title: Blast-induced lower extremity fractures with arterial injury: prevalence and risk factors for amputation after initial limb-preserving treatment.
abstract: OBJECTIVE
  The purpose of this study is to determine the rate of late (secondary) amputation and to identify risk factors for amputation in injuries that were initially treated with limb preservation on the battlefield.
  
  
  METHODS
  A retrospective review at our institution identified 24 consecutive patients with 26 blast-induced open fractures distal to the joint that had associated arterial injuries. All injuries were initially cared for on the battlefield and during the evacuation chain of care with limb preservation protocols. All definitive orthopaedic care was provided by a single fellowship-trained orthopaedic trauma surgeon at a tertiary care stateside facility. Injury factors were analyzed based on radiographic and chart review to determine associations with amputation.
  
  
  RESULTS
  Twenty of 26 injured limbs received an amputation for a total amputation rate of 76.9% (95% confidence interval, 57.9-88.9%). Fourteen limbs received early amputation before limb salvage attempts. Six of the 12 limbs that received limb salvage underwent late amputation.
  
  
  CONCLUSIONS
  The rate of amputation in severe blast-induced extremity fractures combined with an arterial injury initially treated with limb preservation on the battlefield and before transfer to the definitive military treatment facility is extremely high. Blast-injured lower limbs with a combined severe bony and soft tissue injury should be carefully assessed when arterial injury is present because they may require early amputation during initial surgical care on the battlefield.
authors.affiliation: Integrated Department of Orthopaedics and Rehabilitation, National Naval Medical Center, Bethesda, MD, USA. gwinny13@yahoo.com
authors.forename: David E
authors.initials: DE
authors.lastname: Gwinn
authors.forename: Scott M
authors.initials: SM
authors.lastname: Tintle
authors.forename: Anand R
authors.initials: AR
authors.lastname: Kumar
authors.forename: Romney C
authors.initials: RC
authors.lastname: Andersen
authors.forename: John J
authors.initials: JJ
authors.lastname: Keeling
mesh_terms: D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D001158:Arteries / Q000293:injuries*; D006801:Humans; D054542:Iraq War, 2003-2011; D007869:Leg Injuries / Q000175:diagnosis / Q000601:surgery*; D023821:Limb Salvage; D008297:Male; D011183:Postoperative Complications; D012189:Retrospective Studies; D015599:Trauma Severity Indices; D057772:Vascular System Injuries / Q000150:complications / Q000601:surgery*; D014950:Wounds, Penetrating / Q000175:diagnosis / Q000601:surgery*