Postoperative Follow-up Results in Patients with Arterial Injuries of the Extremities: Expecially in the Patients with Complex Open Fractures

Chung, Han Jun; Kim, Young Wook

Abstract

Complex vascular and orthopedic injury of the extremity is one of the challenging tasks in current trauma surgery. Every efforts for limb salvage may result in chronic disability or even limb loss. There is no established indications for the limb salvage procedure for the patients with severe, complex injuries of the extremity which has neurovascular and orthopedic injuries. The purpose of this study is directed to establish optimal management plan for the patients with severe complex vascular injuries in extremity by reviewing our results of vascular reconstructive surgery for them. During the period from January, 1994 to January, 1997, 43 extremities with vascular injuries in 42 patients who underwent vascular reconstrcutions were included. The vascular injuries involved the arteries in 16 upper and 27 lower extremities. The clinical presentations were ischemia in 15, ischemia and bleeding in 13, massive bleeding in 7, false aneurysm in 5, and arteriovenous fistula in 3 limbs. Combined extremity injuries with the arterial injuries were 22 extremity bone fractures, 16 soft tissue losses, 13 nerve injuries, 12 deep venous injuries, and 3 joint dislocations. Among the 43 arterial injuries, 12 limbs had open fractures of extremity bones and nerve, musculotendinous, and associated venous injuries requiring replantation procedures. With the arterial reconstructions including 27 interposition grafts(26 veins and 1 PTFE graft), 11 arteriorrhaphies, 3 end-to-end anastomosis, and 1 arterial ligation and 1 vein patch grafting, venous reconstructions using interposition vein grafts were performed in 12 limbs. Postoperative limb amputations were required in 3 lower and 2 upper extremities. The causes of postoperative limb losses were soft tissue infections in lower extremities and vascular complications in upper extremities. Follow-up examinations for the salvaged limbs were made in 31 limbs(12 upper extremities, 19 lower extremities) during the mean period of 17.8 months(1 - 36 months). Five(41.7%) upper limbs revealed motor paralysis and 2(10.5%) lower limbs were unable to bear weight. After vascular reconstructions for the extremity arterial injuies, the causes of limb loss showed to be different between the upper and lower limbs. After considering the limb function and patient's emotional satisfaction, our current recommendations for the management of extremity arterial injury are directed to an aggressive vascular reconstruction for upper extremity injury to preserve even the functionless hand and a selective vascular reconstruction should be performed for lower extremity injury after an evaluation of combined soft tissue injury and/or contamination.