Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases

Accepted Manuscript Free Tissue Transfer to the Traumatized Upper Extremity: Risk Factors for Postoperative Complications in 282 Cases Dr Amit Gupta, MD, Mr Chrisovalantis Lakhiani, BS, Dr Beng Hai Lim, MD, Dr Johnathon M. Aho, MD, Dr Adam Goodwin, MD, Dr Ashley Tregaskiss, MD, Dr Michael Lee, MD, Dr Luis Scheker, MD, Dr Michel Saint-Cyr, MD PII:

S1748-6815(15)00231-4

DOI:

10.1016/j.bjps.2015.05.009

Reference:

PRAS 4625

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 21 November 2013 Revised Date:

8 January 2015

Accepted Date: 11 May 2015

Please cite this article as: Gupta A, Lakhiani C, Lim BH, Aho JM, Goodwin A, Tregaskiss A, Lee M, Scheker L, Saint-Cyr M, Free Tissue Transfer to the Traumatized Upper Extremity: Risk Factors for Postoperative Complications in 282 Cases, British Journal of Plastic Surgery (2015), doi: 10.1016/ j.bjps.2015.05.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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[Category: Original Research Article] Free Tissue Transfer to the Traumatized Upper Extremity: Risk Factors for

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Postoperative Complications in 282 Cases Amit Gupta, MD Chrisovalantis Lakhiani, BS

Johnathon M. Aho, MD Adam Goodwin, MD

Michael Lee, MD Luis Scheker, MD

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Ashley Tregaskiss, MD

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Beng Hai Lim, MD

Michel Saint-Cyr, MD

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Author Affiliations: Christine M. Kleinert Institute for Hand and Microsurgery (Drs Gupta, Lim, Goodwin, Tregaskiss, and Scheker), Louisville, Kentucky; Department of Surgery (Mr Lakhiani and Dr Lee),

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University of Texas Southwestern Medical Center, Dallas, Texas; and Department of Surgery (Drs Aho and Saint-Cyr), Mayo Clinic, Rochester,

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Minnesota.

Reprints: Michel Saint-Cyr, MD, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]) (Phone: 507-284-4685).

Portions of this manuscript have been published in abstract form:

Plast Reconstr Surg. 2012;130 (Abstract Suppl):56. Text word count: 2,444 Abstract word count: 294

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No. of tables: 7 No. of figures: 2

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Running title: Free Tissue Transfer in Traumatized Limb Publisher: To expedite proof approval, send proof via e-mail to [email protected].

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©2013 Mayo Foundation for Medical Education and Research

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Abstract Background: Complex traumatic upper extremity injuries frequently

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possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to

provide adequate soft tissue coverage. The present study aimed to evaluate

complex upper extremity reconstruction.

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risk factors that contribute to postoperative complications and flap loss in

Methods: Retrospective chart review was performed for all patients

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undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ2 and Fisher exact tests.

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Results: In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n=282). Extremities were repaired within 24 hours (75 cases;

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27%), in days 2 to 7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes.

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Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P<.01) and deep infection (RR, 5.3; P<.01), and osteomyelitis (RR, 4.0; P<.01), although not with flap failure (P=.30).

Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P=.01) and deep (RR, 1.9; P<.01) infection, as well as

osteomyelitis (RR, 1.6; P<.01). Having a closed fracture did not negatively influence postoperative outcomes.

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Conclusions: This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the

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elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk

location were not predictors of flap failure.

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of flap loss, whereas the presence of fracture, fracture fixation, and injury

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Keywords: complications; flap; reconstruction; trauma; upper extremity

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Abbreviations ORIF, open reduction with internal fixation

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RR, relative risk

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RTW, return-to-work

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Introduction Complex traumatic upper extremity injuries frequently possess

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compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. In these instances, free tissue transfer is required to provide adequate soft tissue coverage. Its merits include preservation of

exposed vital structures, earlier mobilization, and salvage of forthcoming

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amputation, fewer operations, decreased hospital stay and cost, and

improved aesthetics (1-8). Sensation may possibly be preserved in select

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cases of relatively proximal injury through the use of fasciocutaneous or musculocutaneous flaps (9). When segmental vascular damage is present or to preserve arterial patency, flow-through flaps provide a novel opportunity for reconstruction without disrupting distal circulation (10-12). Nevertheless, other factors besides flap utilization continue to be important in formulating

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an algorithm for treating the traumatized extremity.

Although there is general consensus that exposure of vital structures (eg, vessels, tendons, nerve) and orthopedic hardware requires

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emergent soft tissue coverage (9,13-17), timing of reconstruction is still a contested issue. Some experts have advocated for early tissue coverage

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(3,6,14,18-25); yet, others have shown success through approaching extremity injuries conventionally with serial débridements and secondary reconstruction in a delayed manner (26-31). In the largest study on this topic to date, Derderian et al (28)

found that reconstruction in the 6-to-21-day period after injury provides the most optimal results. More recently, investigators have suggested that changes in perioperative management—notably, use of the vacuum-assisted closure (VAC; KCI Licensing, Inc) therapy—allows for safe reconstruction,

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as well as serial débridements in the subacute period (29-31). It has also been shown that timing may have no role in reconstructive outcomes (32).

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However, because of differences in sample size, perioperative management, and operator experience with extremity reconstruction and proper

débridement, the clinical significance of these findings is unclear.

Established practices in complex upper extremity management

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include the use of early definitive débridement to minimize infection risk. Early, definitive débridement of necrotic tissue has been shown to be of

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paramount importance in preparing the wound bed for free tissue transfer (9,18-20). Similarly, where fracture is involved, early aggressive and repeated débridement with fracture fixation and 1-stage soft tissue coverage is indicated (21). Yaremchuk et al (26) proposed that all large defects should be considered contaminated, if not infected, which suggests that Gustilo

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grade IIIB/IIIC open extremity fractures are likely contaminated at the time of closure. Furthermore, Gustilo grade IIIB injuries can be accompanied by vascular injury and, by definition, Gustilo grade IIIC injuries require vessel

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repair (33). These issues offer a complex range of variables that merit exploration to determine their effect on reconstructive outcomes.

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Despite the growing experience with extremity reconstruction,

some questions still remain. Herein, we present our 25-year experience with upper extremity free flap reconstruction at a subspecialty tertiary care facility. An extensive literature review was performed to identify potential risk factors for untoward flap outcomes, including smoking, diabetes, timing of reconstruction, location of injury, fracture grade, operative interventions, and flap salvage procedures. The purpose of this study was to examine the role of these potential risk factors with regard to flap loss, infection, hospital

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stay, and return-to-work (RTW) time in the largest series to date, to our knowledge, on upper extremity free flap reconstruction following trauma.

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Methods Retrospective chart review was performed for all patients

undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001, following approval by the Mayo Clinic Institutional Review Board.

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Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative

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interventions, flap salvage procedures, postoperative complications, hospital stay, and RTW time. Derderian et al (28) have described a decreased frequency of complications in 6 to 21 days postinjury. However, because of the insufficient number of patients in that study’s subgroup, we used the timing classification described by Ninkovic et al (34), which classified cases

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as primary (<24 hours of injury), delayed primary (days 2-7), or secondary (>7 days). Flap salvage procedures included reexploration and anastomotic revision. Postoperative complications included recipient site infection,

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osteomyelitis, and flap failure. Infections were classified as either superficial (requiring only antibiotics for treatment) or deep (requiring operative

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drainage). Total flap failure was defined as any flap loss >60%, whereas partial flap failure was defined as any flap loss ≤60%. Data for bony

nonunion were unavailable for analysis. Statistical analysis was performed through χ2 and Fisher exact

tests for contingency tables, to compare proportions of infection, osteomyelitis, and flap loss among groups (SPSS Statistics v19; IBM Corp. Scalar data, including hospital stay and RTW time, were compared with

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Mann-Whitney U test or Kruskal-Wallis 1-way analysis of variance. A P value of <.05 was considered statistically significant.

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Results In the study’s 238 patients, 282 free tissue transfers were

performed. The mean (SD) patient age at time of reconstruction was 31.4 (14.3) years. Ninety-eight patients (41%) were smokers and 5 (2%) had

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diabetes. Occupation was known for 234 (98%) of patients, and 182 patients (78%) were manual laborers (Table 1). Flaps used included the lateral arm,

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latissimus dorsi, groin, scapula, rectus, first web, dorsalis pedis, radial forearm, gracilis, and filet flaps (Table 2). Toe transfers were a large part of the transfers performed. Extremities were repaired within 24 hours (75 cases; 27%), within days 2 to 7 (32 cases; 12%), or after day 7 (172 cases; 62 %) (Table 3). In 3 cases, the timing of reconstruction was unavailable,

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and these cases were excluded from further analysis. Forty-seven injuries (17%) were located proximal to the elbow; 232 (83%) were at the elbow or distal to it. More than half of cases (60%)

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had an associated fracture, with 43% of fractures open and 56% of fractures in a closed patterns. Gustilo grade for fractures which were open were

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characterized as IIIA (2%%), IIIB (28%), and IIIC (13%) of fractures. Infection was a complicating factor in 57 tissue transfers (Table 4). An interpositional vein graft was used in 41 total free tissue transfers (14.5%). Anastomotic revision was performed in the index operation in 53 total free tissue transfers (19%) and was successful in 45 cases (85%). Length of hospital stay was available for 97% of cases (Table 3). Mean (SD) follow-up was 37.5 (49.5) months. In addition, data on return to full-time work were available in 95 (34%) of the 282 cases. Mean time to

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return to full-time work was 15.7 months (range, 9.1-22.2 months), 20.6 months (range, 11.6-29.6 months), and 25.9 months (range, 18.1-33.6

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months) in the primary, delayed primary, and secondary reconstruction groups, respectively.

Postoperative complication rates, RTW time, and hospital stay were compared in the delayed primary reconstruction group and the

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secondary reconstruction group relative to the primary reconstruction group. Timing of reconstruction did not affect postoperative outcomes significantly

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in terms of superficial infection, deep infection, osteomyelitis, total flap loss, partial flap loss, or total + partial flap loss (Figure 1). Differences in RTW time or hospital stay were also not significantly affected by the timing of reconstruction (P=.13 and P=.19, respectively)(Table 3). Risk factors for superficial infection development included

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proximal location of injury and open fracture (Table 5) but not closed fracture (P=.30) or smoking (P=.18). Similarly, risk factors for deep infection development included proximal location of injury and open

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fracture (Table 5), but not closed fracture (P=.70) or smoking (P=.10). Development of osteomyelitis was also found to be significantly associated

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with proximal location of injury and open fracture (Table 5) but not closed fracture (P=.42) or smoking (P=.49). There were insufficient numbers of

patients with diabetes for a well-powered analysis of these aforementioned complications (Table 5). Flaps requiring intraoperative anastomotic revision at the index

operation had an 8.0 times higher risk of overall flap loss, 13 times higher risk of partial flap loss, and 3.5 times higher risk of total flap loss. (Table 6) (Figure 2) Patients who suffered complete flap failure (n=12) underwent

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subsequent free tissue transfer which accounts for 24 free tissue transfers in this series, In 20 patients flaps were utilized to cover donor sites, no patients

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underwent double upper extremity free flap coverage. Gustilo grade IIIC fractures were associated with a higher risk of overall (total + partial) flap loss , as well as partial flap loss, but not total flap loss (Table 6)(Figure 2). Use of an interpositional vein graft was 3.2

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times more likely to result in overall flap loss, but not total flap loss only or partial flap loss only(Table 6 and Figure 2). Smoking, diabetes, and any

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infection (superficial, deep, or osteomyelitis) were not significantly associated with flap failure (P=.66, P=.34, and P=.21, respectively). Factors contributing to increased length of hospital stay included smoking, diabetes, proximal location of injury, presence of a fracture, and use of ORIF (Table 7). Performing open reduction with internal fixation

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(ORIF) was not associated with any adverse outcomes (Table 8). No variables were found to contribute significantly toward increasing the time until full-time work status was achieved, including

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smoking (P=.29), use of ORIF (P=.09), proximal location of injury (P=.45), or presence of a fracture (P=.35). There were an insufficient number of

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patients with diabetes who had data on their return to full-time work for comparison.

Discussion

The merits of free tissue transfer for upper extremity

reconstruction have been clearly established. However, the factors that influence postoperative outcome have yet to be elucidated. Knowledge of risk factors associated with poor outcome following free tissue transfer for

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upper extremity reconstruction allows for more precise operative planning, perioperative management, and patient counseling.

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Several landmark studies found that complication rates in extremity reconstruction varied with time of reconstruction (18,22). Godina et al. (18) reported decreased failure rates when free tissue reconstruction was performed within 72 hours of injury. Still, other authors have advocated

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for emergency microvascular free tissue transfer within 24 hours (10,19,20). Several other authors have found that reconstruction may be safely delayed

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into the subacute period (28-31). In the present series, we did not observe differences in infection rate, flap failure, RTW time, or hospital stay in patients undergoing reconstruction at different time points. Emergency free tissue transfer has been performed with decreasing frequency at our institution (30% before 1990 and 19% in 1990

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and since), and this trend is paralleled in the literature (10,28). Emergency soft tissue reconstruction is clearly indicated when critical neurovascular structures are threatened or exposed, and it has been shown to be safe and

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effective when patient selection is appropriate and débridement adequate (10,20). Nevertheless, one of the most difficult aspects of emergency free

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tissue transfer is accurately determining tissue viability and extent of débridement in tissue contusion and edema. Microvascular free tissue transfer in a more delayed time frame allows for serial débridement and precise planning of procedures. Although our findings with regard to reconstructive timing were not statistically significant, the infectious and flap-related outcomes tended to decrease when reconstruction was performed in the subacute period after multiple débridements (Figure 1).

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The lateral arm flap was used in a majority of extremity reconstructions in the present series. Other studies have similarly found that

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a single flap often predominates extremity reconstructions at an institution (10,18). Although it is useful to have a wide variety of free flaps in the reconstructive armamentarium, using a single flap for the majority of

reconstructions allows for increased operator experience and comfort with

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the operation. A high level of experience with the lateral arm flap for various defects has certainly contributed to the relatively high flap success rate seen

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in this series. Keeping the morbidity limited to the same upper extremity through harvesting the lateral arm flap from the affected limb was also our preferred approach. Higher flap failure rates were encountered when less frequent flaps were selected—for example, the groin flap was also mostly used in the early period, with which operators were less familiar. There is

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also an initial inherent learning curve in free tissue transfers over a 25-year period that needs to be considered.

Injuries located proximal to the elbow were associated with a

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significantly higher risk of infection and osteomyelitis (Table 5). We suspect that the larger bulk of subcutaneous tissues in the proximal upper extremity

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may create a nidus for infection. Less aggressive débridement of the larger proximal muscle mass may further contribute to the higher infection rate because the challenges of tourniquet application and subsequent discrimination of devitalized tissue may be more difficult to discern. Since a greater force is required to generate injury over larger muscle groups, proximally located injuries also likely occurred in the setting of high-energy traumas compared with distally located injuries, making early debridement of borderline viable tissues more difficult to asses. In high-energy injuries

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affecting large muscle bellies, such as proximal injuries, we performed débridements on a serial basis as needed to avoid residual unrecognized

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tissue necrosis and infection. Previous studies have shown an increased risk of infection and osteomyelitis in the clinical setting of open fractures (18,22). Similarly, open fractures were associated with a greater risk of infection and osteomyelitis in

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the present series (Table 5). Higher Gustilo grades correlate with more

extensive soft tissue and bony injury, as well as a higher energy and severity

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of injury mechanism. Gustilo grade IIIC fractures were also associated with a higher rate of flap loss in our study, despite the attempt at vascular repair outside the zone of injury (Table 6). The vascular compromise found in high-grade Gustilo fracture patterns makes reconstruction of these defects challenging and suggests that the zone of injury may be more extensive than

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initially perceived.

Interpositional vein grafts represent a useful technique for reconstructive anastomosis outside the zone of injury, and their use has been

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reported with mixed success (35-37). In our series, the use of interpositional vein grafts was associated with a 3.2-times relative risk of flap loss (Table

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6). This result may in part be attributed to the more extensive vascular extent of these injuries, as well as the underestimation of the zone and extent of injury. In addition, flaps requiring intraoperative anastomotic revision at the index operation had a 7.9-times higher risk of flap loss. This awareness is of value in determining postoperative management, anticipating possible complications, and planning for alternative means of reconstruction in flap failure. This information has also allowed us to better plan our

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reconstruction and flap selections so no interpositional vein grafts are needed.

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The present study is limited by its retrospective nature. In addition, loss to follow-up prevented us from collecting RTW data in nearly two-thirds of the patients. Although the sample size of this series is large, this limitation must be considered as a potential source of bias when

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evaluating why none of the variables examined were associated with either an increase or a decrease in RTW time. Additionally over the course of this

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time period, improvements to trauma care, antibiosis and anesthetic techniques significantly improved, which limits conclusions that may be drawn of the study as a whole, our study did not consider patients as heterogenous with regards to other trauma injuries and overall trauma injury severity which may have taken precedence with regard to extremity

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reconstruction. An additional limitation to this study is lack of data on bony union of the upper extremity as well as quantitative long term functional outcomes after successful flap coverage of the extremity.

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Conclusion

This study supports the safety and efficacy of microvascular free

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tissue transfer for reconstruction of the traumatized upper extremity. Timing did not affect postoperative outcomes in our series. Proximal level injuries and high-energy trauma resulting in open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and intraoperative anastomotic revision at the index operation resulted in significantly higher risk of flap loss. Acknowledgment The authors declare no sources of funding.

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Conflict of Interest Statement

Ethical Statement

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The authors have no conflicts of interest.

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This study was approved by relevant local ethical committees This study conforms to the World Medical Association Declaration of Helsinki (June 1964) and subsequent amendments.

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References 1. Hing DN, Buncke HJ, Alpert BS, Gordon L. Free flap coverage of the

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hand. Hand Clin. 1985 Nov;1(4):741-58. 2. Wood MB, Irons GB. Upper-extremity free skin flap transfer: results and utility as compared with conventional distant pedicle skin flaps. Ann Plast Surg. 1983 Dec;11(6):523-6.

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3. Breidenbach WC 3rd. Emergency free tissue transfer for

Jul;16(3):505-14.

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reconstruction of acute upper extremity wounds. Clin Plast Surg. 1989

4. Katsaros J, Tan E, Zoltie N. Free flap cover of acute hand injuries. Injury. 1989 Mar;20(2):96-7.

5. Chen HC, Buchman MT, Wei FC. Free flaps for soft tissue coverage in the hand and fingers. Hand Clin. 1999 Nov;15(4):541-54.

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6. McCabe SJ, Breidenbach WC. The role of emergency free flaps for hand trauma. Hand Clin. 1999 May;15(2):275-88. 7. Wettstein R, Schurch R, Banic A, Erni D, Harder Y. Review of 197

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consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg. 2008 Jul;61(7):772-6. Epub 2008 Jan 8.

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8. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma. 1989 Aug;29(8):1086-94.

9. Herter F, Ninkovic M, Ninkovic M. Rational flap selection and timing for coverage of complex upper extremity trauma. J Plast Reconstr Aesthet Surg. 2007;60(7):760-8. Epub 2007 May 29.

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10. Hsu CC, Lin YT, Lin CH, Lin CH, Wei FC. Immediate emergency free anterolateral thigh flap transfer for the mutilated upper extremity.

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Plast Reconstr Surg. 2009 Jun;123(6):1739-47. 11. Nasir S, Aydin MA, Sonmez E, Baykal B. Flow-through free

latissimus dorsi flap for reconstruction of injured limbs: evaluation of hemodynamic effects on extremity circulation. Ann Plast Surg. 2010

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Aug;65(2):164-9.

12. Yokota K, Sunagawa T, Suzuki O, Nakanishi M, Ochi M. Short

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interposed pedicle of flow-through anterolateral thigh flap for reliable reconstruction of damaged upper extremity. J Reconstr Microsurg. 2011 Feb;27(2):109-14. Epub 2010 Oct 25.

13. Chen CM, Disa JJ, Lee HY, Mehrara BJ, Hu QY, Nathan S, et al. Reconstruction of extremity long bone defects after sarcoma resection

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with vascularized fibula flaps: a 10-year review. Plast Reconstr Surg. 2007 Mar;119(3):915-24.

14. Chen SH, Wei FC, Chen HC, Chuang CC, Noordhoff MS. Emergency

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free-flap transfer for reconstruction of acute complex extremity wounds. Plast Reconstr Surg. 1992 May;89(5):882-8.

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15. Silverberg B, Banis JC Jr, Verdi GD, Acland RD. Microvascular reconstruction after electrical and deep thermal injury. J Trauma. 1986 Feb;26(2):128-34.

16. Horch RE, Stark GB. The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects. Plast Reconstr Surg. 1999 Apr;103(5):1421-7.

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Gupta et al -19- (CMS)

17. Hollenbeck ST, Toranto JD, Taylor BJ, Ho TQ, Zenn MR, Erdmann D, et al. Perineal and lower extremity reconstruction. Plast Reconstr

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Surg. 2011 Nov;128(5):551e-563e. 18. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986 Sep;78(3):285-92.

Hand Surg Am. 1988 Jan;13(1):22-8.

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19. Lister G, Scheker L. Emergency free flaps to the upper extremity. J

20. Ninkovic M, Deetjen H, Ohler K, Anderl H. Emergency free tissue

Feb;20(1):53-8.

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transfer for severe upper extremity injuries. J Hand Surg Br. 1995

21. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004 Nov;114(6):1457-66.

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22. Byrd HS, Cierny G 3rd, Tebbetts JB. The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg. 1981 Jul;68(1):73-82.

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23. Barner-Rasmussen I, Popov P, Bohling T, Tarkkanen M, Sampo M, Tukiainen E. Microvascular reconstruction after resection of soft

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tissue sarcoma of the leg. Br J Surg. 2009 May;96(5):482-9. 24. Chang DW, Robb GL. Recent advances in reconstructive surgery for soft-tissue sarcomas. Curr Oncol Rep. 2000 Nov;2(6):495-501.

25. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg. 1992 Mar;89(3):478-87.

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Gupta et al -20- (CMS)

26. Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic

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osteocutaneous defects of the lower extremity. Plast Reconstr Surg. 1987 Jul;80(1):1-14.

27. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg. 2001 Sep 15;108(4):1029-41.

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28. Derderian CA, Olivier WA, Baux G, Levine J, Gurtner GC.

Microvascular free-tissue transfer for traumatic defects of the upper

Oct;19(7):455-62.

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extremity: a 25-year experience. J Reconstr Microsurg. 2003

29. Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg. 2009

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Jan;123(1):218-29.

30. Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in

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the subacute period. J Trauma. 2009 Oct;67(4):752-7. 31. Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed

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flap coverage of open extremity fractures after previous vacuumassisted closure (VAC) therapy: worse or worth? J Plast Reconstr Aesthet Surg. 2009 May;62(5):675-83. Epub 2008 Mar 25.

32. Kolker AR, Kasabian AK, Karp NS, Gottlieb JJ. Fate of free flap microanastomosis distal to the zone of injury in lower extremity trauma. Plast Reconstr Surg. 1997 Apr;99(4):1068-73. 33. Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and

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reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg. 2010 Jan;210(1):66-72.

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Epub 2009 Nov 18. 34. Ninkovic M, Mooney EK, Ninkovic M, Kleistil T, Anderl H. A new classification for the standardization of nomenclature in free flap wound closure. Plast Reconstr Surg. 1999 Mar;103(3):903-14.

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35. Bayramiçli M, Tetik C, Sonmez A, Gurunluoglu R, Baltaci F.

Reliability of primary vein grafts in lower extremity free tissue

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transfers. Ann Plast Surg. 2002 Jan;48(1):21-9.

36. Chaivanichsiri P. Influence of recipient vessels on free tissue transplantation of the extremities. Plast Reconstr Surg. 1999 Sep;104(4):970-5.

37. Germann G, Steinau HU. The clinical reliability of vein grafts in free-

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flap transfer. J Reconstr Microsurg. 1996 Jan;12(1):11-7.

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Table 1. Patient Characteristics Characteristic

Value 31.4 (14.3)

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Age, mean (SD), y Smokers, No. of patients

98

Diabetes, No. of patients

5

182 (77.8)

Follow-up, mean (SD), mo

37.5 (49.5)

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Manual laborers, No. of patients (%)

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Table 2. Types of Flaps Used in 282 Free Tissue Transfers Cases, No. (%)

Lateral arm

108 (38.3)

Toe transfer

106 (37.6)

Latissimus dorsi

21 (7.4)

Groin

13 (4.6) 7 (2.5)

Rectus

7 (2.5)

Fibula

5 (1.8)

First web

4 (1.4)

Dorsalis pedis

3 (1.1)

Radial forearm

3 (1.1)

2 (0.7)

TE D

Gracilis Filet

M AN U

SC

Scapula

RI PT

Flap Type

AC C

EP

Finger to thumb

2 (0.7) 1 (0.4)

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Gupta et al -24- (CMS)

Table 3. Timing of 279 Flap Reconstructions Timing

Flaps performed, No.

<24 h

Days 2-7

75 (26.9)

32 (11.5)

(%) 8.3 (7.0-9.6)

8.3 (6.5-10.1)

15.7 (9.1-22.2)

20.6 (11.6-29.6)

RTW time, mean (range), mo

AC C

EP

TE D

Abbreviation: RTW, return-to-work.

M AN U

(range), d

SC

Hospital stay, mean

>7 Days

RI PT

Reconstruction

172 (61.6)

7.2 (6.6-7.9)

25.9 (18.1-33.6)

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Gupta et al -25- (CMS)

Table 4. Observed Postoperative Complications of 279 Flap Reconstruction Procedures Cases, No. (%)

Superficial infection

18 (6.5)

Deep infection

24 (8.6)

Osteomyelitis

15 (5.4) 6 (2.2)

Total flap loss

12 (4.3)

AC C

EP

TE D

M AN U

SC

Partial flap loss

RI PT

Complication

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Gupta et al -26- (CMS)

Table 5. Relative Risk of Factor Associated With Infection Development Relative Risk of Factors

Infection

Deep Infection

Osteomyelitis

Proximal injury

6.5 (P<.001)

5.3 (P<.001)

4.0 (P=.01)

Open fracture

3.1 (P=.01)

1.9 (P<.001)

1.6 (P=.007)

AC C

EP

TE D

M AN U

SC

Variable

RI PT

Superficial

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Gupta et al -27- (CMS)

Table 6. Relative Risk of Factors Associated With Flap Loss Relative Risk of Factors

Variable

Total Flap Loss

Partial Flap Loss

Flap Loss

3.5 (P=.001)

13.0 (P=.02)

7.9 (P<.001)

Gustilo grade IIIC

N/Aa (P=.29)

13.6 (P=.008)

3.5 (P=.03)

Interpositional vein graft

N/A (P=.08)

N/A (P=.14)

3.2 (P=.01)

SC

Anastomotic revision

AC C

EP

TE D

Due to nonsignificance of the interaction.

M AN U

Abbreviation: N/A, not applicable. a

RI PT

Total + Partial

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Gupta et al -28- (CMS)

Table 7. Factors Contributing to Increased Length of Hospitalization Hospital Stay, d

P Value

RI PT

Factor Smoker

8.6 vs 7.0

Diabetes

12.8 vs 7.4

Proximal injury

11.0 vs 6.8

<.001

8.3 vs 6.8

.01

9.4

Closed fracture

7.3

<.001

M AN U

Open fracture

.01

SC

ORIF

.006

No fracture

6.7

AC C

EP

TE D

Abbreviation: ORIF, open reduction with internal fixation.

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Gupta et al -29- (CMS)

Table 8. Open reduction with internal fixation association with adverse outcomes

.24

Deep infection

.08

Osteomyelitis

.11

Total flap loss

.76

Partial flap loss

.65

AC C

EP

TE D

M AN U

Superficial infection

RI PT

P Value

SC

Factor

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Gupta et al -30- (CMS)

Legends Figure 1. Incidence of Flap-Related Complications in the Primary

RI PT

(<24 Hours), Delayed Primary (2-7 Days), and Secondary (>7 Days) Reconstructive Groups. No significant differences were observed among groups.

Figure 2. Relative Risk of Flap Failure for Factors Associated With

SC

Flap Loss. Performing an anastomotic revision was associated with an 8 times greater risk of flap loss (total or partial); cases with a

M AN U

Gustilo grade IIIC fracture were associated with a 3.5 times greater risk. Flaps anastomosed to the recipient artery via an interpositional

AC C

EP

TE D

vein graft had a 3.2 times greater risk.

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

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