Hatem Abou-Sayed1, David L Berger. 1. General Surgical Services, Massachusetts General Hospital, 15 Parkman St, Boston, MA 02114, USA.
Abstract
HYPOTHESIS: Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage. DESIGN: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months). SETTING: Single-institution, academic level I trauma center. PATIENTS: Medical records of patients presenting on an emergency basis with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified. INTERVENTIONS: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone. MAIN OUTCOME MEASURES: Limb salvage rate and necessity for vascular surgical intervention based on angiographic data in patients with normal neurovascular examination results. RESULTS: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (P<.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention. CONCLUSIONS: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.
HYPOTHESIS: Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage. DESIGN: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months). SETTING: Single-institution, academic level I trauma center. PATIENTS: Medical records of patients presenting on an emergency basis with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified. INTERVENTIONS: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone. MAIN OUTCOME MEASURES: Limb salvage rate and necessity for vascular surgical intervention based on angiographic data in patients with normal neurovascular examination results. RESULTS: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (P<.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention. CONCLUSIONS: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.
Authors: Christina Tse; Areg Grigorian; Jeffry Nahmias; Nii-Kabu Kabutey; Sebastian Schubl; Brian Beckord; Nina Bowens; Christian de Virgilio Journal: J Clin Orthop Trauma Date: 2019-05-14