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Risk assessment in delayed free flap reconstruction for severe lower extremity trauma

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European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Purpose

This study aims to identify serum biomarkers that contribute to vascular thrombosis and complete flap failure in delayed reconstruction with free flaps, as well as to develop a scoring system of risk assessment including these biomarkers.

Methods

A retrospective review of the database was conducted for lower extremity open fractures reconstructed between 7 and 90 days from injury, from March 2014 to February 2022. We investigated changes in platelet count (PLT), D-dimer, creatine phosphokinase (CPK), and C-reactive protein (CRP) and then, developed a risk assessment system including these biomarkers as risk factors.

Results

A total of 62 free flaps were enrolled, and vascular thrombosis occurred in 14 flaps (22.6%), 9 of which (14.5%) developed complete flap failure. The risk assessment score was set to a maximum of 6 points for 6 items: age ≤ 40 years, time from injury to coverage ≥ 14 days, zone of injury from middle to distal leg, D-dimer on the day of injury ≥ 60 µg/mL, maximum value of CPK ≥ 10,000 U/L, and maximum value of CRP ≥ 25 mg/dL. The best cutoff score was 3 in the vascular thrombosis model (sensitivity: 0.79, specificity: 0.77) and 4 in the complete flap failure model (sensitivity: 0.78, specificity: 0.92).

Conclusions

Our risk assessment system showed that the risk of vascular thrombosis was high at ≥ 3 points and that of complete flap failure was high at ≥ 4 points. Significantly, elevated levels of D-dimer, CPK, and CRP require more caution during reconstruction using free flaps.

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References

  1. Lee ZH, Stranix JT, Rifkin WJ, Daar DA, Anzai L, Ceradini DJ, Thanik V, Saadeh PB, Levine JP (2019) Timing of microsurgical reconstruction in lower extremity trauma: an update of the Godina paradigm. Plast Reconstr Surg 144(3):759–767. https://doi.org/10.1097/PRS.0000000000005955

    Article  CAS  PubMed  Google Scholar 

  2. Qiu E, Kurlander DE, Ghaznavi AM (2018) Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg 52(5):259–264. https://doi.org/10.1080/2000656X.2018.1470979

    Article  PubMed  Google Scholar 

  3. Lee SY, Seong IH (2021) When is the critical time for soft tissue reconstruction of open tibia fracture patients? J Reconstr Microsurg 37(3):249–255. https://doi.org/10.1055/s-0040-1717151

    Article  PubMed  Google Scholar 

  4. Rezzadeh KS, Nojan M, Buck A, Li A, Vardanian A, Crisera C, Festekjian J, Jarrahy R (2015) The use of negative pressure wound therapy in severe open lower extremity fractures: identifying the association between length of therapy and surgical outcomes. J Surg Res 199(2):726–731. https://doi.org/10.1016/j.jss.2015.06.004

    Article  PubMed  Google Scholar 

  5. Raju A, Ooi A, Ong YS, Tan BK (2014) Traumatic lower limb injury and microsurgical free flap reconstruction with the use of negative pressure wound therapy: is timing crucial? J Reconstr Microsurg 30(6):427–430. https://doi.org/10.1055/s-0034-1371510

    Article  PubMed  Google Scholar 

  6. Shimbo K, Shinomiya R, Sunagawa T, Okuhara Y, Adachi N (2022) Analysis of anastomotic venous factors in traumatic lower extremity injuries reconstructed by free flap. Cureus 14(1):e20978. https://doi.org/10.7759/cureus.20978

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lorenzo AR, Lin CH, Lin CH, Lin YT, Nguyen A, Hsu CC, Wei FC (2011) Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 64(5):649–655. https://doi.org/10.1016/j.bjps.2010.07.028

    Article  PubMed  Google Scholar 

  8. Cho EH, Garcia RM, Pien I, Kuchibhatla M, Levinson H, Erdmann D, Levin LS, Hollenbeck ST (2016) Vascular considerations in foot and ankle free tissue transfer: analysis of 231 free flaps. Microsurgery 36(4):276–283. https://doi.org/10.1002/micr.22406

    Article  PubMed  Google Scholar 

  9. Li D, Long F, Lei M (2019) Predictors affecting anterolateral thigh flap in reconstruction of upper extremity. Medicine 98(46):e17884. https://doi.org/10.1097/MD.0000000000017884

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Olsson E, Svartling N, Asko-Seljavaara S, Lassila R (2001) Activation of coagulation and fibrinolysis in microsurgical reconstructions in the lower extremities. Br J Plast Surg 54(7):597–603. https://doi.org/10.1054/bjps.2001.3687

    Article  CAS  PubMed  Google Scholar 

  11. Weitz JI, Fredenburgh JC, Eikelboom JW (2017) A test in context: D-dimer. J Am Coll Cardiol 70(19):2411–2420. https://doi.org/10.1016/j.jacc.2017.09.024

    Article  CAS  PubMed  Google Scholar 

  12. Asami M, Nakahara S, Miyake Y, Kanda J, Onuki T, Matsuno A, Sakamoto T (2022) Serum D-dimer level as a predictor of neurological functional prognosis in cases of head injuries caused by road traffic accidents. BMC Emerg Med 22(1):51. https://doi.org/10.1186/s12873-022-00613-9

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Pastore Neto M, Gonçalves RV, Machado CJ, Resende V (2018) Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis. Rev Col Bras Cir 45(2):e1604. https://doi.org/10.1590/0100-6991e-20181604

    Article  PubMed  Google Scholar 

  14. Sproston NR, Ashworth JJ (2018) Role of C-reactive protein at sites of inflammation and infection. Front Immunol 9:754. https://doi.org/10.3389/fimmu.2018.00754

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Lee A, Geoghegan L, Nolan G, Cooper K, Super J, Pearse M, Naique S, Hettiaratchy S, Jain A (2022) Open tibia/fibula in the elderly: a retrospective cohort study. JPRAS Open 31:1–9. https://doi.org/10.1016/j.jpra.2021.09.003

    Article  PubMed  Google Scholar 

  16. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ (1992) Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 89(3):478–487

    Article  CAS  PubMed  Google Scholar 

  17. Khouri RK, Shaw WW (1989) Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 29(8):1086–1094. https://doi.org/10.1097/00005373-198908000-00005

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We would like to thank Enago (www.enago.jp) for English language editing.

Funding

No funds, grants, or other support were received for this study.

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Authors and Affiliations

  1. Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, 5-54 Ujinakanda, Hiroshima, Japan

    Keisuke Shimbo

  2. Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan

    Rikuo Shinomiya, Toru Sunagawa & Nobuo Adachi

Authors
  1. Keisuke Shimbo
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  2. Rikuo Shinomiya
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  3. Toru Sunagawa
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  4. Nobuo Adachi
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Correspondence to Keisuke Shimbo.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Shimbo, K., Shinomiya, R., Sunagawa, T. et al. Risk assessment in delayed free flap reconstruction for severe lower extremity trauma. Eur J Orthop Surg Traumatol 33, 2515–2523 (2023). https://doi.org/10.1007/s00590-022-03467-w

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  • DOI: https://doi.org/10.1007/s00590-022-03467-w

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