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A Critical Reappraisal of Indications for Fasciotomy After Extremity Vascular Trauma
Ziad Abouezzi, MD;
Zahi Nassoura, MD;
Rao R. Ivatury, MD;
John M. Porter, MD;
William M. Stahl, MD
Arch Surg. 1998;133:547-551.
ABSTRACT
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Objective To critically reevaluate the indications for fasciotomy in vascular trauma of the extremities.
Design Case-control study.
Setting Level I trauma center.
Materials and Methods One hundred sixty-three vascular injuries to the extremeties were analyzed. Fasciotomy as an adjunct to vascular repair was performed in 45 limbs (28%), based either on the nature of injury or measured compartment pressure of greater than 35 mm Hg.
Main Outcome Measures Need for fasciotomy or limb amputation.
Results Fasciotomy was performed for 29.5% of isolated arterial injuries, 15.2% of isolated venous injuries, and 31.6% of combined arterial and venous injuries, and was not related to venous repair or ligation. Seven delayed fasciotomies were performed either for vascular repair failure (5 patients) or compartment syndrome (2 patients). The highest incidence was for popliteal vessel injury (arterial 57%, combined 61%). Of the 33 lower-extremity fasciotomies, 58% were for popliteal vessel injury. In 51 combined injuries of the lower extremity, only 7 (19%) of 38 patients with injury above the knee required fasciotomy, as compared with 8 (62%) of 13 with injury to the popliteal vessels (P<.001), with or without venous repair. There were 3 amputations, all resulting from vascular repair failure.
Conclusions The presence of a combined vascular injury or the need for venous ligation does not necessitate routine fasciotomy. The need for fasciotomy may be maximal for injuries to popliteal vessels.
INTRODUCTION
THE ROLE of fasciotomy in the management of vascular trauma remains controversial. Some authors recommend "routine" prophylactic fasciotomy, while others reserve the procedure for selected patients.1-28 The proponents of prophylactic fasciotomy argue that morbidity and amputation rates can be unacceptably high if the procedure is delayed until the onset of clinical evidence of compartment syndrome.2, 6 The opponents of this concept cite the small percentage of patients who need an adjunct fasciotomy following extremity vascular injury.1, 7-11 Furthermore, recent data suggest that fasciotomy is not as innocuous as was previously taught. To redefine the role of fasciotomy in vascular injuries of the extremeties, we retrospectively analyzed our 8-year experience with selective application of fasciotomy.
MATERIALS AND METHODS
The records of all patients with upper- or lower-extremity vascular injuries treated surgically between January 1988 and December 1995 at our level I trauma center were reviewed retrospectively. Patients who died within 24 hours of injury were excluded from the study.
All the patients with vascular injuries were treated in the operating room according to standard principles. During the study period, 163 such injuries were identified and treated. Fasciotomy was performed on 45 limbs (33 legs and 12 forearms). The indications for fasciotomy were warm ischemia time greater than 6 hours and clinical evidence of compartment syndrome or elevated compartment pressures (>35 mm Hg). A few patients had prophylactic fasciotomy based on the judgment of the operating surgeon, dictated by the nature, location, and severity of vascular injury. In patients with complex venous injuries who underwent venous ligation because of the extent of injury or hemodynamic instability, clinically evident venous hypertension prompted a fasciotomy. In more stable patients with severe venous injuries, venous stump pressures were measured and guided the need for fasciotomy.12-13
Four-compartment fasciotomy in the legs was performed through an anterolateral and a posteromedial skin incision. Fibulectomy was not employed. Forearm fasciotomy was done either through a volar or a dorsal incision. All fasciotomies were treated postoperatively with wet-and-dry dressing twice daily and were evaluated 5 to 7 days postoperatively by the operating team for possible delayed primary closure or skin grafting.
For the purpose of this study, primary fasciotomy is defined as the procedure done at the initial operation. The fasciotomy is termed delayed when done at a later date for elevated compartment pressures or clinically significant compartment syndrome. The medical records were analyzed for demographics; nature, location, and mechanism of injury; type of vascular repair; and indication for fasciotomy (when performed). Associated fracture and/or nerve injury, the development of compartment syndrome before fasciotomy, and the outcome were recorded. Statistical analysis was performed using the Fisher exact test. P<.05 was considered significant.
RESULTS
A total of 163 extremities were treated for vascular injury during the study period. Of these, 45 fasciotomies (28%) were performed (33 legs and 12 forearms). There were 44 men and 1 woman, with a mean age of 27.7 years (range, 11-46 years). The distribution of vascular injuries in the fasciotomy and no-fasciotomy groups according to mechanism and nature of the injury and the presence or absence of fracture is presented in Table 1. The incidence of fasciotomy according to site of injury and type of repair is described in Table 2. The incidence did not seem to have been influenced by the nature of injuries (arterial vs venous). However, it was the highest in the presence of popliteal vessel injury (arterial, 53%; venous, 67%; combined, 2%). Of the lower-extremity fasciotomies, 57.5% were performed for popliteal vascular trauma. Only 7 (19%) of 38 patients with combined (arterial and venous) injuries proximal to the knee required fasciotomy, while 62% of combined popliteal injuries required such adjunctive treatment (P<.001), with or without venous repair. Fifty-one patients sustained venous injuries, either isolated or combined (Table 3). The surgical management of such injury (ligation vs repair) did not influence the incidence of fasciotomy.
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Table 1. Mechanism and Nature of Injury and Associated Fractures
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Table 2. Site, Nature, and Treatment of Vascular Injury
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Table 3. Venous Repair in Combined Injuries*
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Seven of the 45 fasciotomies performed were delayed (ie, not performed at the time of the vascular repair), 5 following failure of vascular repair and 2 for the onset of clinical compartment syndrome. Table 4 summarizes the characteristics of the patients who had a delayed fasciotomy.
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Table 4. Characteristics of Patients Who Had Delayed Fasciotomy
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There were a total of 3 amputations (2 above-knee and 1 below-knee) in 163 extremity vascular injuries, an incidence of 1.8%. All had extensive popliteal vessel trauma. Of the 3, 2 had primary fasciotomy and 1 had delayed fasciotomy after failure of popliteal artery repair (Table 5).
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Table 5. Characteristics of Patients With Amputations
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Eleven patients had evidence of neurologic injury. Six of them had a delayed fasciotomy (Table 6). It was difficult to establish whether the neuropathy was the result of the original trauma or a consequence of the delay in fasciotomy.
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Table 6. Characteristics of Patients With Nerve Damage
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COMMENT
Compartment syndrome, as defined by Matsen et al,10 is the development of increased pressure in a limited space compromising the circulation and causing ischemia of muscles and nerves in that space. Unless treated, this increased compartment pressure will ultimately result in loss of neural and muscle function and lead to permanent deformity of the extremity as was described by von Volkmann.14 Although compartment syndrome may be caused within an intact compartment by hemorrhage (fracture, arterial injury) or muscle cell swelling (crush injury), it is most commonly a result of ischemia-reperfusion injury.1, 6, 15 Clinical examples of this phenomenon include traumatic arterial lesions, the use of pneumatic antishock garments for the lower extremities,16 and prolonged periods of compression of the upper extremities in drug addicts.17 The major relevance of compartment syndrome is that there are no classic clinical findings that enable a successful prediction of the need for treatment.6, 15 In view of the irreversible neurologic and muscular sequelae of a missed compartment syndrome, there has been a trend for a liberal use of fasciotomy ("prophylactic fasciotomy") to decompress the extremity compartments in peripheral vascular injuries.18 Traditional teaching recommends fasciotomy be based on the patient's clinical status (ischemia time, shock), operative findings (combined arterial and venous injuries), and techniques of repair (eg, ligation of major venous outflow).6, 19-25 Tradition has also supported fasciotomy as a "no risk/high gain" procedure.
Fasciotomy is not, however, without complications. Infection, prolonged hospital stay and the need, in some patients, for reoperation for closure can be troublesome.7 Iatrogenic nerve injury is a rare complication. Furthermore, the concept that fasciotomy is without functional impairment of the limb during the long-term has recently been questioned. In a recent report, Bermudez and associates26 followed up 17 patients with fasciotomy for a period of 6 months to 20 years. The extremities were studied with air plethysmography, comparing the contralateral limb as a control. The limbs with fasciotomy showed a significant reduction in ejection fraction and residual volume as a measure of calf muscle pump function, even though none showed evidence of venous obstruction or venous reflux. These findings were similar in all limbs with fasciotomy, regardless of the primary etiology (vascular repair or soft tissue injury). These authors concluded that fasciotomy independently contributed to long-term calf muscle pump function and chronic venous insufficiency.
These new findings suggest that fasciotomy may cause a functional abnormality and is perhaps best reserved for strict indications. In fact, several recent series suggested a decreasing role of fasciotomy after arterial, combined, or venous injury. In a retrospective review of 233 patients with 321 femoral vascular injuries and fasciotomy in 60 patients, Cargile and colleagues20 reported that fasciotomies were performed in 39%, 13%, and 3% of combined arterial and venous, isolated arterial, and isolated venous injuries, respectively. Field and coworkers,7 in a retrospective review designed to identify patients who will benefit from prophylactic fasciotomy, did not find that the presence of combined injuries influenced the need for fasciotomy. In a review of 141 combined vascular injuries, of which 83% had venous ligation, Timberlake and colleagues27 found no permanent sequelae of venous ligation. Transient extremity edema developed in 32% of patients, regardless of whether the vein was ligated or repaired. A similar experience was reported by Yelon and Scalea.28 Our experience supports these concepts. In our series, venous repair or ligation or combined vascular injuries did not influence the need for fasciotomy or the incidence of compartment syndrome, perhaps because of our use of venous stump pressures and compartmental pressure monitoring.
The experience at our center with the intraoperative estimation of venous stump pressures has been very helpful in the stable patient with complex venous injuries that cannot be repaired by simple techniques. Venous ligation is an option in these patients, provided it will not lead to venous hypertension from the lack of adequate collateral venous drainage due to extensive soft tissue destruction, multiple injuries of the venous system, or other factors. Under such circumstances, we have used the distal (caudal) venous stump pressure as a guide for the need for repair. The measurement of venous stump pressure is simple and consists of placing an intravenous infusion catheter in the caudal end of the injured vein either via the injured segment or via a branch distal to injury. Venous pressure is measured by an attached water manometer. Patients with documented venous hypertension (pressures >40-45 cm of saline) may benefit from venous reconstruction with or without fasciotomy. The venous pressures should fall substantially after reconstruction and fasciotomy.12-13
In our review, the single most important factor influencing the incidence of fasciotomy and/or compartment syndrome was the location of the injury. The incidence was 57% for isolated popliteal arterial injuries and 62% for combined popliteal injuries. In their review of 85 popliteal vascular injuries, Jaggers and colleagues29 performed fasciotomies for 24 of 56 patients with popliteal artery injuries, an incidence similar to ours. In a recent review of 81 popliteal artery injuries (39 arterial and 42 combined), Fainzilber and associates30 performed primary fasciotomy on 53% of their patients. Of the 35 patients who did not have a primary fasciotomy, 6 required an amputation. From these data, they concluded that a fasciotomy at the time of operation was associated with a reduced amputation rate and recommended its routine use at the time of vascular repair. The increased use of fasciotomy in popliteal injury may in part be due to the often prolonged repair time and warm ischemia. In this retrospective review, there were 2 amputations for extensive popliteal vascular injury despite primary fasciotomy, and one amputation after a delayed fasciotomy and failure of the vascular repair. Our overall amputation rate for popliteal injuries was 9%, an incidence similar to recent reports.29-31
The incidence of neurologic damage after vascular injury to the extremity, whether due to a delayed fasciotomy or from the initial wounding agent, is often difficult to estimate.15 It is, however, noteworthy that in the present series 4 of the 9 patients who had neurologic deficit in the extremity also had failure of the vascular repair and delayed fasciotomy. Another patient with femoral venous ligation had a fracture of the femur and extensive soft tissue injury and subsequently developed neuropathy from a compartment syndrome. Prophylactic fasciotomy could be considered under such circumstances, but it cannot replace careful assessment of the clinical situation, intraoperative judgment, and monitoring of the vascular status of the limb, as well as early diagnosis of impending compartment syndrome by clinical and compartmental pressure evaluation.
Compartment fasciotomy remains a valuable adjunct to the treatment of vascular injuries to the extremities. However, current data suggest that the presence of a combined vascular injury does not by itself necessitate routine fasciotomy, regardless of venous repair or ligation, especially in injuries proximal to the knee. The procedure may be used selectively based on objective criteria and not as a routine addition.
AUTHOR INFORMATION
Corresponding author: Rao R. Ivatury, MD, Department of Surgery, Medical College of Virginia, Richmond, VA 23298.
From the Department of Surgery, New York Medical College and Lincoln Medical and Mental Health Center, Bronx, NY.
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