The Effect of Positive Postdebridement Cultures on Local Muscle Flap Reconstruction of the Lower Extremity

Abstract

Background:Local muscle flaps are a reconstructive option for wound coverage in the distal lower extremity, particularly in high-risk patients who are poor candidates for free tissue transfer. At our institution, chronic and infected wounds are managed with serial debridement before definitive reconstruction. There is a paucity of data on optimal timing for reconstruction in this patient population. This study investigates the relationship of positive postdebridement cultures (PDC) and wound closure rates at 90 days.Methods:A retrospective review of patients undergoing local muscle flap coverage of chronic distal lower extremity wounds between 2006 and 2012 was performed. All patients were managed with serial debridement until negative PDC were obtained. In some cases, PDC remained positive or exhibit delayed culture growth in the day(s) following closure. Data recorded include demographics, flap type/location, culture data, and wound closure at 90-day follow-up.Results:Of 76 patients, 60 met inclusion criteria with minimum 90-day follow-up. Despite 100% flap survival, 17 patients (28.3%) had failure of wound closure at 90 days and 22 patients (36%) had positive PDC. Multivariate analysis identified positive PDC (odds ratio, 29.6; 95% CI, 3.6–246.4; P = 0.002) and smoking (odds ratio, 8.9; 95% CI, 1.4–57.6; P = 0.02) as independent predictors of nonclosure at 90 days.Conclusions:In this series of local muscle flap coverage of distal lower extremity wounds, positive PDC were a strong independent predictor of failure of wound closure at 90 days. This study demonstrates the importance of serial debridement to negative cultures before definitive coverage in this patient population.

Modified fourth lumbar artery local perforator flap: an alternative for reconstruction of nonhealing lumbosacral spinal defects

“…The management of infected wounds that also require hardware retention is challenging. The results of several investigations have suggested that positive wound culture is an independent predictor of hardware salvage failure and associated flap failure [ 25 – 27 ]. In our study group, 80% of patients had positive wound cultures, and 66.7% of them required hardware salvage.…”

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

“…Positive postdebridement cultures and smoking have been shown as strong predictors of wound closure failure among local flaps in lower extremity reconstruction. 21 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][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.…”

“…In addition, cigarette smoking is a known vasoconstriction, which can compromise blood supply and portent infectious risk. Positive postdebridement cultures and smoking have been shown as strong predictors of wound closure failure among local flaps in lower extremity reconstruction 21 . 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 .…”

Case Report: Surgical Closure of Chronic Soft Tissue Defects Using Extracellular Matrix Graft Augmented Tissue Flaps

“…Increasing the local blood supply to the defect through vascularization also minimizes risk of infection via increased perfusion of protective immune system elements and/or systemically administered antibiotics ( 25 ). Indeed, proper site preparation is vital for successful closure of chronic defects with positive post-debridement cultures being a proven predictor of failure of flap closure ( 26 ), as such our procedure included aggressive debridement and removal of chronic defective tissues. Additionally, placement of ECM graft material in the defect bed may provide occlusion of dead space between the flap and underlying soft tissues.…”