Background: The timing of free flap reconstruction (FFR) after lower extremity trauma has been a controversial debate since Marko Godina’s original 72 hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction. Other more recent studies have found that free flaps performed after the 72-hour mark are not associated with adverse flap outcomes. However, to date there have been no national-level analyses of free flap timing after lower extremity trauma. This study aimed to quantify the association of complications with respect to timing after injury at a national level.
Methods: The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing FFR for trauma. Risk-adjusted statistical analyses were used to identify risk of infectious (surgical site infection [SSI], osteomyelitis, sepsis), microsurgical, and general wound complications with respect to flap timing. Receiver operator curve (ROC) analysis was used to determine optimal time cutoff for each outcome.
Results: One-thousand and thirty patients undergoing FFR were identified. The median time to flap coverage was 7 (IQR 1-22) days. Thirty-three percent of the flaps were performed within 72 hours, 24% from 72 hours-10 days, 18% from 10-30 days, and 24% after 30 days (FIGURE 1A). Unadjusted analysis revealed significantly increased incidence of microsurgical (P=0.001), infectious (P<0.001), and general wound complications (P<0.001) in flaps performed after 10 days (FIGURE 1B). After controlling for confounders, flaps performed after 10 days were associated with increased risk of SSI (OR 9.57 [95% CI: 3.84-23.83], P<0.001), osteomyelitis (OR 5.24 [95% CI: 1.18-23.33], P=0.030), and composite wound (OR 3.26 [95% CI: 1.36-7.83], P=0.008) complications compared to those performed within 72 hours. Flaps performed between 72 hours and 10 days were not associated with increased risk of any adverse outcomes (all P>0.05). ROC analysis suggested flap coverage by 13.5 days and 9.5 days to optimize infectious and microsurgical complications respectively.
Conclusions: Recent advances in microsurgery appear to have extended the time in which definitive soft tissue coverage is required for lower extremity trauma. However, efforts should continue to be made to achieve timely referral of patients to specialty hospitals such as orthoplastic limb salvage centers in order to perform free flap reconstruction within 10 days to optimize outcomes.