Introduction: The merits and acceptance of free tissue reconstruction of complex extremity injuries have now been clearly established. Despite our growing microsurgical experience, some questions still remain unanswered. Apart from the timing of surgery and radical initial débridement, what are the other important factors that influence final outcome? Purpose: The purpose of this study was two-fold. First, to demonstrate the indications, contra-indications and appropriateness of immediate and delayed reconstruction of the lower and upper extremity using free-flaps. Second, to determine the impact of injury location and fracture fixation on overall flap survival and infection, in both the upper and lower extremities. Material and Methods: One hundred and fifty free tissue transfers were performed for both upper and lower extremity reconstruction. Fifty emergency free-flaps (within 24 hours) were used for coverage and/or salvage of either the upper or lower extremities, whereas the remaining 100 flaps were transferred within 48 hours to 3 years post-injury. Flaps were subdivided within two main groups: upper and lower extremity. Flaps were further classified in order of increasing complexity: 1. Simple free-flaps, 2. Free-flaps with fracture fixation 3. Free-flaps with bone grafting and/or soft tissue reconstruction. Results: A total of 150 free-tissue transfers were performed in 142 patients, (126 men and 16 women), between 1981 and 2002, 122 to the upper extremity, compared to 28 to the lower extremity. Mean patient age at time of surgery was 32.8 years old, with the majority of them being manual workers 86.7% (130/150). The overall flap survival was 96% (144/150), and the overall anastomotic revision rate was 1.3% with a salvage rate of 50% (1/2). The lateral arm flap was most often transferred 48/150. The infection rate was 21.3% (32/150). Superficial infections 6.7% (10/150) resolved with PO or IV antibiotics whereas deep infections 14.7% (22/150) required formal surgical incision and drainage as well as intravenous antibiotics for their resolution. Deep infections were most often associated with high energy lower extremity Gustillo-3B fractures. The total limb salvage rate was 100% with an average hospitalization of 7.8 days following surgery. Risk factors associated with poorer outcomes included open fractures and lower extremity trauma. Conclusion: Successful limb salvage of both upper and lower extremities can be expected in a high number of cases treated with free flaps. Nevertheless, surgeons must be aware of the inherent risks for increased infection and free flap failure following high energy open fractures and lower extremity trauma.
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