Known Preoperative Deep Venous Thrombosis and/or Pulmonary Embolus: To Flap or Not to Flap the Severely Injured Extremity?

A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated With Flap-Based Limb Salvage

OBJECTIVES

To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma.

DESIGN

Retrospective review.

SETTING

Level II trauma center.

PATIENTS

307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014.

INTERVENTION

We reviewed patient medical records, radiographs, and clinical photographs.

MAIN OUTCOME MEASUREMENTS

Early and late amputation rates, time to amputation, reason for amputation.

RESULTS

307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion.

CONCLUSIONS

This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Thrombophilia and Preoperative Deep Venous Thrombosis and Their Effect on Free Flap Survival: A Scoping Review

Background: A proper preoperative planning is essential to prevent flap failure. However, venous workup for flaps has not been commonly performed or utilized as a preoperative screening tool. A scoping review was conducted to explore preoperative venous system screening, including deep vein thrombosis diagnosis, and its effect on flap survival rate. This review identified existing gaps of knowledge and emphasized potential research areas for future studies. Methods: Two independent reviewers searched 3 electronic databases from inception to September 2020. Retrieved appropriate articles were selected systematically by title, abstract, and full review of the article. Studies were included if they enrolled patients who had thrombophilia or deep venous thrombosis (DVT) preoperatively and had undergone a free flap reconstruction. For eligible studies, the following information was extracted: basic demographics (sex, age, comorbidities), preoperative scans type, free flap type, clotting mode (causes), wound type, and flap survival. Results: Seventeen articles were found eligible for this review. Traumatic aetiology was found in 63 (33.6%) patients, while 124 (66.3%) patients had a non-traumatic aetiology. Preoperative screening for patients with non-traumatic aetiology was reported in 119 patients. In these patients, the flap survived in 107 (89.91%) patients. Four studies investigating patients with traumatic DVT aetiology, 60 patients (out of 63) had a preoperative computed tomography angiography or duplex. Those patients had 100% flap survival rates. Conclusion: Further investigations are required to identify venous thrombosis incidence in patients with non-traumatic thrombosis aetiology as this cohort of patients is at high risk of flap failure. Finally, the prognostic validity of available preoperative screening tools to identify high-risk patients should be assessed, such as imaging techniques, which would include venous duplex scanning, may prevent failure in free flap surgery.

Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery

This review aims to highlight the common pharmacological and nonpharmacological interventions utilized for thromboprophylaxis as well as flap salvage in microsurgery. A literature review was conducted in PubMed/National Center for Biotechnology Information, Scopus, Web of Science, and MEDLINE databases. Articles with a focus on thromboprophylaxis in microsurgical procedures spanning head and neck surgery, breast and extremity microvascular reconstruction, deep venous thrombosis/pulmonary embolus in microvascular surgery, and flap thrombosis and salvage were included in this review. The majority of available evidence supports mechanical venous thromboembolism (VTE) prophylaxis in all patients undergoing microsurgery given the presence of multiple risk factors for VTE within this particular patient population. Based on the literature review, addition of VTE chemoprophylactic agents is beneficial and an algorithmic approach to thromboprophylaxis in microsurgery patients and management of patients with thrombosis based on literature review and senior authors' experience is recommended and outlined.

The impact of pre-existing venous pathology on lower limb free flap reconstruction and the role of preoperative screening: a systematic review

Lower limb reconstruction is performed to replace like with like and achieve tissue durability. Free flaps are a method of reconstruction commonly used to manage cases of lower limb deficits. However, the failure rate is 8.5%, with venous thrombosis and congestion playing a significant role. Despite this, preoperative venous mapping of recipient site before free flap reconstruction is not routinely practiced, often resulting in pathologies remaining unidentified until the intraoperative stage. The aim of the review was to evaluate the existing literature on the topic of lower limb preoperative venous assessment, screening, and its effect on lower limb free flap survival. Five different databases were searched from their inception to August 2021. The search terms and included studies were independently reviewed by two investigators for their eligibility. Eleven articles were eligible for inclusion, with a combined patient population of 99, and 107 flaps were identified to have lower limb pathology at the donor or recipient vein. Venous pathology was detected preoperatively in 69 veins using ultrasound duplex scanning and computed tomography angiography; of them, 3 (4.34%) resulted in failure. In comparison, 38 veins were diagnosed with venous pathology intraoperatively; of them, 5 (13.85%) failed. The studies evaluated in this review demonstrated that preoperative screening for venous pathology showed a higher flap survival rate. It can therefore be inferred that developing a standardized preoperative process for identifying venous issues in lower limb free flap reconstruction may improve outcomes. This can be explored in future research, with a focus on assessing the validity and efficacy of such screening tools, and their role in the management of patients identified with venous pathology.

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

Background

The free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT.

Patients and methods

This study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes.

Results

Sixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients.

Conclusion

If DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.

Plastic Surgery at War: A Scoping Review of Current Conflicts

INTRODUCTION

The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations.

MATERIALS AND METHODS

Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered.

RESULTS

The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain.

CONCLUSIONS

Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.

Occult deep vein thrombosis in lower limb trauma requiring microsurgical reconstruction-A retrospective cohort study

BACKGROUND

Delayed microsurgical reconstruction of lower extremity trauma is associated with increased risk of free flap loss, frequently following failure of the venous anastomosis. This has been attributed to thrombocytosis, but occult deep vein thrombosis (DVT) may contribute to this risk.

METHODS

We performed a retrospective cohort study of consecutive patients presenting to our service with lower limb injuries requiring microsurgical reconstruction between 2013 and 2017, and examined venous Duplex ultrasound reports, operation notes and free flap outcomes.

RESULTS

A total of 165 free flap reconstructions for lower limb trauma were performed for 162 limbs in 158 patients. Seventy-two limbs (44.4%) underwent preoperative venous Duplex ultrasound identifying occult DVT in 14 (19.4%) patients. Occult DVT was identified intraoperatively in a further 7 cases. Bilateral lower limb injuries (p = 0.0002), the level of injury at or above the knee (p < 0.0001), multiple levels of injury within the affected limb (p = 0.0008) and critical care admission (p = 0.0008) were significant risk factors for DVT. All 7 cases of DVT diagnosed intraoperatively prompted a change in the surgical plan for the recipient vein; however, preoperative identification of occult DVT also lead to an adjustment in the microsurgical plan in 4 out of 14 cases.

CONCLUSIONS

Prevalence of DVT is high in severe lower limb injury, potentially increasing the risk of free flap loss. Preoperative identification of occult DVT may influence the microsurgical plan and mitigate for this risk.

Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts

BACKGROUND

The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage.

METHODS

Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments.

RESULTS

All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10 days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3 months after their final surgery. At 24 months follow-up, 90% amputation free survival is still maintained.

CONCLUSIONS

Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.

Amputations versus Salvage: Reconciling the Differences

BACKGROUND

 There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation.

METHODS

 In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population.

RESULTS

 The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease.

CONCLUSION

 Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.

[Prevention of venous thromboembolic complications in firearm injury]

Prevention of venous thromboembolic complications in wounded is a complex problem which has not yet been fully resolved throughout the world. Current state of venous thrombosis prevention in wounded in different countries and certain ways of its improvement are analyzed in the article.

Plastic Surgery Challenges in War Wounded I: Flap-Based Extremity Reconstruction

Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.

Ballistic trauma: lessons learned from iraq and afghanistan

Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.

Limb salvage after vascular reconstruction followed by tissue transfer during the Global War on Terror

BACKGROUND

Combat extremity wounds are complex and frequently require an immediate vascular reconstruction in the operational environment followed by delayed tissue coverage at a stateside medical treatment facility. The purpose of this study was to evaluate limb salvage outcomes after combat-related vascular reconstruction that subsequently required delayed soft tissue coverage during the Global War on Terror.

METHODS

Patients who incurred a war-related extremity injury necessitating an immediate vascular intervention followed by definitive limb reconstruction requiring flap coverage from combat injuries were reviewed. Patient demographics, types of vascular and extremity injuries, and surgical interventions were examined. Outcomes included limb salvage, primary and secondary graft patency, flap outcomes, and complications. Differences between upper extremities (UEs) and lower extremities (LEs) were compared.

RESULTS

From 2003 to 2012, 27 patients were treated for combat-related extremity injuries with an immediate vascular reconstruction followed by delayed tissue coverage. Fifteen LEs and 12 UEs were treated. The mean age was 24 years. An explosion was the cause in 77% of patients, with a mean Injury Severity Score (ISS) of 19. An autogenous vein bypass was the most common reconstruction performed in 20 patients (74%). Other vascular repairs included a primary repair, a patch angioplasty with bovine pericardium, and a bypass with use of a prosthetic graft. Eight patients (30%) had a concomitant venous injury, and 23 (85%) had a bone fracture. Thirty flaps were performed at a mean of 33 days from the original injury. Pedicle flaps were used in 24 limbs and free tissue flaps in six limbs. Muscle, fasciocutaneous, bone, and composite flaps were used for tissue coverage. At a mean follow-up of 16 months, primary patency rates of all arterial reconstructions were 66% in the UE and 53% in the LE (P = .69). Secondary patency rates were 100% in the UE and 86% in the LE (P = .48). The overall limb salvage rate was 81%. Limb salvage rates were 66% in the LE and 100% in the UE (P = .04). Three amputated lower limbs (60%) had inline flow to the foot. The flap success rate was 96%. Reasons for amputation included arterial thrombosis, flap failure, persistent soft tissue infection, osteomyelitis, and debilitating peripheral nerve injuries with associated chronic pain.

CONCLUSIONS

Immediate vascular repair followed by delayed tissue coverage can be performed with a high (>80%) limb salvage rate after combat trauma. Limb salvage rates were higher in the UE despite equivocally high arterial patency rates. Wounded warriors can expect limb salvage by use of this international algorithm.

Early Mobilization after Free-flap Transfer to the Lower Extremities: Preferential Use of Flow-through Anastomosis

BACKGROUND

Prolonged bed rest and elevation have traditionally been considered necessary after free-flap transfer to the lower extremities. In this retrospective study, we tried to mobilize patients early after free-flap transfer to the lower extremity by means of flow-through anastomosis for both arteries and veins.

METHODS

This study included 13 consecutive patients who underwent immediate free-flap transfer after wide resection of soft-tissue tumors of the lower extremity from March 2012 through July 2013. The defects were above the knee in 5 patients and below the knee in 8 patients. In all patients, flow-through anastomosis was used for both arteries and veins. The patients were mobilized starting on the first postoperative day, and their activities of daily life were gradually expanded, depending on the wound conditions. Postoperative complications and the progression of their activities of daily life were investigated retrospectively.

RESULTS

No anastomotic failure or take back occurred. Partial flap necrosis occurred in 1 patient because of a poor perforator but was unrelated to early mobilization. All patients could move to wheelchairs on the first postoperative day. Within 1 week, 12 of 13 patients could start dangling and 10 of 13 patients could start ambulating.

CONCLUSIONS

This study demonstrates that early mobilization after free-flap transfer to the lower extremity is made possible by flow-through anastomosis for both arteries and veins. Flow-through flaps have stable circulation from the acute phase and can tolerate early dangling and ambulation.