Subscribe to RSS
Traumatic Lower Limb Injury and Microsurgical Free Flap Reconstruction with the Use of Negative Pressure Wound Therapy: Is Timing Crucial?
03 November 2013
31 December 2013
21 April 2014 (online)
Background The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been described as being optimal if conducted within the early period following injury, as higher rates of infection and flap loss were reported in the subsequent time period. However, for various reasons, reconstruction of these defects may be delayed. The aim of this article is to show that adequate debridement, negative pressure wound dressing, and sound reconstructive principles has led to increased free flap success rates regardless of the period between injury and reconstruction.
Patients and Methods A 10-year retrospective single-center analysis of 50 traumatic lower limb cases from 2002 to 2012 was conducted. All patients had microsurgical free flap reconstruction after a period of negative pressure wound therapy (NPWT). Patient factors and reconstructive methods were analyzed and outcomes were compared.
Results Mean interval between admission and free flap coverage was 17.5 days, and patients underwent NPWT for an average of 12 days (range, 1–35). Approximately 8% of patients had postoperative infections. Overall free flap success rate was 96%. Approximately 90% of patients were able to return to their premorbid footwear, with 96% able to mobilize independently approaching the end of their follow-up period.
Conclusion Our study shows that traumatic lower limb reconstruction in the delayed period is no longer associated with high rates of flap failure. Improvements in microsurgery and the advent of NPWT have made timing no longer crucial in free flap coverage of traumatic lower limb injuries.
- 1 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (3) 285-292
- 2 Byrd HS, Spicer TE, Cierney III G. Management of open tibial fractures. Plast Reconstr Surg 1985; 76 (5) 719-730
- 3 Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987; 80 (1) 1-14
- 4 Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89 (3) 478-487 , discussion 488–489
- 5 Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000; 82 (7) 959-966
- 6 Hollenbeck ST, Toranto JD, Taylor BJ , et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg 2011; 128 (5) 551e-563e
- 7 Kanakaris NK, Thanasas C, Keramaris N, Kontakis G, Granick MS, Giannoudis PV. The efficacy of negative pressure wound therapy in the management of lower extremity trauma: review of clinical evidence. Injury 2007; 38 (Suppl. 05) S9-S18
- 8 Eisenhardt SU, Momeni A, Iblher N , et al. The use of the vacuum-assisted closure in microsurgical reconstruction revisited: application in the reconstruction of the posttraumatic lower extremity. J Reconstr Microsurg 2010; 26 (9) 615-622
- 9 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24 (8) 742-746
- 10 Hildebrand F, Giannoudis P, Kretteck C, Pape HC. Damage control: extremities. Injury 2004; 35 (7) 678-689
- 11 Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg 2009; 123 (1) 218-229
- 12 Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 2005; 54: 447-462
- 13 Kolker AR, Kasabian AK, Karp NS, Gottlieb JJ. Fate of free flap microanastomosis distal to the zone of injury in lower extremity trauma. Plast Reconstr Surg 1997; 99 (4) 1068-1073
- 14 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (8) 632-634
- 15 Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy - worse or worth?. J Plast Reconstr Aesthet Surg 2009; 62 (5) 675-683
- 16 Dini M, Quercioli F, Mori A, Romano GF, Lee AQ, Agostini T. Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb. Injury 2012; 43 (6) 957-959
- 17 Liu DS, Sofiadellis F, Ashton M, MacGill K, Webb A. Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma. Injury 2012; 43 (6) 772-778
- 18 Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 2006; 117 (4) 1315-1322 , discussion 1323–1324
- 19 Wong CH, Tan BK. Perforator-sparing transposition flaps for lower limb defects: anatomic study and clinical application. Ann Plast Surg 2007; 58 (6) 614-621
- 20 Lu TC, Lin CH, Lin CH, Lin YT, Chen RF, Wei FC. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg 2011; 64 (3) 386-393
- 21 Parrett BM, Talbot SG, Pribaz JJ, Lee BT. A review of local and regional flaps for distal leg reconstruction. J Reconstr Microsurg 2009; 25 (7) 445-455
- 22 Fischer JP, Wink JD, Nelson JA , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (6) 407-416
- 23 Economides JM, Patel KM, Evans KK, Marshall E, Attinger CE. Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients. J Reconstr Microsurg 2013; 29 (5) 307-316