Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: A review of the National Trauma Data Bank

Abstract

Introduction and objectives

Lower extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies.

Methods

The National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8 h (early group) or >8 h after open vascular repair (late group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed.

Results

Of the 1469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the early and late fasciotomy groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the late fasciotomy group (23.2% vs. 5.9%, P < .001). Patients in the early fasciotomy group had lower amputation rate (8.5% vs. 24.6%, P < .001), lower infection rate (6.6% vs. 14.5%, P = .028) and shorter total hospital stay (18.5 ± 20.7 days vs. 24.2 ± 14.7 days, P = .007) than those in the late fasciotomy group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14–0.50, P < .0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64–0.94, P = .01).

Conclusion

Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.

Introduction

Compartment syndrome, a clinical condition resulting from pathologically increased tissue pressure in a non-expansile tissue space, may occur in the setting of lower extremity trauma and is associated with significant morbidity and mortality.1, 2, 3, 4, 5, 6 Its prompt diagnosis is mostly based on clinical criteria,6, 7, 8, 9 although direct compartment pressure measurements have been used in certain clinical scenarios to confirm a suspected diagnosis.⁷ Once the diagnosis of an extremity compartment syndrome (ECS) is made treatment entails decompressive fasciotomy.7, 8, 10

In the setting of trauma, ECS can occur due to haemorrhage occurring as a result of vascular injury or fracture, direct tissue injury caused by crushing blunt trauma, or ischemia-reperfusion that can occur during major arterial or venous injury and subsequent repair. The presence of vascular injury more often results in the development of ECS and has been shown to be highly predictive of the need to perform fasciotomy to reduce the risk of limb loss or death.¹¹

There is an abundance of evidence that treatment of an existing ECS requires urgent and complete fasciotomy and that a delay in treatment results in significant morbidity.4, 8, 12, 13 However, the role of prophylactic fasciotomy in the setting of vascular trauma is not clear. A number of factors such as prolonged ischemia,¹⁰ hypotension,¹⁰ combined arterial and venous injury,6, 12 popliteal vascular injury,14, 15 and massive soft tissue injury¹⁰ may predict the development of ECS. Despite knowledge of such risk factors, the decision to perform and timing of a fasciotomy in a patient with vascular injury without established ECS is not standardized, given the variability of patient presentations and surgeon bias. Proponents of prophylactic, or early fasciotomy, suggest that development of ECS and its associated complications can be avoided.2, 7, 12, 14, 16 Detractors point out that fasciotomies have associated short16, 17, 18 and long-term19, 20, 21 complications and that that their prophylactic use is unnecessary.15, 18, 22

We hypothesized that early fasciotomy in the setting of lower extremity arterial vascular trauma is associated with improved outcomes. We thus used the National Trauma Data Bank (NTDB) to compare characteristics and outcomes of patients undergoing early and delayed fasciotomy.