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

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

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

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.

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

Methods IRB approved retrospective review from 2007-2015 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 2007-2015 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.

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

Demographics and Trauma Information Results Demographics and Trauma Information All Patients (n=156) Mean Age 40 ± 16 BMI 27.8 ±7.0 Males (%) 85.3 Smoking (%) 40.4 Diabetes (%) 12.2 Mechanism of Injury Pedestrian vs Motor Vehicle (%) 35.3 Motor Vehicle Accidents (%) 13.5 Motorcycle Collisions (%) 18.6 Fall (%) 20.5 Gunshot Wound (%) 7.7 Crush (%) 1.3 Other (%) 3.2 .

Results Fracture Information All Extremities (n=158) Closed Fracture 20.9% Open Fracture 79.1% Gustilo I 3.2% Gutilo II 30.0% Gustilo IIIA 2.4% Gustilo IIIB 53.6% Gustilo IIIC 6.4% Unreported 4.0% 158 extremities underwent attempted limb salvage. 96.2% of all fractures were tibial/fibular fractures.

Type of Arterial Injury and Intervention Results Type of Arterial Injury and Intervention % % Type of Arterial Injury (n=26) Anterior Tibial Artery 12 (46.2) Peroneal Artery 11 (42.3) Posterior Tibial Artery 11 (42.3) Popliteal Artery 4 (15.4) Superficial Femoral Artery 2 (7.7) Deep Femoral Artery 1 (3.8) Dorsalis Pedis Artery 3 (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.

Results Flap Characteristics Arterial Injury Non-Arterial Injury Arterial Injury Non-Arterial Injury P-Value Median Days to first Flap Procedure 21 19 Mean Flap Size (cm2) 255.1 ± 184.3 146.6 ± 112.8 0.02* Arterial Injury Non-Arterial Injury

Results Factors Associated with Arterial Injuries Arterial Injury Non-Arterial Injury P-Value OR CI n 25 131 Intracranial Hemorrhage 20.0% 6.1% 0.04 3.8 1.1-14.3 Distal Third Fracture 68.0% 42.7% 0.03 2.9 1.1-14.3 Nerve Injury 24.0% 2.3% <0.01 16.6 3.9-70.0 Fasciotomy 34.6% 7.6% <0.01 6.5 2.3-18.2 Total # Surgeries 4.7 ± 1.9 3.8 ± 1.4 <0.01 Distal third fractures included fractures of distal tibia or fibula. Fasciotomy performed for compartment syndrome.

Results Complications of Soft Tissue Reconstruction Arterial Injury Non-Arterial Injury P-Value OR CI n 26 132 Amputation 11.5% 1.5% 0.03 8.5 1.3-53.5 Flap Failure 26.9% 7.6% <0.01 4.5 1.5-13.2 Hematoma 7.7% 4.5% 0.62 Fat Necrosis 3.8% 2.3% 0.52 Flap Necrosis 11.5% 3.8% 0.13 Seroma 0.0% 1.5% 1.00 Wound Dehiscence 7.7% 10.6% 1.00 Any Complication 42.3% 61.4% 0.08 No difference in complication rates based on arterial repair.

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 42.3% 61.4% 0.08 Soft Tissue Infection 38.5% 45.5% 0.66

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.

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.

Thank you Thank you.

References 1. Rasmussen TE, Tai NRM. Rich’s Vascular Trauma. Elsevier Health Sciences; 2015. 405 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. 2011 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. 2015 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. 1997 Mar;63(3):228–31; discussion 231–2. Thank you.