The Effect of Variation in Intraoperative Technique on Outcomes in Lower Extremity Free Flap Reconstruction

Background Blood transfusions have been associated with surgical complications; however, these studies are not specific to lower extremity (LE) reconstruction. We evaluated the effect of perioperative packed red blood cell (PRBC) transfusions on LE free flap outcomes in trauma patients. Methods Patients undergoing LE free flap reconstruction following acute injuries from 2016 to 2021 were retrospectively analyzed. The perioperative period for transfusions was defined as ± 3 days from the procedure. Parameters included demographics, perioperative characteristics, and outcomes. Major complications were complications requiring reoperation. Univariate and multivariate analyses were performed to identify associations. Results Of the 205 patients, 48% received PRBCs perioperatively. There was a trend toward higher major complications rate in the transfusion group (19 vs. 10%, p = 0.09). Wound size, injury severity score (ISS), and intraoperative estimated blood loss were greater in the transfusion group (p < 0.01). Preoperative hemoglobin/hematocrit were lower in the transfusion group (p < 0.001). Units of PRBCs transfused were independently associated with major complications on multivariate analysis (odds ratio [OR] = 1.34, confidence interval [CI]: 1.06–1.70, p = 0.015) and length of hospital stay (LOS; OR = 1.05, CI: 1.02–1.08, p = 0.002). Infection, wound size, ISS, and preoperative hemoglobin/hematocrit were independently associated with increased LOS (p < 0.05) but not with major complications. Conclusion The number of units of PRBCs given perioperatively was the only variable independently associated with major complications on multivariate analysis and was one of many variables associated with increased LOS. These findings suggest the usage of restrictive transfusion protocols in trauma patients requiring LE reconstruction.

Section: Resultsmentioning

confidence: 99%

mentioning

confidence: 99%

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The Hidden Risks of Perioperative Transfusions in Traumatic Lower Extremity Free Flap Reconstruction

Swiekatowski,

Manisundaram,

Woods

et al. 2024

“…Christensen et al found that the anterior and posterior tibial arteries were the most reliable inflow vessels for free flap reconstruction. 56 Regarding outflow, Lee et al demonstrated that lower extremity reconstructions with two venous anastomoses had fewer perfusion-related complications compared with one vein, whereas Mattos et al did not find a significant difference in complications when only one vein is used for anterolateral thigh flaps. 57 58 A claims database study is unable to refute or support such findings without more specific clinical characteristics.…”

Section: Discussionmentioning

confidence: 99%

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures

Le,

McNamara,

Constantine

et al. 2024

Purpose: Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed. Methods: An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0-3, 3-7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor. Results: A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0-3 days, 4-7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections (16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0-3 day (OR = 0.22; 95% CI: 0.15, 0.32) and 4-7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups were protective factors against all-cause complications after bivariate and multivariate regression. Conclusion: Early soft tissue reconstruction of open lower extremity fractures performed within seven days of ORIF reduces complication rates and reduces the variability of complication rates including surgical site infections, acute osteomyelitis, and hardware failure.

“…Their findings underscore the importance of meticulous surgical technique and careful consideration of these variables to optimize outcomes in traumatic lower extremity reconstruction. 25 Another important consideration in lower extremity reconstruction is the choice of flap type. Dow et al conducted a systematic review and meta-analysis comparing outcomes between free muscle flaps and free fasciocutaneous flaps for lower limb reconstruction following trauma.…”

Section: Discussionmentioning

confidence: 99%

Blunt Trauma Induced Closed Femoral Bone Fracture in a Rat Model: Are Vessels Safe to Use for Microsurgery? Further Insight into the Zone of Injury Concept

Basaran,

Datli,

Sagir

et al. 2024

Background: The study aims to investigate the zone of injury for major vessels after high-velocity traumas, as it is unclear whether avoiding vascular structures is necessary during microvascular anastomosis or how long it takes for them to be used again. Methods: This study uses Doppler ultrasonography and a rat model to evaluate the histopathological changes and flow velocity of major vessels in the zone of injury after high-velocity trauma with closed femoral bone fracture. Osteosynthesis was performed using an intramedullary wire. Samples were collected from day 3 and week 3. The unaffected contralateral side is used as control. Results: Results from arterial and venous flow assessments showed no evidence of ischemia in the extremities. Both arteries and veins were patent in both intervals and on the control side. The evaluation of the vessels showed arterial injury with a slightly reduced arterial flow on Day 3 and Week 3. The venous flow was slightly reduced on Day 3 but not on Week 3. Statistically, arterial endothelial injury was higher on day 3 than on week 3 (p = 0.006). Media inflammation was also higher on day 3 (p = 0.06). Arterial endothelization distribution was higher in week 3 (p = 0.006). No significant differences were found in arterial media irregularity, necrosis, platelet aggregation, bleeding, and wall rupture. Venous samples showed no significant differences in any parameter (p < 0.05). Conclusion: High-velocity trauma increases the risk of thrombosis in vessels. Intravascular repair can start on day 2 and continue till week 3 with significant endothelization. Although physiologic findings do not alter arterial or venous flow, histologic findings support vessel injuries leading to potential complications. Microsurgery should be considered out of the injury zone until adequate vessel healing is achieved.