Khan Umar, Harrington Colin, Turner Kristin, Lawrence Joshua, Slobogean Gerard P, O'Toole Robert V, O'Hara Nathan N, Kundi Rishi, Gage Mark J
Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD.
J Orthop Trauma. 2025 Sep 19. doi: 10.1097/BOT.0000000000003078.
To evaluate the impact of time to revascularization on nonunion, deep surgical site infection (SSI), and amputation in Gustilo-Anderson (GA) Type 3C open lower extremity fractures.
Design: Retrospective cohort review.
Single, academic, level-1 trauma center.
Patients aged 18-79 years with GA type 3C open lower extremity fractures and documented avascularity at presentation, treated at a level-1 trauma center between 2016 and 2022 with either immediate amputation or revascularization (direct primary repair, graft reconstruction, or temporizing shunt) and osseous fixation were included. Exclusion criteria were initial admission to another facility, death prior to initial surgery, and unavailable injury time (based on 911 call time in EMS reports).Outcome Measures and Comparisons: The primary outcome was amputation. The secondary outcome was limb salvage with complication, defined as nonunion or deep surgical site infection (SSI). The primary exposure was time from injury to restoration of distal arterial flow. For patients with temporary shunts, this was used as the time to restoration of flow. Multinomial logistic regression was used to evaluate associations between revascularization times and outcomes, adjusting for American Society of Anesthesiologists (ASA) score, sex, and smoking status. Mean times to revascularization were compared among outcome groups (delayed amputation, limb salvage without complication, and limb salvage with complication).
Forty-five patients (46 limbs) were included: 10 (21.7%) underwent limb salvage without complication (median age 25 years, 100% male), 9 (19.6%) underwent limb salvage with complication (median age 36 years, 89% male), 12 (26.1%) underwent delayed amputation (median age 52 years, 67% male), and 15 (32.6%) underwent acute amputation without revascularization (median age 49 years, 60% male), most commonly due to irreparable popliteal or trifurcation-level vascular injuries with severe soft tissue loss. Of the 31 revascularized limbs, 12 (39%) required delayed amputation a mean 18 days post-injury. Nineteen limbs (19/46, 41%) were ultimately salvaged; nine (47% of salvaged; 20% overall) developed nonunion or deep SSI (limb salvage with complication). Mean time to revascularization was 277 minutes for limb salvage without complication, 430 minutes for delayed amputation (mean difference 153 minutes; 95% CI, 48 - 259, p<0.01) and 390 minutes for limb salvage with complication (mean difference 113 minutes; 95% CI, 15 - 211, p=0.03). Each additional hour of ischemia increased the odds of delayed amputation by 3.4-fold (95% CI, 1.1-10.6; p=0.04). When time to revascularization exceeded 6 hours, the probability of limb salvage without complication decreased to 12% (95% CI, 0-25%). ASA classification, DM, HTN, depression/anxiety, smoking, and obesity did not significantly predict likelihood of delayed amputation, nonunion, or deep SSI (p=0.36, 0.81, 0.49, 0.22, 0.23, and 0.66, respectively).
In this cohort of patients with avascular GA Type 3C open lower extremity fractures, prolonged time to revascularization was associated with delayed amputation and limb salvage complications (nonunion, and deep SSI). Revascularization beyond 6 hours of ischemia time was fraught with complications.
Prognostic Level III.
评估血管再通时间对Gustilo-Anderson（GA）3C型开放性下肢骨折不愈合、深部手术部位感染（SSI）和截肢的影响。
设计：回顾性队列研究。
单一的学术性一级创伤中心。
年龄在18 - 79岁之间、患有GA 3C型开放性下肢骨折且就诊时有记录显示存在血管无灌注的患者，于2016年至2022年在一级创伤中心接受了即刻截肢或血管再通（直接一期修复、移植物重建或临时分流）及骨固定治疗。排除标准为最初入住其他机构、初次手术前死亡以及无法获取受伤时间（基于急救医疗服务报告中的911呼叫时间）。
主要结局为截肢。次要结局为伴有并发症的肢体挽救，定义为不愈合或深部手术部位感染（SSI）。主要暴露因素为从受伤到远端动脉血流恢复的时间。对于使用临时分流的患者，此时间用作血流恢复时间。采用多项逻辑回归评估血管再通时间与结局之间的关联，并对美国麻醉医师协会（ASA）评分、性别和吸烟状况进行校正。比较各结局组（延迟截肢、无并发症的肢体挽救、伴有并发症的肢体挽救）的平均血管再通时间。
纳入45例患者（46条肢体）：10例（21.7%）无并发症地接受了肢体挽救（中位年龄25岁，100%为男性），9例（19.6%）伴有并发症地接受了肢体挽救（中位年龄36岁，89%为男性），12例（26.1%）接受了延迟截肢（中位年龄52岁，67%为男性），15例（32.6%）未进行血管再通而接受了急诊截肢（中位年龄49岁，60%为男性），最常见的原因是不可修复的腘动脉或三叉分支水平的血管损伤并伴有严重软组织缺损。在31条接受血管再通的肢体中，12条（39%）在受伤后平均18天需要延迟截肢。19条肢体（19/46，41%）最终得以挽救；9条（挽救肢体中的47%；总体的20%）发生了不愈合或深部SSI（伴有并发症的肢体挽救）。无并发症的肢体挽救的平均血管再通时间为277分钟，延迟截肢为430分钟（平均差异153分钟；95%CI，48 - 259，p<0.01），伴有并发症的肢体挽救为390分钟（平均差异113分钟；95%CI，15 - 211，p = 0.03）。每增加一小时的缺血时间，延迟截肢的几率增加3.4倍（95%CI，1.1 - 10.6；p = 0.04）。当血管再通时间超过6小时时，无并发症的肢体挽救概率降至12%（95%CI，0 - 25%）。ASA分级、糖尿病、高血压、抑郁/焦虑、吸烟和肥胖均未显著预测延迟截肢、不愈合或深部SSI的可能性（p分别为0.36、0.81、0.49、0.22、0.23和0.66）。
在这组患有血管无灌注的GA 3C型开放性下肢骨折的患者中，血管再通时间延长与延迟截肢和肢体挽救并发症（不愈合和深部SSI）相关。缺血时间超过6小时进行血管再通充满并发症。
预后性III级。
