WTA 2014 PLENARY PAPER

Below-the-knee arterial injury: The type of vessel may be more

important than the number of vessels injured

Joseph R. Scalea, MD, Robert Crawford, MD, Stephanie Scurci, MD, Jonathon Danquah, BS,
Rajabrata Sarkar, MD, PhD, Joseph Kufera, MA, James O’Connor, MD,
and Thomas M. Scalea, MD, Baltimore, Maryland

BACKGROUND: There are few data regarding limb salvage following below-the-knee (BK) arterial trauma. Based on published data and clinical
experience, we hypothesized that any single patent vessel BK would allow for limb viability and salvage.
METHODS: The trauma center registry was retrospectively queried, from 2007 through 2012, for patients presenting with BK arterial
injuries (BKAIs), defined as injury below the popliteal artery. Logistic regression, Pearson’s W2, and Student’s t test were used to
analyze data.
RESULTS: A total of 122 patients were identified. The mean age was 35 years, 84% were male, and 43% were non-white. Of the patients,
83 (68%) sustained blunt and 39 (32%) sustained penetrating injuries. Fifty-one (41%) had an injury to a single BK vessel, and
12 (23.5%) of these underwent attempted repair. All seven patients with two-vessel, and one of two patients with three-vessel
BKAIs had attempted repair. No patient had endovascular repair. Amputation was not associated with Injury Severity Score
(ISS), sex, or age. Patients with blunt injury had higher amputation rates than those with penetrating injury (26.8% vs. 7.5%,
p = 0.01). Of 51 patients, 9 (17.6%) with a single BK vessel injury required amputation; when either two or three vessels
were injured, amputation rates were 29% and 50%, respectively ( p = 0.09). In patients with a single-vessel injury following
blunt trauma, an injured anterior tibia (AT) was associated with a higher amputation rate (6 of 17 patients, 35.3%) when compared
with those patients with either posterior tibial (PT) or peroneal (P) injuries (3 of 34 patients, 8.8%, p = 0.045). The adjusted odds
ratio of requiring an amputation after blunt injury to the AT alone, compared with a PT or P injury, was 22.4 ( p = 0.02).
CONCLUSION: BKAIs are uncommon. In contrast to the commonly taught surgical dogma, which suggests that any intact single-vessel BK is
associated with limb salvage, blunt AT vessel injuries were associated with much higher rates of amputation when compared with P
or PT injuries. Further studies should be undertaken to determine when repair BKAI should be attempted. (J Trauma Acute Care
Surg. 2014;77: 920Y925. Copyright * 2014 by Lippincott Williams & Wilkins)
LEVEL OF EVIDENCE: Epidemiologic study, level III.
KEY WORDS: Trauma; surgery; anterior tibial artery; vascular trauma; angiogram.

A lthough there is a large amount of data published on pa-

tients with lower extremity arterial injury, little of that is
published when the arterial injury occurs below the knee.1Y3
higher mortality associated with a blunt mechanism.7 In addition,
soft tissue injury alone can result in amputation.
The reference point for a discussion of below-the-knee
Below-the-knee vascular injury is a complex topic. The artery arterial injury (BKAI) is the experience of Keeley et al.1
or arteries injured, characterization of the injury, as well as as- published in 1983 by the Parkland group. In their study of
sociated venous and orthopedic injuries have all been associ- 51 patients, authors observed that rates of amputation following
ated with the ability to salvage the limb.4Y6 Multiple contributing BKAI were higher for blunt versus penetrating trauma and that
factors make studying limb salvagability following below-the- amputation rates were approximately 9% when a two vessels
knee arterial trauma difficult. Factors historically associated with below the knee were injured, compared with 60% when three
limb salvage include the number of vessels injured, associated vessels were injured. These data lent credence to the surgical
venous injuries, association with orthopedic injures, and the de- dogma suggesting that single-vessel runoff is sufficient for limb
gree and extent of the injury.4Y6 Up to this point, there are no data salvage. Since the publication of the landmark study of Keeley
on the influence that vessel identity has on limb salvage. Mech- et al., the experience with BKAI has not been adequately re-
anism of injury influences mortality in below-the-knee injury, with evaluated. In the recent era of improved diagnostics, resuscitative
protocols, and interventional techniques, we sought to recapit-
ulate these data.
Submitted: January 27, 2014, Revised: July 11, 2014, Accepted: July 15, 2014.
From the Department of Surgery (J.R.S., R.C., S.S., J.D., R.S., J.O., T.M.S.),
The purpose of the study was to characterize injury pat-
University of Maryland Medical Center; and Shock Trauma Center (J.K., J.O., terns and outcomes of BKAI. We hypothesized that a single
T.M.S.), Baltimore, Maryland. vessel below the knee was sufficient for limb salvage.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text, and links to the digital files are provided in the HTML text of
this article on the journal’s Web site (www.jtrauma.com)
Address for reprints: Joseph R. Scalea, MD, Shock Trauma Center, Office of the Director, PATIENTS AND METHODS
22 South Greene Street, Baltimore, MD, 21291; email: [email protected].
Patient data were retrospectively collected from the trauma
DOI: 10.1097/TA.0000000000000458 registry at the R Adams Cowley Shock Trauma Center during a
J Trauma Acute Care Surg
920 Volume 77, Number 6

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J Trauma Acute Care Surg
Volume 77, Number 6 Scalea et al.

and the Student’s t test was applied for comparing continu-

ous variables. Logistic regression models were constructed to
determine the overall effect of AT, PT, or P arterial injuries,
following adjustment by specific patient and injury characteris-
tics (age, sex, hypertension, and Injury Severity Score [ISS]), on
the outcome of amputation. Adjusted odds ratios (ORs) and their
95% confidence intervals (CIs) were computed, and p G 0.05
was considered statistically significant.

RESULTS
Demographics
During the study period, we cared for 122 patients with
BKAI (Fig. 1). The mean (SD) age was 35 (15) years, 84% were
male, and 43% were non-white. The median length of stay was
8.4 days. The mean ISS was 13. Demographics are presented
in Table 1.

Mechanism of Injury
Eighty-three patients (68.0%) experienced blunt trauma,
and 39 patients (32.0%) experienced penetrating trauma. Of
Figure 1. Characterization of BKAIs.
those with blunt trauma, the mean ISS was higher than for pen-
etrating trauma (15 vs. 11, p = 0.02). In blunt trauma patients, the
majority (n = 59, 71.1%) were involved in MVCs or fall from a
5-year period (2007Y2012). Patients with arterial injuries were height (n = 7, 11.1%). Seven patients with blunt trauma experi-
identified using DRG International Classification of DiseasesV9th enced crush injuries. Of these seven, three patients (42%) were
Rev. (ICD-9) codes as well as reports from radiologic studies. injured in an MVC and two were struck by an object. The etiology
Characteristics of associated orthopedic and lower extremity of penetrating trauma was gunfire in 24 patients (61.5%) and
neurologic injuries were collected using ICD-9 codes as well. knife wounds in 10 patients (25.6%).
ICD-9 codes and operative reports were used to determine the
frequency of nerve and venous injury. Data were complete for
all but five patients with regard to which arteries were injured. TABLE 1. Patient Demographics
These patients were included in aggregate data (i.e., overall Age, y 34.5
amputation rate, ISS, demographics) but excluded from artery-
Sex
specific investigation (i.e., rate of amputation following ante-
Male 103
rior tibial [AT] injury). A single patient had an injury to the
Female 19
tibioperoneal trunk, and this was reclassified as a popliteal ar-
ISS
terial injury. Below-the-knee orthopedic injures were charac-
1Y8 25
terized by type (comminuted, open, etc.) and by location (femur,
9Y15 55
fibula, or tibia). The ankle was not included in this analysis.
16Y24 23
Because mangled extremity scores may be unreliable predictors
25+ 17
of amputation, these scores are not routinely calculated at our
Diabetes
institution and were not used in this analysis. Regarding analy-
Yes 5
sis of arterial injuries, all injuries were listed as affecting either
No 117
the AT, posterior tibial (PT), or peroneal (P) arteries with the
Hypertension
exception of one patient with both dorsalis pedis and a con-
Yes 17
comitant AT injury. This patient was classified as AT only. Be-
No 105
cause the total number of two- and three-vessel arterial injuries
Injury type
was less frequent, these two groups (two-vessel and three-vessel
Blunt 83
injuries) were grouped together for statistical analysis. Primary
Penetrating 39
amputation was defined as amputation before any attempts at re-
No. injured vessels
vascularization. Delayed amputation was considered those per-
1 106
formed after revascularization, within the same hospital admission.
2 or 3 16
Anticoagulation and antiplatelet use was at the discretion of the
Length of stay, d
operative surgeon. Pedestrians struck by a motor vehicle were
Median 12.3
considered motor vehicle collisions (MVCs) for analysis.
Range 0.1Y57
For the analysis of patient data, Pearson’s W2 statistic was
Total 122
used to compare proportions between categorical variables,

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 J Trauma Acute Care Surg
Scalea et al. Volume 77, Number 6

Inpatient Mortality Amputation Rates

Inpatient mortality for all patients with BKAI was 2% Amputation was performed in 20.5% of the patients.
(n = 3). Two of these three deaths were in the blunt trauma Patients with blunt injury had higher amputation rates than
group, and the third died of injuries following gunfire. those with penetrating injury (26.8% vs. 7.5%, p = 0.01).
Amputation rates for single PT, AT, and P ranged from 8.0%
Diagnosis of Injury for PT injuries to 35.3% for AT injuries (p = 0.08, Table 2).
When single AT injuries were compared with either single PT
Patients presenting with hard signs of arterial injury (32%)
or P injury (25 PT + 9 P injuries), the difference in the rate of
did not have preoperative imaging. Preoperative imaging was used
amputation (35.3% vs. 8.8%) was higher for patients with AT
in the remainder; 7% were diagnosed with angiogram and 63% by
injuries (p = 0.045). W2 analysis identified AT injury (when
computed tomography.
compared with PT or P injury) as an independent predictor of
amputation in patients who sustained a single-vessel injury
Characterization of Vessel Injury below the knee (p = 0.04). When adjusted by patient and injury
A total of 60 patients sustained an injury to one or more characteristics in logistic regression models, the only indepen-
of the AT, PT, and P. Of these 60 patients, 51 (85%) were to a single, dent variable with p G 0.05 was AT injury. Logistic regression
nonpopliteal vessel below the knee (Table 2). The remaining analysis for patients with a single-vessel injury below the knee,
62 patients (50.8% of all patients) experienced BKAI of the regardless of mechanism, revealed that the adjusted OR of AT
popliteal artery. There was a single injury to the tibioperoneal injury leading to eventual amputation, when compared with PT
trunk. Of those with an injury to a single, nonpopliteal vessel and P injuries, was 11.96 (95% CI, 1.47Y97.54; p = 0.02), as
(Fig. 1), 25 injuries (49%) were to the PTartery, 17 (33%) were to shown in Table 3. The adjusted OR of AT injury leading to
the AT artery, and 9 (18%) had an isolated P artery injury. amputation increased to 22.39 (95% CI, 1.50Y333.57; p = 0.02)

TABLE 2. Amputation Rates Following Traumatic Injury to a Single Arterial Vessel Below the Knee
Amputation
Total Yes No
n n % n %
51 9 17.6 42 82.4 p
Sex
Male 43 8 18.6 35 81.4
Female 8 1 12.5 7 87.5 1.00
ISS
1Y8 12 2 16.7 10 83.3
9Y15 26 4 15.4 22 84.6
16Y24 6 2 33.3 4 66.7
25+ 7 1 14.3 6 85.7 0.78
Diabetes
Yes 0 0 0.0 0 0.0
No 51 9 17.6 42 82.4 NA
Hypertension
Yes 8 2 25.0 6 75.0
No 43 7 16.3 36 83.7 0.62
Injury type
Blunt 33 8 24.2 25 75.8
Penetrating 16 0 0.0 16 100.0
Crush/other 2 1 50.0 1 50.0 0.03
Injury artery
AT 17 6 35.3 11 64.7
PT 25 2 8.0 23 92.0
P 9 1 11.1 8 88.9 0.08
Injury artery
AT 17 6 35.3 11 64.7
PT 34 3 8.8 31 91.2 0.045
Mean (n = 51) SD Mean (n = 122) SD p
Age, y
41.8 9.7 34.5 15.4 0.18

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J Trauma Acute Care Surg
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TABLE 3. Logistic Regression of Significant Variables TABLE 5. Amputation and Associated Mortality by Number of
Associated With Traumatic Injury to a Single Arterial Vessel Vessels Injured
Below the Knee
Count Amputation Rate Mortality
Logistic Regression Results for Single Vessel Blunt Injury Only (n = 35)
1 vessel 51 9 (18%) 0%
Variable With 95% CI 2 vessel 7 2 (29%) 14%
Independent Variable p 9 0.10 Parameter OR of OR p
3 vessel 2 1 (50%) 50%
Age NS Popliteal 55 10 (18%) 2%
Sex NS Popliteal+1 7 2 (29%) 0%
ISS 9Y15+ vs. ISS G 9 NS
ISS 16Y24+ vs. ISS G 9 NS
ISS 25+ vs. ISS G 9 NS 88 patients, 59 patients (67%) sustained injury to the isolated
Hypertension NS tibia and/or fibula. In contrast, 14 patients (16%) with LEOI had
AT vs. PT/P AT vs. PT/P 2.48 11.96 1.47Y97.54 0.02 isolated femur injury. Fifteen patients (17%) with LEOI had
femoral injuries in addition to the fibular and/or tibial injuries.
Twenty patients (16%) had associated lower extremity neurolo-
when penetrating injuries were excluded (Table 4). There were gic injuries (LENI). Eighteen patients (15%) experienced both
five patients with penetrating injuries of the AT, and none (0%) of LENI and LEOI. Fourteen patients (11%) had an associated
these patients required amputation. Nine patients had BKAI venous injury of the lower extremity. Of this group, 11 patients
involving two or three vessels (Supplemental Digital Content 1 (79%) sustained injury to the popliteal vein, 1 patient (7%) to the
[SDC 1], at http://links.lww.com/TA/A488). The observed rate femoral vein, and 2 (14%) to an unspecified vein. Two patients
of amputation was 37.5% when there are two or more injured (14%) with an associated lower extremity venous injury required
vessels versus 17.6% when there is a single-vessel injury (p = amputation. Both of these patients sustained complete transec-
nonsignificant [NS]). tions of the popliteal vein, and both had associated BKAIs of the
popliteal artery, and neither patient with a venous injury underwent
Popliteal Artery Injuries a repair. Forty patients (73%) with an isolated BKPI had asso-
Of the 62 patients who experienced BKAI of the popliteal ciated LEOI. Eight patients (15%) with an isolated BKPI had
artery, 55 patients had isolated below-the-knee popliteal artery associated LENI. Moreover, 8 (80%) of the 10 isolated BKPIs
injury (BKPI). Seven patients had injuries to the popliteal as well had associated LEOI, and 2 had associated LENI.
as one additional vessel (a single AT and a single PT). Because
the popliteal artery feeds the three crural vessels below the knee, Repair
we next sought to determine if isolated BKPI was associated Sixty-five percent of the patients had a repair of BKAI.
with similar outcome when compared with three-vessel injury. Sixteen patients (12%) never underwent arterial reconstruction
Ten patients (18%) of isolated below-the-knee popliteal vessel because amputation preceded repair. No injuries were repaired
injuries underwent amputation, as compared with 29% to 50% endovascularly. Approximately one third of the patients were
of the patients with two or three below-the-knee arterial injuries treated expectantly (SDC 2, at http://links.lww.com/TA/A489).
(Table 5 and SDC 1, at http://links.lww.com/TA/A488). Of these The types of vascular interventions performed included artery li-
10, 70% (n = 7) were above-the-knee amputations and 30% (n = 3) gation, open thrombectomy, thromboendarterectomy with patch
were below-the-knee amputations. repair, vessel repair with or without graft, and bypass. Twenty-seven
percent of the patients that underwent repair had one-vessel in-
Injuries Associated with BKAI jury compared with 4% and 0% for two- and three-vessel injuries,
Eighty-eight patients (72.1%) with BKAI had associ- respectively. In contrast, 67% of the patients that underwent
ated lower extremity orthopedic injuries (LEOI). Of these repair had BKPIs.

DISCUSSION
TABLE 4. Logistic Regression of Significant Variables Associ-
ated With Traumatic Injury to a Single Arterial Vessel Following Below-the-knee arterial trauma is infrequent. We reasoned
Blunt Trauma Alone, Below the Knee that because our trauma center admits approximately 8,000 patients
Logistic Regression Results for Single Vessel Blunt Injury Only (n = 35) per year, we may be capable of characterizing this otherwise rare
Variable With 95% CI and morbid injury. In this report, we sought to characterize am-
Independent Variable p 9 0.10 Parameter OR of OR p putation rates and associated injuries for patients who presented
with below-the-knee arterial injuries. We found that blunt trauma
Age NS
was associated with a higher rate of amputation when compared
Sex NS
with penetrating trauma. In addition, AT injuries placed patients
ISS 9Y15+ vs. ISS G 9 NS
at a significantly higher risk for amputation. In contrast to BKPI,
ISS 16Y24+ vs. ISS G 9 NS
other BKAI vessels are infrequently repaired. These data suggest
ISS 25+ vs. ISS G 9 NS
that, contrary to common surgical teaching, injury to the AT is
Hypertension NS
associated with higher rates of amputation when compared with
AT vs. PT/P AT vs. PT/P 3.11 22.39 1.50Y333.57 0.02
P or PT injuries.

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 J Trauma Acute Care Surg
Scalea et al. Volume 77, Number 6

Managing BKAI can be challenging, and much of the The impetus to revisit this topic was borne out of obser-
literature surrounding the management of these patients has vations in a patient with AT injuries where the anterior com-
focused on minimization of ischemia time, the associated or- partment was lost entirely despite adequate flow in the PT and
thopedic repair, and subsequent anticoagulation.2,8Y11 Early P artery. Even if we do not entirely understand the reason for
studies and anecdotal practice have taught us that single-vessel its increased importance, our report heightens our clinical con-
runoff is sufficient for limb salvage following BKAI.1 How- cern for possible limb loss when the AT has been injured.
ever, more recent studies have described high amputation rates Regarding repair, published work has shown that following
in patients with below-the-knee arterial injury.5 While common infrapopliteal arterial injury, single crural vessel injuries are most
femoral and superficial femoral arterial injuries are more likely commonly treated nonoperatively, whereas three-vessel injuries
associated with mortality, popliteal and tibial injuries are more have more commonly undergone arterial bypass.6 In contrast,
commonly associated with amputation.2,3 Keeley et al.1 pub- patients with two-vessel injury underwent approximately equal
lished the first large civilian study of BKAI in 1983. In that study, rates of bypass or nonoperative treatment. In cases where two
the authors characterized patterns of injury and found that 67% of three vessels below the knee were injured, amputation rate was
of their 51 patients experienced penetrating trauma. Ampu- more frequent when inline flow to the foot was only maintained
tation rate was higher overall in blunt trauma (23%) as vascular by the peroneal artery at 40%, followed by the AT at 36% and PT
injury in the current study. Keeley et al. observed an ampu- at 17%.6 In the present study, we found that the majority of the
tation rate of 3% when a single artery was injured, 9% when two patients who underwent repair had BKPI. Consistent with pre-
arteries were injured, and 60% when three arteries were injured. vious work, many patients with nonpopliteal BKAI did not get
These results lent support to the hypothesis that ‘‘single-vessel repaired. This may be because of the technical challenges of
runoff’’ or single-vessel patency was adequate for limb sal- repairing the smaller AT, PT, and P vessels or possibly because
vage. Our study revealed a much higher overall amputation rate these patients are sicker. Another possible explanation for the
of 29% with injuries to the AT alone, conferring a greater risk decreased rate of operative repair for nonpopliteal BKAI is
for amputation when compared with injuries to the other tibial the unfounded belief that single-vessel runoff is sufficient for
vessels. We can only hypothesize as to the reasons for this leg salvage and the reconstruction is not necessary. We showed
finding. It is possible that injuries to the AT are associated with in this article, however, that single AT injury led to amputation
higher blunt force, greater severity of soft tissue, or orthopedic in 35% of the patients who sustained a single-vessel injury be-
injury. Although we were not able to make such an association low the knee and that AT injury was associated with an OR
in our current study, this may be realistically attributed to an for amputation of 22.39 (Tables 2 and 3). The majority of the
issue of study power. Another possibility lies in the anatomical patients admitted with BKAI had associated LEOI and/or LENI.
compartmentalization on the AT in the anterior compartment. In the study of Keeley et al.,1 59%, 22%, and 16% had ortho-
It is possible that lack of collaterization into the anterior pedic, nerve, and venous injury, respectively. This is similar to
compartment contributes to eventual muscle death and am- the 72%, 16%, and 11%, respectively, observed in the present
putation in patients with AT injures. The importance of the AT study. Thus, it does not seem that injury patterns have changed
may have a scientific basis in the differential sensitivity of over time, despite improvement in diagnostics.
the different muscles of the calf to ischemia. The anterior Studies evaluating arterial injury that has occurred above
tibialis is composed of a different muscle fiber type, when the knee demonstrate that such injuries are more frequently as-
compared with other muscles of the lower extremity, and it is sociated with penetrating trauma.7,13Y15 In addition, as much as
more sensitive to ischemia. In addition, the tibialis anterior 70% of extremity arterial trauma affects the femoral vessels.16
undergoes a greater degree of necrosis than other muscles in More proximal injuries are also more frequently repaired.7 In a
the leg when challenged with an ischemic event.12 On the other large series of lower extremity trauma published by Franz et al.7
end of the spectrum is the peroneal vessel, which when injured authors observed that 76.8% of lower extremity arterial in-
in isolation, led infrequently to amputation. As this vessel’s juries were treated surgically. The majority of these repairs were
irrigated beds are collateralized by the PT, injury to the pe- performed for proximal injuries, with greater than 90% of
roneal vessel may be of less clinical significance. Thus, injury popliteal vessel injuries being treated with bypass grafting.7
severity seems to follow the pattern AT 9 PT 9 peroneal. The Consistent with the results of this study, only 23% of patients
importance of concomitant bony and soft tissue injury frequently with tibial arterial trauma underwent repair. In addition, ligation
seen in blunt (vs. penetrating) trauma cannot be overempha- of the affected vessel was more common below the knee.7 When
sized in this report. We attempted to clarify this distinction by we consider amputation, Cakir et al.17 observed that only 3 of
comparing blunt and penetrating AT injury, the group with the 36 patients with femoral arterial trauma went on to require am-
highest rate of amputation. We observed that no patients (0%) putation. Other authors have described similar, low rates of
with penetrating AT injuries required amputation. Although the amputation.5,7,15,16 Other authors have also described lower
numbers in this group were small, this 0% amputation rate is amputation rates and greater success with repair of the proximal
in contrast to more than a third of those with blunt injuries, lower extremity vessels.5,7,15,16 With regard to surgical therapy,
suggesting that the blood supply to the anterior compartment endovascular repair has distinct advantages over open repairs in
represents only one factor (albeit major) contributing to ampu- the proximal vessels of the lower extremity, for selected patients,
tation risk. Lastly, it is conceivable that our study was flawed by as it decreases time to definitive repair.18 From the present study
a Type II statistical error. By increasing the number of patients and others, we glean that endovascular repair plays only a very
and associated injures, possibly with a multi-institutional trial, limited role in the treatment of BKAI. Taken together, we can
this type of error might be minimized. appreciate that BKAI is a distinct traumatic pathology that has

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J Trauma Acute Care Surg
Volume 77, Number 6 Scalea et al.

both a distinct natural history and which requires a different vascular injury: an analysis of the National Trauma Data Bank. J Vasc
treatment strategy when compared with above-the-knee arterial Surg. 2006;44(1): 94Y100.
injury. 3. Kauvar DS, Sarfati MR, Kraiss LW National trauma databank analysis
of mortality and limb loss in isolated lower extremity vascular trauma.
The data presented here should be approached carefully.
J Vasc Surg. 2011;53(6):1598Y1603.
The management of BKAI needs to be considered in the 4. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-
context of the patient’s concomitant injuries. Our data would threatening lower limb trauma: lessons learned from the Lower Extremity
suggest that repair of the AT is required when injury occurs Assessment Project (LEAP). 2006. J Am Acad Orthop Surg. 2006;
because there is a higher risk of limb loss without operative 14(10 Spec No.):S205YS210.
treatment. However, the operative surgeon needs to critically 5. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results
assess the pros and cons of vascular intervention, particularly of 550 cases and review of risk factors associated with limb loss. 2001.
when there is extensive soft tissue or bony injury. Although the J Vasc Surg. 2001;33(6):1212Y1219.
vessel may be salvageable, the remainder of the extremity may 6. Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K,
Propper BW, Rasmussen TE. Outcomes of selective tibial artery repair
not be worth salvaging, and other options, such as primary
following combat-related extremity injury. J Vasc Surg. 2010;52(1): 91Y96.
amputation, may be a more reasonable. So, when should the AT 7. Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year
be repaired? A prospective study including comparator groups review of management of lower extremity arterial injuries at an urban level I
(patients with a similar degree of bony and soft tissue injury, trauma center. J Vasc Surg. 2011;53(6): 1604Y1610.
single vessel AT injury, and nonoperative management) would 8. Melton SM, Croce MA, Patton JH Jr, Pritchard FE, Minard G, Kudsk KA,
help us answer this question. Fabian TC. Popliteal artery trauma. Systemic anticoagulation and intraopera-
In conclusion, BKAIs are uncommon. Multiple BKAIs tive thrombolysis improves limb salvage. Ann Surg. 1997;225(5): 518Y527;
are more likely to undergo repair. In addition, amputation is discussion 527Y529.
more common following blunt versus penetrating trauma. In 9. Desai P, Audige L, Suk M. Combined orthopedic and vascular lower
extremity injuries: sequence of care and outcomes. Am J Orthop (Belle
contrast to the commonly taught surgical dogma, which sug-
Mead NJ). 2012;41(4): 182Y186.
gests that any intact single vessel below the knee is associated 10. Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage fol-
with limb salvage, blunt AT vessel injuries were associated lowing fractures with vascular injury: a systematic review and new man-
with much higher rates of amputation when compared with P agement algorithm. J Plast Reconstr Aesthet Surg. 2009;62(5):571Y579.
or PT injuries. Which patients require attempted AT repair 11. Rich NM, Spencer FC. Vascular Trauma. Philadelphia, PA: Saunders;
remains unclear, and further studies should be undertaken to 1978.
determine when repair of BKAI should be attempted. 12. Paek R, Chang DS, Brevetti LS, Rollins MD, Brady S, Ursell PC, Hunt TK,
Sarkar R, Messina LMS. Correlation of a simple direct measurement of
AUTHORSHIP muscle pO(2) to a clinical ischemia index and histology in a rat model of
J.R.S., R.C., J.K., J.O., and T.M.S. designed this study. J.R.S., S.S., and chronic severe hindlimb ischemia. J Vasc Surg. 2002;36(1): 172Y179.
J.D. contributed to the data gathering. J.R.S., R.C., R.S., J.K., J.O., and 13. Diamond S, Gaspard D, Katz S. Vascular injuries to the extremities in
T.M.S. performed the data analysis. J.R.S., S.S., J.D., J.K., and T.M.S. a suburban trauma center. Am Surg. 2003;69(10): 848Y851.
wrote the manuscript, which J.R.S., R.C., R.S., J.O., and T.M.S. edited. 14. Modrall JG, Weaver FA, Yellin AE. Diagnosis and management of pen-
etrating vascular trauma and the injured extremity. Emerg Med Clin North
Am. 1998;16(1): 129Y144.
DISCLOSURE 15. Weaver FA, Papanicolaou G, Yellin AE. Difficult peripheral vascular
The authors declare no conflicts of interest. injuries. Surg Clin North Am. 1996;76(4): 843Y859.
16. Carrillo EH, Spain DA, Miller FB, Richardson JD. Femoral vessel injuries.
Surg Clin North Am. 2002;82(1): 49Y65.
REFERENCES 17. Cakir O, Subasi M, Erdem K, Eren N. Treatment of vascular injuries as-
1. Keeley SB, Snyder WH 3rd, Weigelt JA. Arterial injuries below the knee: sociated with limb fractures. Ann R Coll Surg Engl. 2005;87(5): 348Y352.
fifty-one patients with 82 injuries. J Trauma. 1983;23(4): 285Y292. 18. Simmons JD. Role of endovascular grafts in combined vascular and
2. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. skeletal injuries of the lower extremity: a preliminary report. Arch Trauma
Limb salvage and outcomes among patients with traumatic popliteal Res. 2013;2(1): 40Y45.

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