1. Outcomes of Soft Tissue Reconstruction for Traumatic Lower Extremity Fractures with Compromised Vascularity
Ido Badash, BA, Karen E. Burtt, BS, Hyuma A. Leland, MD, Daniel Gould, MD, PhD, Alexis Rounds, BS, Beina Azadgoli, BS, Ketan M. Patel, MD, Joseph N. Carey, MD
Division of Plastic and Reconstructive Surgery
Keck School of Medicine of USC, Los Angeles, California

2. Disclosures No financial disclosures
No funding was utilized for preparation of this chart review

3. Background
Lower extremity fractures with arterial damage are limb and life-threatening1.
The rate of amputation is as high as 76.9%2.
Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries which result in ischemic damage, tissue necrosis and a higher risk of secondary amputation1.
The rate of amputation is as high as 76.9% for complicated wounds involving combined arterial, skeletal and soft tissue damage2

4. Background
Decreased perfusion and ischemia may complicate flap coverage.
A flap complication rate of 31% has been reported in combat vascular injury3.
The effects of arterial injuries on limb salvage in urban trauma are not well reported.
Definitive flap coverage may be complicated by reduced blood flow and ischemia associated with arterial injuries.
A flap complication rate of 31% has been reported in patients with vascular injuries in combat trauma3.
The effects of arterial injuries on lower extremity salvage for fractures in urban trauma are not well reported.

5. Purpose
To investigate the impact of arterial injuries on flap complication rates and limb salvage in the setting of lower extremity traumatic fractures.

6. Methods
IRB approved retrospective review from at LAC+USC Trauma Center.
All patients with flap coverage for lower extremity fractures below the knee were included (n=156).
Patient demographics, injury information, perioperative data, flap characteristics and outcomes evaluated.
IRB approved retrospective review from at LAC+USC Trauma Center.
All patients requiring soft tissue reconstruction for lower extremity fractures below the knee, including tibial, fibular, ankle and foot fractures, were included (n=156).
Patient demographics, injury information, perioperative data, flap characteristics and outcomes were collected and evaluated.

7. Methods
X-ray/CT angiogram (CTA) reports and provider notes reviewed for documented arterial injuries.
An arterial injury was defined as an occlusion, transection, laceration or other damage to an artery resulting from initial trauma.
Type of vascular repair was obtained from operative reports and provider notes.
X-ray/computed tomographic angiogram (CTA) reports and provider notes were reviewed for documented diagnosis of an arterial injury.
An arterial injury was defined as an occlusion, transection, laceration or other damage to an artery resulting from initial trauma.
Type of vascular repair was obtained from operative reports and provider notes, and was performed was at the discretion of the operating surgeons.
In some cases, no arterial repair was performed based on the judgment of the surgical team

8. Demographics and Trauma Information
Results
Demographics and Trauma Information
All Patients (n=156)
Mean Age ± 16
BMI ±7.0
Males (%)
Smoking (%)
Diabetes (%)
Mechanism of Injury
Pedestrian vs Motor Vehicle (%)
Motor Vehicle Accidents (%)
Motorcycle Collisions (%)
Fall (%)
Gunshot Wound (%)
Crush (%)
Other (%) .

9. Results Fracture Information
All Extremities (n=158)
Closed Fracture %
Open Fracture %
Gustilo I %
Gutilo II %
Gustilo IIIA %
Gustilo IIIB %
Gustilo IIIC %
Unreported %
158 extremities underwent attempted limb salvage.
96.2% of all fractures were tibial/fibular fractures.

10. Type of Arterial Injury and Intervention
Results
Type of Arterial Injury and Intervention
% %
Type of Arterial Injury (n=26)
Anterior Tibial Artery (46.2)
Peroneal Artery (42.3)
Posterior Tibial Artery (42.3)
Popliteal Artery (15.4)
Superficial Femoral Artery (7.7)
Deep Femoral Artery (3.8)
Dorsalis Pedis Artery (11.5)
Management (n=26)
Intervention 12 (46.2)
Vein Grafting 8 (66.6)
Ligation 4 (33.3)
Observation 14 (53.8)
All popliteal artery injuries were repaired.

11. Results Flap Characteristics Arterial Injury Non-Arterial Injury
Arterial Injury Non-Arterial Injury P-Value
Median Days to first Flap Procedure
Mean Flap Size (cm2) ± ± *
Arterial Injury
Non-Arterial Injury

12. Results Factors Associated with Arterial Injuries
Arterial Injury Non-Arterial Injury P-Value OR CI n
Intracranial Hemorrhage 20.0% %
Distal Third Fracture % %
Nerve Injury % % <
Fasciotomy % % <
Total # Surgeries 4.7 ± ± <0.01
Distal third fractures included fractures of distal tibia or fibula.
Fasciotomy performed for compartment syndrome.

13. Results Complications of Soft Tissue Reconstruction
Arterial Injury Non-Arterial Injury P-Value OR CI n
Amputation % %
Flap Failure % % <
Hematoma 7.7% %
Fat Necrosis % %
Flap Necrosis % %
Seroma % %
Wound Dehiscence % %
Any Complication % %
No difference in complication rates based on arterial repair.

14. Results Infection Characteristics
Rate of soft tissue infection (p=0.66) and osteomyelitis were not significantly different between groups (p=0.74).
All 3 patients with arterial injuries who were amputated had failed limb salvage secondary to nonhealing infection.
Two of these patients developed osteomyelitis.
Any Complication % %
Soft Tissue Infection 38.5% %

15. Conclusions
Limb Salvage was successful in the majority of patients with arterial injuries (88.5%).
Patients with arterial injuries had a greater rate of amputation and flap failure than patients without vascular compromise.
Severity of trauma may have played a role in the worse outcomes of patients with arterial injuries.

16. Conclusions
A high index of suspicion for other injuries is necessary in patients with vascular compromise.
Emphasis on wound infection prophylaxis and treatment is critical.
Further studies needed assessing impact of arterial repair on outcomes of lower extremity fractures with compromised vasculature.

17. Thank you
Thank you.

18. References
1. Rasmussen TE, Tai NRM. Rich’s Vascular Trauma. Elsevier Health Sciences; p.
2. Gwinn DE, Tintle SM, Kumar AR, Andersen RC, Keeling JJ. Blast-Induced Lower Extremity Fractures With Arterial Injury: Prevalence and Risk Factors for Amputation After Initial Limb-Preserving Treatment: J Orthop Trauma Sep;25(9):543–8.
3. Casey K, Sabino J, Jessie E, Martin BD, Valerio I. Flap coverage outcomes following vascular injury and repair: chronicling a decade of severe war-related extremity trauma. Plast Reconstr Surg Jan;135(1):301–8.
4. Harrell DJ, Spain DA, Bergamini TM, Miller FB, Richardson JD. Blunt popliteal artery trauma: a challenging injury. Am Surg Mar;63(3):228–31; discussion 231–2.
Thank you.