Emergency and delayed microsurgical salvage of traumatic lower extremities
Reconstruction of lower extremity injuries
Keywords:Delayed reconstruction, Free flap, Immediate reconstruction, Lower limb reconstruction.
Background/Aim: The power of free flaps for lower extremity injury reconstruction is no longer a matter of debate; however, contrasting views remain regarding the timing of reconstruction. The mainstay article of Godina reported that reconstruction within the first three days after injury was more advantageous than surgery at later times, but different views about the best day for reconstruction have also been described in the literature. With developments in the field of microsurgery, plastic surgeons have become more experienced, shortened the times needed for surgery, and achieved flap success. We have also become more experienced with surgical times, and reconstruction on the day of injury has been performed as an emergency reconstruction (ER) procedure since 2018. However, despite the disadvantages of a delayed wait period, patients still experience delayed reconstruction (DR) due to their pre-operative conditions and dispatches from peripheral centers over delayed time periods. This study aimed to present our experiences with lower extremity reconstruction in emergency situations and after delayed periods with descriptions of technical tips for each situation.
Methods: Between 2018 and 2021, patients who underwent lower extremity reconstructions were examined as retrospective case-control study. Twenty-four patients (17 male and seven female) underwent lower extremity reconstructions with microsurgical free flap coverage. Patients’ ages ranged from 6 to 75 years old. Ten patients underwent ERs (on the day of injury), and 14 patients underwent DRs. Twenty anterolateral thigh, two medial sural artery perforator, one latissimus dorsi, and one radial forearm flaps were chosen for reconstructions. Flaps were chosen for one-third of the distal lower extremity reconstructions (n=11) and Gustilo type 3B injuries (n=11), Gustilo type 3C injuries (n=1), and one-third for middle lower extremity soft tissue reconstructions (n=1). Infections, length of hospital stays, time spent during the reconstructive surgery, vascular complications, and additional debridement necessity counts were recorded and compared with previous statistical analyses.
Results: One venous thrombosis in the emergency group and three venous and one arterial thrombosis in the delayed group were reported. The patients were taken to the operating room immediately after which re-anastomoses were performed successfully, and all flaps survived. The hospital stay was between 4 and 60 days in the emergency group and 20 and 99 days in delayed group. Infections (P=0.03), vascular complications (P=0.04), and hospital stays (P=0.01) were statistically significantly lower in the emergency group than in the delayed group.
Conclusion: ER has many advantages, such as preventing time consuming surgeries and providing short hospital stays and low complication rates, over DR. However, DR is inevitable for some reasons, and despite its more complicated nature, meticulous flap follow-up and salvage procedures may provide the same flap success as found with ERs.
Korompilias, AV, Lykissas MG, Vekris, MD, Beris AE, Soucacos PN. Microsurgery for lower extremity injuries. Injury. 2008;39.3:103-8. DOI: https://doi.org/10.1016/j.injury.2008.06.004
Kang Y, Wu Y, Ma Y, Liu J, Gu J, Zhou M, et al. “Primary free-flap tibial open fracture reconstruction with the Masquelet technique” and internal fixation. Injury. 2020;51(12):2970-4. DOI: https://doi.org/10.1016/j.injury.2020.10.039
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986 Sep;78(3):285-92. DOI: https://doi.org/10.1097/00006534-198609000-00001
Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg. 2018 Oct;52(5):259-64. DOI: https://doi.org/10.1080/2000656X.2018.1470979
Haykal S, Roy M, Patel A. Meta-analysis of Timing for Microsurgical Free-Flap Reconstruction for Lower Limb Injury: Evaluation of the Godina Principles. J Reconstr Microsurg. 2018 May;34(4):277-92. DOI: https://doi.org/10.1055/s-0037-1621724
Lee ZH, Stranix JT, Rifkin WJ, Daar DA, Anzai L, Ceradini DJ, et al. Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm. Plast Reconstr Surg. 2019 Sep;144(3):759-67. DOI: https://doi.org/10.1097/PRS.0000000000005955
Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery. 2008;28(8):632-4. DOI: https://doi.org/10.1002/micr.20551
Patterson CW, Stalder MW, Richardson W, Steele T, Wise MW, St Hilaire H. Timing of Free Flaps for Traumatic Wounds of the Lower Extremity: Have Advances in Perioperative Care Changed the Treatment Algorithm? J Reconstr Microsurg. 2019 Oct;35(8):616-21. DOI: https://doi.org/10.1055/s-0039-1688712
Hou Z, Irgit K, Strohecker KA, Matzko ME, Wingert NC, DeSantis JG, et al. Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture. J Trauma. 2011 Dec;71(6):1705-8. DOI: https://doi.org/10.1097/TA.0b013e31822e2823
Starnes-Roubaud MJ, Peric M, Chowdry F, Nguyen JT, Schooler W, Sherman R, et al. Microsurgical Lower Extremity Reconstruction in the Subacute Period: A Safe Alternative. Plast Reconstr Surg Glob Open. 2015 Aug 10;3(7):e449. DOI: https://doi.org/10.1097/GOX.0000000000000399
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 May;62(5):675-83. DOI: https://doi.org/10.1016/j.bjps.2007.09.041
Singh J, Dhillon MS, Dhatt SS. Single-stage “Fix and Flap” gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study. Malays Orthop J. 2020 Mar;14(1):61–73. DOI: https://doi.org/10.5704/MOJ.2003.010
Al-Hourani K, Fowler T, Whitehouse MR, Khan U, Kelly M. Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated with Outcomes? J Orthop Trauma. 2019 Dec;33(12):591-7. DOI: https://doi.org/10.1097/BOT.0000000000001562
Hill JB, Vogel JE, Sexton KW, Guillamondegui OD, A Del Corral G, Shack RB. Re-evaluating the paradigm of early free flap coverage in lower extremity trauma. Microsurgery. 2013 Jan;33(1):9-13. DOI: https://doi.org/10.1002/micr.21994
Georgescu AV, Ivan O. Emergency free flaps. Microsurgery. 2003;23(3):206-16. DOI: https://doi.org/10.1002/micr.10128
Chen HC, Chuang CC, Chen S, Hsu WM, Wei FC. Selection of recipient vessels for free flaps to the distal leg and foot following trauma. Microsurgery. 1994;15(5):358-63. DOI: https://doi.org/10.1002/micr.1920150514
Mykula R, Beswick W, Mohindra A, Kerstein R, Khan MA. Rethink on the Use of the Anterior Tibial Artery as Recipient Site in Lower Limb Reconstruction. Plastic and Reconstructive Surgery. 2015;136.4S:11. DOI: https://doi.org/10.1097/01.prs.0000472286.86212.4f
Zeiderman MR, Bailey CM, Arora A, Pu LLQ. Anterior tibial vessel turnover as recipient vessel for complex free tissue transfer around the knee. J Plast Reconstr Aesthet Surg. 2020 Oct;73(10):1897-916. DOI: https://doi.org/10.1016/j.bjps.2020.05.069
Colen DL, Colen LB, Levin LS, Kovach SJ. Godina's Principles in the Twenty-First Century and the Evolution of Lower Extremity Trauma Reconstruction. J Reconstr Microsurg. 2018 Oct;34(8):563-71. DOI: https://doi.org/10.1055/s-0037-1607348
Lee KT, Mun GH. The efficacy of postoperative antithrombotics in free flap surgery: a systematic review and meta-analysis. Plast Reconstr Surg. 2015 Apr;135(4):1124-39. DOI: https://doi.org/10.1097/PRS.0000000000001100
How to Cite
Copyright (c) 2023 Ersin Gur, Yigit Ozer Tiftikcioglu, Turgut Furkan Kuybulu, Kutay Durukan, Mehmet Emre Yegin, Nadir Ozkayin
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.