Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm

Abstract

Sir: The study by Lee et al. investigating the optimal timing of flap reconstruction in lower extremity trauma is timely, as this remains a hot topic among surgeons worldwide.1 Using a multi-institutional registry, the authors found that flaps performed less than or equal to 3 days after injury had 60 percent lower likelihood of major flap complications versus those performed after 4 to 90 days. Cases were divided into three new groups: less than or equal to 3 days, 4 to 9 days, and 10 to 90 days. Multivariable analyses then found that outcomes did not differ significantly between the less than or equal to 3-day and 4- to 9-day groups. Although the authors conclude that reconstruction can therefore be safely extended to less than or equal to 10 days of injury, we believe this requires careful interpretation. The goal in traumatic lower extremity reconstruction is to restore function and minimize complications.2 Nonunion, infection, osteomyelitis, and amputations are all outcomes that may adversely affect long-term lower limb function, and may be affected by the timing of reconstruction.3,4 However, these outcomes were not assessed in the study. Moreover, delay in definitive reconstruction may also unnecessarily expose patients to various hospital-admission–related risks, including deep venous thrombosis, and delays rehabilitation.5,6 The authors’ conclusion that reconstruction can be safely extended to less than or equal to 10 days after injury only holds from the perspective of flap outcomes and therefore seems somewhat overdrawn. Second, the authors raise negative-pressure wound therapy as a contributing factor for their findings. However, they were not able to directly adjust for negative-pressure wound therapy because of inconsistent documentation. Although we strongly believe in the practical benefits of negative-pressure wound therapy as a temporary coverage, the Wound Management of Open Lower Limb Fractures (n = 460), multicenter (n = 24), randomized controlled trial comparing negative-pressure wound therapy versus standard dressings in severe open lower extremity fractures has demonstrated no differences for various 1-year outcomes, including infection and quality of life.7 Is it likely that subdividing the 4- to 90-day group into two new subgroups resulted in too limited statistical power to find differences instead of the assumed beneficial effects of negative-pressure wound therapy. Third, the final multivariable analyses adjusted for age, timing, arterial injury, and flap type for a valid comparison. This also assumes that these are the key factors to account for. In practice, however, decision-making in traumatic lower extremity reconstruction is complex, and depends on many more factors that may influence outcomes, such as methods and timing of fixation, injury severity, and further débridement requirement. Were the groups of less than or equal to 3 days and 4 to 9 days also similar regarding these characteristics? In addition, can the authors explain why the univariable analysis (their Table 4) shows exactly the opposite (much lower complication rate in the 10- to 90-day group versus the 4- to 9-day group) of the multivariable analysis (their Table 5)? We commend the authors on a highly relevant study, suggesting that flap success rates are similar after less than or equal to 10 days instead of less than or equal to 3 days.8 Nevertheless, we believe there is a need for future studies examining the extent to which union rates, osteomyelitis, and long-term function are affected by delaying reconstruction. Decision-making in such cases is complex and should therefore be individualized.9 As reconstructive surgeons, it is our duty to collaborate effectively with our orthopedic colleagues to provide rapid definitive reconstruction to maximize outcomes. DISCLOSURE None of the authors has a financial interest in relation to this communication.

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