Background
Although the risk of extremity amputation related to an isolated vascular injury is
low, it increases significantly with concomitant orthopedic injury. Our study aims
to evaluate and quantify the impact of risk factors associated with trauma-related
extremity amputation in patients with vascular injury. We sought to determine whether
there are other potential predictors of amputation.
Methods
A retrospective review of patients with extremity vascular injury presenting to a
single level 1 academic trauma center between January 1, 2007, and December 31, 2018,
was performed. All patients diagnosed with major vascular injury to the upper or lower
extremity were included. Data on patient demographics, medical comorbidities, anatomic
location of vascular injury, and the presence of soft tissue or orthopedic injury
were collected. The main outcome measure was major amputation of the affected extremity.
Major amputation included below-the-knee amputation, above-the-knee amputation, as
well as any amputation of the upper extremity at or proximal to the wrist.
Results
We identified 250 extremities with major vascular injury in 234 patients. Of these,
216 (86.4%) were male and 34 (13.6%) female. The mean age was 32.2 years (range 18–79 years)
and mean follow-up was 6.9 (standard deviation: 3.3) years. Just over half of injuries,
130 (52.0%) involved the lower extremity. Forty extremities (29 lower and 11 upper),
or 16.0%, of total injured extremities, required major amputation during the follow-up
period. Concomitant orthopedic injury was present in 106 of 250 (42%) injured extremities.
Using univariable logistic regression models, variables with a significant association
with major amputation included older age, higher body mass index, blunt mechanism
of injury, concomitant orthopedic injury, soft tissue injury, and nerve injury, and
the need for fasciotomy (P < 0.05). In multivariable analyses, blunt mechanism of injury (odds ratio [OR] (confidence
ratio {CI}): 6.51 (2.29, 18.46), P < 0.001) and concomitant orthopedic injury (OR [CI]: 7.23 [2.22, 23.55], P = 0.001) remained significant predictors of amputation.
Conclusions
Concomitant orthopedic injury and blunt mechanism in the setting of vascular injury
are associated with a higher likelihood of amputation in patients with extremity vascular
injury. Further development of a vascular extremity injury protocol may be needed
to enhance limb salvage. Findings may guide patient discussion regarding limb-salvage
decision-making.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Estimating the prevalence of limb loss in the United States: 2005 to 2050.Arch Phys Med Rehabil. 2008; 89: 422-429
- Cleaning up the mess: can machine learning Be used to predict lower extremity amputation after trauma-associated arterial injury?.J Am Coll Surg. 2021; 232
- Combined orthopedic and vascular lower extremity injuries: sequence of care and outcomes.Am J Orthop (Belle Mead NJ). 2012; 41: 182-186
- Vascular trauma revisited.J Am Coll Surg. 2018; 226: 1-13
- Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index.Am Surg. 1987; 53: 205-208
- The validity of the mangled extremity severity score in the assessment of upper limb injuries.J Bone Joint Surg Br. 2005; 87-B: 1516-1519
- Extremity vascular trauma in civilian population: a seven year review from north India.Injury. 2006; 37: 295-296
- Knee dislocations with vascular injury: outcomes in the lower extremity assessment project (LEAP) study.J Trauma. 2007; 63: 855-858
- Predictors of poor outcome in infrainguinal bypass for trauma.J Vasc Surg. 2019; 70: 1816-1822
- Objective criteria accurately predict amputation following lower extremity trauma.J Orthop Trauma. 1989; 3: 166
- Management of severe proximal vascular and neural injury of the upper extremity.J Vasc Surg. 1998; 27: 43-49
- Limb salvage versus traumatic amputation a decision based on a seven-Part Predictive index.Ann Surg. 1991; 213: 473-481
- Can mangled extremity scoring system (MESS) solve the mess of vascular trauma.Indian J Vasc Endovascular Surg. 2020; 7: 22-28
- Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system.BMC Musculoskelet Disord. 2015; 16: 372
- The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: a meta-analysis.Injury. 2009; 40: 72-76
- Lower extremity assessment Project (LEAP) – the best available evidence on limb-threatening lower extremity trauma.Orthop Clin North Am. 2010; 41: 233-239
- Concomitant orthopedic and vascular injuries as predictors for limb loss in blunt lower extremity trauma.Am Surg. 1997; 63: 24-28
- Meta-Analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma.J Vasc Surg. 2015; 62: 265
- The mangled extremity score and amputation.J Trauma Acute Care Surg. 2017; 82: 518-523
- Gustilo IIIC fractures in the lower limb.J Bone Joint Surg Br. 2012; 94-B: 698-703
- Popliteal scoring assessment for vascular extremity injuries in trauma study.J Vasc Surg. 2021; 74: 804-813.e3
Article info
Publication history
Published online: December 20, 2022
Accepted:
December 2,
2022
Received:
July 25,
2022
Footnotes
Disclosure: There are no disclosures to declare for this study. There were no financial or employment interests associated with this publication.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
