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Background: Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries., Methods: A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel., Results: A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries., Conclusion: Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries., Clinical Question/level of Evidence: Therapeutic, IV.

Background  There are many different variables to consider in lower extremity microvascular soft tissue reconstruction including flap choice. Our aim is to objectively evaluate recipient complications related to lower extremity donor flap laterality. Methods  A total of 77 lower extremity soft tissue reconstructions utilizing microvascular free tissue transfers for Gustilo type III between 1979 and 2016 were collected. We compared complication rates between ipsilateral and contralateral donor sites relative to the injured leg. The following parameters were analyzed: overall complications, total flap failure, partial flap failure, major complications, operative takebacks, and salvage rates. Results  In this study, 25 ipsilateral reconstructions were performed, while 52 cases utilized the contralateral leg. Overall complication rates were higher in the ipsilateral group (40.0%) compared with the contralateral side (23.1%) but were not statistically significant (p  = 0.12). The ipsilateral group was four times as likely to experience vascular compromise (24.0 vs. 5.8%; p  = 0.05). However, there were no significant differences in complications, flap failures or flap survival. Mean operative time was significantly greater in the same side group as compared with the contralateral group (11.3 vs. 7.5 hours; p  = 0.006). Conclusion  Although there is a higher risk of anastomotic thrombosis, particularly venous thrombosis, associated with ipsilateral donor-site group, there were no significant differences in complications or flap survival. Flaps can be harvested from a traumatized leg with acceptable complication rates while avoiding the morbidity of operating on an uninjured limb. [ABSTRACT FROM AUTHOR]

Microsurgical free tissue transfer is an important treatment option for nonhealing lower extremity diabetic wounds. The purpose of this study was to identify factors that affect flap survival and wound complications. A retrospective review was conducted of 806 lower extremity free-flap reconstructions performed from 1979 to 2016. A total of 33 free flaps were used for coverage of nonhealing lower-extremity diabetic ulcers. Primary outcome measures were perioperative complications and long-term wound breakdown. The average age was 54 ± 12.3 y. 15.2% of patients were smokers, 12.1% had coronary artery disease and 12.1% had end-stage renal disease. Muscle flaps predominated (75.8%) compared to fasciocutaneous flaps (24.2%). There were 7 patients (21.2%) that underwent a revascularization procedure before (71.4%) or at the same time (28.6%) as the free flap. Immediate complications occurred in 7 flaps (21.2%) with 4 partial losses (12.1%) and 3 total flap failures (9.1%). Major wound complications occurred in 18.2% of patients. An end-to-side (E-S) anastomosis for the artery was used in 63.6% (n = 22) of flaps compared with an end-to-end (E-E) anastomosis. E-S anastomosis was associated with a significantly lower risk of wound complications compared with an arterial E-E anastomosis (0% versus 45.5%, P = 0.001). The use of microvascular free flaps can be used successfully to cover lower-extremity diabetic wounds. E-E arterial anastomosis should be avoided if possible as it is associated with higher rates of wound breakdown, likely by impairing perfusion to a distal limb with an already compromised vasculature. Level III. [ABSTRACT FROM AUTHOR]

Background  The distal lower extremity poses unique reconstructive challenges due to its requirements for durability of the load-bearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. This study compares outcomes between muscle and fasciocutaneous flaps in patients with foot and ankle defects. Methods  A retrospective review of soft tissue free flaps used for traumatic foot and ankle defects was performed. Outcomes included takebacks, partial flap failure, total flap failure, and wound complications. Results  A total of 165 cases met inclusion criteria, with muscle flaps (n  = 110) comprising the majority. Defects involving the non–weight-bearing surface were more common (n  = 86) than those of the weight-bearing surface (n  = 79). Complications occurred in 56 flaps (33.9%), including 11 partial losses (6.7%) and 6 complete losses (3.6%). There were no differences in take backs, partial flap failure, or total flap failure between muscle and fasciocutaneous flaps; however, fasciocutaneous flaps had significantly fewer wound complications compared with muscle flaps (7.3% vs. 19.1%, p  = 0.046). On multivariable regression analysis, defects of the weight-bearing surface had significantly increased risk of wound breakdown compared with those in the non–weight-bearing surface (odds ratio: 5.05, p  = 0.004). Conclusion  Compared with fasciocutaneous flaps, muscle flaps demonstrated higher rates of wound complications. While the flap selection in foot and ankle reconstruction depends on the nature of the defect, our findings support the use of fasciocutaneous over muscle flaps in this region. [ABSTRACT FROM AUTHOR]

Background  Venous outflow problems are the most common reasons for perioperative flap complications. Size mismatch in venous anastomoses poses a theoretical problem by promoting turbulent flow and subsequent thrombus formation. The purpose of this study was to determine if increased vein size mismatch is predictive of flap failure. Methods  Retrospective review of our institutional flap registry from 1979 to 2016 identified 410 free flaps performed for reconstruction of lower extremity trauma. Patient demographics, flap characteristics, and flap outcomes were examined. Venous size mismatch was defined as a difference in size ≥ 1 mm between the recipient vein and flap vein. Results  Vein size mismatch ≥ 1mm was present in 17.1% (n  = 70) of patients. The majority of anastomoses were end-to-end (n  = 379, 92.4%), and end-to-side anastomoses were preferentially used in the presence of vein size mismatch (p  < 0.001). Major complications occurred in 119 (29%) flaps, with 35 (8.5%) partial flap losses and 34 (8.3%) total flap losses. Looking specifically at flaps with end-to-end venous anastomoses, venous size mismatch was associated with increased total flap failure (p  = 0.031) and takeback for vascular compromise (p  = 0.030). Recipient vein size relative to flap vein size (larger or smaller) had no effect on flap outcomes. Multivariable regression analysis controlling for age, sex, flap type, number of veins, recipient vein size, flap vein size, venous coupler use, and vein size mismatch demonstrated that flaps with ≥ 1 mm vein mismatch were predictive of total flap failure (p  = 0.045; odds ratio: 2.58). Conclusion  Flaps with vein size mismatch ≥ 1 mm demonstrated increased flap complication rates in the setting of end-to-end venous anastomoses. End-to-side anastomosis was preferentially used in vein size mismatch and carried a higher risk of flap failure. Our results support using veins of similar size for anastomosis whenever feasible to protect against flap complications. [ABSTRACT FROM AUTHOR]