Debridement of all necrotic and contaminated tissues followed by immediate soft: tissue coverage in order to obtain primary healing is nowadays the standard approach to all open injuries of the extremities. In 1977 Foucher et al. introduced for the first time the concept of immediate treatment at one time of all injured tissues in complex traumas of the upper limb. The final goal of this therapeutic approach is early postoperative mobilization of the hand and of the whole upper extremity. Any delay in treatment will lead to higher risk of infection, to granulation tissue formation and extended fibrosis, reduced flap survival rate, longer hospital stay, late rehabilitation and eventually to poor function. The advantages of an emergency free-flap reconstruction are salvage of exposed vital structures, reduction of bacterial colonization and immediate reconstruction of all damaged structures in the first surgical procedure, allowing for early rehabilitation and eventually leading to better functional recovery. In the absence of life-threatening injuries the absolute indication for an emergency free flap is exposure of a reconstructed vessel and/or of the main artery of the limb. Other absolute indications are salvage free flaps harvested from non replantable amputated parts and the flow-through flaps used for limb revascularization. The golden period for free-tissue transfer is the first 24 hours after injury. In the literature there is evidence that three days and even five days are of no detriment to final outcome if debridement is accurate and bacterial load low. Longer delays are consistently associated with higher infection rate, flap failure, multiple secondary procedures, longer hospital stay and eventually poor function. Disadvantages are the need for a well experienced surgeon capable, first of all, of a careful assessment of the general condition of the patient and of the remaining function of the affected limb. Further critical points are the extent of the debridement and the choice of the receiving vessels. Only when a surgically clean wound is obtained should a definitive closure be undertaken. In our opinion there are multiple methods available to close a complex wound of the extremities and the surgeon should choose the technique that offers the best chance of success at the lowest risk for the patient.
Calcagni, M., Martorana, U., De Cristofalo, V., Pajardi, G. (2004). Emergency free flaps for the reconstruction of open injuries of the upper limb: a review. RIVISTA ITALIANA DI CHIRURGIA PLASTICA, 36(1-2), 45-50.
Emergency free flaps for the reconstruction of open injuries of the upper limb: a review
MARTORANA, Umberto;
2004-01-01
Abstract
Debridement of all necrotic and contaminated tissues followed by immediate soft: tissue coverage in order to obtain primary healing is nowadays the standard approach to all open injuries of the extremities. In 1977 Foucher et al. introduced for the first time the concept of immediate treatment at one time of all injured tissues in complex traumas of the upper limb. The final goal of this therapeutic approach is early postoperative mobilization of the hand and of the whole upper extremity. Any delay in treatment will lead to higher risk of infection, to granulation tissue formation and extended fibrosis, reduced flap survival rate, longer hospital stay, late rehabilitation and eventually to poor function. The advantages of an emergency free-flap reconstruction are salvage of exposed vital structures, reduction of bacterial colonization and immediate reconstruction of all damaged structures in the first surgical procedure, allowing for early rehabilitation and eventually leading to better functional recovery. In the absence of life-threatening injuries the absolute indication for an emergency free flap is exposure of a reconstructed vessel and/or of the main artery of the limb. Other absolute indications are salvage free flaps harvested from non replantable amputated parts and the flow-through flaps used for limb revascularization. The golden period for free-tissue transfer is the first 24 hours after injury. In the literature there is evidence that three days and even five days are of no detriment to final outcome if debridement is accurate and bacterial load low. Longer delays are consistently associated with higher infection rate, flap failure, multiple secondary procedures, longer hospital stay and eventually poor function. Disadvantages are the need for a well experienced surgeon capable, first of all, of a careful assessment of the general condition of the patient and of the remaining function of the affected limb. Further critical points are the extent of the debridement and the choice of the receiving vessels. Only when a surgically clean wound is obtained should a definitive closure be undertaken. In our opinion there are multiple methods available to close a complex wound of the extremities and the surgeon should choose the technique that offers the best chance of success at the lowest risk for the patient.
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