Lower Extremity Arterial Injury Patterns and Reconstructive Outcomes in Patients with Severe Lower Extremity Trauma: A 26-Year Review Nicholas T Haddock, MD, Katie E Weichman, MD, Derek D Reformat, BS, Brad E Kligman, BS, Jamie P Levine, MD, Pierre B Saadeh, MD, FACS BACKGROUND: Management of severe traumatic lower extremity injuries remains a considerable challenge. Free tissue transfer is now a standard part of reconstruction for Gustilo IIIB and IIIC injuries. There is limited information on arterial injury patterns in this population. We undertook a review of our experience to gain insight on vascular injury patterns and surgical outcomes. STUDY DESIGN: A 26-year retrospective analysis was performed of all lower extremity Gustilo IIIB and IIIC injuries requiring microvascular reconstruction at New York University Medical Center. Patient demographics, Gustilo classification, angiographic findings (conventional/computed tomo- graphic angiography/magnetic resonance angiography), recipient vessels, elapsed time from injury, flap choices, and outcomes were examined. RESULTS: Two hundred twenty-two free flaps on 191 patients were performed from September 1982 until March 2008. There were 151 males and 40 females ranging in age from 4 to 83 years (median age 33 years). Patients sustained either Gustilo IIIB (170 patients) or IIIC (21 patients) open fractures. One hundred fifty-four patients had angiograms (78.2% IIIB, 100% IIIC). Sixty-six (42.9%) had normal 3-vessel runoff and 88 (57.1%) were abnormal. Sixty-one patients (31.9%) had anterior tibial injuries, 17 patients (8.9%) had posterior tibial injuries, and 30 (15.7%) had peroneal injuries. Sixty-three complications occurred (11 early thrombosis, 33 requiring secondary procedures, and 10 requiring amputation). CONCLUSIONS: Angiography of severe lower extremity injuries requiring free flap reconstruction usually re- vealed arterial injury and is generally indicated. In our experience, the anterior tibial artery is most commonly injured and the posterior tibial artery is most likely to be spared and used as a recipient. (J Am Coll Surg 2010;210:66–72. © 2010 by the American College of Surgeons) Management of severe traumatic lower extremity injuries remains a formidable challenge. The multidisciplinary team approach, which has been widely accepted in the care of extensive lower extremity trauma, includes trauma, or- thopaedic, vascular, and plastic surgical teams. 1 This ap- proach has led to increased limb salvage rates and decreased morbidity. 1 Although individual advances within each spe- cialty have improved these salvage rates, adequate soft tis- sue coverage remains an essential component of limb sal- vage and has been greatly facilitated by the advent of microsurgical reconstruction. 2-4 Even though there is extensive literature about arterial injury above the knee, 5 the redundant blood supply below the knee optimizes perfusion to the foot and is usually investigated only if severely compromised or if reconstruc- tion is planned. Given that the population requiring free flap reconstruction usually suffers from severe trauma (usu- ally Gustilo IIIB or greater) (Table 1) and commonly un- dergoes angiographic evaluation of lower extremity vascu- lature, we considered this cohort ideal for study. Although trauma, orthopaedic, and vascular surgeons desire a complete assessment of a patient’s vascular injuries in determining the patient’s near-term operative triage, the reconstructive surgeon has the additional consideration of adequate recipient vessel selection for free tissue transfer, a critical element to successful limb salvage. 6-9 In the setting of severe lower extremity trauma, the native blood supply Disclosure Information: Nothing to disclose. Presented at the American Society for Reconstructive Microsurgery, Maui, HI, January 2009. Received July 29, 2009; Revised September 23, 2009; Accepted September 29, 2009. From the Institute of Reconstructive Plastic Surgery (Haddock, Reformat, Levine, Saadeh), the Department of Surgery (Weichman), and the School of Medicine (Kligman), New York University Langone Medical Center, New York, NY. Corresponding address: Pierre B Saadeh, MD, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, 560 First Avenue – TCH-169, New York, NY 10016. 66 © 2010 by the American College of Surgeons ISSN 1072-7515/10/$36.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2009.09.040