SLR - December 2011 - Nicholas R. Schmerbach
Reference: Shi Hao Liu, D., Sofiadellis, F., Ashton, M., MacGill, K., & Webb, A. (2011). Early soft tissue coverage and negative pressure wound therapy optimizes patient outcomes in lower limb trauma. Injury.
Scientific Literature Review
Reviewed by: Nicholas R. Schmerbach, DPM
Residency Program: Columbia St. Mary’s Hospital, Milwaukee, WI
Podiatric Relevance:
The timing of soft tissue coverage in lower extremity trauma is important for overall patient outcomes and can greatly influence the amount and types of complications that may result after a lower extremity trauma. This article looks at the issue of timing of soft tissue coverage as well as the use of negative pressure wound therapy to potentially aid in delayed closure situations.
Methods:
This is a retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma center between June 2002 and July 2009. The article looked at 103 consecutive patients who underwent 105 free-flap reconstructions during the time period. The data compiled for each patient was made up of patient characteristics, trauma mechanisms, Injury Severity Score (ISS), Gustilo and Anderson (GA) grading of fracture severity, American Society of Anesthesiology (ASA) score, injury locations, time of presentation and reconstruction, presence of exposed hardware and wound infection prior to free-flap reconstruction, use of NPWT, the methods, outcomes and complications of fracture fixation and free-flap transfers encountered during index treatment until one-year follow-up. Of the 103 total patients reviewed, 78 patients underwent negative pressure wound therapy (NPWT) and 25 patients received moist gauze dressings to open fractures prior to free-flap coverage.
Results:
Of the 105 free-flaps reviewed, there were 3 (2.9%) total and 12 (11.4%) partial flap failures. Soft tissue infection was present in all flap failures. At one-year follow-up, 20 (19.0%) patients were unable to fully weight bear and 25 (23.8%) had radiographic evidence of non-union. There were a total of 13 (12.4%) patients that developed osteomyelitis and 7 (6.7%) that required an amputation. Rates of complications including flap take-back, deep metal infection and osteomyelitis were significantly higher in patients who were reconstructed more than 7 days after the initial injury compared to with those that were reconstructed within the first 3 days following the initial injury. There was no significant difference in the rate of flap failure, fracture non-union and weight bearing capacity in patients who were reconstructed after 7 days compared to within 3 days from injury. Delayed reconstruction had a close association with a greater number of total operations and procedures performed after free-flap transfer and as a result a greater amount of total operating time as well as hospital stay. The rate of flap take-back was significantly lower in the NPWT group. It was noticed that there were higher rates of flap failure, deep metal infection and osteomyelitis observed in patients treated with NPWT. Despite NPWT, the rate of flap take-back, deep metal infection and osteomyelitis was significantly higher in patients reconstructed after 7 days from injury compared with within 3 days.
Conclusions:
The primary conclusions from this study included free-flaps transferred within 3 days from injury and immediate coverage of exposed hardware optimized surgical outcomes and minimized resource utilization, free-flaps transferred beyond 7 days from injury and hardware exposed beyond 1 day significantly increased the rate of surgical complications, delayed free-flap transfer and prolonged hardware exposure beyond 7 days were associated with a marked increase in pre-flap wound infection which independently predicted adverse surgical outcomes and NPWT reduced the rate of flap take-back but was associated with an increased rate of flap failure, deep metal infection and osteomyelitis. NPWT did not prevent a rise in surgical complications when free-flap transfer was delayed beyond 7 days from injury. These findings all support the theory of early soft tissue coverage of open fractures, ideally at the time of fixation. Soft tissue reconstruction should be undertaken within 7 days of injury as further delays risk unacceptably high short- and long-term complication rates. NPWT may provide effective temporary wound coverage, but it is not a solution for avoiding complications.