Division of Plastic and Reconstructive Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana.
J Reconstr Microsurg. 2019 Oct;35(8):616-621. doi: 10.1055/s-0039-1688712. Epub 2019 May 14.
Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases.
We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance.
Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications ( = 0.051) and flap-specific complications ( = 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance.
Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient.
尽管 30 年前 Godina 进行了具有里程碑意义的研究，但文献中对下肢复杂创伤伤口的处理仍存在不同意见。我们报告了一系列下肢血管化游离组织重建，并研究了影响这些病例成功的围手术期因素。
我们回顾了 8 年来 88 例创伤性下肢伤口游离皮瓣重建患者的资料。主要结果是皮瓣感染、皮瓣坏死、总皮瓣特定并发症和总受区并发症。特定于围手术期护理的独立变量，包括皮瓣覆盖时间、损伤分类、外露或感染的内固定物、既往骨髓炎、使用创面负压辅助闭合（VAC）治疗以及并发多发伤，均用于研究其对主要结果的影响。每个独立变量均采用卡方或 Fisher 精确检验进行评估，并纳入逻辑回归分析以确定其显著性。
88 例患者中，8 例出现皮瓣坏死，8 例出现皮瓣感染，共有 23 例出现主要不良结局。重建时间、VAC 使用、损伤分类、既往内固定物或伤口情况、多发伤对主要结果均无统计学意义。但总受区并发症（ = 0.051）和皮瓣特定并发症（ = 0.073）的损伤分类/严重程度有统计学意义的趋势；然而，亚组分析未达到统计学意义。包括所有独立变量的任何受区并发症的逻辑回归也未显示显著性。
尽管 Godina 的原始研究表明早期覆盖是优化结果的关键，但在先进伤口护理的现代时代，我们的研究增加了越来越多的证据，支持减少对 72 小时重建间隔的强调。我们目前的治疗重点是更有效地协调创伤期和围手术期护理，为经常非常复杂的多发伤患者提供个体化的治疗。
