Plastic Surgery Research Council

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Timing of Traumatic Lower Extremity Free Flap Reconstruction: Does Time to Coverage Impact Outcomes?
William J. Rifkin, BA, John T. Stranix, MD, Zachary M. Borab, MD, Adam Jacoby, MD, Z-Hye Lee, MD, Lavinia Anzai, MD, Joshua M. Cohen, BS, Daniel J. Ceradini, MD, Vishal Thanik, MD, Pierre B. Saadeh, MD, Jamie P. Levine, MD.
Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA.

PURPOSE: Microvascular free-tissue transfer is commonly used for the reconstruction of traumatic lower extremity injuries, particularly in cases of open fractures with substantial associated soft-tissue defects. Initial outcomes studies in the late 1970s and early 1980s established the principle of early flap coverage in an effort to minimize fibrosis, edema, and infection that may complicate repair. However, this has been challenged by several more recent studies that suggest reconstruction can be performed beyond this early window with comparable outcomes. Additionally, clinical and logistical factors—including associated injuries and patient transport—often preclude immediate reconstruction. The aim of this study was to determine whether reconstructive timing influences outcomes and complication rates in traumatic lower extremity free flap repair.
METHODS: Retrospective review of our institutional flap registry from 1979-2016 identified 806 lower extremity free flaps; 393 soft tissue free flaps for Gustilo IIIB/C coverage met inclusion criteria. Patients were stratified based on clinically relevant intervals between injury and free flap coverage: 0-10 days, 11-90 days, and >90 days. Demographics, flap characteristics, and outcomes were compared between groups using Chi-square and one-way ANOVA. Multivariate logistic regression was performed to control for variables with significant differences between groups on univariate analysis as well as clinically relevant variables, including timing within cohort (1976-1996 vs. 1997-2006), arterial injury, flap type and size, and use of vein grafts. Primary outcomes assessed included total and partial flap failure as well as overall success (defined as lack of any failure). Secondary outcomes included overall complications, artery and vein complications, operative takebacks, and takeback success rate.
RESULTS: 134 free flaps (34.1%) were performed 0-10 days after initial injury, 142 (36.1%) flaps within 11-90 days, and 117 (29.8%) flaps were performed >90 days after injury. Demographics and flap characteristics were similar between groups, although there was a significant difference between groups in presence of arterial injury (57% 0-10 days vs. 42% 11-90 days vs. 63% >90 days; p=0.011) and mean flap size (350cm vs. 257cm vs. 235cm; p<0.0001). Univariate analysis revealed significant differences in rates of overall success (76% 0-10 days vs. 84% 11-90 days vs. 89% >90 days; p=0.026), partial flap failure (13% vs. 12% vs. 3%; p=0.024), and overall complications (49% vs. 37% vs. 39%; p=0.014). On multivariate analysis, free flaps performed >90 days after initial injury had significantly higher success rates as compared to the 0-10 day group (OR 3.33, p=0.03). The >90 day group also showed a trend toward decreased rates of partial flap failure (OR 0.22, p=0.074). There was no association between time to coverage and rates of total flap failure (p=0.423), overall complications (p=0.272), operative takebacks (p=0.406), or any other outcomes assessed.
CONCLUSION: There was no association between timing of reconstruction and rates of total or partial flap failure, overall complications, or operative takebacks. In fact, repairs performed >90 days demonstrated higher success rates. These findings suggest that, in appropriate patients, delayed free flap reconstruction for lower extremity trauma is safe and as effective as early coverage.


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