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J Reconstr Microsurg 2015; 31(06): 414-419
DOI: 10.1055/s-0035-1548550
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Impact of Timing of Admission and Microvascular Reconstruction on Free Flap Success Rates in Traumatic Upper Extremity Defects

Jonas Kolbenschlag
1   Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
2   Department for Hand, Plastic and Reconstructive Surgery, BG Trauma Center, Ludwigshafen, Germany
,
Marek Klinkenberg
2   Department for Hand, Plastic and Reconstructive Surgery, BG Trauma Center, Ludwigshafen, Germany
,
Susanne Hellmich
2   Department for Hand, Plastic and Reconstructive Surgery, BG Trauma Center, Ludwigshafen, Germany
3   Department of Plastic and Reconstructive Surgery, Protestant Hospital Göttingen – Weende, Göttingen, Germany
,
Günter Germann
4   Ethianum Clinic for Plastic and Reconstructive Surgery, Aesthetic and Preventive, Heidelberg, Germany
,
Kai Megerle
2   Department for Hand, Plastic and Reconstructive Surgery, BG Trauma Center, Ludwigshafen, Germany
5   Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
› Author Affiliations
Further Information

Publication History

30 December 2014

04 February 2015

Publication Date:
24 March 2015 (online)

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Abstract

Background Despite a growing body of knowledge, the timing of microsurgical reconstruction for the upper extremity remains a controversial topic. Most of the available literature deals with lower extremity reconstruction and the few reports on microsurgical reconstruction of the upper extremity are mostly concerned with infection rates and rarely consider thrombosis and changes in coagulation parameters.

Methods We performed a retrospective review of all free flaps performed for upper extremity reconstruction at our institution from 2000 to 2010. Only acute, isolated traumatic defects of the upper extremity requiring a free flap for reconstruction were included in this study. A review of medical records was performed to assess, among others, comorbidities, timing of reconstruction, and platelet levels.

Results A total of 41 patients were included in this study, 70% of whom were male. Mean age at the time of surgery was 40.8 ± 15.4 years. Patients who were directly referred to our hospital underwent reconstruction significantly faster than those who were transferred secondarily (p = 0.0001). The number of surgical revisions as well as the flap loss rate was higher in patients undergoing reconstruction more than 1 week after trauma (p = 0.09 and 0.033, respectively). A significantly higher platelet count was seen in the patients undergoing delayed reconstruction (p = 0.002).

Conclusion In our study, early microsurgical reconstruction of the upper extremity yielded better results in terms of lower rates of surgical revisions and flap loss. This might be partly because of a trauma-induced thrombocythemia, with a maximum level of platelets in the 2nd week post trauma. We, therefore, advocate a timely coverage of these defects along with an anticoagulatory regimen including some form of platelet inhibition.

Keywords

free flap - timing - microsurgical reconstruction - upper extremity - coagulation - platelets - trauma
 

  • References

  • 1 Culliford IV AT, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59 (1) 18-21 , discussion 21–22
    CrossrefPubMedGoogle Scholar
  • 2 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (7) 2219-2226 , discussion 2227–2230
    Google Scholar
  • 3 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (3) 285-292
    CrossrefPubMedGoogle Scholar
  • 4 Fischer JP, Wink JD, Nelson JA , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (6) 407-416
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Hill JB, Vogel JE, Sexton KW, Guillamondegui OD, Corral GA, Shack RB. Re-evaluating the paradigm of early free flap coverage in lower extremity trauma. Microsurgery 2013; 33 (1) 9-13
    CrossrefPubMedGoogle Scholar
  • 6 Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008; 28 (8) 632-634
    CrossrefPubMedGoogle Scholar
  • 7 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 (6) 772-778
    CrossrefPubMedGoogle Scholar
  • 8 Harrison BL, Lakhiani C, Lee MR, Saint-Cyr M. Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report. Plast Reconstr Surg 2013; 132 (3) 591-596
    CrossrefPubMedGoogle Scholar
  • 9 Vetter M, Germann G, Bickert B, Sauerbier M. Current strategies for sarcoma reconstruction at the forearm and hand. J Reconstr Microsurg 2010; 26 (7) 455-460
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Sauerbier M, Ofer N, Germann G, Baumeister S. Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity. Plast Reconstr Surg 2007; 119 (2) 605-615
    CrossrefPubMedGoogle Scholar
  • 11 Baccarani A, Follmar KE, De Santis G , et al. Free vascularized tissue transfer to preserve upper extremity amputation levels. Plast Reconstr Surg 2007; 120 (4) 971-981
    CrossrefPubMedGoogle Scholar
  • 12 Galanakos SP, Bot AG, Zoubos AB, Soucacos PN. Psychological and social consequences after reconstruction of upper extremity trauma: methods of detection and management. J Reconstr Microsurg 2014; 30 (3) 193-206
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Henry M. Degloving combined with structural trauma at the digital level: functional coverage with fascial free flaps. J Reconstr Microsurg 2007; 23 (2) 59-62
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Kremer T, Bickert B, Germann G, Heitmann C, Sauerbier M. Outcome assessment after reconstruction of complex defects of the forearm and hand with osteocutaneous free flaps. Plast Reconstr Surg 2006; 118 (2) 443-454 , discussion 455–456
    CrossrefPubMedGoogle Scholar
  • 15 Georgescu AV, Ivan O. Emergency free flaps. Microsurgery 2003; 23 (3) 206-216
    CrossrefPubMedGoogle Scholar
  • 16 Ninkovic M, Deetjen H, Ohler K, Anderl H. Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg [Br] 1995; 20 (1) 53-58
    CrossrefPubMedGoogle Scholar
  • 17 Brenner P, Lassner F, Becker M, Berger A. Timing of free microsurgical tissue transfer for the acute phase of hand injuries. Scand J Plast Reconstr Surg Hand Surg 1997; 31 (2) 165-170
    CrossrefPubMedGoogle Scholar
  • 18 Derderian CA, Olivier W-AM, Baux G, Levine J, Gurtner GC. Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience. J Reconstr Microsurg 2003; 19 (7) 455-462
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma 2009; 67 (4) 752-757
    CrossrefPubMedGoogle Scholar
  • 20 White NJ. Mechanisms of trauma-induced coagulopathy. Hematology Am Soc Hematol Educ Program 2013; 2013: 660-663
    CrossrefPubMedGoogle Scholar
  • 21 Fuse I. Disorders of platelet function. Crit Rev Oncol Hematol 1996; 22 (1) 1-25
    CrossrefPubMedGoogle Scholar
  • 22 Kutcher ME, Redick BJ, McCreery RC , et al. Characterization of platelet dysfunction after trauma. J Trauma Acute Care Surg 2012; 73 (1) 13-19
    CrossrefPubMedGoogle Scholar
  • 23 Marck RE, Montagne HL, Tuinebreijer WE, Breederveld RS. Time course of thrombocytes in burn patients and its predictive value for outcome. Burns 2013; 39 (4) 714-722
    CrossrefPubMedGoogle Scholar
  • 24 Davenport RA, Brohi K. Coagulopathy in trauma patients: importance of thrombocyte function?. Curr Opin Anaesthesiol 2009; 22 (2) 261-266
    CrossrefPubMedGoogle Scholar
  • 25 Furie B, Furie BC. Mechanisms of thrombus formation. N Engl J Med 2008; 359 (9) 938-949
    CrossrefPubMedGoogle Scholar
  • 26 Kolbenschlag J, Daigeler A, Lauer S , et al. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery?. Microsurgery 2014; 34 (4) 253-260
    CrossrefPubMedGoogle Scholar
  • 27 Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower-extremity free tissue transfer I: perioperative anticoagulation. Ann Plast Surg 2007; 59 (3) 311-315
    CrossrefPubMedGoogle Scholar
  • 28 Jokuszies A, Radtke C, Herold C, Vaske B, Vogt PM , Microsurgery Reporting Group. A survey of anticoagulation practice among German speaking microsurgeons—Perioperative management of anticoagulant therapy in free flap surgery. GMS Ger Plast Reconstr Aesthet Surg 2012; (2) Doc03
    PubMedGoogle Scholar
  • 29 Mirhosseini SJ, Forouzannia SK, Mostafavi Pour Manshadi SM, Ali-Hassan-Sayegh S, Naderi N, Sanatkar M. Comparison of aspirin plus heparin with heparin alone on asymptomatic perioperative deep vein thrombosis in candidates for elective off-pump coronary artery bypass graft: a randomized clinical trial. Cardiol J 2013; 20 (2) 139-143
    PubMedGoogle Scholar
  • 30 Devereaux PJ, Mrkobrada M, Sessler DI , et al; POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370 (16) 1494-1503
    CrossrefPubMedGoogle Scholar
  • 31 Kanzaki R, Inoue M, Minami M , et al. Feasibility of aspirin continuation during the perioperative period for pulmonary resection in lung cancer patients: a retrospective study at a single institute in Japan. Surg Today 2014; 44 (12) 2243-2248
    CrossrefPubMedGoogle Scholar
  • 32 Rossini R, Musumeci G, Visconti LO , et al; Italian Society of Invasive Cardiology (SICI-GISE); Italian Association of Hospital Cardiologists (ANMCO); Italian Society for Cardiac Surgery (SICCH); Italian Society of Vascular and Endovascular Surgery (SICVE); Italian Association of Hospital Surgeons (ACOI); Italian Society of Surgery (SIC); Italian Society of Anaesthesia and Intensive Care Medicine (SIAARTI); Lombard Society of Surgery (SLC); Italian Society of Maxillofacial Surgery (SICMF); Italian Society of Reconstructive Plastic Surgery and Aesthetics (SICPRE); Italian Society of Thoracic Surgeons (SICT); Italian Society of Urology (SIU); Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Periodontology (SIdP); Italian Federation of Scientific Societies of Digestive System Diseases Lombardia (FISMAD); Association of Obstetricians Gynaecologists Italian Hospital Lombardia (AOGOI); Society of Ophthalmology Lombardia (SOL). Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. EuroIntervention 2014; 10 (1) 38-46
    CrossrefPubMedGoogle Scholar
  • 33 Sahebally SM, Healy D, Coffey JC, Walsh SR. Should patients taking aspirin for secondary prevention continue or discontinue the medication prior to elective, abdominal surgery? Best evidence topic (BET). Int J Surg 2014; 12 (5) 16-21
    CrossrefPubMedGoogle Scholar
  • 34 Wolf AM, Pucci MJ, Gabale SD , et al. Safety of perioperative aspirin therapy in pancreatic operations. Surgery 2014; 155 (1) 39-46
    CrossrefPubMedGoogle Scholar
  • 35 Yamamoto K, Wada H, Sakakura K , et al. Cardiovascular and bleeding risk of non-cardiac surgery in patients on antiplatelet therapy. J Cardiol 2014; 64 (5) 334-338
    CrossrefPubMedGoogle Scholar
  • 36 Enajat M, Aziz Mohammadi M, Debeij J, van der Hulst RR, Mureau MA. Effect of acetylsalicylic acid on microvascular thrombosis in autologous breast reconstruction. J Reconstr Microsurg 2014; 30 (1) 65-70
    PubMedGoogle Scholar
  • 37 Cho EH, Ligh C, Hodulik KL, Hollenbeck ST. Role of platelet inhibition in microvascular surgery. J Reconstr Microsurg 2014; 30 (9) 589-598
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Brinkman JN, Derks LH, Klimek M, Mureau MA. Perioperative fluid management and use of vasoactive and antithrombotic agents in free flap surgery: a literature review and clinical recommendations. J Reconstr Microsurg 2013; 29 (6) 357-366
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 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 (6) 427-430
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Rugeri L, Levrat A, David JS , et al. Diagnosis of early coagulation abnormalities in trauma patients by rotation thrombelastography. J Thromb Haemost 2007; 5 (2) 289-295
    CrossrefPubMedGoogle Scholar
  • 41 Goertz O, Kapalschinski N, Skorzinski T , et al. Wound healing complications in smokers, non-smokers and after abstinence from smoking [in German]. Chirurg 2012; 83 (7) 652-656
    CrossrefPubMedGoogle Scholar