title: Below-the-knee arterial injury: the type of vessel may be more important than the number of vessels injured.
abstract: 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 χ, 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).
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Epidemiologic study, level III.
authors.affiliation: From the Department of Surgery (J.R.S., R.C., S.S., J.D., R.S., J.O., T.M.S.), University of Maryland Medical Center; and Shock Trauma Center (J.K., J.O., T.M.S.), Baltimore, Maryland.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Scalea
authors.forename: Robert
authors.initials: R
authors.lastname: Crawford
authors.forename: Stephanie
authors.initials: S
authors.lastname: Scurci
authors.forename: Jonathon
authors.initials: J
authors.lastname: Danquah
authors.forename: Rajabrata
authors.initials: R
authors.lastname: Sarkar
authors.forename: Joseph
authors.initials: J
authors.lastname: Kufera
authors.forename: James
authors.initials: J
authors.lastname: O'Connor
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
mesh_terms: D000328:Adult; D000671:Amputation, Surgical; D001158:Arteries / Q000293:injuries*; D005260:Female; D006801:Humans; D007866:Leg / Q000098:blood supply; D007869:Leg Injuries / Q000473:pathology* / Q000601:surgery; D023821:Limb Salvage / Q000379:methods; D008297:Male; D012042:Registries; D012189:Retrospective Studies