J Reconstr Microsurg
DOI: 10.1055/a-2332-0263
Original Article

Blunt Trauma Induced Closed Femoral Bone Fracture in a Rat Model: Are Vessels Safe to Use for Microsurgery? Further Insight into the Zone of Injury Concept

Karaca Basaran
1   Uskudar University, Plastic, Reconstructive and Aesthetic Surgery Department, Istanbul, Turkiye
2   Istinye University, Plastic, Reconstructive and Aesthetic Surgery Department, Istanbul, Turkiye
Mehmet Sagir
3   Private Acibadem Hospital, Plastic, Reconstructive and Aesthetic Surgery Department, Istanbul, Turkiye
Mehmet Sar
4   Private Clinic, Istanbul, Turkiye
Esra Bilgi
5   Health Science University, Radiology Department, Istanbul, Turkiye
› Author Affiliations
Funding None.


Background The study aims to investigate the zone of injury for major vessels after high-velocity traumas, as it is unclear whether avoiding vascular structures is necessary during microvascular anastomosis or how long it takes for them to be used again.

Methods This study uses Doppler ultrasonography and a rat model to evaluate the histopathological changes and flow velocity of major vessels in the zone of injury after high-velocity trauma with closed femoral bone fracture. Osteosynthesis was performed using an intramedullary wire. Samples were collected from day 3 and week 3. The unaffected contralateral side is used as control.

Results Results from arterial and venous flow assessments showed no evidence of ischemia in the extremities. Both arteries and veins were patent in both intervals and on the control side. The evaluation of the vessels showed arterial injury with a slightly reduced arterial flow on day 3 and week 3. The venous flow was slightly reduced on day 3 but not on week 3. Statistically, arterial endothelial injury was higher on day 3 than on week 3 (p = 0.006). Media inflammation was also higher on day 3 (p = 0.06). Arterial endothelization distribution was higher in week 3 (p = 0.006). No significant differences were found in arterial media irregularity, necrosis, platelet aggregation, bleeding, and wall rupture. Venous samples showed no significant differences in any parameter (p < 0.05).

Conclusion High-velocity trauma increases the risk of thrombosis in vessels. Intravascular repair can start on day 2 and continue till week 3 with significant endothelization. Although physiologic findings do not alter arterial or venous flow, histologic findings support vessel injuries leading to potential complications. Microsurgery should be considered out of the injury zone until adequate vessel healing is achieved.

Publication History

Received: 23 February 2024

Accepted: 05 May 2024

Accepted Manuscript online:
23 May 2024

Article published online:
24 June 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Yates YJ, Farias CL, Kazmier FR, Puckett CL, Concannon MJ. The effect of tirofiban on microvascular thrombosis: crush model. Plast Reconstr Surg 2005; 116 (01) 205-208
  • 2 Gravvanis AI, Tsoutsos DA, Lykoudis EG. et al. Microvascular repair following crush-avulsion type injury with vein grafts: effect of direct inhibitors of thrombin on patency rate. Microsurgery 2003; 23 (04) 402-407 , discussion 408–409
  • 3 Uraloğlu M, Orbay H, Livaoğlu M, Aydın N, Saraç N, Alagöz S. An objective evaluation of an injured vessel wall using fluorescein sodium before microvascular anastomosis in an experimental rat model. J Reconstr Microsurg 2011; 27 (05) 321-326
  • 4 Mitchell GM, Morrison WA, Papadopoulos A, O'Brien BM. A study of the extent and pathology of experimental avulsion injury in rabbit arteries and veins. Br J Plast Surg 1985; 38 (02) 278-287
  • 5 Hong JP, Park CJ, Suh HP. Importance of vascularity and selecting the recipient vessels of lower extremity reconstruction. J Reconstr Microsurg 2021; 37 (01) 83-88
  • 6 Hong JP, Kim HB, Park CJ, Suh HP. Using duplex ultrasound for recipient vessel selection. J Reconstr Microsurg 2022; 38 (03) 200-205
  • 7 Karlander LE, Lidman D, Franzén L. The effect of severe contusion on the vessels of the femoral region. An experimental morphological study. Scand J Plast Reconstr Surg Hand Surg 1991; 25 (01) 1-4
  • 8 Mitchell GM, McCann JJ, Rogers IW, Hickey MJ, Morrison WA, O'Brien BM. A morphological study of the long-term repair process in experimentally stretched but unruptured arteries and veins. Br J Plast Surg 1996; 49 (01) 34-40
  • 9 Glover MG, Seaber AV, Urbaniak JR. Arterial intimal damage in avulsion and crush injuries in rat limbs. J Reconstr Microsurg 1985; 1 (04) 247-251
  • 10 Loos MS, Freeman BG, Lorenzetti A. Zone of injury: a critical review of the literature. Ann Plast Surg 2010; 65 (06) 573-577
  • 11 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (08) 632-634
  • 12 Celiköz B, Sengezer M, Işik S. et al. Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines. Microsurgery 2005; 25 (01) 3-14 , discussion 15
  • 13 Colen DL, Colen LB, Levin LS, Kovach SJ. Godina's principles in the twenty-first century and the evolution of lower extremity trauma reconstruction. J Reconstr Microsurg 2018; 34 (08) 563-571
  • 14 Hallock GG. The mangled foot and ankle: soft tissue salvage techniques. Clin Podiatr Med Surg 2014; 31 (04) 565-576
  • 15 Isenberg JS, Sherman R. Zone of injury: a valid concept in microvascular reconstruction of the traumatized lower limb?. Ann Plast Surg 1996; 36 (03) 270-272
  • 16 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (07) 1937-1948
  • 17 Nieminen H, Kuokkanen H, Tukiainen E, Asko-Seljavaara S. Free flap reconstructions of tibial fractures complicated after internal fixation. J Trauma 1995; 38 (04) 660-664
  • 18 Van Belle E, Bauters C, Asahara T, Isner JM. Endothelial regrowth after arterial injury: from vascular repair to therapeutics. Cardiovasc Res 1998; 38 (01) 54-68
  • 19 Giannoudis PV, Tosounidis TI, Kanakaris NK, Kontakis G. Quantification and characterisation of endothelial injury after trauma. Injury 2007; 38 (12) 1373-1381
  • 20 Karlander LE, Lidman D, Franzén L. Microvascular surgery after severe contusion of the femoral artery in rats. Scand J Plast Reconstr Surg Hand Surg 1994; 28 (01) 19-23
  • 21 Mitchell GM, Frykman GK, Morrison WA, O'Brien BM. The nature and extent of histopathologic injury in human avulsed arteries and veins and in experimentally avulsed monkey arteries. Plast Reconstr Surg 1986; 78 (06) 801-810
  • 22 Zeeman BJ, Mitchell GM, Olazabal AE, Collopy PA, Morrison WA, O'Brien BM. The significance of resection length on the patency rate, and the histopathology, of experimentally avulsed and microsurgically repaired blood vessels. Br J Plast Surg 1988; 41 (05) 509-514
  • 23 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
  • 24 Le ELH, McNamara CT, Constantine RS, Greyson MA, Iorio ML. The continued impact of Godina's principles: outcomes of flap coverage as a function of time after definitive fixation of open lower extremity fractures. J Reconstr Microsurg 2024; ( e-pub ahead of print). DOI: 10.1055/a-2273-4075.
  • 25 Christensen JM, Ahn L, Meulendijks MZ. et al. Technical variables in lower extremity free flap reconstruction. J Reconstr Microsurg 2024; 40 (01) 78-86
  • 26 Dow T, ElAbd R, McGuire C. et al. Outcomes of free muscle flaps versus free fasciocutaneous flaps for lower limb reconstruction following trauma: a systematic review and meta-analysis. J Reconstr Microsurg 2023; 39 (07) 526-539