

INTRODUCTION

To highlight an alternative method of treatment for femoral fractures associated with vascular injury, allowing both fracture fixation and vascular repair from the same surgical approach.

DESIGN

Retrospective case series.

METHODS

Twelve patients with arterial injury as a consequence of femoral fracture were treated by internal fixation. There were five femoral diaphysis, seven distal femoral including supracondylar and intercondylar fractures. Four patients had injury to the popliteal artery, whereas eight to the superficial femoral artery. Seven patients had a nerve injury. Medial femoral approach was used both for the fixation of the fracture and vascular repair. Fracture fixation was done by plate-screw in all patients, whereas vascular injuries were treated using saphenous vein interposition graft in ten patients and end-to-end repair in two patients. Nerve injuries were not dealt by exploration during the vascular repair.

RESULTS

All of the limbs were ultimately survived. Clinical and radiological union was observed in all patients at the last follow-up radiographs. Of the 4 total sciatic nerve palsies, 2 had developed total, one had tibial nerve recovery. One patient had no motor recovery. Of the 3 peroneal nerve palsies, 1 patient had recovery, 2 patients had no motor improvement.

CONCLUSIONS

A midlateral approach is traditionally used for fractures of femur when plates and screws are used for fixation. In association with vascular injury, this procedure requires two separate incisions. The added soft tissue disruption associated with open reduction and internal fixation by lateral incision can be reduced with the use of single medial approach, which allows bony stabilization under direct visualization of the repaired vessels.

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.

The ortho-plastic approach to soft tissue management in trauma

Fractures with associated soft tissue injuries, or those termed 'open,' are not uncommon. There has been much discussion regarding there management, with the guidance from the combined British Orthopaedic Association and British Association and Aesthetic Surgeons teams widely accepted as the gold level of therapy. We aim to discuss the current evidence about the initial management of this group of injuries, taking a journey from arrival in the accident and emergency department through to the point of definitive closure. Other modes of therapy are also reviewed.

Impact of high prevalence of pseudomonas and polymicrobial gram-negative infections in major sub-/total traumatic amputations on empiric antimicrobial therapy: a retrospective study

Introduction

Emergency treatment of major sub-/total traumatic amputations continue to represent a clinical challenge due to high infection rates and serious handicaps. Effective treatment is based on two columns: surgery and antimicrobial therapy. Detailed identification of pathogen spectrum and epidemiology associated with these injuries is of tremendous importance as it guides the initial empiric antibiotic regimen and prevents adverse septic effents.

Methods

In this retrospective study 51 patients with major traumatic amputations (n = 16) and subtotal amputations (n = 35) treated from 2001 to 2010 in our trauma center were investigated. All patients received emergency surgery, debridement with microbiological testing within 6 h after admission and empircic antimicrobial therapy. Additionally to baseline patient characteristics, the incidence of positive standardized microbiologic testing combined with clinical signs of infection, pathogen spectrum, administered antimicrobial agents and clinical complications were analyzed.

Results

70.6% of the patients (n = 36) acquired wound infection. In 39% wounds were contaminated on day 1, whereas the mean length of duration until first pathogen detection was 9.1 ± 13.4 days after injury. In 37% polymicrobial colonization and 28% Pseudomonas were responsible for wound infections during hospitalization. In 45% the empirc antimicrobial therapy focussed on Gram positive strains did not cover the detected bacteria, according antimicrobial resistogram. It was significantly more often found in infections associated with Pseudomonas (p 0.02) or polymicrobial wound infections.

Conclusions

This epidemiologic study reveals a pathogen shift from Gram-positive to Gram-negative strains with high incidence of Pseudomonas and polymicrobial infections in sub-/total major traumatic amputations. Therefore, empiric antimicrobial treatment historically focussing on Gram-positive strains must be adjusted. We recommend the use of Piperacillin/Tazobactam for these injuries. As soon as possible antimicrobial treatment should be changed from empiric to goal directed therapy according to the microbiological tests and resistogram results.

Gustilo IIIC fractures in the lower limb: our 15-year experience

Controversy continues to surround the management of patients with an open fracture of the lower limb and an associated vascular injury (Gustilo type IIIC). This study reports our 15-year experience with these fractures and their outcome in 18 patients (15 male and three female). Their mean age was 30.7 years (8 to 54) and mean Mangled Extremity Severity Score (MESS) at presentation was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent amputation (two immediate and one delayed). Four patients underwent stabilisation of the fracture by external fixation and 12 with an internal device. A total of 11 patients had damage to multiple arteries and eight had a vein graft. Wound cover was achieved with a pedicled flap in three and a free flap in six. Seven patients developed a wound infection and four developed nonunion requiring further surgery. At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue scale for pain was 64 (10 to 90). Depression and anxiety were common. Activities were limited mainly because of pain, and the MESS was a valid predictor of the functional outcome. Distal tibial fractures had an increased rate of nonunion when associated with posterior tibial artery damage, and seven patients (39%) were not able to return to their previous occupation.

[Prevention of infection in the current treatment of open fractures: an evidence-based systematic analysis]

BACKGROUND

Treatment of open fractures remains an interdisciplinary challenge. Even success and evidence of infection prevention especially of new treatment options is not clear.

METHOD

A systematic search in available electronic databases over the years 1974 until 2011 was conducted. Only clinical analyses with more than 5 adult patients in the German, English or French languages were included. All studies were rated according to Centre for Evidence-Based Medicine (CEBM) criteria.

RESULTS

Over 855 articles were found due to the search and after applying the exclusion and inclusion criteria 49 studies were finally assessed to contribute to the evidence-based recommendations. Grade A recommendation: early application of antibiotics against gram-positive organisms for all open fracture types, additional coverage of gram-negative organisms for type III open fractures. Early surgical debridement should be performed. Grade B recommendation: type III open fractures should be treated with antibiotics for a minimum of 72 h but not longer than 24 h after wound closure. Vacuum treatment is justified and beneficial if wound closure is not achieved. Grade C recommendation: additional local antibiotic treatment in combination with systematic antibiotics may be of benefit. Definitive wound closure should be achieved within 1 week.

DISCUSSION

This evidence-based analysis shows that there is good evidence for the treatment of open fractures with antibiotics and surgical debridement. Vacuum treatment can be recommended if wound closure is not possible.

A meta-analysis of amputation versus limb salvage in mangled lower limb injuries--the patient perspective

This meta-analysis evaluates the quality of life in post-traumatic amputees in comparison with limb salvage. Studies included in this meta-analysis had a minimum of 24 months of follow-up and used a validated quality-of-life outcome assessment scale (Short Form-36 or Sickness Impact Profile) for physical and psychological outcomes. Two reviewers performed the search and data extraction independent of each other. A total of 214 studies were identified; 11 fulfilled the inclusion criteria; thus, 1138 patients were available for meta-analysis (769 amputees and 369 cases of reconstruction). The meta-analysis demonstrated that lower limb reconstruction is more acceptable psychologically to patients with severe lower limb trauma compared with amputation, even though the physical outcome for both management pathways was more or less the same.

No evidence of infection after retrograde nailing of supracondylar femur fracture in gunshot wounds

BACKGROUND

The aim of the study was to determine whether osteomyelitis of the femur or septic arthritis of the knee develops after retrograde intramedullary nailing of the femur performed within 7 days of supracondylar femur fracture, secondary to gunshot wounds, without skin defects.

METHODS

Fifteen patients with a mean age of 27.8 years (range, 18-52 years), with supracondylar fractures of the femur due to gunshot wounds and without skin defects. Retrograde intramedullary nails were inserted through the intercondylar notch of the femur. We evaluated whether osteomyelitis of the femur or ipsilateral septic arthritis of the knee joint developed postoperatively.

RESULTS

None of the patients who were followed up for a mean period of 11.7 months (range, 9-16 months) showed evidence of ipsilateral septic arthritis of the knee or osteomyelitis of the femur.

CONCLUSION

Retrograde intramedullary nailing of the femur can be performed in patients with supracondylar fractures of the femur due to gunshot wounds, and without skin defects, in the first 7 days after the trauma. Neither osteomyelitis of the femur nor septic arthritis of the knee develops in these patients.

Comparison of vacuum-assisted closure to the antibiotic bead pouch for the treatment of blast injury of the extremity

The surgical care of modern combatants involves treatment of massive extremity wounds from blast mechanism. Currently up to 70% of combat wounds are extremity related. Clinical outcomes for these patients are dependent on the care of these wounds. The Vacuum-Assisted Closure (VAC) Therapy system (KCI Inc, San Antonio, Texas) is ubiquitous in theater and is often considered the only way to treat these wounds. However, the VAC Therapy system is not without problems. It is expensive and requires extensive amounts of product and machinery, as well as functioning suction, and therefore a power source at all times. In addition, the VAC Therapy system requires a trained and vigilant nursing staff. We hypothesized that the antibiotic bead pouch would be a viable alternative to the VAC Therapy system for such blast injuries. We retrospectively analyzed 2 matched groups of 12 patients in terms of outcome and cost. We found that the VAC Therapy system produced more late methicillin-resistant Staphylococcus aureus infections (30%), more unanticipated returns to the operating room for wound problems (4:12 vs 0:12), and required more surgeries overall until closure of the wounds. In addition, the VAC Therapy system cost $12,000 more for 12 patients than the antibiotic bead pouch. We recommend the bead pouch be considered as an equivalent option to the VAC Therapy system in the treatment of blast injury.

The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: A meta-analysis

OBJECTIVE

The optimal sequence of surgical repair for lower extremity injury with associated vascular injuries is unclear. Lower extremity injury in our study is defined as femoral fracture, tibial fracture, and/or knee dislocation. Advocates of performing the vascular repair prior to lower extremity fixation argue that reversal of ischaemia in the limb is the most important factor in limb survival and should take precedence. Advocates of lower extremity fixation prior to revascularisation worry that the manipulation during fixation could disrupt the vascular repair and that total ischaemia time is more relative than absolute.

METHODS

A literature search was performed to identify studies with the following criteria: adult population, femoral fracture, tibial fracture, and/or knee dislocation with associated vascular injury, an intervention of fracture fixation or knee stabilisation prior to revascularisation and/or revascularisation prior to fracture fixation, and amputation as an outcome measurement.

RESULTS

934 articles were identified and narrowed to 14 articles through exclusion criteria. Meta-analysis of the data shows no statistical difference in regards to the incidence of amputation between lower extremity fixation prior to revascularisation and revascularisation prior to fracture fixation.

CONCLUSION

Lower extremity injuries with associated vascular injury are uncommon. There has been a widespread but unsupported belief that manipulation and traction during lower extremity fixation will disrupt the vascular repair. Ischaemic time should be considered a relative, but not absolute predictor of amputation. Soft tissue injury and neurologic deficits have been found highly correlated with disability and amputation. Surgical sequence has not been shown to affect the rate of amputations in lower extremity fractures.

Prophylactic Antibiotic Use in Open Fractures: An Evidence-Based Guideline

BACKGROUND

Prolonged courses of broad-spectrum antibiotics are often cited as the standard of care for prevention of infective complications of open fractures. The origins of these recommendations are obscure, however, and multi-drug-resistant systemic infections attributable to antibiotic overuse are common life-threatening problems in current intensive care unit practice.

OBJECTIVE

To review systematically the effects of prophylactic antibiotic administration on the incidence of infections complicating open fractures.

DATA SOURCES

Computerized bibliographic search of published research and citation review of relevant articles.

STUDY SELECTION

All published clinical trials claiming to evaluate, or cited elsewhere as being authoritative regarding, the role of antibiotics in open fracture management were identified and then evaluated according to published guidelines for evidence-based medicine. Only small studies (<20 patients), practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis.

DATA EXTRACTION

Information on demographics, study dates, fracture grade, antibiotic type, duration and route of administration, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted by the authors. The primary results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document.

DATA SYNTHESIS

Current antibiotic management of open fractures is based on a small number of studies that generally are more than 30 years old and do not reflect current management priorities in trauma and critical care. With a few noteworthy exceptions, these primary studies suffer from a variety of methodologic problems, including co-mingling of prospective and retrospective data sets, absence of or inappropriate statistical analysis, lack of blinding, or failure of randomization.

CONCLUSIONS

The data support the conclusion that a short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopedic fracture wound management. There is insufficient evidence to support other common management practices, such as prolonged courses or repeated short courses of antibiotics, the use of antibiotic coverage extending to gram-negative bacilli or clostridial species, or the use of local antibiotic therapies such as beads. Large, randomized, blinded trials are needed to prove or disprove the value of these traditional approaches. Such trials should be performed in patients with high-grade fractures who (1) are well-stratified according to the degree of local injury and (2) undergo standardized fracture and wound management. Trials also must be powered to study the effects of extended antibiotic coverage on nosocomial infections. Antibiotic regimens confirmed to improve local fracture outcomes in such studies could then be used rationally, balancing the risks of local fracture-related infections and of multi-drug-resistant systemic infections to achieve optimal global outcomes.

Complications and outcomes of open pediatric forearm fractures

Few reports have documented the complications and outcomes of open pediatric forearm fractures. The authors completed of all patients (1987-1999) with open forearm fractures. Sixty-five patients with 65 injured extremities were identified, with an average age of 10.3 years. Fifty-two open fractures were grade I, 12 were grade II, and 1 was grade IIIA. Implants stabilized 40 extremities (62%), which improved alignment but not outcome. Forearms initially stabilized with implants did not undergo additional realignment procedures (0%), compared with 18.5% of forearms without stabilization. Eleven patients (16.9%) experienced complications. Overall, 47 (72%) were classified as having excellent results, 11 (17%) as good, and 7 (11%) as fair. Open pediatric forearm fractures have a high percentage of excellent and good outcomes. Early, thorough surgical débridement produces a low frequency of deep infections, and bony stabilization can be a safe technique, permitting more anatomic alignment and preventing the need for reoperation due to malalignment.

The functional outcome of lower-extremity fractures with vascular injury

Salvage of lower-extremity Gustilo type IIIC fractures is difficult, time-consuming for the patients and physicians, and not universally successful because of poor functional outcomes. Even if successful with limb salvage, the functional result may be unsatisfactory because of mutilating injuries to muscle and nerve, bone loss, and the presence of chronic infection. From July 1991 until July 1994, revascularizations of open IIIC fractures were attempted for wounds with Mangled Extremity Severity Score (MESS) < or = 10. The functional results were evaluated at 2 years after injury. Thirty-six lower-extremity revascularizations were performed on 34 patients, including 1 patient with bilateral distal tibial IIIC fractures and a child with IIIC femoral fracture accompanied by ipsilateral distal tibial amputation. Excluded were patients with below-ankle IIIC fractures as well as patients who underwent immediate amputation at admission. After the revascularization, seven patients with IIIC fractures (7 of 36, 19.4%) underwent secondary amputation within 1 week. At the 2-year follow-up, the overall secondary amputation rate was 25% (9 of 36) and the salvage rate was 75% (27 of 36). Those were no deaths. Of the 29 salvaged limbs among these 27 patients, 23 limbs (23 of 29, 79.3%) required secondary coverage procedures that included 12 free flap transfers (12 of 29, 41.4%). Every patient needed subsequent reconstructive surgery to achieve an acceptable functional result. In this series, MESS was able to predict the secondary amputation rate and the functional result. Sixteen of the 17 limb-salvaged patients with MESS < or = 7 were able to achieve minimal functional requirements, whereas 3 of the 10 patients with MESS = 8 to 10 failed to achieve minimal functional requirements at the 2-year follow-up. Using statistical analysis, we found that the salvaged limbs with MESS < or = 9 exhibited a significant difference in achieving adequate function compared with limbs with MESS > 9. Using our protocol for treatment for IIIC fractures, the threshold for immediate amputation can be raised from MESS = 7 to MESS = 9. Our conclusions are (1) more severely injured limbs have poor functional results, (2) every patient needs subsequent reconstructive surgery, and (3) the MESS may be helpful in decision-making.

Fracture healing in tibia fractures with an associated vascular injury

BACKGROUND

Tibial fractures with an associated vascular injury are a challenging management problem for the orthopedic and vascular surgeon. The effect of a concomitant vascular injury on fracture healing has not been specifically delineated previously.

METHODS

We performed a retrospective review of 29 fractures of the tibial shaft with an associated vascular injury in 28 patients.

RESULTS

Overall there were 44 vessels injured (38 arterial and six venous). A total of six patients had an amputation performed; patients requiring amputation were significantly older than those without amputation. Fractures with an associated injury to the posterior tibial artery had a significantly higher nonunion rate and a greater number of weeks to union than fractures without this vascular injury.

CONCLUSION

Outcomes of tibial fractures with an associated vascular injury are poorest in older patients (who are at increased risk of amputation) and those with an injury to the posterior tibial artery (who are at increased risk of delayed union and nonunion).