A large, multicentre cohort study provides a simple, practical method to effectively stratify patients preoperatively into low- and high-risk major amputation categories.
According to lead author Leigh Ann O’Banion (University of California, San Francisco, San Francisco, USA), “traumatic popliteal artery injuries present a serious clinical challenge because they are associated with the greatest risk of limb loss of all peripheral vascular injuries, with major amputation rates of 14–25%.”
Previous scoring systems, such as the Mangled Extremity Severity Score (MESS), attempt to determine a threshold beyond which repair is futile. O’Banion states: “The aim of the present study, unlike the older systems, was to provide an easy to use scoring system that could be used to preoperatively and effectively risk stratify patients with traumatic popliteal vascular injuries for major amputation.”
As reported in the September 2021 issue of the Journal of Vascular Surgery, O’Banion and colleagues from 11 medical centres from the Western Vascular Society retrospectively examined the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries from 2007–2018 and identified the factors independently associated with limb loss.
They compared the clinical data between those who ultimately required major (above ankle) amputation with those who did not, and subsequently validated the new scoring system in a random 20% of this population.
Characteristics of the study population (n=355) included:
- Mean age of 33±14 years,
- Male, 80%,
- Blunt injury, 66%, and
- Associated orthopaedic injury, 80% (41% dislocation).
At a mean follow-up of 69 days, the overall amputation rate was 16%, but those who lost primary patency had a major amputation rate of 46%. These findings underscore the critical need for close follow-up.
Significant preoperative risk factors for amputation included:
- Systolic blood pressure <90mmHg (odds ratio [OR] 3.2),
- Orthopaedic injury (OR 4.9), and
- Lack of pedal Doppler signals (OR 5.5).
Using this information, a Popliteal Scoring Assessment for Vascular Extremity Injuries in Trauma (POPSAVEIT) score was created, assigning one point for blood pressure and two points for both the orthopaedic injury and no Doppler signals.
The study validated the scoring system revealing amputation rates were:
- 25.5% for a score of 3–5 points vs.
- 5.9% for a score of 0–2 points (p<0.001).
O’Banion explains: “When evaluating the patient comprehensively, the POPSAVEIT score divides the findings into three critical components: measures of global physiologic insult (blood pressure), musculoskeletal deformity (orthopaedic injury), and ischaemia (Doppler examination).
“This preoperative assessment tool could be used to effectively communicate and risk stratify patients across centres similar to the American Association for the Surgery of Trauma’s injury scoring scales, which are widely accepted and used across trauma centres. Additionally, the ability to risk stratify could be useful in discussing the prognosis and setting expectations with patients, their families, and other providers.”
This study confirms that patients with popliteal vascular injuries are at significant risk for amputation. The POPSAVEIT tool is a valuable tool to assess this risk as soon as the patient enters the emergency room.