title: The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: A meta-analysis.
abstract: OBJECTIVE
  The optimal sequence of surgical repair for lower extremity injury with associated vascular injuries is unclear. Lower extremity injury in our study is defined as femoral fracture, tibial fracture, and/or knee dislocation. Advocates of performing the vascular repair prior to lower extremity fixation argue that reversal of ischaemia in the limb is the most important factor in limb survival and should take precedence. Advocates of lower extremity fixation prior to revascularisation worry that the manipulation during fixation could disrupt the vascular repair and that total ischaemia time is more relative than absolute.
  
  
  METHODS
  A literature search was performed to identify studies with the following criteria: adult population, femoral fracture, tibial fracture, and/or knee dislocation with associated vascular injury, an intervention of fracture fixation or knee stabilisation prior to revascularisation and/or revascularisation prior to fracture fixation, and amputation as an outcome measurement.
  
  
  RESULTS
  934 articles were identified and narrowed to 14 articles through exclusion criteria. Meta-analysis of the data shows no statistical difference in regards to the incidence of amputation between lower extremity fixation prior to revascularisation and revascularisation prior to fracture fixation.
  
  
  CONCLUSIONS
  Lower extremity injuries with associated vascular injury are uncommon. There has been a widespread but unsupported belief that manipulation and traction during lower extremity fixation will disrupt the vascular repair. Ischaemic time should be considered a relative, but not absolute predictor of amputation. Soft tissue injury and neurologic deficits have been found highly correlated with disability and amputation. Surgical sequence has not been shown to affect the rate of amputations in lower extremity fractures.
authors.affiliation: Department of Orthopaedic Surgery, Temple University, Philadelphia, PA, United States.
authors.forename: John
authors.initials: J
authors.lastname: Fowler
authors.forename: Neil
authors.initials: N
authors.lastname: Macintyre
authors.forename: Saqib
authors.initials: S
authors.lastname: Rehman
authors.forename: John P
authors.initials: JP
authors.lastname: Gaughan
authors.forename: Shawn
authors.initials: S
authors.lastname: Leslie
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000379:methods; D001808:Blood Vessels / Q000293:injuries*; D005264:Femoral Fractures / Q000601:surgery; D005592:Fracture Fixation / Q000379:methods; D006801:Humans; D007718:Knee Injuries / Q000601:surgery; D007866:Leg / Q000098:blood supply*; D007869:Leg Injuries / Q000601:surgery*; D023821:Limb Salvage / Q000379:methods*; D013978:Tibial Fractures / Q000601:surgery; D016896:Treatment Outcome