LOWER-EXTREMITY FREE FLAPS - A REVIEW

OBJECTIVE: To identify factors related to free-flap coverage of lower extremity fractures that are linked to a negative outcome. DESIGN: A c hart review. SETTING: A large microsurgical referral centre. PATIENTS: From 1981 to 1989, the records of all patients who underwent free-tis sue transfer to the lower extremity with more than 1 year of follow-up were selected. From this was drawn a subgroup of 49 patients (mean ag e, 36 years) who had tibial fractures (55% were motor vehicle injuries ) and in almost all cases established soft-tissue or bony defects. The y formed the study group. INTERVENTION: Free-flap transfer. OUTCOME ME ASURES: Factors that might be associated with free-flap failure: mecha nism of injury, grade of tibial fracture, history of smoking, diabetes , peripheral vascular disease, ischemic heart disease, vascular compro mise in the leg preoperatively, recipient artery used, type of anastom osis, and hypertension or hypotension intraoperatively. RESULTS: Type IIIB tibial fractures were the most frequent (67%) and carried a signi ficantly (p = 0.02) higher risk of free-flap failure than other types of fracture. Patients underwent a mean of four procedures before refer ral for free-tissue transfer. The mean time from injury to flap covera ge was 1006 days. Stable, long-term coverage of the free flaps was ach ieved in 78% of patients. Wound breakdown was most often caused by rec urrent osteomyelitis (65%). Seventy-four percent of the fractures heal ed. The amputation rate was 10%. Four patients required repeat free-fl ap transfer for limb salvage. CONCLUSION: Only the grade of tibial fra cture could be significantly related to postoperative free-flap failur e.