ABSTRACT
Microvascular free-tissue transfer has been a major advance in the treatment of complex
traumatic defects of the upper extremity. One hundred and fifty microvascular free-tissue
transfers were performed in 133 patients with complex traumatic upper extremity defects
at Bellevue Hospital Center from 1976 to 2000. The indication for microvascular free
tissue transfers was exposure of vital structure (81 percent), bone defect (11 percent),
and functional deficit (8 percent). The parascapular region was the most common donor
site used (26 percent). Microvascular free-tissue transfer was performed either emergently
at the time of injury (9.3 percent), during days 1 to 5 post injury (19.3 percent),
during days 6 to 21 (19.3 percent), or after day 21 (52 percent). The overall flap
failure rate was 9 percent. A decreased incidence of flap failure was observed in
patients treated from 6 to 21 days post injury (3 percent p<0.05). The most common acute complication was infection at the recipient site, observed
in 14 percent of patients overall. A decreased incidence of recipient-site infection
was seen in patients who received free flaps at days 6 to 21 (3 percent; p<0.05). In long-term follow-up, the incidences of osteomyelitis and nonunion were
lowest in patients treated from 6 to 21 days post injury (0.0 percent and 11 percent,
respectively; p<0.05). During the last 10 years, the timing of reconstruction has been altered, and
now preferentially microvascular free flaps are performed 6 to 21 days post injury.
The treatment algorithm has been simplified and now only four different flaps are
used in the majority of patients (70 percent). With this, the authors have witnessed
a decrease in failure rates from 11 percent to 4 percent, a decrease in recipient-site
infections from 16 percent to 10 percent and a decrease in osteomyelitis from 12 percent
to 4 percent. The preferred timing for microvascular free-tissue transfers to the
upper extremity is concluded to be 6 to 21 days post injury.
KEYWORDS
Trauma - upper extremity - free flap - reconstruction
