Evaluating the Efficacy of Indocyanine Green Fluorescence Angiography in Lower Extremity Injuries: A Systematic Review

Background: Accurate assessment of tissue viability is essential in the surgical management of lower extremity injuries, particularly during debridement and soft tissue reconstructions.Fluorescence imaging (FI) with indocyanine green (ICG) enables real-time visualisation of tissue perfusion and may offer advantages over conventional clinical assessment.This systematic review evaluates the current evidence on the use of FI in lower extremity injury management.Methods: A systematic search of PubMed, Embase and the Cochrane Library was conducted up to February 2025.Studies were eligible if they examined the use of FI in debridement, soft tissue reconstruction or amputation stump viability in lower extremity injuries.Only studies with cohorts of at least 10 patients were included.Two reviewers independently screened the studies.Data were extracted on FI timing, imaging protocols, methods for quantitative perfusion analysis, and the impact on intra-operative decision-making and clinical outcomes.Results: Thirteen studies met the inclusion criteria: Two evaluated FI in debridement procedures, six in reconstructive procedures, and five in amputation stumps.There was notable heterogeneity in study design, objectives and imaging protocols.Fluorescence imaging was used both in the intra-and post-operative settings.In four studies, intra-operative assessment with FI directly guided surgical interventions, including debridement planning, adjusting flap design or perforator selection.In three of these four studies, intra-operative FI contributed to improved outcomes compared to conventional assessment methods.Seven studies incorporated quantitative perfusion analysis in their study. Conclusion:Fluorescence imaging appears to be a valuable adjunct in the surgical management of lower extremity injuries, with potential to improve assessment of tissue viability and reduce post-operative complications.However, wide variation in protocols, interpretation methods, and outcome measures currently limits broader clinical adoption.Clinical significance: This review highlights the clinical potential of fluorescence imaging to enhance intra-operative assessment and guide surgical strategy in the management of lower extremity injuries.