Outcomes of Local versus Free Flaps for Lower Extremity Trauma

Abstract

Background Lower extremity reconstruction often requires soft tissue transfer for limb salvage. Flaps are allocated based on injury size, location, and shape coupled with surgeon expertise. Ideally, vascularized tissue should have similar outcomes across local and free tissue transfers. By evaluating outcomes from a Level 1 trauma center, we aim to provide recommendations regarding surgical management of leg reconstruction with respect to local versus free flap implementation. Methods This retrospective review evaluated patient medical history, demographics, flap characteristics, and outcomes from LAC + USC between 2007-2021 using an internal database. Outcomes included failure rates, complications, and ambulation. Results 357 lower extremity flaps were placed on 322 patients; 187 (52.4%) were local and 170 (47.6.%) were free flaps. Twenty-one (11.2%) local flaps suffered significantly more postoperative hardware infections and/or osteomyelitis compared to nine (5.3%) free flaps. Eleven (5.9%) local flaps developed partial necrosis, four requiring revision; 12 (6.4%) total local flaps required revision. Comparatively, sixteen (9.4%) free flaps developed partial necrosis, seven requiring revision; 18 (10.6%) total free flaps required revision. Flap survival was 96.3% for local versus 93.5% for free flaps. Percentage of fully ambulatory patients and time to final ambulation was not significant across cohorts. Discussion Local flaps may portent higher risk for infection; though the cause is not clear, the results may be confounded by comorbidities. Nevertheless, there were no significant differences in flap survival or number of fully ambulatory patients across cohorts. Future studies should evaluate aesthetic results and patient satisfaction across flap types.

Outcomes of Local Versus Free Flaps for Reconstruction of the Proximal One-Third of the Leg

“…Conventional teaching states that local flaps are best allocated to proximal-middle-third leg injuries, whereas free flaps are better suited for distal-third or pedal injuries. 10,11 The versatility of free flaps is demonstrated by their ability to successfully cover large defects of variable geometry; furthermore, they are reliable in acute trauma as the recipient vessel may be sourced away from the zone of injury, as seen in our cohort (Table 2). 12 Through advances in microsurgery and vascular mapping, reconstructive surgeons can harness the power of a free flap and apply these aforementioned advantages to proximal-third leg coverage.…”

“…These findings may be confounded by several preoperative factors as 7 patients in the local flap cohort exhibited preflap hardware infection, 4 of whom required hardware removal. This low rate of infectious outcomes in the free flap cohort may speak to the reliability of a well-vascularized free flap; however, there were significantly more overall operations ( P = 0.013) and flap revisions ( P = 0.039) in the free flap cohort—likely secondary to complications inherent with vascular anastomosis and heightened by the inflammatory and hypercoagulable state of a trauma victim 11,13,14 . Future work with this database is indicated to delineate the number of operations performed by different surgical teams as well as those performed preflap and postflap placement to examine how they correlate with postoperative complications.…”

“…[22][23][24] Given the high-acuity setting of a level 1 trauma center, our patient population lacks the preoperative medical optimization afforded in the outpatient setting when smoking cessation, blood pressure management, and proper glycemic control would be optimized; furthermore, preoperative angiography has proven to be of added benefit, especially for patients with diabetes mellitus or peripheral vascular disease. 11,25 Further work with this database should evaluate outcomes across with microvascular compromise and poor glycemic control and identify the incidence of patients who received preoperative vascular diagnostic or therapeutic interventions. The GA classification system for open fractures can be a surrogate for injury severity, which begets infectious risk.…”

“…Aggressive debridement and wound bed preparation serve as critical initial steps to guarantee minimal complications with a high local flap success rate in managing both acute and chronic wounds 22–24 . Given the high-acuity setting of a level 1 trauma center, our patient population lacks the preoperative medical optimization afforded in the outpatient setting when smoking cessation, blood pressure management, and proper glycemic control would be optimized; furthermore, preoperative angiography has proven to be of added benefit, especially for patients with diabetes mellitus or peripheral vascular disease 11,25 . Further work with this database should evaluate outcomes across patients with microvascular compromise and poor glycemic control and identify the incidence of patients who received preoperative vascular diagnostic or therapeutic interventions.…”