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ORIGINAL ARTICLE
Year : 2022 | Volume
: 9
| Issue : 5 | Page : 364-369
A descriptive study of concomitant vascular and bone injuries of the limbs in a tertiary care hospital in South India
Deepak Sulya, Siddhant Rajendra Vairagar, B V Saichandran, Durgaprasad Rath, S P Ramsankar, M Hemachandren, KSP Sreevathsa
Department of Cardiothoracic and Vascular Surgery, JIPMER, Puducherry, India
Correspondence Address:
Dr. Siddhant Rajendra Vairagar
Department of Cardiothoracic and Vascular Surgery, JIPMER, Puducherry
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_71_22
Background: We studied patients with concomitant vascular and orthopedic trauma to limbs to assess their outcome and factors that affect the outcome of the limb. Methodology: We conducted a retrospective descriptive study and data from 68 patients was collected. Factors such as demography, mode of injury, and clinical parameters such as pulses, capillary refill time (CRT), sensory-motor function, compartment syndrome, type of bone and vessel injury, and ischemia time were compared and analyzed. Results: Out of 68 patients (n = 68) with concomitant vascular and orthopedic injury included in the study, 63 (92.65%) patients were males, and the mean age in the study was 30.16 ± 16.33 years; 56 (82.35%) patients sustained road traffic accident and 12 (17.65%) patients sustained fall from height, 7 (10.29%) patients were hypertensive, and 2 (2.94%) patients had diabetes mellitus; popliteal (30 patients – 22.06%) and brachial arteries (30 patients – 22.06%) are the most (total 44.12%) followed by femoral artery (seven patients, 10.29%) and radial artery (one patient, 1.47%); sensory function was absent in 20 (29.4%) patients; CRT was more than 3 s in 49 (72.06%) patients. No mortality occurred during the hospital stay in any of the 68 patients. The overall rate of amputation in the study was 20.59% (14 amputations). Significant association of amputation rate was found with increased CRT (P = 0.01), fracture (P = 0.05), open fracture (P = 0.05), transected vessel (P = 0.017), nonextremity injury (P = 0.01), and compartment syndrome (P = 0.002). Fasciotomy was done for 49 (72.06%) patients, and no significant association was found with the amputation rate. Mangled extremity severity score (MESS) was 7 or more than 7 in 23 (33.82%) patients. All the 14 (100%) patients who required amputation in the study had a MESS of 7 or more (P = 0.01), and limb salvage index (LSI) was 6 or more in 17 patients; among the 14 patients who underwent amputation, 13 patients had an LSI of 6 or more than 6 (P = 0.01). The vascular repair was redone in 3 (21.4%) patients, excessive bleeding requiring blood transfusion happened in 2 (14.3%) patients, and hypotension occurred in 4 (28.6%) patients. Intraoperative complications were associated with an increased rate of amputations (P = 0.001). The mean ischemia time was 15 ± 6.5 h with a median of 15 h; the shortest ischemia time was 10 h, and the longest was 19 h. The mean ischemia time was 14 h in the limb salvage group and 18.5 h in the amputation group. Long ischemia time was associated with increased amputation rates (P = 0.03). There was no significant difference in time between the time of injury and presentation to the hospital, the time between presentation and surgery, and the duration of surgery between the two groups (amputated vs. salvaged). Conclusion: The extent of soft-tissue injury and ischemia time are prime determinants of outcome in cases with concomitant vascular and skeletal injury. Early diagnosis, quick referral, addressing compartment syndrome, and proper vascular repair are the critical factors in salvaging a limb.
Keywords: Amputation, mean ischemia time, orthopedic trauma, soft-tissue injury, vascular injury, vascular repair
The occurrence of concomitant vascular and bone injuries of the limbs is not uncommon, and cases with severe injuries in this condition often end up with amputation. They are often associated with concurrent injuries, and severe complications can sometimes be a threat to life.
The incidence of vascular trauma associated with skeletal injury varies by population (civilian vs. military), geographic location (plains vs. hilly area; rural vs. urban), and mode of injury (road traffic accident vs. falls from height vs. penetrating injury).[1],[2]
Extremity trauma is found more in young individuals and mostly males. The injury mode's high force and velocity are more devastating to the limb than injuries of low force and lesser velocity.[3]
As such, blunt injuries are found to be more damaging than penetrating injuries. Blunt injuries caused extensive damage to soft tissues, whereas penetrating injuries cause injuries with clean margins and affect the smaller area.[4]
There are different kinds of scoring systems used in various studies to predict the salvageability of the affected limb. The rate of amputation of limbs in this condition is proportionate to the severity and the duration of ischemia, extent of soft-tissue injury, and physiological derangements. Sometimes the soft-tissue injury is too extensive to salvage the limb with not only having the risk of reperfusion injury and its severe complications causing multisystem damage but also a wastage of resources and time; moreover, such extensive injury may lead to the development of severe complications such as wound infection, sepsis, and arterial blowout due to a necrotic limb. Operations to salvage a limb are complex and lengthy. Revision operations are warranted at times that may ultimately fail, requiring secondary amputation. In such cases, a better option is to do a primary amputation.[5]
The influence of vascular trauma on the outcome can also be confounded by the presence of concomitant injuries to nonextremities and physiological derangements due to trauma. Vascular damage may sometimes be missed during the initial examination and diagnosed later when the patient clinically deteriorates or when a computed tomographic angiogram is done out of suspicion. After being diagnosed to be having a vascular injury, the cases are managed with emergency vascular interventions if the facilities are available, whereas in the centers without such facilities, they are referred to the other vascular centers.
In India, often, the patients are referred to other centers as vascular units are available only in larger cities. Some of the cases with limb injuries are just diagnosed with bone fractures missing the associated vascular injuries.
MethodologyIn this study, we analyzed the epidemiology, factors, and outcome of the condition with concomitant vascular and bone injuries of the limbs.
Study group
From January 2013 to December 2020, data from subjecs with concomitant vascular and bony injuries were collected from the case records and studied under a single group.
Crush injury of the limbs (direct injury to the soft tissue of limbs resulting in extensive skin damage, muscle laceration, and nerve injury) and life-threatening trauma to the abdomen, chest, and head were excluded.
Study design
This study was a retrospective descriptive study.
The procedure of the study
Factors such as age, sex, mode of injury, comorbidities (hypertension, coronary artery disease, peripheral vascular disease, and diabetes mellitus), site and side of injury, clinical parameters (pulses, capillary refill time [CRT], and sensory and motor function), bone and vessel injured, type of bone and vessel injury, presence of compartment syndrome, mangled extremity severity score (MESS), limb salvage index (LSI), ischemia time, vitals at admission, and vitals during the operation were assessed to find the cause, leading to amputation of the limb.
Confounding/interacting factors
Logistic factors, especially the availability of emergency operation theater facilities on the day of the arrival of the patient, are confounding/interacting factors.
Statistical analysis
The distribution of qualitative variables was expressed in terms of frequency and percentage. The distribution of quantitative variables such as age, ischemia time, the time between injury and presentation to hospital, the time between presentation and surgery, and duration of surgery was expressed in terms of the median with range (since data were nonnormal). The association of outcome with the other categorical variables was carried out using the Mann–Whitney U test.
All statistical analysis was performed in IBM PASW statistics 16.0 SPSS 26.0 (Statistical Package for Social Sciences; IBM, Chicago, IL, USA) and graphed in Microsoft word.
ResultsOut of 68 patients (n = 68) with concomitant vascular and orthopedic injury included in the study, 63 (92.65%) patients were males, and 5 (7.35%) were females. The mean age in the study was 30.16 ± 16.33 years. Out of 68 patients, 56 (82.35%) patients sustained road traffic accidents, and 12 (17.65%) patients sustained falls from height. Comorbidities were found in nine patients, out of which 7 (10.29%) patients were hypertensive, and 2 (2.94%) patients had diabetes mellitus [Table 1].
The right-sided extremity was injured in 48 patients, whereas 20 patients had left-sided injuries. Popliteal and brachial arteries were injured the most in 30 patients each (44.12%), followed by the femoral artery in seven patients (10.29%) and the radial artery in 1 patient (1.47%). Sensory function was absent in 20 (29.4%) patients. CRT was more than 3 s in 49 (72.06%) patients [Table 2].
Mortality
No mortality occurred during the hospital stay in any of the 68 patients.
Amputation rate
The overall rate of amputation in the study was 20.59% (14 amputations). The table shows a univariate analysis of risk factors associated with amputation.
Capillary refill time
CRT was more than 3 s in 49 (72.06%) patients. Out of them, 14 patients underwent amputation. The delayed CRT at the time of presentation was associated with a high rate of amputations (P = 0.01).
Type of bone injury
Among the 68 patients, 49 (72.06%) patients had a fracture of the associated bone, and 19 (27.94%) had joint dislocation. Finally, amputation was done in 13 patients who had a fracture and one patient who had joint dislocation. The fracture was associated with increased amputation rates (P = 0.05).
Type of fracture
The type of fracture, whether closed or open, also determined the outcome (P = 0.05). Among the 49 patients with fractures, 32 (65.31%) patients had closed fractures, and 17 (34.69%) patients had open fractures. Five patients with closed fractures and eight patients with open fractures underwent amputation.
Type of vessel injury
Contused vessel was present in 43 (63.24%) patients and transected vessel in 25 (36.76%) patients. Out of 43 patients with a contused vessel, five patients underwent amputation, whereas out of 25 patients with a transected vessel, nine patients underwent amputation. The amputation rate was high when the vessel was transected in 9 (64.3%) patients, P = 0.017.
Other injuries
Among the 68 patients, 13 patients were noted to have another severe injury. Of these, 10 patients underwent amputation. Two (14.3%) patients had a head injury, and 1 (7.1%) had a thoracic injury. Femoral vein laceration, radius fracture, and popliteal vein laceration with fibula fracture were found in 1 (7.1%) patient. Fibula fracture was found in 2 (14.3%) patients. The amputation rate was high when another injury was present (P = 0.01) [Table 3].
Compartment syndrome
Compartment syndrome was found in 17 (25%) patients and absented in 51 (75%) patients. Out of the 17 patients with compartment syndrome, eight patients underwent amputation. Of the 51 patients with no compartment syndrome, 45 did not require amputation (P = 0.002). Hence, the absence of compartment syndrome was associated with increased chances of limb salvage, whereas the presence of compartment syndrome was associated with increased amputation rates (P = 0.002). Fasciotomy was done for 49 (72.06%) patients. There was no significant difference in amputation rates between the patients who received fasciotomy and those who did not (P = 0.201). This may be because fasciotomy was done even when compartment syndrome was absent and fasciotomy was prophylactic. Passive stretch pain was present in 18 (26.47%) patients, out of which 8 (57.1%) patients underwent amputation.
Mangled extremity severity score and limb salvage index
MESS was 7 or more than 7 in 23 (33.82%) patients. All 14 (100%) patients who required amputation in the study had a MESS of 7 or more than 7 (P = 0.01).
Seventeen patients had limb salvage score of 6 or more. Among the 14 patients who underwent amputation, 13 had an LSI of 6 or more than 6 (P = 0.01).
Vascular intervention
Among the 68 patients, embolectomy was done in 23 (42.6%) patients, primary repair in 23 (42.6%) patients, and vein graft in 8 (14.8%) patients in the limb salvage group. Embolectomy was done in 2 (14.3%) patients, primary repair in 6 (42.9%) patients, and vein graft in 6 (42.9%) patients in the limb amputation group. The amputation rate was high in patients who received primary arterial repair and vein graft (p 0.03). Primary repair was done in 29 patients out of which 6 (20.6%) patients underwent amputation, embolectomy was done in 25 patients, out of which 2 (8%) patients underwent amputation, and vein graft was used in 14 patients, out of which 6 (42.8%) patients underwent amputation [Table 4].
Intraoperative events
Among the 68 patients, 17 (25%) patients had some intraoperative complications. Out of them, nine patients underwent amputation. The procedure was redone in 3 (21.4%) patients, excessive bleeding requiring blood transfusion happened in 2 (14.3%) patients, and hypotension occurred in 4 (28.6%) patients. Intraoperative complications were associated with an increased rate of amputation (P = 0.001).
Ischemia time
The mean ischemia time was 922 ± 404.13 min (15 ± 6.5 h) with a median of 900 min (15 h). The shortest ischemia time was 615 min (10 h), and the longest ischemia time was 1140 min (19 h). The mean ischemia time was 840 min (14 h) in the limb salvage group and 1110 min (18.5 h) in the amputation group. Long ischemia time was associated with increased amputation rates (P = 0.030). There was no significant difference in time between the time of injury and presentation to the hospital, the time between presentation and surgery, and the duration of surgery between the two groups.
DiscussionManagement of concomitant vascular and orthopedic injury is a challenge requiring early diagnosis and intervention for better outcomes with the goal of having a functional limb.
A multidisciplinary approach, including a team of orthopedic and vascular, is helpful for managing traumatic limbs. Other specialty surgeons, such as plastic and general surgeons, are also involved in cases of unsalvageable limbs for amputation and microvascular procedures for hands or feet. The decision for amputation is based on the extent of soft tissue and neurovascular injury. Whenever there is doubt about the salvageability of the limb, revascularization is done provided the ischemic time is within the acceptable limits. Amputation is done if limb necrosis happens. It should be kept in mind that a nonfunctional limb is an obstacle to the quality of life with respect to day-to-day activities, and hence, it is suggested to go for primary amputation than to save a nonfunctional limb.
In our institute, the protocol of performing orthopedic intervention before the vascular procedure was followed for all the patients. The concern was preventing any vascular repair damage by the orthopedic manipulation, which may prolong the anesthesia time. We have not used shunts for temporary restoration of blood flow distal to injury as they would be time-consuming and sometimes could not be successfully placed.[6],[7]
Modrall et al. recommend that vascular repair can be done later if only external fixation and closed reduction of fracture are anticipated. If internal fixation and open reduction of a fracture are planned, then arterial repair should be done first.[8]
A normal CRT is < 3 s. A diminished capillary refill is given 2 points in MESS. Good digital perfusion can still occur if good collaterals are present, even when the main artery is occluded. It may also be increased in states of shock and give a false idea of vascular compromise in closed trauma cases with no distal pulses. We found a significant association between increased CRT with high amputation rates (P = 0.01), i.e., 28.5% of patients with increased CRT underwent amputation.
In this study, 13 out of 49 patients (26.55%) who had fractures and 1 out of 19 (5.2%) patients who dislocated a joint underwent amputation. The rate of incidence of popliteal artery (30 patients, 44.12%) and brachial artery (30 patients, 44.12%) injury was the highest, and these have a high incidence of trauma to the tibia (20 patients, 29.41%) and humerus (21 patients, 30.88%). High-velocity injuries caused extensive damage to the bone and soft tissues. Penetrating injuries cause clean-cut injuries with minimal damage to the neighboring structures. Open fractures and traumatic subtotal amputations are associated with higher amputation rates and functional impairment of the involved limbs; these subsets associated with irreversible necrosis and extensive damage to soft tissue account for the high amputation rate. Eight out of seventeen patients (47%) who had open fractures eventually required amputation.
Higher amputation rates have been found in cases with arterial transection.[9] In our study, out of 25 patients with transected arteries, 9 (36%) patients underwent amputation. This is consistent with the reports in the literature. We found the contused vessel in 43 (63.24%) patients and transected vessels in 25 (36.76%) patients, and amputation was required in 5 and 9 patients, respectively. The amputation rate was high when the vessel was transected in 9 (64.3%) patients, P = 0.017.
Diagnosing a concurrent injury is also essential in the early management of trauma cases. The presence of other associated injuries complicates management in these patients. Management of injuries that can prove life-threatening should be addressed first. Suppose a patient is shifted for surgery for other concurrent injury and radiological investigation is not possible. In that case, local wound exploration can be done if a vascular injury is suspected clinically. In this study, a significant association was found between amputation and concurrent injuries; the presence of head, abdominal, and chest injuries and fractures at multiple levels of the same bone or fractures of more than one bone significantly increased the risk of amputation.
A high rate of amputation was found in patients who develop compartment syndrome at some point after injury.[10] As per our results, the chance of limb salvage increases if compartment syndrome does not develop, whereas the presence of compartment syndrome increases the risk of amputation. Prophylactic fasciotomy is recommended as it restores collateral circulation rather than waiting for the signs of compartment syndrome to develop to perform a fasciotomy.[11],[12] If fasciotomy is not done preoperatively or intraoperatively, regular monitoring of the limb for the development of compartment syndrome is done so that fasciotomy can be done as soon as needed.
Various scoring systems, such as MESS, LSI, and predictive salvage index, have been used globally in the decision-making process for the management of mangled lower extremities. We used MESS and LSI in this study. Various studies have found different values of the scoring systems to prognosticate the outcome of limb trauma. Bosse et al. found these scoring systems to have low sensitivity and high specificity in predicting limb salvage rate.[13],[14] Sharma et al. found a good predictive value of MESS and Sharma et al. found a 100% positive predictive value of MESS in the Indian population.[15]
Bosse et al. also found good sensitivity of LSI in cases with Type III tibial fractures.[13] We found similar findings in this study, with all 14 patients (100%) who underwent amputation with MESS of more than 7, and 13 (92.85%) patients having LSI of more than 6. A significant association between intraoperative complications with amputation rates was found in this study (0.001). The factors such as failure of vascular repair followed by redoing of repair, excessive intraoperative bleeding requiring blood transfusion, and intraoperative hypotension were assessed. The success of vascular repair can be assessed in the table with the return of distal pulses and Doppler signals. The absence of distal Doppler signals and pulses warrants taking down the anastomosis and redoing it. Sometimes anastomosis may become narrowed such that distal pulses cannot be felt, but Doppler signals may be present, and the surgeon may redo the anastomosis; in such situations, it not only increases the ischemia time but also increases the anesthesia time. Margins of vessels may give way while repairing if damaged segments are not completely trimmed out, requiring further trimming of the margins again and redoing the repair. Transient hypotension is given 1 point, and persistent hypotension is given 2 points in MESS. Need for blood transfusion due to bleeding at any point after an injury is found to be negatively associated with limb salvage rate.[16]
Studies have found the failure to diagnose vascular injury at presentation and then delay to take up the case for vascular intervention as causes of increased ischemia time, leading to amputation. Failure at an initial assessment can be due to the presence of pulses and inconspicuous clinical findings.[17],[18],[19]
Need for computed tomography scan and angiography further increase the ischemia time. There was a significant difference in mean ischemia time of 18.5 h in the limb amputation group, while it was significantly high as compared to the mean ischemia time of 14 h in the limb salvage group, P = 0.030. However, no significant difference was found in a delayed presentation to the hospital and delayed take-up for surgery after the presentation. Duration of surgery was also not significantly different between the two groups (0.341) [Figure 1].
Figure 1: Comparison of time factor between limb salvage and amputation group (in minutes) Conclusion The extent of soft-tissue injury along with ischemia time are prime determinants of outcome in cases with concomitant vascular and skeletal injury. Early diagnosis, quick referral, addressing compartment syndrome, and proper vascular repair are the critical factors in salvaging a limb.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
References
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