When is the Critical Time for Soft Tissue Reconstruction of Open Tibia Fracture Patients?Funding This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science and ICT (NRF-2017R1D1A1B03035452 and 2019R1A2C2010150).
Background The timing of soft tissue reconstruction for soft-tissue defect in patients with open fractures in the lower extremity is known to be critical for successful outcomes. However, medical advances, including development of dressing materials and refinement in the microsurgical techniques, might have undergone modifications in this “critical period.” There have been no studies on the role of timing on reconstructive outcomes. Thus, we have analyzed the effect of reconstruction timing on optimal surgical outcomes and complication rates in a single type of lower extremity injury.
Methods Data of patients who underwent microvascular free tissue transfer with an open fracture in the lower extremity from 2014 through 2016 were retrospectively reviewed (n = 103). Surgical outcomes, including flap complication rate, flap revision rate, and long-term bony complications, were analyzed serially in accordance with time interval until coverage using the receiver operating characteristic (ROC) curve analysis. Significant factors with a p < 0.05 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors.
Results A total of 46 patients (33 males and 13 females) were finally included in the study. Based on the association between surgical timing and flap-related complication rate, the best cutoff period for surgery was 33 days, with an area under the curve of 0.658 (p = 0.040). Further, in the revision rate, the cutoff period was identified as 10 days (p = 0.016). Regarding the incidence of bony complications, ROC curve showed that the maximal period until operation was 91 days with no influence on the occurrence of bony complications (p = 0.029).
Conclusion Although the best method is an early reconstruction, many modalities such as negative pressure wound therapy play a role as a temporary measure. Our study suggests that the acute or early period for successful reconstruction might be extended compared with previous studies.
Received: 21 April 2020
Accepted: 25 August 2020
14 October 2020 (online)
© 2020. Thieme. All rights reserved.
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 Liu DS, Sofiadellis F, Ashton M, MacGill K, Webb A. Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma. Injury 2012; 43 (06) 772-778
- 2 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
- 3 Byrd HS, Spicer TE, Cierney III G. Management of open tibial fractures. Plast Reconstr Surg 1985; 76 (05) 719-730
- 4 Cierny III G, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. Clin Orthop Relat Res 1983; (178) 54-63
- 5 Sinclair JS, McNally MA, Small JO, Yeates HA. Primary free-flap cover of open tibial fractures. Injury 1997; 28 (9-10): 581-587
- 6 Small JO, Mollan RA. Management of the soft tissues in open tibial fractures. Br J Plast Surg 1992; 45 (08) 571-577
- 7 Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000; 82 (07) 959-966
- 8 Hertel R, Lambert SM, Müller S, Ballmer FT, Ganz R. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg 1999; 119 (1-2): 7-12
- 9 Singh DP, Gabriel A, Parvizi J, Gardner MJ, D'Agostino Jr R. Meta-analysis of comparative trials evaluating a single-use closed-incision negative-pressure therapy system. Plast Reconstr Surg 2019; 143 (1S Management of Surgical Incisions Utilizing Closed-Incision Negative-Pressure Therapy): 41S-46S
- 10 Heitzmann LG, Battisti R, Rodrigues AF, Lestingi JV, Cavazzana C, Queiroz RD. Postoperative chronic osteomyelitis in the long bones—current knowledge and management of the problem. Rev Bras Ortop (Sao Paulo) 2019; 54 (06) 627-635
- 11 Raju A, Ooi A, Ong YS, Tan BK. Traumatic lower limb injury and microsurgical free flap reconstruction with the use of negative pressure wound therapy: is timing crucial?. J Reconstr Microsurg 2014; 30 (06) 427-430
- 12 Cherubino M, Valdatta L, Tos P. et al. Role of negative pressure therapy as damage control in soft tissue reconstruction for open tibial fractures. J Reconstr Microsurg 2017; 33 (S01): S08-S13
- 13 Patterson CW, Stalder MW, Richardson W, Steele T, Wise MW, St Hilaire H. Timing of free flaps for traumatic wounds of the lower extremity: have advances in perioperative care changed the treatment algorithm?. J Reconstr Microsurg 2019; 35 (08) 616-621
- 14 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 (01) 1-14
- 15 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 (03) 478-487 , discussion 488–489
- 16 Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg 2018; 52 (05) 259-264
- 17 Lee ZH, Stranix JT, Rifkin WJ. et al. Timing of microsurgical reconstruction in lower extremity trauma: an update of the Godina paradigm. Plast Reconstr Surg 2019; 144 (03) 759-767
- 18 Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: a review. J Clin Orthop Trauma 2019; 10 (05) 845-848
- 19 Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy—worse or worth?. J Plast Reconstr Aesthet Surg 2009; 62 (05) 675-683
- 20 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (08) 632-634
- 21 Li RG, Ren GH, Tan XJ, Yu B, Hu JJ. Free flap transplantation combined with skin grafting and vacuum sealing drainage for repair of circumferential or sub-circumferential soft-tissue wounds of the lower leg. Med Sci Monit 2013; 19: 510-517
- 22 Rinker B, Amspacher JC, Wilson PC, Vasconez HC. Subatmospheric pressure dressing as a bridge to free tissue transfer in the treatment of open tibia fractures. Plast Reconstr Surg 2008; 121 (05) 1664-1673
- 23 Colen DL, Colen LB, Levin LS, Kovach SJ. Godina's principles in the twenty-first century and the evolution of lower extremity trauma reconstruction. J Reconstr Microsurg 2018; 34 (08) 563-571
- 24 Haykal S, Roy M, Patel A. Meta-analysis of timing for microsurgical free-flap reconstruction for lower limb injury: evaluation of the Godina principles. J Reconstr Microsurg 2018; 34 (04) 277-292