Download PDF
J Reconstr Microsurg 2003; 19(7): 455-462
DOI: 10.1055/s-2003-44633
Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Microvascular Free-Tissue Transfer for Traumatic Defects of the Upper Extremity: A 25-Year Experience

Christopher A. Derderian, Wendy-Ann M. Olivier, Germania Baux, Jamie Levine, Geoffrey C. Gurtner
  • 1Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY
Further Information

Publication History

Publication Date:
24 November 2003 (online)

Also available at
    Permissions and Reprints

ABSTRACT

Microvascular free-tissue transfer has been a major advance in the treatment of complex traumatic defects of the upper extremity. One hundred and fifty microvascular free-tissue transfers were performed in 133 patients with complex traumatic upper extremity defects at Bellevue Hospital Center from 1976 to 2000. The indication for microvascular free tissue transfers was exposure of vital structure (81 percent), bone defect (11 percent), and functional deficit (8 percent). The parascapular region was the most common donor site used (26 percent). Microvascular free-tissue transfer was performed either emergently at the time of injury (9.3 percent), during days 1 to 5 post injury (19.3 percent), during days 6 to 21 (19.3 percent), or after day 21 (52 percent). The overall flap failure rate was 9 percent. A decreased incidence of flap failure was observed in patients treated from 6 to 21 days post injury (3 percent p<0.05). The most common acute complication was infection at the recipient site, observed in 14 percent of patients overall. A decreased incidence of recipient-site infection was seen in patients who received free flaps at days 6 to 21 (3 percent; p<0.05). In long-term follow-up, the incidences of osteomyelitis and nonunion were lowest in patients treated from 6 to 21 days post injury (0.0 percent and 11 percent, respectively; p<0.05). During the last 10 years, the timing of reconstruction has been altered, and now preferentially microvascular free flaps are performed 6 to 21 days post injury. The treatment algorithm has been simplified and now only four different flaps are used in the majority of patients (70 percent). With this, the authors have witnessed a decrease in failure rates from 11 percent to 4 percent, a decrease in recipient-site infections from 16 percent to 10 percent and a decrease in osteomyelitis from 12 percent to 4 percent. The preferred timing for microvascular free-tissue transfers to the upper extremity is concluded to be 6 to 21 days post injury.

KEYWORDS

Trauma - upper extremity - free flap - reconstruction

REFERENCES

  • 1 Kerrigan C L, Daniel R K. Free tissue transfer to the upper extremity.  Ortho Clin North Am . 1986;  17 383-394
    PubMedGoogle Scholar
  • 2 Hing D N, Buncke H J, Alpert B S, Gordon L. Free flap coverage of the hand.  Hand Clin . 1985;  1 741-758
    PubMedGoogle Scholar
  • 3 Wood M B, Irons G B. Upper-extremity free skin flap transfer: results and utility as compared with conventional distant pedicle skin flaps.  Ann Plast Surg . 1983;  11 523-526
    PubMedGoogle Scholar
  • 4 Breidenbach W C. Emergency free tissue transfer for reconstruction of acute upper extremity wounds.  Clin Plast Surg . 1989;  16 505-514
    PubMedGoogle Scholar
  • 5 Whitney T M, Buncke H J, Lineaweaver W C, Alpert B S. Reconstruction of the upper extremity with multiple microvascular transplants: analysis of method, cost, and complications.  Ann Plast Surg . 1989;  23 396-400
    CrossrefPubMedGoogle Scholar
  • 6 Katsaros J, Tan E, Zoltie N. Free flap cover of acute hand injuries.  Injury . 1989;  20 96-97
    CrossrefPubMedGoogle Scholar
  • 7 Chen H C, Buchman M T, Wei F C. Free flaps for soft tissue coverage in the hands and fingers.  Hand Clin . 1999;  15 541-554
    PubMedGoogle Scholar
  • 8 McCabe S J, Breidenbach W C. The role of emergency free flaps for hand trauma.  Hand Clin . 1999;  15 275-288
    PubMedGoogle Scholar
  • 9 Ikuta Y. Vascularized free flap transfer in the upper limb.  Hand Clin . 1985;  1 297-309
    PubMedGoogle Scholar
  • 10 Brown D M, Upton J, Khouri R K. Free flap of the hand.  Clin Plast Surg . 1997;  24 57-62
    PubMedGoogle Scholar
  • 11 Gustilo R, Anderson J. Prevention of infection in the treatment of one thousand and twenty five open fractures of long bones.  J Bone Joint Surg . 1976;  58A 453-458
    PubMedGoogle Scholar
  • 12 Gustilo R, Gruninger R, Davis T. Classification of type III (severe) open fractures relative to treatment and results.  Orthopedics . 1987;  10 1781-1788
    PubMedGoogle Scholar
  • 13 Gustilo R, Mendoza R, Williams D. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures.  J Trauma . 1984;  24 742-746
    CrossrefPubMedGoogle Scholar
  • 14 Merritt K. Factors increasing the risk of infection in patients with open fractures.  J Trauma . 1988;  28 823-827
    PubMedGoogle Scholar
  • 15 Yaremchuk M, Brumback R, Manson D. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.  Plast Reconstr Surg . 1987;  80 1-14
    CrossrefPubMedGoogle Scholar
  • 16 Byrd H, Cierny III G, Tebbetts J. Management of open tibial fractures with associated soft tissue loss: external pin fixation with early flap coverage.  Plast Reconstr Surg . 1981;  68 73-82
    CrossrefPubMedGoogle Scholar
  • 17 Byrd H, Spicer T, Cierny III G. Management of open tibial fractures.  Plast Reconstr Surg . 1985;  76 719-730
    CrossrefPubMedGoogle Scholar
  • 18 Cierny III G, Byrd H, Jones R. Primary versus delayed soft tissue coverage for severe open tibial fractures.  Clin Orthop . 1983;  178 54-63
    PubMedGoogle Scholar
  • 19 Godina M. Early microsurgical reconstruction of complex trauma of the upper extremities.  Plast Reconstr Surg . 1986;  78 285-292
    CrossrefPubMedGoogle Scholar
  • 20 Lister G, Scheker L. Emergency free flaps to the upper extremity.  J Hand Surg . 1988;  13A 22-28
    PubMedGoogle Scholar
  • 21 Ninkovic M, Deetjan H, Ohier K, Anderl H. Emergency free tissue transfer for severe upper extremity injuries.  J Hand Surg . 1995;  20B 53-58
    PubMedGoogle Scholar
  • 22 Chen S H, Wei F C, Chen H C. et al . Emergency free-flap transfer for reconstruction of acute complex extremity wounds.  Plast Reconstr Surg . 1992;  89 882-888
    CrossrefPubMedGoogle Scholar
  • 23 Brenner P, Lassner P, Becker M, Berger A. Timing of microsurgical tissue transfer for the acute phase of hand injuries.  Scand J Plast Reconstr Surg Hand Surg . 1997;  31 165-170
    CrossrefPubMedGoogle Scholar
  • 24 Manktelow R T. Functioning microsurgical muscle transfer.  Hand Clin . 1988;  4 289-296
    PubMedGoogle Scholar
  • 25 Manktelow R T, Zuker R M. The principles of functioning muscle transplantation: applications to the upper arm.  Ann Plast Surg . 1989;  22 275-282
    CrossrefPubMedGoogle Scholar
  • 26 Chuang D C, Strauch R J, Wei F C. Technical considerations in two-stage functioning free muscle transplantation reconstruction of both flexor and extensor functions of the forearm.  Microsurgery . 1994;  15 338-343
    CrossrefPubMedGoogle Scholar
  • 27 Chuang D C. Functioning free-muscle transplantation for the upper extremity.  Hand Clin . 1997;  13 279-289
    PubMedGoogle Scholar
  • 28 Urbania J R, Koman L A, Goldner R D. et al . The vascularized cutaneous scapular flap.  Plast Reconstr Surg . 1982;  69 772-778
    CrossrefPubMedGoogle Scholar
  • 29 Nassif T M, Vidal L, Boret J L, Bandet J. The parascapular flap: a new cutaneous microsurgical free flap.  Plast Reconstr Surg . 1982;  69 591-600
    CrossrefPubMedGoogle Scholar
  • 30 Burns J T, Schlafly B. Use of the parascapular flap in hand reconstruction.  J Hand Surg. . 1986;  11B 872-875
    PubMedGoogle Scholar
  • 31 Song R, Song Y, Yu Y. The upper arm free flap.  Clin Plast Surg . 1982;  9 27-35
    PubMedGoogle Scholar
  • 32 Katsaros J. Indications of free soft-tissue flap transfer to the upper limb and the role of alternative procedures.  Hand Clin . 1992;  8 479-507
    PubMedGoogle Scholar
  • 33 Chen H C, el-Gammal T A. The lateral fascial flap for resurfacing of the hand and fingers.  Plast Reconstr Surg . 1997;  99 454-459
    CrossrefPubMedGoogle Scholar
  • 34 Chang N, Mathes S J. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps.  Plast Reconstr Surg . 1982;  70 1-10
    PubMedGoogle Scholar
  • 35 Chase R A. The development of tissue transfer in hand surgery.  J Hand Surg . 1984;  9A 463-477
    PubMedGoogle Scholar
  • 36 Rao V K, Baertch A. Microvascular reconstruction of the upper extremity with the rectus abdominis muscle.  Microsurgery . 1994;  15 746-750
    PubMedGoogle Scholar
  • 37 Horch R E, Stark G B. The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects.  Plast Reconstr Surg . 1999;  103 1421-1427
    CrossrefPubMedGoogle Scholar
  • 38 McGregor I A, Jackson I T. The groin flap.  Br J Plast Surg . 1972;  25 3-16
    CrossrefPubMedGoogle Scholar
  • 39 O'Brien B M, Shanmugan N. Experimental transfer of composite free flaps with microvascular anastamosis.  Aust N Z J Surg . 1973;  43 285-288
    PubMedGoogle Scholar
  • 40 McCraw J B, Furlow L T. Dorsalis pedis arterialized flap: a clinical study.  Plast Reconstr Surg . 1975;  55 177-185
    CrossrefPubMedGoogle Scholar
  • 41 Ohmori K, Harii K. Free dorsalis pedis sensory flap to the hand with microneurovascular anastamosis.  Plast Reconstr Surg . 1976;  58 546-554
    CrossrefPubMedGoogle Scholar
  • 42 Takami H, Takahashi S, Ando M. Use of the dorsalis pedis free flap for reconstruction of the hand.  Hand . 1983;  15 173-178
    PubMedGoogle Scholar