Free Tissue Transfer for Reconstruction of the Traumatized ...



Free Tissue Transfer for Reconstruction of the Traumatized Extremities: Predictors of Outcome in 347 Cases. Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY.

Michel Saint-Cyr, MD, Adam Goodwin, MD, Ashley Tregaskiss, MD, Luis R. Scheker, MD.

Introduction

The benefits and acceptance of free tissue reconstruction of complex extremity injuries following trauma have now been clearly established. So have the appropriateness and advantages of early versus delayed reconstruction, as confirmed by numerous authors. Despite our growing microsurgical experience in extremity reconstruction, some questions still remain unanswered. Apart from early timing of surgery and radical initial débridement, what other predictive factors exist which can significantly influence outcome?

Purpose

To evaluate, other then timing of reconstruction, the impact of injury location, fracture fixation, fracture severity, flap type used and patient demographics on overall flap survival and complication rate in extremity micro-reconstruction.

Material and Methods:

All free flaps performed for extremity reconstruction from 1976 to 2001 at our institution were reviewed. Inclusion criteria included trauma to the upper and lower extremities requiring free-tissue reconstruction in either an emergency, early or delayed setting. Of all cases identified, a total 347 met the inclusion criteria and were selected. The impact of injury location was evaluated by dividing flaps into two major groups: upper and lower extremity. Extremity injuries were further classified as proximal or distal within the same limb. Proximal limb injuries were defined as proximal to and/or including the knee or elbow. Distal injuries were defined as distal to and excluding the latter. When injuries crossed the elbow or knee they were considered both a proximal and distal injury (both). Fracture fixation, open or closed fracture, and Gustillo grade were all evaluated to determine their impact on flap survival, infection and overall complications. Other factors measured included timing of reconstruction, flap type, use of vein graft as well as patient factors such as gender, age, manual work and smoking.

Total flap failure was defined as any flap loss greater then 60%. Statistical analysis was performed on two groups: Group 1 (total flap loss) group 2 (total and partial flap losses combined). Complications were classified as minor (superficial infection, haematoma, skin graft loss) and major (flap loss, deep infection, osteomyelitis, fracture nonunion). Superficial infections were defined as ones resolving with intravenous antibiotics whereas deep infections were defined as those requiring surgical intervention for treatment. Statistical analysis was performed using a combination of Chi Square, pearson correlation and logistic regression analysis.

Results:

A total of 347 free-tissue transfers were performed with the majority being done to the upper extremity 78.9% vs. 21.1 % for the lower extremity. Most limb injuries were distal 84% vs. 13% proximal injuries vs. 3% for both. Mean age at time of reconstruction was 30.1 ( 15 years with injuries occurring predominantly in men (84.8%) and manual workers (73.1%). Closed and open fractures were seen in 26.7% and 33.6% of injuries respectively. Gustillo fracture grade was 3A (2.1 %), 3B (20.5%), 3C (9.6%) and half of the patients required a fracture stabilizing procedure using either open reduction with internal fixation or a closed percutaneous technique. The majority of the 347 flaps used were fasciocutaneous FC flaps 159 (45.8%), whereas 65 were myocutaneous MC flaps (18.7%), 18 were muscle M only flaps (5.2%) and 105 were toe transfers TT (30.3%). The lateral arm flap was the most frequently used fasciocutaneous flap (74.2%) with the latissimus dorsi most often used as both a myocutaneous flap (69.2%) and muscle flap (50%). The total flap loss rate (( 60% flap necrosis) was 5.5% (19 flaps) for an overall flap survival rate of 94.5%. The flap loss rate when considering all total and partial losses was 8.9% for a survival rate of 90.1% overall. The failure rate for fasciocutaneous flaps was 5% (8/159), for myocutaneous flaps 10.8% (7/65), for muscle flaps 0% and for toe transfers 3% (4/105). More then half of the fasciocutaneous flap losses occurred using the groin flap earlier in the series (failure rate 31.3%, 5/16 groin flaps lossed). Conversely, flap survival was highest in the most commonly used flaps such as the lateral lap (98.3% survival) and latissimus dorsi and rectus muscle flaps (both with 100% survival rates). Inter-positional vein grafts were required in 14.9% of flaps transferred. Free flaps were performed within 24 hours in 28% of cases, within 3 days in 56% of cases and within 1 week in 69% of cases. There was no significant difference in rate of flap loss when performed within 24hrs vs. after 24 hrs (P=0.484), or within 2 days vs. 3 days or later (0.114) or at 6 days or less vs. 1 week or more (p=0.086). When considering all flap losses (partial and total combined) there was no significant difference in flap loss rate when surgery was performed within 24 hrs vs. after 24 hrs (p=0.113). Presence of a fracture, whether open (26.7%) or closed (33.6%) did not effect flap outcome, P=0.072. Flaps associated with a fracture fixation procedure, whether open or closed, were comparable to simple free flaps with regards to survival, P=0.729. Higher energy open fractures such as Gustillo type 3A,B, and C also did not impact flap survival, P=0.375, nor did the use of inter-positional vein grafts, P=0.188 or type of flap used for reconstruction, P=0.202. Revision of the anastomosis for venous or arterial insufficiency was associated with a 4.7 time higher risk of flap failure compared to no revision, p ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download