AAPS Main SiteMicrosurgical Lower Extremity Reconstruction in the Sub-acute Period: A Safe Alternative
Margaret J. Starnes-Roubaud, MD.
University of Southern California, Los Angeles, CA, USA.
BACKGROUND: Microsurgical reconstruction of the lower extremity is an increasingly common and successful procedure, performed as an integral part of limb salvage due to lower extremity trauma. Early studies, including those by Byrd and Godina, cite the sub-acute period (approximately 5 days to six weeks post-injury) as the most dangerous time to reconstruct lower extremity wounds due to prolonged inflammation, increased rates of infection, and flap failure. In recent years, several studies have emerged with flaps being performed outside this critical “early window,” with equivalent success. The LAC+USC medical center serves as catch-all for polytrauma in a city of 4 million people. Between January 2000 and December 2009, approximately 50% of patients with lower extremity trauma requiring microsurgical reconstruction at our institution did not receive soft tissue reconstruction until greater than 15 days post-injury secondary to primary trauma, physiologic instability, patient comorbidities, or orthopedic and plastic surgery operative backlog. Our study evaluated the outcomes in patients reconstructed earlier than 15 days post-injury to greater than 15 days post-injury, for both safety and efficacy.
METHODS: A retrospective review of 74 patients, ages 18-95, who underwent microsurgical lower extremity reconstruction at LAC+USC County Hospital from January 2000 to December 2009. Independent risk factors included patient demographics, type and severity of injury, and reconstructive procedure performed. Dependent variables assessed included flap survival, radiographic evidence of bony union, and rate of osteomyelitis.
RESULTS: 74 patients had lower extremity injuries requiring microsurgical reconstruction, with 77 free flaps performed. See table 1 for complete demographic and injury characteristics. The length of time between injury and free flap was <15 days in 36% of patients (27/74), 15-90 days in 45% (33/74), and >90 days in 19% (6/74). Most patients underwent 1-4 total reconstructive procedures (68%, 50/73), while 32% (23/73) underwent 5-9 procedures. The average length of clinical follow-up was 548±665 days. Five patients (7%, 5/74) had total flap failure. There was no significant difference in flap failure comparing patients reconstructed <15 days post-injury to 15-90 days post-injury (<15 days=11%, 3/27; 15-90 days=6%, 2/33; >90 days=0%, 0/6, p=0.65). 27 patients presented prior to fracture union and had radiographic information available for long-term assessment. There was no significant difference in union rates based on timing of reconstruction (<15 days=64%, 7/11; 15-90 days= 92%, 12/13; >90 days=100%, 3/3; p=0.13). Osteomyelitis was present in 25 patients at some point in their treatment. When comparing patients who developed post-flap osteomyelitis with those who never did, there was no significant differences in patient or injury characteristics, nor in the time between injury and flap reconstruction (17±8 versus 25±22, p=0.39). Of 36 patients with known final post-injury ambulation status, 97% (35/36) were ambulating independently or with an assistive device.
CONCLUSIONS: Microsurgical reconstruction of the lower extremity in the sub-acute period is both safe and effective.
| Demographic Characteristics | Total (col %) |
| Age (years) Mean ±SD (n) Total Gender Male Triaged by trauma team Tobacco use Alcoholism Drug Abuse Incarcerated Diabetes Hypertension Pre-injury Ambulation Status Independent With assistive device With prosthesis | 40±14 (74) 84% (62/74) 57% (42/74) 31% (23/74) 28% (21/74) 27% (20/74) 4% (3/74) 5% (4/74) 16% (12/74) 97% (68/70) 1% (1/70) 1% (1/70) |
| Injury Characteristics | |
| Mechanism of Injury Motor Vehicle Accident Motorcycle Accident Auto vs Pedestrian Fall Gun-shot wound Other Injury Severity Score >16 AIS extremity 2 3 4 Open Injury Comminuted injury Location of bony injury Proximal 1/3 tibia Middle 1/3 tibia Distal 1/3 tibia with or without fibula Tibial pilon, Calcaneus, Ankle and foot complex Soft tissue deficit 150cm Preexisting Osteomyelitis Preexisting/Failed Local Flap Gastrocnemius Soleus Other | 18% (13/74) 14% (10/74) 16% (12/74) 23% (17/74) 12% (9/74) 18% (13/74) 14% (6/42) 25% (10/40) 72% (29/40) 3% (1/40) 74% (55/74) 62% (46/74) 7% (5/74) 10% (7/74) 31% (23/74) 31% (23/74) 4% (3/74) 10% (7/74) 17% (10/58) 40% (23/58) 43% (25/58) 27% (17/64) 14% (1/7) 43% (3/7) 43% (3/7) |
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