Effectiveness of indocyanine green in assessing tissue perfusion in lower limb open fractures: A prospective pilot study

Background Lower limb open fractures (LLOFs) represent complex injuries in which accurate intraoperative assessment of tissue viability is crucial to prevent infection, necrosis, and delayed healing. Clinical evaluation of perfusion is subjective and may underestimate ischemic areas, especially in high-energy trauma. Indocyanine green (ICG) fluorescence angiography provides a real-time, objective visualization of tissue perfusion and may optimize surgical decision-making during debridement. Materials and Methods This prospective, single-center case series included patients with Gustilo–Anderson type III open fractures and/or severe degloving injuries who underwent bone and soft-tissue reconstruction between March 2024 and July 2025. Tissue viability was first assessed clinically and then with ICG fluorescence angiography (SPY/Spy-PHI® system). Areas with < 40% relative fluorescence were considered hypoperfused. Discrepancies between clinical and ICG-defined debridement margins were measured, and postoperative outcomes were recorded. Results Eight patients (ten traumatic wounds) were included. In six wounds, ICG-guided assessment modified surgical debridement compared with clinical evaluation, while two showed identical margins and two were treated by clinical assessment alone. The mean ICG-defined area was 114% larger than the clinically defined area (95% CI 7.8–220.6; p = 0.038). Postoperative skin necrosis occurred in 3 of 10 wounds (30%): 2 of 2 managed clinically and 1 of 8 managed with ICG guidance. No ICG-related adverse events were recorded. At four weeks, 6 of 8 wounds (75%) in the ICG-guided group achieved complete healing, whereas none in the clinical group did. All soft-tissue defects healed within six months, and radiographic union occurred in 9 of 10 fractures. Discussion ICG fluorescence angiography enhanced intraoperative discrimination of viable from hypoperfused tissue, expanding debridement where occult ischemia was present and avoiding unnecessary excision of viable tissue. The technique improved early wound healing and reduced necrosis compared with standard clinical assessment, though the sample size limits statistical power and generalizability. Conclusions ICG fluorescence angiography is a safe, feasible, and objective adjunct to clinical evaluation in the management of LLOFs. Its integration into orthoplastic trauma surgery may reduce early complications and improve wound outcomes. Larger controlled studies are warranted to validate perfusion thresholds and confirm clinical benefit.