The Optimal Timing of Traumatic Lower Extremity Reconstruction





Marko Godina in his landmark paper in 1986 established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries to minimize edema, fibrosis, and infection while optimizing outcomes. However, with the evolution of microsurgery and wound management, there is emerging evidence that timing of reconstruction is not as critical as once believed. Multidisciplinary care with a combined orthopedic and reconstructive approach is more critical for timely and appropriate definite treatment for severe lower extremity injuries.


Key points








  • Although early reconstruction within 72 hours of injury has long been held as the gold standard for treating traumatic lower extremity injuries, recent evidence suggests this ideal window can likely be extended 1 to 2 weeks.



  • Advances in local wound care, particularly negative pressure wound therapy, have allowed for successfully temporizing lower extremity wounds.



  • Although timing of reconstruction may be less important than previously suggested, expeditious treatment using a multidisciplinary approach remains the ultimate goal.




Introduction


Lower extremity reconstruction, particularly in the setting of trauma, remains one of the most challenging tasks for the plastic surgeon. Relevant factors to consider include bony restoration, flap choice, and timing. Considerable debate has continued regarding the ideal timing of reconstruction for lower extremity trauma. For nearly 3 decades, early reconstruction within 72 hours of injury has been considered the gold standard. However, with the evolution of microsurgical practices and new advances in wound care, specifically negative pressure wound therapy (NPWT), there has been a paradigm shift in the timing for managing these injuries.


Evidence for early timing of reconstruction


In 1986, Marko Godina’s landmark paper “Early Microsurgical Reconstruction of Complex Trauma of the Extremities” provided evidence for the benefits of free flap coverage within 72 hours from initial injury. His large series of over 500 patients demonstrated lower rates of flap failure and postoperative infection in the early group compared with flaps performed after 72 hours ( Figs. 1–5 ). The tenet of early reconstruction in lower extremity trauma came to be accepted as the relative gold standard as subsequent studies provided further corroboration. However, although Godina’s original work established some of the guiding principles for free flap reconstruction in lower extremity trauma, there were some limitations. Most notably, his analysis did not control for the learning curve that occurred over time: his first 100 cases had a flap failure rate of 26% compared with only 4% in his last 100 cases, and most of his initial 100 cases were performed in a delayed fashion. Despite this confounding factor, the concept of early coverage within 3 days of injury became the standard of care, especially given the rationale of less scarring and fibrosis in the immediate stages after injury. Furthermore, it has been well documented that the onset of significant inflammation in the delayed period after injury can affect all tissue types of the lower extremity, from the skin and muscle to the neurovascular structures, resulting in compromised outcomes after free flap reconstruction.




Fig. 1


Results from Godina’s landmark paper establishing 72 hours as the ideal window for reconstruction after lower extremity trauma.

( Data from Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285–92.)



Fig. 2


Current flap failure rates from NYU for early, delayed and late lower extremity reconstruction.



Fig. 3


Workflow for management of lower extremity trauma patients.



Fig. 4


( A ) 19-year-old woman with Gustilo 3C right lower extremity open tibia-fibula fracture. ( B ) 8 days after injury after serial debridement and VAC placement. ( C ) Markings for myocutaneous latissimus dorsi free flap. ( D ) Postoperative day 2. ( E ) 4 weeks after reconstruction. ( F ) 18 months after reconstruction.



Fig. 5


( A ) 21-year-old woman with Gustilo 3B right lower extremity open tibia-fibula fracture initially managed with serial debridements and external fixation. ( B ) Soft tissue coverage with myocutaneous latissimus dorsi flap at 3 weeks after injury. ( C ) Appearance of wound after flap failure and debridement followed by serial NPWT dressing changes. ( D ) Significant decrease in wound size after skin graft to most of the wound with persistent exposure of comminuted tibia. ( E ) Fibula free flap for tibial reconstruction and soft tissue coverage with fibula flap skin paddle.


With the development of regional trauma centers specializing in limb salvage, treatment of severe lower extremity injuries has become standardized with a multidisciplinary approach involving vascular, orthopedic, and plastic surgeons. Open fractures are debrided early and fixated either with temporary external fixators or internal fixation, followed by stable soft tissue coverage, usually in the form of free tissue transfer. However, delays in flap coverage can occur because of delay in referral to a tertiary trauma center, other life-threatening injuries, or attempts at wound closure with skin grafts or local flaps. Given these practical limitations and the arbitrary nature of Godina’s original timing groups, several additional studies have investigated the impact of timing on outcomes after free flap reconstruction of the lower extremity and whether this early safe period of 3 days can be extended ( Table 1 ). ,



Table 1

Articles on timing in lower extremity reconstruction

Data from Refs. , , , , , ,

















































































Author, Year Study Design (# of Patients) Outcomes Assessed Reconstruction Criteria Timing Windows Conclusion
Byrd et al, 1985 Prospective (n = 191) Flap failure
Amputation rate
Osteomyelitis
Time to bony union
Length of stay
Time to closure
Open tibial fractures (type I-IV) Acute 1-5 d
Subacute 1-6 w
Chronic >6 w
Acute best for all outcomes
Godina et al, 1986 Retrospective (n = 532) Flap failure
Infections
Time to bony union
Length of stay
Lower extremity trauma Early <72 h
Delayed 72 h-3 mo
Late >3 mo
Acute best for all outcomes
Francel et al, 1992 Retrospective (n = 72) Flap failure
Reoperations
Osteomyelitis
SSI
Length of stay (LOS)
Time to bony union
Gustilo IIIB injuries <15 d
15–30 d
>30 d
<15 d group:
Fewer flap failures and reoperations, decreased LOS and time to bony union
Kolker et al, 1997 Retrospective (n = 451) Flap failure
Reoperation
Below knee injuries Acute <22 d
Subacute 22–60 d
Chronic >60 d
No difference in outcomes
Karanas et al, 2008 Retrospective (n = 14) Flap failure
Osteomyelitis
Lower extremity trauma All >72 h No flap loss in 14 patients
Hill et al, 2012 Retrospective (n = 60) Flap failure
Reoperation
SSI
Lower extremity trauma <30 d
31–90 d
>91 d
No significant difference in outcomes
Trend toward lower rates of failure among >91 d group
Raju et al, 2014 Retrospective (n = 50) Flap failure
Reoperation
Infection
Lower extremity trauma (All received NPWT prior to flap) 1 wk
2 wk
3 wk
4 wk
5 wk
6 wk
7 wk
No difference in outcomes
Bellidenty et al, 2014 Retrospective (n = 89) Flap failure
Osteomyelitis
Lower extremity trauma
Gustilo 3B injuries (emergency vs delayed cases referred to center for coverage)
Emergency
Delayed
Lower failure and infection rates in ‘emergency’ group, increased in delayed group
Starnes-Roubaud et al, 2015 Retrospective (n = 51) Flap failure
Osteomyelitis
Bony union
Ambulation
Lower extremity trauma <15 d
>15 d
No difference in outcomes
Lee et al, 2018 Retrospective (n = 358) Flap failure
Return to OR
Lower extremity trauma 0–3 d
3–9 d
10–90 d
>90 d
No difference in outcomes between 0–3 and 3–9 d; higher complications for 10–90 d

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Jun 13, 2021 | Posted by in General Surgery | Comments Off on The Optimal Timing of Traumatic Lower Extremity Reconstruction

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