Concomitant Orthopedic Injury is the Strongest Predictor of Amputation in Extremity Vascular Trauma

Abstract

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. 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. 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 32.2years (range 18-79years) 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. 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.