Abstract
BACKGROUND: Open fractures with bone and soft tissue loss pose significant challenges in orthopedic surgery. External fixator-assisted techniques, such as acute angulation and shortening, have been proposed to facilitate wound closure. However, the vascular implications of these techniques remain unclear. This cadaveric study aimed to evaluate the effect of acute angulation on arterial narrowing at the proximal tibia and distal femur, identifying angulation thresholds and comparing the vascular tolerance between these anatomical sites. METHODS: Eight lower extremities from four fresh-frozen cadavers were used. Osteotomies were performed at the distal femoral and proximal tibial metaphyses. An Ilizarov circular external fixator provided controlled angulation in varus, valgus, procurvatum, and recurvatum directions. A contrast agent was used for vascular visualization under fluoroscopy. Angulation was gradually increased until arterial narrowing was observed, and the critical angles were recorded. RESULTS: In the proximal tibia, the mean angulation thresholds for arterial narrowing were 45.5° in varus, 26.5° in valgus, 33.8° in procurvatum, and 13.5° in recurvatum. In the distal femur, arterial narrowing occurred at 27° in varus, 32.3° in valgus, 52° in procurvatum, and 22° in recurvatum. Varus angulation was significantly better tolerated at the tibia (p = 0.0286), while procurvatum (p = 0.0294) and recurvatum (p = 0.0286) were better tolerated at the femur. No significant difference was found in valgus angulation (p = 0.559). CONCLUSIONS: The tibia demonstrated higher tolerance for varus angulation, while the femur allowed greater procurvatum and recurvatum before vascular compromise. Recurvatum deformities in the tibia resulted in the earliest arterial narrowing, suggesting a higher risk of vascular complications. These findings provide critical insight for surgeons performing external fixator-assisted soft tissue coverage, helping optimize angulation strategies to prevent vascular complications.