Eur J Plast Surg (1992) 15:63-68 European 111hI ~ l Journal of I ~ l ~ l Q T I d O b

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© Springer-Verlag 1992

The use of free flaps in the treatment of severe lower leg trauma

W. Boeckx 1, P .H. Blondee l 1, D. Van R a e m d o n c k 2, P. Broos z and P. R o m m e n s 2

1 Department of Plastic and Reconstructive Surgery and 2 Department of Traumatology, University Hospitals, Katholieke Universiteit, Leuven, Belgium

Summary. In a p e r i o d o f 51/2 years, the use o f 43 free f laps in the t r e a t m e n t o f severe lower leg t r a u m a was reviewed. The m a j o r i t y o f the pa t ien t s had severe t ib ia l f rac tures wi th extensive soft t issue loss and severe con- t amina t i on . One f lap fai led in the ear ly g roup , 3 in the d e l a y e d group . There were no f lap fai lures in the late group. The pos tope ra t i ve infec t ion ra te was the h ighes t in the subacu te group . H o s p i t a l s tay a n d b o n y hea l ing t ime were d i rec t ly re la ted to the t iming o f free f lap sur- gery. Refe r ra l diff icult ies causing de lay in free f lap sur- gery, t iming o f free f lap surgery, d o n o r vessel qua l i ty and pa t i en t fo l low-up are discussed.

Key words: Free f laps - L o w e r leg t r a u m a

In 1986, G o d i n a [2] pub l i shed the la rges t series o f ex- t r emi ty r econs t ruc t ion us ing free flaps. He emphas i zed the i m p o r t a n c e o f t h o r o u g h d e b r i d e m e n t and ear ly re- cons t ruc t i on and s ta ted tha t there was decreased f lap fai lure rate, fewer p o s t o p e r a t i v e infect ions, ear l ier bone heal ing, decreased hosp i t a l s tay and decreased n u m b e r o f re in tervent ions . This review will assess the results o f r econs t ruc t ion o f lower leg injuries, t ak ing in to accoun t severi ty and p r eope ra t i ve bac te r io log ica l s ta tus o f the w o u n d as well as the type and t iming o f free f lap surgery.

Materials and methods

In a retrospective study, the medical records of 40 patients who underwent microsurgical reconstruction for severe lower leg trauma between June 1984 and December 1989 were reviewed. The age ranged from 2 to 78 years with a mean of 30 years. 50% of the patients were younger than 25 years. There was a male predomi- nance, only 15% being female.

The etiology of the trauma is shown in Table 1. All injuries

Requests for reprints: W. Boeckx, M.D., Catholic University of Louvain, Department of Plastic and Reconstructive Surgery Brus- selsestraat 69, B-3000 Leuven, Belgium

were caused by high velocity, most of them being motorcycle (40%) and car accidents (17.5%) or crush injuries in working environ- ments (12.5%).

35 out of 40 patients had a tibial fracture, 27 having associated fibular fracture. 22 tibial fractures were on the left side, 13 on the right. The tibial fracture was mostly localized in the middle and distal third of the tibia (proximal 5, middle 14, distal 16). Fractures were classified according to the AO guidelines: 80% had complex tibial fractures, falling into the B-group (31.4%) and C- group (48.6%). 6 patients had bifocal fractures, 3 of them with extensive bone loss. Severity of open tibial fracture, i.e., the asso- ciated soft tissue damage, is shown in Table 2 [3]. The Gustilo subclassification of type III open tibial fractures was used, since this is an accurate prognostic indicator for late functional failures as confirmed by Yakuboff et al. [10]. Type IIIa open tibial fractures have an adequate soft tissue coverage despite extensive laceration. Type IIIb open tibia fractures have extensive soft tissue injury with periosteal stripping and massive contamination. Type IIIc open tibial fractures combine the preceding factors with associated blood vessel injury requiring repair. Table 2 demonstrates that the majori- ty of patients had severe tibial fractures with extensive soft tissue loss and severe contamination. 7 tibial fractures, which on admis-

Table 1. Etiology of trauma

Traffic accident: Motorcycle 16 (40%) Car 7 (17.5%) Pedestrian 4 (10%) Cyclist 3 (7.5%)

Working accident: Crush 5 (12.5%) Avulsion 2 (5%) Fall 1 (2.5%) Burn 1 (2.5%)

Suicide attempt: 1 (2.5%)

40 (100%)

Table 2. Type of tibial fracture

Closed 3 (8.6%) Open grade I 4 (11.4%)

grade II 3 (8.6%) III A: 5 grade III 25 (71.4%) III B : 13

III C: 7

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No. of patients

15

14

11

1 2 3 4 5 6 7 8

Number of operations

Fig. 1. Number of operations before flap surgery (Total: 100 = 2.5 operations/patient

sion were classified as closed (3) and open grade I (4), became more complex wounds after open fasciotomy and debridement.

The severity of soft tissue damage is once again demonstrated; its localization and extent is assessed regardless of the fractures: 13 patients had isolated but extensive skin defects, mostly on the anteromedial side; 12 patients had combined skin and muscle de- fects mostly on the anterolateral and anteromedial side; 15 patients had concurrent skin, muscle, blood vessel and nerve defects.

External fixation was used for primary fracture stabilization in 27 cases [9] and with plate and screws in 8 cases.

Since microsurgical repair could only be done in a later post- traumatic stage in the majority of our patients, each patient under- went at least one surgical intervention before flap surgery (Fig. 1). Although 14 patients needed only one intervention, there was 1 patient who underwent 8 interventions before microsurgical repair. The type of operations before flap surgery are shown in Table 3. The first intervention was immediately after the trauma and con- sisted of fracture fixation, debridement, fasciotomy, muscular and/ or vascular repair as required. At a second stage, several days or weeks later, an attempt was made to repair soft tissue or bony defects. 7 out of the 8 transposition flaps failed and ultimately needed replacement by a free flap.

Qualitative and semi-quantitative bacteriological studies were performed in each wound twice a week and 2 days before free flap surgery. Wound cultures were positive in 11 patients (27.5%), most of the pathogens being gram negative rods (Table 4), and culture-specific antibiotics were administered.

Timing and type of free flap surgery, free flap size, type, sites and quality of microvascular anastomosis, hospital stay, mortality, flap failure rates, postoperative infections and long-term results were studied. Follow-up ranged from 8 to 72 months with an aver- age of 32.8 months.

R e s u l t s

Timing and type o f free f lap surgery are shown in Ta- ble 5 . 4 0 pa t i en t s h a d 43 free f laps : 39 pa t ien t s h a d one free f lap, 1 pa t i en t h a d 2 p r i m a r y free f laps a n d 2 pa - t ients h a d a second free f lap af ter in i t ia l free f lap fai lure. The pa t ien t s were d iv ided in to 3 g roups : 6 mic rosu rg ica l repa i r s in the ear ly g r o u p (within 72 h pos t - t r auma ) , 23

Table 3. Type of operations before flap surgery

Primary repair Debridement 1X/PT 21

2X/PT 7 3X/PT 3 4X/PT 3

Fasciotomy 7 Vascular procedure 4 Muscle repair 4

Secondary operations Skingrafts 14 Transposition

- Fasciocutaneous 4 - Gastrocnemius 3 - Soleus 1

Autogenous bone grafts 3 Fore foot amputation 2 Adjust. osteosynthesis 1

Table 4. Preoperative wound infection. No. Patients = 11 = 27.5%

Pseudomonas aeruginosa 4 Staphylococcus aureus 2 Klebsiella pneumoniae 2 Enterococcusfaecalis 2 Acinetobacter 1 Serratia liquefaciens 1 Escherichia coli 1 Bacillus species 1 En terobacter 1

in the subacu te g roup (3 to 80 days , m e a n 39 days) and 12 in the late g roup ( la ter t han 3 mon ths , m e a n 281 days) .

The la t i ss imus dors i free f lap was f avo red as a m y o c u - t aneous free f lap or as a muscle free f lap wi th skin graf ts in mos t o f ou r cases. The i l iac crest vascu la r i zed on the deep c i rcumflex i l iac vessels was used as an os teo- m y o c u t a n e o u s free flap. F o r less bu lky recons t ruc t ions , f a sc iocu taneous free f laps, e.g., rad ia l , s capu la r and tem- p o r a l were used (Table 5). The average free f lap size was 20.7 cm to 11.8 cm. Pos t e r io r and an te r io r t ibia l ar ter ies were used as the rec ip ient a r t e ry in respect ive ly 31 and 8 cases. Popl i tea l , f ibu la r and sural ar ter ies were used in the r ema in ing 4 cases. In 3 cases, a vein graf t was necessary. As a rec ip ient vein, m o s t l y the venae commi - tan tes o f the pos t e r io r and an te r io r t ibia l ar ter ies were used. In 3 cases, we used the vena s a phe na m a g n a and 3 cases h a d doub le venous anas tomoses . Rec ip ien t vessel qua l i ty was excel lent in 35 cases. There were signs o f d i rec t t r a u m a in 3 cases and rec ip ient vessel t h r o m b o s i s in a no the r 3 cases. These were t r ea ted wi th vein in te rpo- s i t ion or F o g a r t y e mbo le c tomy . 2 pa t ien t s had severe a therosc leros is .

M i c r o v a s c u l a r a n a s t o m o s i s was p e r f o r m e d outs ide the in ju red are in 39 cases and inside the in ju red a rea in fou r cases. Ar t e r i a l a n a s t o m o s i s was end- to - s ide in 34 cases (Figs. 2a , b) a n d venous anas tomos i s end- to - end in 31 cases. The qua l i ty o f a n a s t o m o s i s was excel lent in 41 cases. 2 a n a s t o m o s e s o f doub t fu l qua l i ty were re- spons ib le for 2 o f 4 f lap fai lures.

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Table 5. Timing and type of free flap sur- gery

Early <72 h

Sub- acute < 3 months

Late > 3 months

Muscle + skin graft Latissimus dorsi (L.D.) Rectus abdominis L.D. ~- serratus anterior

Myocutaneous Latissimus dorsi Tensor fascia lata

Osteomyocutaneous

Deep circumflex Iliac crest TFL + groin flap

Fasciocutaneous Groin flap Radial artery free flap Scapular free flap Temporal free flap

12 1 1

5 2

Total 6 23 12 2

Secondary

Table 6. Results

Early Subacute Late

No. of patients 6 23 12 Flap failure rate 1 16.7% 3 13% 0 0% Post-op infections 1 16.7% 4 17.4% 1 8.3% Hospital stay 45 days 66 days 107 days Bony healing time (13.6 months) ~ 8.5 months 14 months Bone healing 2 33.3% 7 35% 5 50% complications

See text

The average flap ischemia time was 37 min. The aver- age flap ischemia time in single artery and vein anasto- mosis without recipient vessel problems was 24 min.

2 patients from the early group died one week postop- eratively from causes unrelated to free flap surgery (mul- tiple organ failure and disseminated intravascular coagu- lation). Flap failure rate is shown in Table 6. One failure occurred in the early group due to recipient artery ath- erosclerosis. 3 flap failures occurred in the subacute group: i patient had massive preoperative infection, 1 arterial anastomosis thrombosed and massive postoper- ative infection with a subflap abscess occurred in the last patient. There were no failures in the late group. Ultimately, 2 amputations were necessary (J in the early, 1 in the delayed group) and in 2 cases a second free flap was necessary. In one case, in an early postoperative stage, a hematoma under the free flap necessitated early revision.

The postoperative infection rate was the highest in the subacute group (Table 6). 3 patients in the subacute group had preoperative wound infection. In the 3 other

cases, there was recipient vessel damage. In 5 out of 6 cases, partial wound margin necrosis occurred; only one patient demonstrated infectious signs early postop- eratively. The entire flap was saved in this case by intra- venous antibiotics. Once again, pathogens were mostly gram negative rods with Pseudomonas aeruginosa as the most common bacteria.

Hospital stay (mean 71 days, range 21-270 days) was proportional to the timing of wound cover (Table 6). The earlier the free flap surgery, the earlier the discharge from the hospital.

Long-term results

Bony healing time ranged from 4 to 37 months (Table 6). Average bony healing time in the early group was 13.5 months. We do not believe that this figure is representa- tive for actual bony healing in this group. Out of the 6 patients from this group, 2 patients died, 1 needed amputation and 2 patients had large bony defects (14 and 23 cm). In the remaining case, tibial fracture healing was completed 5 months postoperatively. In the other groups, bony healing time was proportional to free flap surgery timing. Complications of bony healing were pseudoarthrosis in 6 cases (hypertrophic-l , hypotrophic- 3, atrophic-2), osteomyelitis with osteocutaneous fistula in 5 cases and delayed union in 3 cases. The distribution of these complications in the 3 groups is shown in Ta- ble 6.

Finally, 26 patients needed late surgical interventions (Table 7). 17 patients underwent bony surgery. Several surgical interventions, e.g., autogenous bone grafts or reosteosynthesis were often necessary in one patient to overcome the high number of bony healing complica- tions. 16 patients needed soft tissue reintervention. Fur-

66

Fig. 2a, b. Microvascular end-to-side anastomosis: the posterior wall is sutured at first in order to inspect the intima as long as possible. Stitches are placed in such a way that intima to intima contact is guaranteed

ther skin grafting was often necessary due to isolated graft failure. Secondary flap adjustment was indicated in cases of wound margin necrosis or bulky flaps. On the average, each patient underwent 2.7 surgical inter- ventions after microsurgical repair. There was no signifi- cant difference in number of late interventions between the three groups.

Follow-up time ranged from 2 to 48 months (mean

T a b l e 7. Type and number of late interventions (total 26 patients)

Total Early Sub- Late acute

Bony surgery (17 patients) - Autogenous bone grafts 18 3 10 5 - Reosteosynthesis 10 1 7 2 - Debridement 4 2 2 - Others 3 2 1

Soft tissue surgery (16 patients) - Late flap correction 17 2 12 3 - Autogenous skingrafts 16 6 8 2 - Debridement 2 1 1

Operations/patient 70 12 42 16 2.7 2.4 2.2 1.8

T a b l e 8. Late functional failures (14 patients)

Objective: Mobility Knee Reduced mobility 3 Ankle Drop foot 5

Reduced mobility 3 Arthrodesis 3 Ankylosis 1 Valgus 1 3 2

6 (15%) 3 2 1

2-48 months 16.9 months

Limb shortening Lymphoedema

Subjective: Limp Swelling Pain Fatigue

Total revalidation Range time mean

16.9 months). Late functional results are shown in Ta- ble 8.14 patients had objective functional deficits, most- ly reduced mobility in the knee and the ankle. Dropfoot was frequently found in patients with direct trauma to the fibular nerve. Limb shortening was only seen in 3 cases, varying from 1 to 3 cm. Lymphoedema occurred in 2 patients, both of whom received conservative treat- ment with satisfactory results.

15% of patients complained of limping. Swelling, pain and fatigue was less, but these were significant com- plaints. Gustilo's subclassification [2, 10] is a good prog- nostic indicator for late functional failures, since 50% of patients with late functional failures are in the IIIc group.

D i s c u s s i o n

In a retrospective study of 40 patients with severe lower leg injury treated with free tissue transfer, good results were obtained in the delayed and late group; there were few early reconstructions. Unfortunately, patients are admitted to the traumatology department and after bony surgery, soft tissue cover is with local flaps or skin grafts (Fig. 3). I f this regime fails, they are transferred after

ist step < 4h

Emergency floor Department of Plastic Surgery

1

Emergency floor Peripheral Department of [hospitals Traumatology

20 19

mean 83 days

I I I

1 3 8 17 8 3

2nd step Department of Department of Department of Plastic Surgery Traumatology [IOrthopedics

25 3 i

6 early transfers ] 12 mean 87 days

6 late transfers

28

3rd step IDepartment of ] Plastic Surgery]

Fig. 3. Re~rralpolicy at our hospital

67

Fig. 4a, b. Case T.M.: a Crush trauma, left lower leg; fracture configuration 42 B3, type IIIb. After external fixation and initial debridement, autogenous bone and skin grafts were placed. 35 days post-trauma, a free myocutaneous latissimus dorsi flap was anasto- mosed to the anterior tibial artery, b 8 months post-free flap sur- gery

a mean of 87 days for microsurgical reconstruction. In 51/2 years, only 6 patients had early surgery; 2 patients died f rom unrelated causes and one had an amputat ion. Over the past year, more early cases have been treated with better results. We agree with Byrd et ah [1] that early free flap surgery, avoiding wound cover in the sub- acute stage, diminishes infection, hospital stay and bony healing time.

The incidence of bone healing complications and the time for bone healing are related to the efficacy of soft tissue cover in addition to the severity and configuration of the tibial fracture. Even with a perfect microsurgical repair, bony healing complications would still relate to the severity and configuration of the tibia fracture (AO classification). On the other hand, the application of well vascularized tissue to any exposed and fractured bone is the second most important factor after fracture immobilization and is manda to ry for periosteal bone healing. Early cover reduces bone healing time and com- plications.

The preoperative infection rate was high and is direct- ly related to the nature of trauma. The postoperative infection rate was the highest in the subacute group, partially due to infections present before flap surgery, al though several debridements had been done, exposed nerves and vessels did not permit any further delay in wound coverage [1, 4]. Better results were obtained in the late group in which sterile granulation tissue was present. A thorough debridement and conscientious lo- cal infection control is therefore of major importance before free flap surgery is performed [2, 6] (Figs. 4, 5).

Pre-existing recipient vessel disease was responsible for significant flap morbidity. Recipient artery athero- sclerosis caused one flap failure in the early group and insufficient blood flow resulting in severe postoperative infection in a second case. Direct t rauma to the recipient

Fig. 5a, b. Case S.F..' a Traffic accident involving left lower leg; fracture configuration 43 C3, type IIIb. After several debridements, the wound remained contaminated with Enterococcus faecalis. A combined latissimus dorsi and serratus anterior muscle free flap was anastomosed to the posterior tibial artery 37 days post-trauma, as the posterior tibial vessels and nerve were exposed. Postoperative superficial wound infection was treated with intravenous antibiot- ics but necessitated a second skin grafting, b 3 months post-free flap surgery. Later an arthrodesis of the ankle was performed

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artery caused one free flap failure and one abscess be- neath the free flap. One case of insufficient venous drain- age was also related to an acute wound infection with partial wound necrosis. The intima of the blood vessel should be carefully examined and if necessary a vein interposition or Fogarty embolectomy should be per- formed.

In our review, 7 out of 8 local pedicled flaps failed; small local flaps must be avoided by good planning, due to crush injury, these flaps will frequently necrose [111.

Gustilo's subclassification of type III open tibial frac- tures is an accurate prognostic indicator for late func- tional failures [10]; 50% of our late functional failures were in the type IIIc group. Nevertheless, compared to the severity of the lower leg injuries (71% type III open tibial fractures and 15 patients with combined skin, mus- cle, vascular and nervous defects), total number and na- ture of late functional failures have been very acceptable.

Patients frequently required several procedures for complete rehabilitation, both before and after free flap surgery [5, 8]. Bony healing complications remain fre- quent in all three groups, especially in the late group.

Conclusion

In contrast to Godina's and Byrd's experience, there were no flap failures and very few postoperative wound infections in the late group. Early free flap surgery un- doubtedly results in reduced hospital stay and early bony healing; this should be performed within 24 h of trauma. If debridement and local infection control is adequately performed, comparable results can be achieved in the early and delayed group. Early free flap surgery is, there-

fore, preferable but not mandatory. Wound cover should be avoided in a subacute stage if possible.

Acknowledgement. We wish to thank Mrs. Hilde Pelsers for her assistance in preparing this manuscript.

References

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5. Masquelet AC, Augereau B, Apoil A, Nordin JY (1987) Traite- merit des fractures complexes de jambe par lambeaux muscu- laires de recouvrement, p6dicules ou libres et apport osseux complementaire. Rev Chir Orthop 73:11%121

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7. Reath DB, Taylor JW (1989) Free rectus abdominis muscle flap : advantages in lower extremity reconstruction. South Med J 82:1143-1146

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