The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery and Orthopedic Injuries

BACKGROUND The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. METHODS All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a Level 1 Trauma Center from 2014-2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing operative order were analyzed. RESULTS Twenty-nine patients were treated for popliteal artery injuries. Twelve from these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and ORIF (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend towards lower blood pressure on arrival (p=0.068). There was no significant difference in ED to OR time, OR time, ISS, MESS, EBL, or blood transfusion for sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs 100%, p=0.19). Of the remaining limbs available for follow up, limb salvage at 4.25 years is 100%. CONCLUSION In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.