Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure

Abstract

Background Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. Methods Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002–2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. Results One hundred eighty‐eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap‐failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. Conclusions When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

“…This is the first study to compare surgical outcomes in patients admitted to the floor versus ICU immediately following free flap reconstruction of chronic LE wounds. Our overall flap success rate was 97.2%, which parallels other high‐volume limb salvage centers (Bigdeli et al, 2019; Culliford et al, 2007; Othman et al, 2021). Routine ICU admission following microsurgical LE reconstruction is presumed to decrease incidence of flap failure and postoperative complications, however in the present study, flap failure was comparable between groups.…”

Timing of Unplanned Reoperation After Lower Extremity Free Flap Reconstruction

“…Compared with other anatomic locations, the LE poses a myriad of unique anatomical and physiologic challenges, such as gravity dependent positioning, tightly bound anatomic compartments, variable integrity of vasculature, among others 14 . In addition, as microsurgical techniques have expanded, so too have the indications and etiologies for which reconstruction is possible in LE limb salvage efforts 15–18 . Understanding the pathophysiologic differences and failure rates between the various indications for LE reconstruction may provide valuable information for free flap salvage efforts as well as in optimizing postoperative monitoring and dangle protocols (Fig.…”

Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction

“…Immunosuppression was associated with complications although not significant on multivariable analysis. Immunosuppressants delay wound healing, induce thrombosis, and have been associated with flap loss 42–44. Understandably, many patients presenting with facial cutaneous lesions, especially squamous cell carcinoma, are chronically immunosuppressed.…”

“…Immunosuppressants delay wound healing, induce thrombosis, and have been associated with flap loss. [42][43][44] Understandably, many patients presenting with facial cutaneous lesions, especially squamous cell carcinoma, are chronically immunosuppressed. As such, this risk factor should not be considered an absolute contraindication to forehead flap surgery, but appropriate counseling and close monitoring is needed.…”