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Background: The Gustilo classification serves as a proxy for injury severity, but recent data suggest rising complications with decreasing arterial runoff. This study aims to compare different microsurgical anastomosis options based on the number of patent vessels in the lower extremity., Methods: A single-center retrospective review of 806 lower extremity free flaps performed from 1976 to 2016 was performed. Patients with Gustilo type IIIB injuries were grouped based on the number of patent vessels in the leg (three, two, or one). Patients were compared based on the type of anastomosis performed, evaluating for perioperative complications and flap failures., Results: Perioperative complications occurred in 111 flaps (27 percent): 71 take-backs (17 percent), 45 partial losses (11 percent), and 37 complete losses (9 percent). Among patients with three-vessel runoff (61.8 percent), there was no difference in take-backs or flap loss between those with end-to-end versus end-to-side anastomoses. In 68 patients (18.7 percent) with two-vessel runoff, no difference between take-backs or flap loss was noted when comparing any anastomosis (i.e., end-to-end into an injured vessel, end-to-end into an uninjured vessel, or end-to-side into an uninjured vessel), although vein grafts were required more often in the end-to-side groups (p < 0.01). Finally, in 39 patients (10.7 percent) with single-vessel runoff, no difference was seen between end-to-end anastomosis into an injured vessel or end-to-side anastomosis into an uninjured vessel in terms of take-backs or flap loss., Conclusion: Higher rates of flap failure correlated with decreasing numbers of patent vessels in the leg, but neither type of microvascular anastomosis nor vessel selection demonstrated any impact on reconstructive outcomes., Clinical Question/level of Evidence: Therapeutic, III.

Background:  Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand-sewn venous anastomoses in traumatic lower extremity reconstruction., Methods:  Retrospective review of our institutional flap registry from 1979 to 2016 identified soft tissue free flaps performed for the reconstruction of Gustilo type IIIB/IIIC open tibial fractures. Patient demographics, flap characteristics, use of a venous anastomotic coupler, and perioperative outcomes were examined. Analysis was performed using chi-square and Student's t -tests., Results:  A total of 361 patients received a microvascular free flap for coverage of a Gustilo type IIIB or IIIC tibial fracture following traumatic injury. After excluding cases that lacked adequate information on coupler use, 358 free flaps were included in the study. There were 72 (20%) free flaps performed using a venous coupler and 286 (80%) performed with hand-sewn venous anastomoses. There were comparable rates of major complications (22.2 vs. 26.1%; p  = 0.522), total flap failure (6.5%, vs. 10.2%; p  = 0.362), and partial flap failure (9.7 vs. 12.2%; p  = 0.579) between venous coupler and hand-sewn anastomoses, respectively. Furthermore, use of the venous coupler was not associated with increased rates of operative take backs (22.8 vs. 23.0%; p  = 0.974). However, reconstructions performed using a venous coupler were significantly more likely to have a second venous anastomosis performed (37.5 vs. 21.3%; p  = 0.004)., Conclusion:  Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand-sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction., Methods: Retrospective review between 1979 and 2016 identified 361 soft tissue flaps performed for Gustilo IIIB/C coverage meeting inclusion criteria. Muscle flaps were performed in 287 cases (79.9%) and fasciocutaneous flaps in 72 cases (20.1%). Single-vein anastomosis was performed in 76% of cases and dual-vein anastmoses in 24% of cases. Patient demographics, flap characteristics, and outcomes were examined., Results: Fasciocutaneous flaps were more likely to have two veins performed (P < .001). Complications occurred in 143 flaps (39.8%): 45 take-backs (12.4%), 37 partial losses (10.3%), 31 complete losses (8.6%). Compared to single-vein flaps, two veins reduced major complications (P = .005), partial flap failures (P = .008), and any flap failure (P = .018). Multivariable regression analysis demonstrated two veins to be protective against complications (RR = 2.58, P = .009). Subset regression analysis by flap type demonstrated an even more significant reduction in complications among muscle flaps (RR = 3.92, P = .005). Additionally, a >1 mm vein size mismatch was predictive of total flap failure (RR = 3.02, P = .038)., Conclusion: Lower extremity trauma free flaps with two venous anastomoses demonstrated a fourfold reduction in complication rates compared to single-vein flaps. Additionally, venous size mismatch >1 mm was an independent predictor of total flap failure, suggesting beneficial effects of both two-vein outflow and matched vessel diameter., (© 2017 Wiley Periodicals, Inc.)

Purpose: Free tissue transfer after lower extremity trauma is associated with notoriously high complication rates. Theoretically, the inclusion of a cutaneous paddle on muscle free flaps may improve clinical flap monitoring. The effect of skin paddle presence on muscle free flap salvage outcomes after take-back was examined., Methods: Retrospective query of our institutional free-flap registry (1979-2016) identified 362 muscle-based flaps performed for soft tissue coverage after below-knee trauma. Primary outcome measures were perioperative complications, specifically take-back indications, timing, and flap salvage rates. Univariate and multivariate regression analyses were performed where appropriate., Results: The most common flaps were latissimus dorsi (166; 45.9%), rectus abdominis (123; 34%), and gracilis (42; 11.6%) with 90 flaps (24.9%) including skin paddles. Take-backs for vascular compromise occurred in 44 flaps (12.2%), of which 39% contained a skin paddle while 61% did not. Overall salvage rate was 20.5%, with 31.8% partial failures and 47.7% total flap losses. Muscle flaps with skin paddles were more likely to return to the operating room within 48 hours postoperatively than those without (57.1% vs 18.2%, P = 0.036). After take-back, significantly more muscle flaps with skin paddles were salvaged compared with muscle flaps without paddles (35.7% vs 4.5%, P = 0.024). Similarly, more muscle-only flaps after take-back failed compared with their counterparts with skin paddles (95.5% vs 65.3%, P = 0.024)., Conclusions: Muscle flaps with a cutaneous paddle were associated with earlier return to the operating room and more successful flap salvage after take-back compared with muscle-only flaps. These findings suggest that skin paddle presence may improve clinical flap monitoring and promote recognition and treatment of microvascular compromise in lower extremity reconstruction.

Background:  Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes., Methods:  Retrospective review (1979-2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed., Results:  More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses ( p  = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p  = 0.978) or total flap failures (9.3% vs 9.3%; p  = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis ( p  = 0.58) and weighted comparative analysis ( p  = 0.39) found no difference in flap failure rates between proximal and distal groups., Conclusion:  Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Considering that muscle has higher metabolic demand than fasciocutaneous tissue and can be more difficult to monitor clinically, the authors compared take-back salvage rates between fasciocutaneous and muscle free flaps for lower extremity trauma reconstruction., Methods: The authors conducted a retrospective review of 806 free flaps (1979 to 2016); 481 soft-tissue flaps performed for below-knee trauma met inclusion criteria. Primary outcome measures were perioperative complications, specifically, take-backs and flap salvage rates. Univariate and multivariate regression analysis was performed where appropriate., Results: Take-backs occurred in 71 flaps (muscle, n = 44; fasciocutaneous, n = 27) at an average of 3.7 ± 5.4 days postoperatively. Indications were venous (48 percent), arterial (31 percent), unknown (10 percent), and hematoma (10 percent). Overall outcomes were complete salvage (37 percent), partial failure (25 percent), and total failure (38 percent). Take-backs occurring within 48 hours postoperatively correlated with higher salvage rates (p = 0.022). Fasciocutaneous flaps demonstrated increased take-back rates compared with muscle flaps (p = 0.005) that more frequently occurred within 48 hours postoperatively (relative risk, 13.2; p = 0.012). Fasciocutaneous flaps were successfully salvaged more often than muscle-based flaps (p < 0.001). Multivariable regression strongly demonstrated higher risk of take-back failure for muscle flaps (relative risk, 9.42; p = 0.001), despite higher take-back rates among fasciocutaneous flaps (relative risk, 2.28; p = 0.004)., Conclusions: Compared with muscle-based flaps, fasciocutaneous flaps demonstrated earlier and more frequent take-backs for suspected vascular compromise, with higher successful take-back salvage rates. Furthermore, muscle flaps with skin paddles also demonstrated better salvage outcomes than those without. These findings may reflect a combination of lower metabolic demand and easier visual recognition of vascular compromise in fasciocutaneous tissue., Clinical Question/level of Evidence: Therapeutic, III.

Background: Open tibia fractures are commonly stratified by the Gustilo classification, an orthopedic grading system that does not incorporate the presence of arterial injury when limb perfusion is intact. In the authors' experience, however, the presence of arterial injury appears to negatively impact microsurgical outcomes., Methods: In a retrospective review of 806 lower extremity reconstructions between 1979 and 2016, 361 soft-tissue flaps performed for Gustilo type IIIB/C coverage met inclusion criteria. Patient demographics, flap characteristics, and outcomes were analyzed., Results: Most patients suffered type IIIB [n = 332 (91.9 percent)] injuries; 29 (8.0 percent) had type IIIC injuries. Preoperative angiography [n = 243 (67.3 percent)] demonstrated arterial injury in 126 (51.8 percent); 27 arterial injuries were identified intraoperatively; and the overall incidence was 153 of 361 (42.4 percent). Complications occurred in 143 flaps (39.6 percent) and included 37 partial losses (10.2 percent) and 31 total losses (8.6 percent). Injured recipient arteries [n = 62 (17.2 percent)] had more complications (p = 0.004); specifically, increased take-backs (p = 0.009). Decreasing vessel runoff increased the risk of complications (p = 0.025), take-backs (p = 0.007), and total flap failures (p = 0.024) accordingly. Specifically, among grade IIIB injuries, controlling for age, sex, time since injury, and vein number, single-vessel runoff was associated with higher rates of complications (relative risk, 3.07; p = 0.012), take-backs (relative risk, 3.43; p = 0.013), and total flap failures (relative risk, 4.80; p = 0.010) compared with three-vessel runoff., Conclusions: Arterial injury was common among Gustilo type IIIB patients and correlated with increased reconstructive complications. Nonischemic arterial injury appears to negatively impact reconstructive outcomes and should be accounted for when considering free tissue transfer for lower extremity salvage. The authors propose a 3-2-1 modification of the Gustilo type IIIB classification to incorporate degree of arterial injury, as it appears to add prognostic value and certainly influences the reconstructive plan., Clinical Question/level of Evidence: Risk, IV.