Blunt tibial artery trauma: predicting the irretrievable extremity.

Patients suffering blunt leg trauma resulting in below-knee fracture, tibial artery injury, and soft-tissue damage are at major risk for amputation. In an attempt to identify the factors which may forecast limb loss despite vascular surgical repair, all patients with tibial fractures admitted between 1980-1988 were reviewed. Forty-four of 366 (12%) patients presented with clinical evidence of tibial artery injury. Twenty-seven of these 44 patients had angiographic evidence of at least one patent tibial vessel providing adequate distal flow. The remaining 17 patients required operative repair of injured tibial arteries because of persistent distal ischemia. The amputation rate was 35% (6/17--4 BKA, 2 AKA), three of these having patent vascular repairs at the time of the amputation. Operative indications for amputation were ischemic nonviable muscle in three patients, and severe soft-tissue wound infection in three. Patients who required amputation had a significantly greater incidence (Fisher's exact test) of three or more fascial compartments involved in muscular injury (p = 0.005), two or more injured tibial vessels (p = 0.01), failed vascular reconstruction (p = 0.03), a cadaveric foot at initial exam (p = 0.03), and severe muscle crush injury or muscle tissue loss (p = 0.03). No extremity was salvaged when more than two of these factors was present, and a failed vascular reconstruction led to limb amputation in all cases. These factors will predict an irretrievable extremity following blunt tibial artery trauma, allowing amputation before life-threatening wound sepsis develops.