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Emergency free flaps to the upper extremity
Emergency
free flaps to the upper extremity
Thirty-one emergency free flaps were applied to the upper extremities
of patients who ranged
in age from 16 to 57 years. The size of the skin defects ranged from 13 to 540 square centimeters, with an average of 145 square centimeters. A variety of flaps were used, including 14 lateral arm, seven groin, five latissimus, three first web space of the foot, one scapular and one medial arm. In patients with small defects, the operative time ranged from 3 to 9 hours, with an average The hospital stay was never longer than 4 days. In patients with medium size defects, the operating time ranged from 3 to 18 hours, with an average of 7 hours
of 4 hours and 54 minutes.
and 45 minutes. The hospital stay averaged 7.4 days. In large defects in which extensive reconstruction was undertaken
before Rap application,
the operative time ranged from 3 to 20 hours,
with an average of 11 hours and 54 minutes. The average hospital stay was 11.8 days. Twentynine of the 31 flaps survived in their entirety (93.5%).
In one of the successful flaps (3.2%),
exploration was required after the patient left the operating room. Severe infection occurred in only one case, that being one of the two flap failures. Twenty-seven of the 31 patients returned to work, 18 of them to their original employment. (J HAND SURG 1988;13A:22-8.)
Graham Lister, MD, and Luis Scheker, MD, Salt Lake City, Utah, and Louisville,
T
he increase in experience and success with elective free tissue transfer has been paralleled by the formation of emergency microsurgical teams for digital replantation. A logical outcome of this parallel development is the use of free flap transfer for coverage of soft tissue defects at the first surgical procedure after injury-the so-called emergency free flap.’ Emergency free flaps are defined as those that are performed at the end of the primary debridement, within 24 hours of the time of the injury. The indications for such a procedure are those for distant flap coverage, namely a defect that is too large to be covered by a local or regional flap, and for which a simple skin graft would be inappropriate, either because the bed of the defect would not support it, or because expected function of underlying
From the University of Utah, Salt Lake City, Utah, and the University of Louisville, Louisville. Ky. Received for publication April 16, 1987.
Sept. 15, 1986; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Graham Lister, MD, University of Utah, Division of Plastic Surgery, 50 N. Medical Dr., Salt Lake City, UT 84132.
22
THEJOURNAL OF HAND SURGERY
structures or considerations make a graft less desirable.
Ky.
for later reconstruction
Materials and methods Between October 1980 and October 1984, 31 emergency free flaps were applied to patients whose ages ranged from 16 to 57 years. Twenty-six were males and five were females. The causes of injury were seven motor vehicle accidents, 13 industrial and five farm injuries, four gun shot wounds and two accidents that were associated with recreation. These resulted in primarily mixed, complex injuries but with some pure avulsion, blast, and rip wounds. The size of the skin defects ranged from 13 to 540 square centimeters, with an average of 14.5 square centimeters. Emergency free flaps have been divided into small (an area up to 30 sqaure centimeters) in five cases, medium (31 to 150 square centimeters) in 16 cases, and large (greater than 15 1 square centimeters) in ten patients. A variety of free flaps were used in this early series; in order of frequency were 14 lateral arm flaps,* seven groin flaps, 3-6 five latissimus dorsi flaps,‘-‘* three first web space of the foot,13, I4 one scapular,‘5~‘y and one medial arm.” Five lateral arm and two latissimus dorsi flaps were taken without skin, that is, as fascial and muscular flaps, respectively. They were subsequently
Vol. 13A, No. 1 January 1988
Emergency free flaps to upper extremity
23
Fig. 1. A, Case 1. This complete pulp avulsion was sustained in a ski boat accident. B, A neurovascular island flap was designed on the fibular aspect of the left great toe based on the first dorsal metatarsal artery and including the fibular digital nerve. C-D, Satisfactory pulp restoration was achieved with two-point discrimination 2 years after transfer of 5 mm, correctly localized.
grafted with split skin harvested at the time of the emergency free flap procedure. In the majority of cases aerobic and anaerobic cultures were taken in the emergency room. After the patient was anesthetized, the limb was cleansed and washed with an iodine solution for 5 minutes. After draping, the wounds were irrigated thoroughly with
Ringer’s lactate solution. With the tourniquet inflated, all contaminated, contused, or avascular tissue was excised. Without removing vital structures unnecessarily, every attempt was made to eliminate cavities and dead spaces. Any area that did not bleed on release of the tourniquet was reexcised. On completion of debridement, rapid slide and culture specimens were again
24
The Journal of HAND SURGERY
Lister and Scheker
Fig. 2. A, Case 2. Injury to the right dominant hand when a 600 pound anchor fell on it from a height. There were fractures of the first four metacarpals and the proximal phalanx of the index tinger, with destruction of the metacarpophalangeal joint of the long finger. B, After closure and debridement, there was a 10 X 6 cm skin defect. This was closed with an immediate transfer of a lateral arm flap. C, Three months later, good healing has been achieved, the skeleton has united, and the patient awaits tenolysis.
taken, and the wounds were irrigated with cefamandole solution. According to the philosophy of the surgeon, and the extent and nature of the wound, antibiotics were prescribed, triple therapy (clindamycin, tobramycin and cefamandole) in three cases, double (cefazolin and tobramycin) in eight cases, and cefazolin in the remainder. In all cases in which it was necessary, bone fixation was performed. In two cases a large bony defect was filled with a silicone block after an external fixator had been applied (case 3). The block was later replaced with cancellous bone graft. Tendons, nerves, and vessels were repaired or reconstructed. In performing all of the flap transfers, topical heparin was used for irrigation. In 27 cases aspirin was administered rectally before the anastomosis. In 18 cases low molecular weight dextran was used. In ten cases par-
enteral heparin was used either as a bolus before opening the anastomosis or as a formal anticoagulant continued for some days.
Case reports Case 1. Small defect. L. K., a 30-year-old salesman, sustained an avulsion of the pulp of his dominant right thumb in a ski-boat accident (Fig. 1). A matching pulp flap was taken from the lateral aspect of his right great toe. The first dorsal metatarsal artery was anastomosed to the princeps pollicis, the digital nerve of the toe joined to the ulnar digital nerve, and one dorsal vein was anastomosed. The procedure lasted 3 hours and 40 minutes. The patient remained in hospital for 3 days. When reviewed 2 years later the thumb had a good appearance and two-point discrimination of 5 mm. He reported no problems with either the thumb or the donor site.
Vol. 13A, No. 1 January 1988
Emergency free jlaps to upper extremify
25
Fig. 3. A-B, Case 3. Shotgun wound to the right dominant forearm. C, The distal third of the radius was absent in its entirety, and there were 12 cm defects in the median and radial nerves, with extensive tendon injury. The hand was viable and ulnar nerve function intact. D, An external fix&or was applied and a silicone block placed in the defect of the radius. ‘Primary tendon transfers were performed. E, The soft tissue defect was covered with a free latissimus dorsi muscle flap. Split-thickness skin was harvested and was applied in a meshed fashion 2 days later. F, The hand healed satisfactorily. The carpus was later centralized and sural nerve grafts were applied to the median nerve. At 15 months the patient had a stable skeleton, intact skin cover, and modest grasp and pinch function.
Case 2. Medium defect. N. J., a %-year-old selfemployed carpenter, had a 600~pound anchor fall on his dominant right hand (Fig. 2). He sustained fractures of the first four metacarpals, with destruction of the metacarpophalangeal joint of the long finger. The extensor pollicis longus was avulsed from the muscle proximally. Primary fixation of the
fractures was carried out. The destroyed joint was replaced with a Swanson implant. Extensor indicis was transferred to replace the extensor pollicis longus. After debridement of the crushed skin edges, there remained a skin defect of 10 cm x 6 cm. This was covered with a lateral arm flap taken from the same extremity. The surgical procedure lasted
26
The Journal of HAND SURGERY
Lister and Scheker
9 hours and 45 minutes. The patient was discharged from the hospital after 9 days. Release of his carpal tunnel was done, as an out-patient, 1 month later. At 3 months all fractures were healed, skin wounds were softening, and tenolysis of the flexor pollicis longus and the extensors to the index and middle was planned. Case 3. Large defect. M. H., a 47-year-old electrician, sustained a shotgun wound to his right dominant forearm (Fig. 3). He presented with a segmental loss of the distal third of his radius, 12 cm defects in his median and radial nerves, and defects of varying lengths in the flexor digitomm superficialis to the index and long fingers, the flexor digitorum profundus to the index finger, the flexor pollicis longus, the radial wrist extensors, and brachioradialis. His hand was viable and ulnar nerve function intact. An external fixator was applied, and a silicone block was placed in the defect in the radius. A transfer of the ring superficialis to the flexor pollicis longus was performed, and the profundus tendons of the index and long fingers were cross-linked. The reconstruction was covered with a free latissimus dorsi muscle flap, to which was applied meshed split-thickness skin. The operating time was 8 hours and 55 minutes. There were no postoperative complications, and the patient remained in hospital for 14 days. At a later procedure the catpus was centralized on the ulna and stabilized with a 3.5 mm &hole plate, and sural nerve grafts were inserted in the gap in the median nerve. At review 15 months later, the patient had a stable skeleton, intact skin cover, and modest grasp and pinch function. The Tine1 sign was advancing through the palm.
Results In the group of patients with small defects, the operative time ranged from 3 to 9 hours, with an average of 4 hours and 54 minutes. The hospital stay was never longer than 4 days. The operating time in the medium size group ranged from 3 to 18 hours, with an average of 7 hours and 45 minutes. The hospital stay in this group ranged from 5 to 13 days, with an average of 7.4 days. In the large flaps, the operative time ranged from 3 to 20 hours, with an average of 11 hours and 54 minutes. The hospital stay ranged from 7 to 21 days, with an average of 11.8 days. The average operating time varied according to the flap used: the neurovascular island of the foot averaged 3.8 hours, the groin flap, 8.5 hours, the lateral arm flap, 8.9 hours, and the latissimus dorsi, 11.6 hours. The average hospital stay for the neurovascular island was 4.3 days, for the groin flap, 8 days, for the lateral arm, 8.3 days, and for the latissimus, 12 days. Twenty-nine (93.5%) of the 31 flaps in this series survived in their entirety. The two flap failures were both on large defects, a latissimus dorsi with three small pedicles and a groin flap in a patient having multiple
replantation. Only one (3.2%) of the successful flaps required exploration after the patient left the operating room. Complications included one minor infection in the form of cellulitis and one severe infection in the latissimus dorsi flap, which failed. Five of the seven split-skin grafts applied to fascial and muscle flaps showed partial loss, ranging from 7 to 23 square centimeters. Two required repeat skin grafts. The follow-up period ranged from 6 weeks to 4% years. Twenty-seven patients returned to work; 18 to their original jobs. The number of operations ranged from one to five, with a mean of two procedures.
Discussion Immediate, or emergency, free flap coverage is a natural extension of two recent developments: the predictably successful microvascular transfer of tissue and the availability of experienced microsurgical teams at all hours for replantation services. The third essential for uncomplicated healing is a suitable primary wound. Such a wound should be over a stable skeleton and should contain no contamination and no tissue of compromised blood supply. The goal in treating untidy wounds should be to convert them into surgically clean excised areas suitable for immediate cover. Thus, all doubtful tissue, which has been shown to reduce host resistance,” is excised back to bleeding margins. This should be done under tourniquet control, otherwise the briskness of the bleeding would obscure the viability or ischemia of tissues incised thereafter. Where tissue will hopefully be better perfused later after vessel repair, as in major limb replantation, that which will be viable can be demonstrated by cannulating the vessel to be repaired and perfusing the distal part with heparinized Ringer’s lactate. “Weeping” of cut tissue will indicate its potential viability. Excision of wounds in this manner will tend to produce a relatively flat, even bed for the flap. To further ensure such a bed, additional excision, or suture of adjacent muscle bellies is justified to eliminate dead spaces and interstices. The only exceptions to the rule of radical debridement are longitudinal structures, which carry promise of function, intact tendons or nerves, major vessels carrying flow. These should be cleansed with the help of magnification. Once debridement is complete, rigid skeletal fixation should be applied. Plates are used for long bones and type A intraosseous wiring for phalanges. Where bony defects exist, external fixation is employed. Small defects are filled with cancellous bone grafts and large defects with either a projection of the flap cover or with a block of silicone pending later reconstruction. Wartime experiencez2 taught that infection was re-
Vol. 13A, No. 1 January 1988
duced by serial debridement and delayed reconstruction. However, if the wound is left open for some days, exposed bone dries and dies, despite the use of wet dressings. Soft tissues become edematous and indurated. The granulation that commences is always infectedz3 and poorly penetrated by antibiotics.*4 It is the precursor of fibrosis.25 Inflammation joins edema to form the triad that leads to joint stiffness and tendon adhesionP and immobility. The most cogent argument against delayed wound closure may be that it encourages shoddy primary debridement. For all but the most disciplined there is the thought, “That’s doubtful, but let’s wait because we are going to leave the wound open anyway.” The tissue in question will probably never be efficiently removed at later excision, hidden as it will be among the fibrin and granulation. It remains as a nidus for infection and later wound breakdown. With delay after injury, divided major vessels become permanently constricted. All vessels, divided or not, become friable and difficult to handle. Extension of edema and inflammation along tissue planes away from the wound causes such vessel changes over an increasing area, necessitating the use of longer pedicles in later free flaps. In the past it has been argued that free flaps are less predictable than pedicle flaps and they require more operating room and hospital time. The same argument has been advanced against “emergency” as distinct from “elective” free flaps. The series reported here showed a survival rate of 93.5%, with exploration being required in only 3.2% of cases. The average operating time and hospital stay was 4 hours and 54 minutes and 4 days for small defects, 7 hours and 45 minutes, and 7 days for medium defects, and 11 hours and 54 minutes and 12 days for large defects. Keeping in mind that some defects, as exemplified by cases 2 and 3, involve much more than simple flap transfer, these figures bear comparison to either pedicle flap or elective free flap reconstructions. The superiority of early over later free flap cover in lower extremity injuries has been shown with unanswerable cogency by Godina,” with flap failure rates of 0.75% in immediate reconstructions versus 12% in delayed and 9.5% in late and average total hospital times of 27 days, 130 days, and 256 days, respectively. Doubts still tend to remain regarding the potential for infection with such ambitious early reconstruction. The infection rate of 9.7%, which includes one of the two flaps that failed, compares favorably with the 52% found in delayed treatment by Nylen and Carlsson.” A direct comparison between immediate and delayed skin cover is shown by the work of Godina.” He had an infection rate of 1.5% in 134 patients treated with im-
Emergency free japs to upper extremity
27
mediate skin cover as opposed to 17.5% in 167 patients treated by delayed wound closure. The point of separation of the two groups was 72 hours after injury. Provided tissues are well vascularized, wounds can be closed primarily without fear of infection and with benefit to the patientz9 What exactly qualifies as an emergency free flap? We chose 24 hours as the upper limit in our series in the upper extremity. Godina*’ reported “early” flaps as those being done within 72 hours. He had two distinct subgroups in his immediate cover patients. In one case (performed in Yugoslavia where he had a full microsurgical team available at all hours) the flap was applied at the time of debridement , as were those reported here. In the other cases (treated in Kuwait where he was in charge of an elective microsurgical service) radical debridement was done at the primary hospital by his team and the free flap was applied at a second procedure at the central hospital within 72 hours. He found no difference between the subgroups and concluded that this brief delay was permissible “. . . provided that . . . a proper debridement is done immediately after the injury.“27 Should any patient be denied an emergency free flap? Age certainly is no barrier. Our youngest and oldest patients to undergo emergency free flap procedures were aged 2 and 76 years of age, respectively. Both had injuries to the lower extremity and are therefore not included here. Both did well and now walk on limbs that would otherwise have required amputation. The choice of flap is important in the older patient who handles chest wounds poorly. By contrast, their skin grafts heal well, and the forearm flap provides a logical and suitable alternative. Other patients who are unfit for a long surgical procedure must, of course, be rejected. There are two final groups who do not qualify for emergency free flap cover. The first group consists of patients with wounds so complex and crushed that total, radical debridement would destroy any possibility of function. Here delay is necessary, but with the knowledge that a golden opportunity has probably been lost. Where such delay perforce extends beyond 72 hours because of continued doubt regarding viability, if possible, the wounds are better skin grafted to achieve initial healing. A dramatic instance of such delay has been reported in the heterotopic implantation for temporary storage of an amputated hand by Godina and others.30 The second group of patients who should not have emergency free flap cover are those in which dispassionate assessment determines that eventual function will be minimal and worse than a prosthesis. With the powerful new tools of microsurgical revascularization,
28
Lister and Scheker
skeletal fixation and free flap skin cover to achieve sound primary healing, the modem surgeon must not overlook the ultimate goal of useful function. Such function can only be attained by an acceptably sensate hand, with mobile joints controlled by sufficient musculotendinous units. In massive wounds being considered for complex microsurgical reconstruction, the potential, or otherwise, for useful function can only be assessed by an experienced and objective hand surgeon. The authors thank their colleagues in Louisville Hand Surgery, some of whom contributed cases to the aggregate analyzed. They also acknowledge the skill of Douglas Hanel, M.D., who undertook the major portion of the surgery in case 3 above.
REFERENCES 1. Lister GD. The hand: Diagnosis and indications. 2nd ed. Edinburgh: Churchill Livingstone, 1984:82-6. 2. Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RD. The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984; 12:489-500. 3. Baudet J, LeMaire JM, Guimberteau JC. Ten free groin flaps. Plast Reconstr Surg 1976;57:577-95. 4. Harii K, Ohmori K, Torri S, et al. Free groin skin flaps. Br J Plast Surg 1975;28:225-37. 5. McConnell CM, Hyland WT, Neale HW. Microvascular free groin flap for soft-tissue coverage of the extremities. J Trauma 1980;20:593-8. 6. Shah KG, Garrett JC, Buncke HJ. Free groin flap transfer to the upper extremity. Hand 1979;11:315-20. 7. Bailey BN, Godfrey AM. Latissimus dorsi muscle free flaps. Br J Plast Surg 1982;35:47-52. 8. Lassen M, Krag C, Nielsen IM. The latissimus dorsi flap. Stand J Plast Reconstr Surg 1985;19:41-51. 9. Maxwell R, Manson P, Hoopes J. Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 1979;64: l-8. 10. Nielsen IM, Lassen M, Gregersen BN, Krag C. Experience with the latissimus dorsi flap. Stand J Plast Reconstr Surg 1985;19:53-63. 11. Stem PJ, Neale HW, Gregory RO, McDonough JJ. Functional reconstruction of an extremity by free tissue transfer of the latissimus dorsi. J Bone Joint Surg 1983; 65A:729-37. 12. Watson JS, Craig P, Orton C. The free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1979;64:299305.
The Journal of HAND SURGERY
13. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plast Reconstr Surg 1980;65: 616-26. 14. Minami A, Usu M, Katoh H, lshii S. Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques. J HAND SURG 1984;9B:239-44. 15. Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69:779-85. 16. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:601-4. 17. Hamilton SGL, Morrison WA. The scapular free flap. Br .I Plast Surg 1982;35:2-7. 18. Mayou BJ, Whitby D, Jones BM. The scapular flapan anatomical and clinical study. Br J Plast Surg 1982;35:8-13. 19. Santos LF. The scapular flap: A new microsurgical free flap. Revista Brasileria de Cirurgia 1980;70:133-41. 20. Kaplan EN, Pearl RM. An arterial medial arm flap: Vascular anatomy and clinical applications. Ann Plast Surg 1980;4:205. 21. Haury B, Rodeheaver G, Vensko J, Edgerton MT, Edlich RF. Debridement: An essential component of traumatic wound care. Am J Surg 1978;135:238-42. 22. Burkhalter WE, Butler B, Metz W, Omer G. Experiences with delayed primary closure of war wound of the hand in Viet Nam. J Bone Joint Surg 1968;50A:945-54. 23. Burke JF. Effects of inflammation on wound repair. J Dent Res 1971;50:296. 24. Robson MC, Edstrom LE, Krizek TJ, Groskin MG. The efficacy of systemic antibiotics in the treatment of granulating wounds. J Surg Res 1974;16:299-306. 25. Peacock EE. Wound repair. 3rd ed. Philadelphia: WB Saunders, 1984. 26. Edgerton MT. Immediate reconstruction of the injured hand. Surgery 1954;36:329-43. 27. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92. 28. Nylen S. Carlsson B. Time factor, infection frequency and quantitative microbiology in hand injuries. Stand J Plast Reconst Surg 1980;14:185-9. 29. Lister GD. Commentary on Chapter 6. In: Carter D, Polk H, eds. Trauma. Butterworth’s International medical review of surgery. Vol 1. London: Butterworth, 1981: 180-4. 30. Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986;78: 295-9.
free flaps to the upper extremity
Thirty-one emergency free flaps were applied to the upper extremities
of patients who ranged
in age from 16 to 57 years. The size of the skin defects ranged from 13 to 540 square centimeters, with an average of 145 square centimeters. A variety of flaps were used, including 14 lateral arm, seven groin, five latissimus, three first web space of the foot, one scapular and one medial arm. In patients with small defects, the operative time ranged from 3 to 9 hours, with an average The hospital stay was never longer than 4 days. In patients with medium size defects, the operating time ranged from 3 to 18 hours, with an average of 7 hours
of 4 hours and 54 minutes.
and 45 minutes. The hospital stay averaged 7.4 days. In large defects in which extensive reconstruction was undertaken
before Rap application,
the operative time ranged from 3 to 20 hours,
with an average of 11 hours and 54 minutes. The average hospital stay was 11.8 days. Twentynine of the 31 flaps survived in their entirety (93.5%).
In one of the successful flaps (3.2%),
exploration was required after the patient left the operating room. Severe infection occurred in only one case, that being one of the two flap failures. Twenty-seven of the 31 patients returned to work, 18 of them to their original employment. (J HAND SURG 1988;13A:22-8.)
Graham Lister, MD, and Luis Scheker, MD, Salt Lake City, Utah, and Louisville,
T
he increase in experience and success with elective free tissue transfer has been paralleled by the formation of emergency microsurgical teams for digital replantation. A logical outcome of this parallel development is the use of free flap transfer for coverage of soft tissue defects at the first surgical procedure after injury-the so-called emergency free flap.’ Emergency free flaps are defined as those that are performed at the end of the primary debridement, within 24 hours of the time of the injury. The indications for such a procedure are those for distant flap coverage, namely a defect that is too large to be covered by a local or regional flap, and for which a simple skin graft would be inappropriate, either because the bed of the defect would not support it, or because expected function of underlying
From the University of Utah, Salt Lake City, Utah, and the University of Louisville, Louisville. Ky. Received for publication April 16, 1987.
Sept. 15, 1986; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Graham Lister, MD, University of Utah, Division of Plastic Surgery, 50 N. Medical Dr., Salt Lake City, UT 84132.
22
THEJOURNAL OF HAND SURGERY
structures or considerations make a graft less desirable.
Ky.
for later reconstruction
Materials and methods Between October 1980 and October 1984, 31 emergency free flaps were applied to patients whose ages ranged from 16 to 57 years. Twenty-six were males and five were females. The causes of injury were seven motor vehicle accidents, 13 industrial and five farm injuries, four gun shot wounds and two accidents that were associated with recreation. These resulted in primarily mixed, complex injuries but with some pure avulsion, blast, and rip wounds. The size of the skin defects ranged from 13 to 540 square centimeters, with an average of 14.5 square centimeters. Emergency free flaps have been divided into small (an area up to 30 sqaure centimeters) in five cases, medium (31 to 150 square centimeters) in 16 cases, and large (greater than 15 1 square centimeters) in ten patients. A variety of free flaps were used in this early series; in order of frequency were 14 lateral arm flaps,* seven groin flaps, 3-6 five latissimus dorsi flaps,‘-‘* three first web space of the foot,13, I4 one scapular,‘5~‘y and one medial arm.” Five lateral arm and two latissimus dorsi flaps were taken without skin, that is, as fascial and muscular flaps, respectively. They were subsequently
Vol. 13A, No. 1 January 1988
Emergency free flaps to upper extremity
23
Fig. 1. A, Case 1. This complete pulp avulsion was sustained in a ski boat accident. B, A neurovascular island flap was designed on the fibular aspect of the left great toe based on the first dorsal metatarsal artery and including the fibular digital nerve. C-D, Satisfactory pulp restoration was achieved with two-point discrimination 2 years after transfer of 5 mm, correctly localized.
grafted with split skin harvested at the time of the emergency free flap procedure. In the majority of cases aerobic and anaerobic cultures were taken in the emergency room. After the patient was anesthetized, the limb was cleansed and washed with an iodine solution for 5 minutes. After draping, the wounds were irrigated thoroughly with
Ringer’s lactate solution. With the tourniquet inflated, all contaminated, contused, or avascular tissue was excised. Without removing vital structures unnecessarily, every attempt was made to eliminate cavities and dead spaces. Any area that did not bleed on release of the tourniquet was reexcised. On completion of debridement, rapid slide and culture specimens were again
24
The Journal of HAND SURGERY
Lister and Scheker
Fig. 2. A, Case 2. Injury to the right dominant hand when a 600 pound anchor fell on it from a height. There were fractures of the first four metacarpals and the proximal phalanx of the index tinger, with destruction of the metacarpophalangeal joint of the long finger. B, After closure and debridement, there was a 10 X 6 cm skin defect. This was closed with an immediate transfer of a lateral arm flap. C, Three months later, good healing has been achieved, the skeleton has united, and the patient awaits tenolysis.
taken, and the wounds were irrigated with cefamandole solution. According to the philosophy of the surgeon, and the extent and nature of the wound, antibiotics were prescribed, triple therapy (clindamycin, tobramycin and cefamandole) in three cases, double (cefazolin and tobramycin) in eight cases, and cefazolin in the remainder. In all cases in which it was necessary, bone fixation was performed. In two cases a large bony defect was filled with a silicone block after an external fixator had been applied (case 3). The block was later replaced with cancellous bone graft. Tendons, nerves, and vessels were repaired or reconstructed. In performing all of the flap transfers, topical heparin was used for irrigation. In 27 cases aspirin was administered rectally before the anastomosis. In 18 cases low molecular weight dextran was used. In ten cases par-
enteral heparin was used either as a bolus before opening the anastomosis or as a formal anticoagulant continued for some days.
Case reports Case 1. Small defect. L. K., a 30-year-old salesman, sustained an avulsion of the pulp of his dominant right thumb in a ski-boat accident (Fig. 1). A matching pulp flap was taken from the lateral aspect of his right great toe. The first dorsal metatarsal artery was anastomosed to the princeps pollicis, the digital nerve of the toe joined to the ulnar digital nerve, and one dorsal vein was anastomosed. The procedure lasted 3 hours and 40 minutes. The patient remained in hospital for 3 days. When reviewed 2 years later the thumb had a good appearance and two-point discrimination of 5 mm. He reported no problems with either the thumb or the donor site.
Vol. 13A, No. 1 January 1988
Emergency free jlaps to upper extremify
25
Fig. 3. A-B, Case 3. Shotgun wound to the right dominant forearm. C, The distal third of the radius was absent in its entirety, and there were 12 cm defects in the median and radial nerves, with extensive tendon injury. The hand was viable and ulnar nerve function intact. D, An external fix&or was applied and a silicone block placed in the defect of the radius. ‘Primary tendon transfers were performed. E, The soft tissue defect was covered with a free latissimus dorsi muscle flap. Split-thickness skin was harvested and was applied in a meshed fashion 2 days later. F, The hand healed satisfactorily. The carpus was later centralized and sural nerve grafts were applied to the median nerve. At 15 months the patient had a stable skeleton, intact skin cover, and modest grasp and pinch function.
Case 2. Medium defect. N. J., a %-year-old selfemployed carpenter, had a 600~pound anchor fall on his dominant right hand (Fig. 2). He sustained fractures of the first four metacarpals, with destruction of the metacarpophalangeal joint of the long finger. The extensor pollicis longus was avulsed from the muscle proximally. Primary fixation of the
fractures was carried out. The destroyed joint was replaced with a Swanson implant. Extensor indicis was transferred to replace the extensor pollicis longus. After debridement of the crushed skin edges, there remained a skin defect of 10 cm x 6 cm. This was covered with a lateral arm flap taken from the same extremity. The surgical procedure lasted
26
The Journal of HAND SURGERY
Lister and Scheker
9 hours and 45 minutes. The patient was discharged from the hospital after 9 days. Release of his carpal tunnel was done, as an out-patient, 1 month later. At 3 months all fractures were healed, skin wounds were softening, and tenolysis of the flexor pollicis longus and the extensors to the index and middle was planned. Case 3. Large defect. M. H., a 47-year-old electrician, sustained a shotgun wound to his right dominant forearm (Fig. 3). He presented with a segmental loss of the distal third of his radius, 12 cm defects in his median and radial nerves, and defects of varying lengths in the flexor digitomm superficialis to the index and long fingers, the flexor digitorum profundus to the index finger, the flexor pollicis longus, the radial wrist extensors, and brachioradialis. His hand was viable and ulnar nerve function intact. An external fixator was applied, and a silicone block was placed in the defect in the radius. A transfer of the ring superficialis to the flexor pollicis longus was performed, and the profundus tendons of the index and long fingers were cross-linked. The reconstruction was covered with a free latissimus dorsi muscle flap, to which was applied meshed split-thickness skin. The operating time was 8 hours and 55 minutes. There were no postoperative complications, and the patient remained in hospital for 14 days. At a later procedure the catpus was centralized on the ulna and stabilized with a 3.5 mm &hole plate, and sural nerve grafts were inserted in the gap in the median nerve. At review 15 months later, the patient had a stable skeleton, intact skin cover, and modest grasp and pinch function. The Tine1 sign was advancing through the palm.
Results In the group of patients with small defects, the operative time ranged from 3 to 9 hours, with an average of 4 hours and 54 minutes. The hospital stay was never longer than 4 days. The operating time in the medium size group ranged from 3 to 18 hours, with an average of 7 hours and 45 minutes. The hospital stay in this group ranged from 5 to 13 days, with an average of 7.4 days. In the large flaps, the operative time ranged from 3 to 20 hours, with an average of 11 hours and 54 minutes. The hospital stay ranged from 7 to 21 days, with an average of 11.8 days. The average operating time varied according to the flap used: the neurovascular island of the foot averaged 3.8 hours, the groin flap, 8.5 hours, the lateral arm flap, 8.9 hours, and the latissimus dorsi, 11.6 hours. The average hospital stay for the neurovascular island was 4.3 days, for the groin flap, 8 days, for the lateral arm, 8.3 days, and for the latissimus, 12 days. Twenty-nine (93.5%) of the 31 flaps in this series survived in their entirety. The two flap failures were both on large defects, a latissimus dorsi with three small pedicles and a groin flap in a patient having multiple
replantation. Only one (3.2%) of the successful flaps required exploration after the patient left the operating room. Complications included one minor infection in the form of cellulitis and one severe infection in the latissimus dorsi flap, which failed. Five of the seven split-skin grafts applied to fascial and muscle flaps showed partial loss, ranging from 7 to 23 square centimeters. Two required repeat skin grafts. The follow-up period ranged from 6 weeks to 4% years. Twenty-seven patients returned to work; 18 to their original jobs. The number of operations ranged from one to five, with a mean of two procedures.
Discussion Immediate, or emergency, free flap coverage is a natural extension of two recent developments: the predictably successful microvascular transfer of tissue and the availability of experienced microsurgical teams at all hours for replantation services. The third essential for uncomplicated healing is a suitable primary wound. Such a wound should be over a stable skeleton and should contain no contamination and no tissue of compromised blood supply. The goal in treating untidy wounds should be to convert them into surgically clean excised areas suitable for immediate cover. Thus, all doubtful tissue, which has been shown to reduce host resistance,” is excised back to bleeding margins. This should be done under tourniquet control, otherwise the briskness of the bleeding would obscure the viability or ischemia of tissues incised thereafter. Where tissue will hopefully be better perfused later after vessel repair, as in major limb replantation, that which will be viable can be demonstrated by cannulating the vessel to be repaired and perfusing the distal part with heparinized Ringer’s lactate. “Weeping” of cut tissue will indicate its potential viability. Excision of wounds in this manner will tend to produce a relatively flat, even bed for the flap. To further ensure such a bed, additional excision, or suture of adjacent muscle bellies is justified to eliminate dead spaces and interstices. The only exceptions to the rule of radical debridement are longitudinal structures, which carry promise of function, intact tendons or nerves, major vessels carrying flow. These should be cleansed with the help of magnification. Once debridement is complete, rigid skeletal fixation should be applied. Plates are used for long bones and type A intraosseous wiring for phalanges. Where bony defects exist, external fixation is employed. Small defects are filled with cancellous bone grafts and large defects with either a projection of the flap cover or with a block of silicone pending later reconstruction. Wartime experiencez2 taught that infection was re-
Vol. 13A, No. 1 January 1988
duced by serial debridement and delayed reconstruction. However, if the wound is left open for some days, exposed bone dries and dies, despite the use of wet dressings. Soft tissues become edematous and indurated. The granulation that commences is always infectedz3 and poorly penetrated by antibiotics.*4 It is the precursor of fibrosis.25 Inflammation joins edema to form the triad that leads to joint stiffness and tendon adhesionP and immobility. The most cogent argument against delayed wound closure may be that it encourages shoddy primary debridement. For all but the most disciplined there is the thought, “That’s doubtful, but let’s wait because we are going to leave the wound open anyway.” The tissue in question will probably never be efficiently removed at later excision, hidden as it will be among the fibrin and granulation. It remains as a nidus for infection and later wound breakdown. With delay after injury, divided major vessels become permanently constricted. All vessels, divided or not, become friable and difficult to handle. Extension of edema and inflammation along tissue planes away from the wound causes such vessel changes over an increasing area, necessitating the use of longer pedicles in later free flaps. In the past it has been argued that free flaps are less predictable than pedicle flaps and they require more operating room and hospital time. The same argument has been advanced against “emergency” as distinct from “elective” free flaps. The series reported here showed a survival rate of 93.5%, with exploration being required in only 3.2% of cases. The average operating time and hospital stay was 4 hours and 54 minutes and 4 days for small defects, 7 hours and 45 minutes, and 7 days for medium defects, and 11 hours and 54 minutes and 12 days for large defects. Keeping in mind that some defects, as exemplified by cases 2 and 3, involve much more than simple flap transfer, these figures bear comparison to either pedicle flap or elective free flap reconstructions. The superiority of early over later free flap cover in lower extremity injuries has been shown with unanswerable cogency by Godina,” with flap failure rates of 0.75% in immediate reconstructions versus 12% in delayed and 9.5% in late and average total hospital times of 27 days, 130 days, and 256 days, respectively. Doubts still tend to remain regarding the potential for infection with such ambitious early reconstruction. The infection rate of 9.7%, which includes one of the two flaps that failed, compares favorably with the 52% found in delayed treatment by Nylen and Carlsson.” A direct comparison between immediate and delayed skin cover is shown by the work of Godina.” He had an infection rate of 1.5% in 134 patients treated with im-
Emergency free japs to upper extremity
27
mediate skin cover as opposed to 17.5% in 167 patients treated by delayed wound closure. The point of separation of the two groups was 72 hours after injury. Provided tissues are well vascularized, wounds can be closed primarily without fear of infection and with benefit to the patientz9 What exactly qualifies as an emergency free flap? We chose 24 hours as the upper limit in our series in the upper extremity. Godina*’ reported “early” flaps as those being done within 72 hours. He had two distinct subgroups in his immediate cover patients. In one case (performed in Yugoslavia where he had a full microsurgical team available at all hours) the flap was applied at the time of debridement , as were those reported here. In the other cases (treated in Kuwait where he was in charge of an elective microsurgical service) radical debridement was done at the primary hospital by his team and the free flap was applied at a second procedure at the central hospital within 72 hours. He found no difference between the subgroups and concluded that this brief delay was permissible “. . . provided that . . . a proper debridement is done immediately after the injury.“27 Should any patient be denied an emergency free flap? Age certainly is no barrier. Our youngest and oldest patients to undergo emergency free flap procedures were aged 2 and 76 years of age, respectively. Both had injuries to the lower extremity and are therefore not included here. Both did well and now walk on limbs that would otherwise have required amputation. The choice of flap is important in the older patient who handles chest wounds poorly. By contrast, their skin grafts heal well, and the forearm flap provides a logical and suitable alternative. Other patients who are unfit for a long surgical procedure must, of course, be rejected. There are two final groups who do not qualify for emergency free flap cover. The first group consists of patients with wounds so complex and crushed that total, radical debridement would destroy any possibility of function. Here delay is necessary, but with the knowledge that a golden opportunity has probably been lost. Where such delay perforce extends beyond 72 hours because of continued doubt regarding viability, if possible, the wounds are better skin grafted to achieve initial healing. A dramatic instance of such delay has been reported in the heterotopic implantation for temporary storage of an amputated hand by Godina and others.30 The second group of patients who should not have emergency free flap cover are those in which dispassionate assessment determines that eventual function will be minimal and worse than a prosthesis. With the powerful new tools of microsurgical revascularization,
28
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skeletal fixation and free flap skin cover to achieve sound primary healing, the modem surgeon must not overlook the ultimate goal of useful function. Such function can only be attained by an acceptably sensate hand, with mobile joints controlled by sufficient musculotendinous units. In massive wounds being considered for complex microsurgical reconstruction, the potential, or otherwise, for useful function can only be assessed by an experienced and objective hand surgeon. The authors thank their colleagues in Louisville Hand Surgery, some of whom contributed cases to the aggregate analyzed. They also acknowledge the skill of Douglas Hanel, M.D., who undertook the major portion of the surgery in case 3 above.
REFERENCES 1. Lister GD. The hand: Diagnosis and indications. 2nd ed. Edinburgh: Churchill Livingstone, 1984:82-6. 2. Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RD. The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984; 12:489-500. 3. Baudet J, LeMaire JM, Guimberteau JC. Ten free groin flaps. Plast Reconstr Surg 1976;57:577-95. 4. Harii K, Ohmori K, Torri S, et al. Free groin skin flaps. Br J Plast Surg 1975;28:225-37. 5. McConnell CM, Hyland WT, Neale HW. Microvascular free groin flap for soft-tissue coverage of the extremities. J Trauma 1980;20:593-8. 6. Shah KG, Garrett JC, Buncke HJ. Free groin flap transfer to the upper extremity. Hand 1979;11:315-20. 7. Bailey BN, Godfrey AM. Latissimus dorsi muscle free flaps. Br J Plast Surg 1982;35:47-52. 8. Lassen M, Krag C, Nielsen IM. The latissimus dorsi flap. Stand J Plast Reconstr Surg 1985;19:41-51. 9. Maxwell R, Manson P, Hoopes J. Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 1979;64: l-8. 10. Nielsen IM, Lassen M, Gregersen BN, Krag C. Experience with the latissimus dorsi flap. Stand J Plast Reconstr Surg 1985;19:53-63. 11. Stem PJ, Neale HW, Gregory RO, McDonough JJ. Functional reconstruction of an extremity by free tissue transfer of the latissimus dorsi. J Bone Joint Surg 1983; 65A:729-37. 12. Watson JS, Craig P, Orton C. The free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1979;64:299305.
The Journal of HAND SURGERY
13. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plast Reconstr Surg 1980;65: 616-26. 14. Minami A, Usu M, Katoh H, lshii S. Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques. J HAND SURG 1984;9B:239-44. 15. Barwick WJ, Goodkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69:779-85. 16. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:601-4. 17. Hamilton SGL, Morrison WA. The scapular free flap. Br .I Plast Surg 1982;35:2-7. 18. Mayou BJ, Whitby D, Jones BM. The scapular flapan anatomical and clinical study. Br J Plast Surg 1982;35:8-13. 19. Santos LF. The scapular flap: A new microsurgical free flap. Revista Brasileria de Cirurgia 1980;70:133-41. 20. Kaplan EN, Pearl RM. An arterial medial arm flap: Vascular anatomy and clinical applications. Ann Plast Surg 1980;4:205. 21. Haury B, Rodeheaver G, Vensko J, Edgerton MT, Edlich RF. Debridement: An essential component of traumatic wound care. Am J Surg 1978;135:238-42. 22. Burkhalter WE, Butler B, Metz W, Omer G. Experiences with delayed primary closure of war wound of the hand in Viet Nam. J Bone Joint Surg 1968;50A:945-54. 23. Burke JF. Effects of inflammation on wound repair. J Dent Res 1971;50:296. 24. Robson MC, Edstrom LE, Krizek TJ, Groskin MG. The efficacy of systemic antibiotics in the treatment of granulating wounds. J Surg Res 1974;16:299-306. 25. Peacock EE. Wound repair. 3rd ed. Philadelphia: WB Saunders, 1984. 26. Edgerton MT. Immediate reconstruction of the injured hand. Surgery 1954;36:329-43. 27. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92. 28. Nylen S. Carlsson B. Time factor, infection frequency and quantitative microbiology in hand injuries. Stand J Plast Reconst Surg 1980;14:185-9. 29. Lister GD. Commentary on Chapter 6. In: Carter D, Polk H, eds. Trauma. Butterworth’s International medical review of surgery. Vol 1. London: Butterworth, 1981: 180-4. 30. Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986;78: 295-9.