Long bone fractures with associated vascular injury: Who should go first?

Long bone fractures with concomitant vascular injury have the potential to be life and limb threatening injuries, with increased risk for limb loss. There is currently no established surgical order of operations for orthopaedic and vascular intervention. This study compares injury classification, warm ischemia time and patient outcomes in patients with long bone fractures and associated vascular injury after orthopaedic versus vascular primary intervention.

Design: Retrospective review Setting: Level 1 Trauma Center Patient Selection Criteria: Included were patients treated between 2016 and 2021 with fractures of the femur, tibia, fibula, or knee dislocation (OTA/AO 32, 33, 41, 42 and 43) with associated vascular injury necessitating vascular repair. Outcome Measures and Comparisons: Warm ischemia time, intraoperative transfusion requirements, readmission, definitive amputation, fasciotomy, infection, need for vascular revision, and return to weight bearing were compared between the two groups (primary vascular intervention (VP) and primary orthopaedic intervention (OP)).

35 patients were included with 29 patients in the VP group and 6 patients in the OP group. There was no significant difference in the warm ischemia time between groups (p = 0.52) or total operative time (p = 0.13). 3/29 patients in the VP group required definitive amputation and 0/6 patients in the OP group required amputation (p = 1.00). There were no statistically significant differences in rates of infection, fasciotomy, readmission, length of stay, vascular revision, or time to weight bearing between groups.

This study demonstrates collaborative care between surgical teams to minimize warm ischemia time is crucial in patients with lower extremity fractures associated with vascular injury. There is no significant difference in patient outcomes including definitive intraoperative transfusion requirements, amputation, time to weight bearing or infection when comparing primary orthopaedic versus vascular intervention.