Timing of Free Flaps for Traumatic Wounds of the Lower Extremity: Have Advances in Perioperative Care Changed the Treatment Algorithm?

Abstract

Background Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases. Methods We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance. Results Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications (p = 0.051) and flap-specific complications (p = 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance. Conclusion Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma

“…This increase may be attributable to NPWT, which has allowed extending the interval to coverage without adverse effects, decreased rates of infection and may decrease rates of flap reconstruction [ 33–36 ]. Recent studies suggest the ideal period for early reconstruction can be extended to 10–14 days without adverse effect on outcomes [ 30 , 31 , 37 ]. In the absence of definitive guidelines, the authors suggest reconstruction as soon as possible when the patient is medically optimized and the wound clean, preferably within 2 weeks of injury.…”

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

“…50 This model enables a controlled and target-oriented approach with good long-term outcomes, thus guaranteeing the right timing of free flaps in these complex cases. 51 In case of free flap salvage urgent re-exploration within the first 24 hours ensures the highest chances for salvage. In a recent study of 581 free flaps re-exploration rate accounted for 14.8% and its subsequent salvage rate for 75.6%, thus demonstrating an overall survival rate of 94.7%.…”

Evaluation of the American Society of Anesthesiologists Physical Status Classification System in Risk Assessment for Lower Extremity Reconstruction with Free Tissue Transfer

“…Although the original study by Godina 24 suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, some studies have supported the de-emphasis of the 72-hour reconstruction interval. 27,40 Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the complicated ASA 3 and ASA 4 patients.…”