Abstract
The literature states pre-operative angiography of open tibial fractures (OTFs) should only be considered if abnormal pedal pulses are present.
Aim
Does pre-operative angiography of OTFs benefit patient management?
Method
43 patients were admitted with OTFs to Charing Cross Hospital, London between 3/2004 and 6/2005. Pedal pulses were documented and routine pre-operative angiography performed following primary surgical debridement. At definitive operation, data was collected prospectively assessing vasculature and the microsurgical findings. All patients underwent free flap reconstruction or amputation. Comparison was made with angiographic findings and whether surgical management had been affected. Retrospective audit of all angiograms was performed by a consultant radiologist establishing the sensitivity/specificity.
Results
Patients' mean age was 36 (18-86) with ratio 31M:12F. 40 patients had normal pedal pulses; 3 abnormal. 26 had normal angiography and 17 abnormal. 13/17 were due to injury, 2 anatomical variants and 2 atherosclerotic disease. Commonest vessel damaged was the anterior tibial (AT) n=8. Posterior tibial artery (PT) was not damaged alone but with AT n=3. AT damaged alone n=4 and AT with peroneal n=1. Popliteal artery was damaged alone n=1. 4/13 vessels with injury-induced damage required adjustment of pedicle anastomosis along with 1 from the variant group and 1 from the atherosclerotic group. Therefore 6/43 (14%) patients had surgery adjusted and the findings detected angiographically were confirmed clinically. 40 free flaps were performed and 3 amputations. All free flaps survived. 2 cases had abnormal vasculature not detected by angiogram (thrombosed venae commitans n=1 and distal PT ligated n=1). Audit of the angiograms when compared to clinical findings revealed sensitivity 90% and specificity 100%.
Conclusion
A six times increase in vessel damage was discovered after angiography compared with clinical assessment alone. The findings significantly affected surgical practice. A high degree of sensitivity/specificity was seen with angiography. The authors advocate routine angiography for all OTFs.
