Fasciocutaneous Free Flaps Are More Reliable Than Muscle Free Flaps in Lower Limb Trauma Reconstruction: Experience in a Single Trauma Center

 

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Abstract

Background Muscle (M) and fasciocutaneous (FC) free flaps are frequently used options in the reconstruction of traumatic lower limb injuries. The use of one flap over another has remained the topic of controversy in the literature. With a large experience, we sought to evaluate key outcomes of M versus FC free flap reconstructions in lower limb trauma in a single trauma center.

Methods A consecutive 7- year review of all free flap reconstructions for lower limb trauma performed at the Royal Melbourne Hospital was conducted. Patient data were prospectively entered into a unit database and retrospectively reviewed.

Results One hundred three patients underwent 105 free flap reconstructions (M = 48 and FC = 57) in lower limb trauma. We experienced a rate of 2.9% total flap failures and 11.4% partial flap losses. Total flap failures represented 6.3% M and 0% FC flaps. The partial flap failures included 15.8% of M and 5.3% of FC flaps. Latissimus dorsi (40% of M group) and radial forearm free flaps (67% of FC group) were most commonly used in each group. There was a statistically significant difference between groups in rates of reoperation (M = 44% versus FC = 16%), postoperative infection (M = 38% versus FC = 12%), fracture nonunion (M = 40% versus FC = 21%), and donor site morbidity (M = 25% versus FC = 4%). Nonstatistically significant differences were encountered with higher rates of osteomyelitis (M = 14.6% versus FC = 10.5%), unplanned bone graft (M = 14.6 versus FC = 10.5%), and inability to bear full weight at 1 year (M = 30.2% versus FC = 17.0%) found in the M group. In our cohort, M flaps used for metal coverage resulted in higher rates of reoperation, postoperative infections, and flap loss than FC flaps (M = 61% versus FC = 25%, p < 0.05).

Conclusion Statistically higher complication rates in key reliability markers were found in the M free flap group. This study found FC free flaps to be more reliable for reconstruction of lower limb injuries in a major trauma center.

• References

• 1 Chang N, Mathes SJ. Comparison of the effect of bacterial inoculations in musculocutaneous and random pattern flaps. Plast Resonstr Surg 1982; 70: 1-10
  PubMedGoogle Scholar
• 2 Bunkis J, Walton RL, Mathes SJ. The rectus abdominis free flap for lower extremity reconstruction. Ann Plast Surg 1983; 11: 373-380
  CrossrefPubMedGoogle Scholar
• 3 Guzman-Stein G, Fix RJ, Vasconez LO. Muscle flap coverage for the lower extremity. Clin Plast Surg 1991; 18: 545-552
  PubMedGoogle Scholar
• 4 Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001; 108: 1029-1041 ; quiz 1042
  CrossrefPubMedGoogle Scholar
• 5 Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma 2000; 48: 913-917
  CrossrefPubMedGoogle Scholar
• 6 Yaremchuk MJ. Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg 1986; 13: 621-632
  PubMedGoogle Scholar
• 7 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; 89: 478-487 ; discussion 488–489
  CrossrefPubMedGoogle Scholar
• 8 Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003; 112: 129-140 ; discussion 141–142
  CrossrefPubMedGoogle Scholar
• 9 Hallock GG. Complications of 100 consecutive local fasciocutaneous flaps. Plast Reconstr Surg 1991; 88: 264-268
  CrossrefPubMedGoogle Scholar
• 10 Fix RJ, Vasconez LO. Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg 1991; 18: 571-582
  PubMedGoogle Scholar
• 11 Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987; 80: 1-14
  CrossrefPubMedGoogle Scholar
• 12 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78: 285-292
  CrossrefPubMedGoogle Scholar
• 13 Byrd HS, Cierny III G, Tebbetts JB. The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg 1981; 68: 73-82
  CrossrefPubMedGoogle Scholar
• 14 Byrd HS, Spicer TE, Cierney III G. Management of open tibial fractures. Plast Reconstr Surg 1985; 76: 719-730
  CrossrefPubMedGoogle Scholar
• 15 Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989; 29: 1086-1094
  CrossrefPubMedGoogle Scholar
• 16 Bostwick III J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg 1979; 63: 31-41
  CrossrefPubMedGoogle Scholar
• 17 Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982; 69: 815-829
  CrossrefPubMedGoogle Scholar
• 18 Eshima I, Mathes SJ, Paty P. Comparison of the intracellular bacterial killing activity of leukocytes in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1990; 86: 541-547
  CrossrefPubMedGoogle Scholar
• 19 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103: 1937-1948
  CrossrefPubMedGoogle Scholar
• 20 Weinzweig N, Davies BW. Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases. Plast Reconstr Surg 1998; 102: 1999-2005
  CrossrefPubMedGoogle Scholar
• 21 Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006; 117: 2468-2475 ; discussion 2476–2477
  CrossrefPubMedGoogle Scholar
• 22 Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1986; 77: 785-794
  CrossrefPubMedGoogle Scholar
• 23 Gosain A, Chang N, Mathes SJ, Hunt TK, Vasconez L. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1990; 86: 1152-1162 ; discussion 1163
  CrossrefPubMedGoogle Scholar
• 24 Harry LE, Sandison A, Pearse MF, Paleolog EM, Nanchahal J. Comparison of the vascularity of fasciocutaneous tissue and muscle for coverage of open tibial fractures. Plast Reconstr Surg 2009; 124: 1211-1219
  CrossrefPubMedGoogle Scholar
• 25 Rodriguez ED, Bluebond-Langner R, Copeland C, Grim TN, Singh NK, Scalea T. Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma 2009; 66: 1311-1314
  CrossrefPubMedGoogle Scholar
• 26 Hong JP, Shin HW, Kim JJ, Wei FC, Chung YK. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 2005; 115: 142-147
  PubMedGoogle Scholar
• 27 Rozen WM, Donahoe S, Wilson JL. The profunda femoris artery “fourth perforator” island flap: a new perforator flap in lower-limb reconstruction. J Reconstr Microsurg 2011; 27: 273-276
  Article in Thieme ConnectPubMedGoogle Scholar
• 28 Behan FC, Terrill PJ, Ashton MW. Fasciocutaneous island flaps for orthopaedic management in lower limb reconstruction using dermatomal precincts. Aust N Z J Surg 1994; 64: 155-166
  CrossrefPubMedGoogle Scholar