More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury

Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, = .028). In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.