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Methods: Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using a Chi Square and Fischer’s exact tests.
Results: Two hundred eighty-two cases met inclusion criteria. Wounds underwent soft tissue reconstruction within 24 hours (25.9%), days 2-7 (12.2%), or after day 7 (61.9%). Forty-seven (16.7%) of injuries were located proximally. Over half of the cases had an open (25.9%) or closed (34.4%) fracture. Gustilo fracture grade was IIIA (0.1%), 3B (17.4%), or IIIC (7.8%). Superficial infection, deep infection, and osteomyelitis occurred in seventeen (6%), twenty-four (8.5%), and fifteen (5.3%) cases, respectively. Twelve cases (4.3%) experienced total, and five (1.8%) partial, flap loss. An interpositional vein graft was used in 41 (14.5%) and anastomotic revision was performed in 53 (18.8%). Mean follow-up was 37.5 ± 49.5 months.
Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (RR=6.5, p<0.01) and deep infection (RR=5.3, p<0.01), and osteomyelitis (RR=4.0, p<0.01), although not with flap failure (p=0.3). Presence of an open fracture was significantly associated with developing superficial (RR=3.1, p=0.013) and deep infection (RR=1.9, p<0.01), as well as osteomyelitis (RR=1.6, p<0.01). Having a closed fracture did not negatively influence postoperative outcomes.
Gustilo IIIC fractures were associated with a higher risk of flap loss (RR=3.5, p=0.03). Use of an interpositional vein graft was 3.2 times more likely to result in flap loss (14.6% vs. 4.56%, p=0.01). Flaps requiring anastomotic revision had a 7.9 times higher risk of experiencing flap loss (20.75% vs. 0.26%, p<0.01).
Conclusions: This study supports the safety using early free tissue transfer for reconstruction of the traumatized upper extremities. Injuries proximal to the elbow, and trauma resulting in open fracture, were associated with a significantly higher infection rate. Gustilo IIIC fractures, need for interpositional vein grafts, and anastomotic revision resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, injury location, and use of vein grafts were not predictors of flap failure.