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Purpose <p>To evaluate whether incorporation of arterial injury into CT-based zone-of-injury (ZOI) models improves complication prediction after open tibial shaft fractures.</p> Methods <p>A retrospective cohort study was conducted at an urban multicenter academic hospital (2012–2024). Patients ≥ 18&#xa0;years with open OTA 42A-C tibia fractures, preoperative CT, and ≥ 6&#xa0;months follow-up were included. Arterial injury and wound location within the anterior tibial, posterior tibial, or peroneal angiosomes were identified on CT angiography. Soft-tissue ZOI (longitudinal extent of soft-tissue air) and fracture ZOI (fracture span) were normalized to tibial length. The primary outcome was a composite complication of fracture-related infection, nonunion, or amputation. Logistic regression identified predictors, and ROC analysis compared discrimination of (1) an angiosome-augmented ZOI model, (2) a standard ZOI model, and (3) Gustilo–Anderson classification.</p> Results <p>Eighty-two patients were included: 32 (39.0%) developed major complications. Arterial injury was present in 11 patients and significantly associated with complications (72.7% vs 33.8%, p = 0.020). The augmented ZOI model included arterial injury, anterior angiosome involvement, number of angiosomes affected, normalized soft-tissue ZOI, and BMI (AUROC 0.777), outperforming the standard ZOI model (AUROC 0.707) and Gustilo–Anderson classification (AUROC 0.592). DeLong testing showed no significant difference between ZOI and the augmented model.</p> Conclusion <p>The original CT-based ZOI model, which incorporates soft-tissue injury measurements normalized to tibial length and BMI, remains a robust objective predictor of complications following open tibial shaft fractures, consistent with prior published work. While arterial injury is associated with adverse outcomes, its addition to ZOI-based models does not significantly improve predictive performance. Notably, only the arterial-augmented ZOI model demonstrated a statistically significant improvement in discrimination over the Gustilo–Anderson classification, whereas the standard ZOI model did not reach significance in this cohort, suggesting that augmentation may be necessary to meaningfully surpass subjective wound grading.</p> Level of evidence <p>III.</p>

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Integration of arterial and angiosome injury into computed tomography (CT) soft-tissue zone of injury models for open OTA 42A-C tibia fractures

  • 期刊论文

  • 发表日期：

    2026年7月4日

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  • Amelia R. Goldstein,
  • Natalie Vu,
  • Abhishek Ganta,
  • Kenneth A. Egol,
  • Sanjit R. Konda

摘要

Purpose

To evaluate whether incorporation of arterial injury into CT-based zone-of-injury (ZOI) models improves complication prediction after open tibial shaft fractures.

Methods

A retrospective cohort study was conducted at an urban multicenter academic hospital (2012–2024). Patients ≥ 18 years with open OTA 42A-C tibia fractures, preoperative CT, and ≥ 6 months follow-up were included. Arterial injury and wound location within the anterior tibial, posterior tibial, or peroneal angiosomes were identified on CT angiography. Soft-tissue ZOI (longitudinal extent of soft-tissue air) and fracture ZOI (fracture span) were normalized to tibial length. The primary outcome was a composite complication of fracture-related infection, nonunion, or amputation. Logistic regression identified predictors, and ROC analysis compared discrimination of (1) an angiosome-augmented ZOI model, (2) a standard ZOI model, and (3) Gustilo–Anderson classification.

Results

Eighty-two patients were included: 32 (39.0%) developed major complications. Arterial injury was present in 11 patients and significantly associated with complications (72.7% vs 33.8%, p = 0.020). The augmented ZOI model included arterial injury, anterior angiosome involvement, number of angiosomes affected, normalized soft-tissue ZOI, and BMI (AUROC 0.777), outperforming the standard ZOI model (AUROC 0.707) and Gustilo–Anderson classification (AUROC 0.592). DeLong testing showed no significant difference between ZOI and the augmented model.

Conclusion

The original CT-based ZOI model, which incorporates soft-tissue injury measurements normalized to tibial length and BMI, remains a robust objective predictor of complications following open tibial shaft fractures, consistent with prior published work. While arterial injury is associated with adverse outcomes, its addition to ZOI-based models does not significantly improve predictive performance. Notably, only the arterial-augmented ZOI model demonstrated a statistically significant improvement in discrimination over the Gustilo–Anderson classification, whereas the standard ZOI model did not reach significance in this cohort, suggesting that augmentation may be necessary to meaningfully surpass subjective wound grading.

Level of evidence

III.