Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Surgery
Published in: BMC Surgery 1/2022

Open Access 01-12-2022 | External Fixator | Research

Management algorithm of external fixation in lower leg arterial injury for limb salvages

Authors: Lei Jin, Song Zhang, Yuxuan Zhang, Xin Lin, Dehong Feng, Kejia Hu

Published in: BMC Surgery | Issue 1/2022

Login to get access

Abstract

Purpose

The aim of this study is to investigate the outcome of these limb-threatening injuries through external fixation treatment and to discuss the case of patients’ functional recovery after external fixation.

Methods

Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery.

Results

Eighty-eight patients were identified and 80 patients (90 legs) maintained a successful lower leg salvage. The mean age was 32.7 ± 10.8 years, and 81.8% were male. The primary outcomes included the following complications: pin-tract infection (8 legs), pins loosening (4 pins), wound superficial infection (7 legs), deep infection developed osteomyelitis (3 legs), bone nonunion or bone defect (17 legs) and amputation (8 legs). The average healing time of fracture was 5.6 ± 4.3 months. The maintain of external fixation average time was 5.8 ± 3.6 months. The improvement of scores of the pain, function and quality of life in our follow-up was statistically significant.

Conclusion

For the lower extremity fracture patients with vascular injuries, using external fixation correctly can improve clinical outcomes and produce the improvement of pain, function and the quality of life.

Level of evidence

Retrospective cohort, level IV.
Literature
1.
Kohli A, Singh G. Management of extremity vascular trauma: Jammu experience. Asian Cardiovasc Thorac Ann. 2008;16(3):212–4.PubMedCrossRef
2.
Tejwani N, Polonet D, Wolinsky PR. External fixation of tibial fractures. J Am Acad Orthop Surg. 2015;23(2):126–30.PubMedCrossRef
3.
Carroll EA, Koman LA. External fixation and temporary stabilization of femoral and tibial trauma. J Surg Orthop Adv. 2011;20(1):74–81.PubMed
4.
Chandran P, Puttaswamaiah R, Dhillon M, Gill S. Management of complex open fracture injuries of the midfoot with external fixation. J Foot Ankle Surg. 2006;45(5):308–15.PubMedCrossRef
5.
Iannacone WM, Taffet R, DeLong WG Jr, Born CT, Dalsey RM, Deutsch LS. Early exchange intramedullary nailing of distal femoral fractures with vascular injury initially stabilized with external fixation. J Trauma. 1994;37(3):446–51.PubMedCrossRef
6.
Zhong W, Lu S, Chai Y, Wen G, Wang C, Han P. One-stage reconstruction of complex lower extremity deformity combining Ilizarov external fixation and sural neurocutaneous flap. Ann Plast Surg. 2015;74(4):479–83.PubMedCrossRef
7.
Montpetit K, Hamdy RC, Dahan-Oliel N, Zhang X, Narayanan UG. Measurement of health-related quality of life in children undergoing external fixator treatment for lower limb deformities. J Pediatr Orthop. 2009;29(8):920–6.PubMedCrossRef
8.
Manner HM, Huebl M, Radler C, Ganger R, Petje G, Grill F. Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator. J Child Orthop. 2007;1(1):55–61.PubMedCrossRef
9.
Ganjwala D, Shah S, Shah S. Ensuring precision in lower limb deformity correction through a combination of temporary external fixation followed by internal fixation: results of a retrospective study. Indian J Orthop. 2014;48(5):495–500.PubMedPubMedCentralCrossRef
10.
Sawyer JR, Kelly DM, Rhodes LN, Beaty JH, Terry Canale S, Warner WC Jr. Use of a “kickstand” modification for external fixation of lower extremity fractures in children. J Child Orthop. 2011;5(1):63–7.PubMedCrossRef
11.
Oka Y, Kim WC, Yoshida T, et al. Hybrid fixation for paediatric femoral supracondylar fracture during circular external fixation of the lower limb. Strat Trauma Limb Reconstr. 2020;15(3):179–83.CrossRef
12.
Logan C, Hess A, Kwon JY. Damage control orthopaedics: Variability of construct design for external fixation of the lower extremity and implications on cost. Injury. 2015;46(8):1533–8.PubMedCrossRef
13.
14.
Behdad S, Rafiei MH, Taheri H, et al. Evaluation of Mangled Extremity Severity Score (MESS) as a predictor of lower limb amputation in children with trauma. Eur J Pediatr Surg. 2012;22(6):465–9.PubMedCrossRef
15.
Cahill L, Joughin B, Kwon W, et al. Multiplexed plasma immune mediator signatures can differentiate sepsis from noninfective SIRS: American Surgical Association 2020 Annual Meeting Paper. Ann Surg. 2020;272(4):604–10.PubMedCrossRef
16.
Mahajna A, Aboud N, Harbaji I, et al. Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study. Lancet (London, England). 2002;359(9320):1795–800.CrossRef
17.
Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286:241–6.CrossRef
18.
Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781–8.PubMedCrossRef
19.
Schollmeier G, Uhthoff HK, Sarkar K, Fukuhara K. Effects of immobilization on the capsule of the canine glenohumeral joint. A structural functional study. Clin Orthop Relat Res. 1994;304:37–42.CrossRef
20.
Bendon CL, Giele HP. Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction. J Plast Reconstr Aesthet Surg. 2016;69(7):888–93.PubMedCrossRef
21.
Keen RR, Meyer JP, Durham JR, et al. Autogenous vein graft repair of injured extremity arteries: early and late results with 134 consecutive patients. J Vasc Surg. 1991;13(5):664–8.PubMedCrossRef
22.
Martin LC, McKenney MG, Sosa JL, et al. Management of lower extremity arterial trauma. J Trauma. 1994;37(4):591–8.PubMedCrossRef
23.
Fainzilber G, Roy-Shapira A, Wall MJ Jr, Mattox KL. Predictors of amputation for popliteal artery injuries. Am J Surg. 1995;170(6):568–70.PubMedCrossRef
24.
Nemoto M, Ishikawa S, Kounoike N, Sugimoto T, Takeda A. Free flap transfer to preserve main arterial flow in early reconstruction of open fracture in the lower extremity. Plast Surg Int. 2015;2015:213892.PubMedPubMedCentral
25.
Katsamouris AN, Steriopoulos K, Katonis P, et al. Limb arterial injuries associated with limb fractures: clinical presentation, assessment and management. Eur J Vasc Endovasc Surg. 1995;9(1):64–70.PubMedCrossRef
26.
Boyce R, Singh K, Obremskey W. Acute management of traumatic knee dislocations for the generalist. J Am Acad Orthop Surg. 2015;23(12):761–8.PubMedCrossRef
27.
Malan E, Tattoni G. Physio- and anatomo-pathology of acute ischemia of the extremities. J Cardiovasc Surg. 1963;4:212–25.
28.
Labbe R, Lindsay T, Walker PM. The extent and distribution of skeletal muscle necrosis after graded periods of complete ischemia. J Vasc Surg. 1987;6(2):152–7.PubMedCrossRef
29.
Forrest I, Lindsay T, Romaschin A, Walker P. The rate and distribution of muscle blood flow after prolonged ischemia. J Vasc Surg. 1989;10(1):83–8.PubMedCrossRef
30.
Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm. J Plast Reconstr Aesth Surg. 2009;62(5):571–9.CrossRef
31.
Watson JT, Moed BR, Karges DE, Cramer KE. Pilon fractures. Treatment protocol based on severity of soft tissue injury. Clin Orthop Relat Res. 2000;375:78–90.CrossRef
32.
Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma. 2005;19(7):448–55.PubMedCrossRef
33.
Cohn MR, Unnanuntana A, Pannu TJ, Warner SJ, Lane JM. Materials in fracture fixation. In: Ducheyne P, editor. Comprehensive biomaterials II. Elsevier: Oxford; 2017. p. 278–97.CrossRef
34.
Bhandari M, Zlowodzki M, Tornetta P III, Schmidt A, Templeman DC. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma. 2005;19(2):1.CrossRef
35.
36.
Menon DK, Dougall TW, Pool RD, Simonis RB. Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing. J Orthop Trauma. 2002;16(7):491–7.PubMedCrossRef
37.
Bilir M, Tekin SB. Evaluation of complications in patients with open fractures of the upper and lower extremity treated with internal fixation after the external fixation. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES. 2020;26(6):865–9.
38.
Lin CH, Wei FC, Levin LS, Su JI, Yeh WL. The functional outcome of lower-extremity fractures with vascular injury. J Trauma. 1997;43(3):480–5.PubMedCrossRef
39.
Zhou FY, Guo XS, Gao WY, Chen XL, Li ZJ, Jiang LF. Clinical significance of MESS scoring system in the treatment of fractures of lower limb combined with vascular injuries. Zhongguo Gu Shang. 2010;23(6):445–7.PubMed
40.
Fochtmann A, Mittlböck M, Binder H, Köttstorfer J, Hajdu S. Potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures. J Trauma Acute Care Surg. 2014;76(4):1076–81.PubMedCrossRef
41.
Gupta A, Parikh S, Rajasekaran RB, Dheenadhayalan J, Devendra A, Rajasekaran S. Comparing the performance of different open injury scores in predicting salvage and amputation in type IIIB open tibia fractures. Int Orthop. 2020;44(9):1797–804.PubMedCrossRef
42.
Sheean AJ, Krueger CA, Napierala MA, Stinner DJ, Hsu JR. Evaluation of the mangled extremity severity score in combat-related type III open tibia fracture. J Orthop Trauma. 2014;28(9):523–6.PubMedCrossRef
43.
Stranix JT, Lee ZH, Jacoby A, et al. Not all gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg. 2017;140(5):1033–41.PubMedCrossRef
44.
45.
Hao ZC, Xia Y, Xia DM, Zhang YT, Xu SG. Treatment of open tibial diaphyseal fractures by external fixation combined with limited internal fixation versus simple external fixation: a retrospective cohort study. BMC Musculoskelet Disord. 2019;20(1):311.PubMedPubMedCentralCrossRef
46.
Abulaiti A, Yilihamu Y, Yasheng T, Alike Y, Yusufu A. The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect. Injury. 2017;48(12):2842–6.PubMedCrossRef
47.
van der Merwe L, Birkholtz F, Tetsworth K, Hohmann E. Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction. Injury. 2016;47(8):1756–60.PubMedCrossRef
Metadata
Title
Management algorithm of external fixation in lower leg arterial injury for limb salvages
Authors
Lei Jin
Song Zhang
Yuxuan Zhang
Xin Lin
Dehong Feng
Kejia Hu
Publication date
01-12-2022
Publisher
BioMed Central
Published in
BMC Surgery / Issue 1/2022
Electronic ISSN: 1471-2482
DOI
https://doi.org/10.1186/s12893-022-01486-2

Other articles of this Issue 1/2022

BMC Surgery 1/2022 Go to the issue

Review

In correspondence to “Spontaneous common bile duct perforation in full term pregnancy: a rare case report and review of literature”

Research

Preoperative plasma D-Dimer level is correlated with peritoneal cancer index of patients with pseudomyxoma peritonei

Research

Long-term postoperative outcomes of Roux-en-Y cholangiojejunostomy in patients with benign biliary stricture

Research

Perioperative pectoral nerve block type II and postoperative recurrence in breast cancer: a randomized controlled trial

Research article

Laparoscopic extralevator abdominoperineal excision in distal rectal cancer patients: a retrospective comparative study

Research

A prospective comparison of 3 hamstring ACL fixation devices—rigidfix, bioscrew, and intrafix—randomized into 4 groups with a minimum follow-up of 5 years