时机至关重要：长骨骨折合并主要动脉损伤对结局的影响。
Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes.
机构信息
From the Department of Surgery University of Tennessee Health Science Center, Memphis, Tennessee.
出版信息
J Trauma Acute Care Surg. 2022 Jan 1;92(1):21-27. doi: 10.1097/TA.0000000000003430.
BACKGROUND
Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury.
METHODS
Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST).
RESULTS
One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017).
CONCLUSION
Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach.
LEVEL OF EVIDENCE
Prognostic study, Level IV.
背景
伴有主要血管损伤的肢体骨折固定时机仍存在争议。一些人赞成在确定性血管修复之前临时固定骨折，以限制潜在的移植物并发症。另一些人则主张立即进行血运重建，以最大限度地减少缺血时间。本研究的目的是评估骨折固定时机对伴有长骨骨折和主要动脉损伤的患者结局的影响。
方法
对 11 年来同一肢体需要手术修复的合并长骨骨折和主要动脉损伤的患者进行识别，并根据骨折固定时机进行分层。比较血管相关发病率（横纹肌溶解症、急性肾损伤、移植物失败、肢体截肢）和死亡率在血管前置固定（PRE）或后置固定（POST）的患者之间的差异。
结果
共确定 104 例患者：19 例 PRE 和 85 例 POST。两组在年龄、性别、损伤严重程度评分、入院基础不足、24 小时浓缩红细胞和伴行静脉损伤方面相似。PRE 组穿透性损伤较少（32% vs. 60%，p=0.024），血运重建时间较长（9.5 小时 vs. 5.8 小时，p=0.0002）。虽然死亡率无差异（0% vs. 2%，p>0.99），但 PRE 组血管相关并发症更多（58% vs. 32%，p=0.03）：具体来说，横纹肌溶解症（42% vs. 19%，p=0.029）、移植物失败（26% vs. 8%，p=0.026）和肢体截肢（37% vs. 13%，p=0.013）。多变量逻辑回归确定骨折固定 PRE 是移植物失败（优势比，3.98；95%置信区间，1.11-14.33；p=0.03）和肢体截肢（优势比，3.924；95%置信区间，1.272-12.111；p=0.017）的唯一独立预测因素。
结论
在血运重建之前固定骨折会增加血管相关发病率，并且始终被确定为伴有长骨骨折和主要动脉损伤的患者移植物失败和肢体截肢的唯一可改变的危险因素。对于这些患者，应延迟临时或确定性骨折固定至 POST，这是首选方法。
证据水平
预后研究，IV 级。
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