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1、1 The Author(s)2021.Published by Oxford University Press.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(http:/creativecommons.org/licenses/by-nc/4.0/),which permits non-commercial re-use,distribution,and reproduction in any mediu
2、m,provided the original work is properly cited.For commercial re-use,please contact Burns&Trauma,2021,9,tkab024https:/doi.org/10.1093/burnst/tkab024ReviewReviewContemporary approach to soft-tissuereconstruction of the lower extremity aftertraumaMatthew R.Zeiderman,MD and Lee L.Q.Pu,MD,PhD*Divisionof
3、Plastic&ReconstructiveSurgery,DepartmentofSurgery,UniversityofCalifornia,Davis,Sacramento,CA,USA*Correspondence.Email:llpuucdavis.eduReceived 20 December 2020;Revised 22 February 2021;Editorial decision 25 May 2021AbstractThe complex lower extremity wound is frequently encountered by orthopedic and
4、plastic surgeons.Innovations in wound care,soft tissue coverage and surgicalfixation techniques allow forimprovedfunctional outcomes in this patient population with highly morbid injuries.In this review,theprinciples of reconstruction of complex lower extremity traumatic wounds are outlined.Thesepri
5、nciples include appropriate initial evaluation of the patient and mangled extremity,as wellas appropriate patient selection for limb salvage.The authors emphasize proper planning forreconstruction,timing of reconstruction and the importance of an understanding of the mostappropriate reconstructive o
6、ption.The role of different reconstructive and wound care modalities isdiscussed,notably negative pressure wound therapy and dermal substitutes.The role of pedicledflaps and microvascular free-tissue transfer are discussed,as are innovations in understanding ofperforator anatomy and perforator flap
7、surgery that have broadened the reconstruction surgeonsarmamentarium.Finally,the importance of a multidisciplinary team is highlighted via the principleoftheorthoplasticapproachtomanagementofcomplexlowerextremitywounds.Uponcompletionof this review,the reader should have a thorough understanding of t
8、he principles of contemporarylower extremity reconstruction.Key words:Lower extremity,Soft tissue,Reconstruction,Trauma,Surgical approachHighlightsInnovations in wound care,soft tissue coverage and surgical fixation techniques allow for improved functional outcomes afterhighly morbid injuries.Approp
9、riate initial evaluation of the patient and mangled extremity,as well as appropriate patient selection for limb salvageare reviewed.The authors emphasize proper planning for reconstruction,timing of reconstruction and the importance of an understandingof the most appropriate reconstructive option.Th
10、e importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management ofcomplex lower extremity wounds.Downloaded from https:/ by Shanghai Jiao Tong University user on 29 January 20232Burns&Trauma,2021,Vol.9,tkab024BackgroundThe past 30 years have demon
11、strated much innovation inlower extremity reconstruction.Advances in wound man-agement,microvascular free-tissue transfer and improvedunderstanding of vascular anatomy has allowed surgeons topush the envelope when reconstructing the traumatized lowerextremity 1,2.The addition of negative pressure wo
12、undtherapy(NPWT)over the past 20 years has changed themanagement of complex lower extremity wounds,makingsoft-tissue coverage less of a limiting factor 24.A multi-disciplinary group of surgeons,infectious disease experts andrehabilitation specialists is often called upon at tertiary med-ical care ce
13、nters to assist in the care of these highly morbidinjuries.It is important for the reconstructive plastic surgeonor orthopedic surgeon to be familiar with the appropriatework-up and most recent innovations in the field to providethe patient with the best possible outcome.In this review,we outline th
14、e evaluation of the traumatic lower extremitypatient,discuss the indications for reconstruction vs.ampu-tationandtheappropriatetimeline,andreviewcontemporarytechniques in lower extremity soft-tissue reconstruction.ReviewEvaluation of traumatic lower extremity patientA comprehensive approach to manag
15、ement of lower extrem-ity trauma begins with appropriate patient selection.Hisor her medical condition must be carefully evaluated,par-ticularly if there are other associated traumatic injuries.Athorough past medical and surgical history is essential toidentify major surgical risks.Major risks inclu
16、de previousheart attack,stroke,poorly controlled diabetes,uncontrolledhypertension,hepatic or renal insufficiency,hypercoagulablestate and peripheral arterial disease.A thorough physicalexam of the neurovascular status to the extremity is essential.Initial treatment includes debridement of contamina
17、tedand devitalized tissues,as well as fracture stabilization.Sev-eral debridements may be needed to achieve a clean woundbed.Bony injuries to be treated by the orthopedic trauma-tologist are identified and assessed with standard X-rays andcomputed tomography(CT)scans at the time of presentation.Leg
18、perfusion should be assessed clinically.This can be doneby physical examination and at the bedside with a handheldDoppler.Major vascular injury often occurs concurrentlywith severe limb injury.CT angiography(CTA)of the lowerextremity or formal arteriogram should be considered whenthere is a large zo
19、ne of injury which may include vessels forpotential microvascular anastomosis 5.CTA is less invasivethan a formal arteriogram,but is limited in ability to assessdirectional flow as well as ability to assess vasospasm or localinjury 6.An arteriogram or color duplex ultrasound maybe needed in these si
20、tuations;both assess flow directionalityand measure vessel caliber.Magnetic resonance angiogra-phy(MRA)is also an option for vascular imaging whenthe patient cannot tolerate iodinated contrast,but is timeconsuming and prone to scatter if metal is in the imagedfield 7.Where there is concern for venou
21、s injury or deepvein thrombosis,vein mapping should be performed priorto reconstructive efforts.Additional imaging modalities forperforator mapping and flap planning are discussed later inthe article.Indications for limb salvage vs amputationThe advent of microsurgical soft-tissue transfer has expan
22、dedindications for lower extremity salvage.Soft-tissue coverageis no longer a limiting factor.Limb salvage is indicated insevere limb trauma to a child,or healthy adults with intactsensation or expected return of function.A comprehensiveevaluation of the patient s injury characteristics,age,medicalc
23、o-morbidities,ultimate functional status and rehabilitationpotential all weigh into the decision whether to pursue limbsalvage or amputate.The need for amputation is life changingand disturbing to many patients.Acceptance may take timeand careful counseling is needed.The decision should notbe rushed
24、.The Lower Extremity Assessment Project(LEAP),a multi-institutional prospective study of lower extremitytrauma outcomes,demonstrated neither option has superiorclinical outcomes 8,9.Both amputee and limb reconstruc-tion patients have disappointing return to work proportionsat 7 years post-injury(0.6
25、2 reconstruction,0.47 amputation,0.58 cumulative),a non-significant difference after adjust-ment,according to a LEAP study analysis by MacKenzieet al.10.A 2011 meta-analysis of 1138 patients(769amputee,369 reconstructions)by Akula et al.found thatlimb salvage is more psychologically acceptable to pa
26、tientsthan amputation,but physical outcomes are similar follow-ing amputation 11.This meta-analysis utilized the vali-dated quality-of-life outcomes scoring systems including theShort Form-36(SF-36)and Sickness Impact Profile(SIP).Notably,mean psychological SIP scores were 15.6 and 11.5for amputatio
27、n and reconstruction,respectively(p=0.05).Mean physical SIP scores were 16.2 and 13.3 for amputationand reconstruction,respectively(NS).More recent studiesof the US military population in the Afghanistan and Iraqwars have also looked into these differences 12.The authorsfound that early amputation w
28、as generally associated withsimilar or fewer adverse health outcomes relative to lateamputation or limb salvage.Notably,patient undergoinglate amputation had high rates of adverse psychological andphysical outcomes.The 2013 Military Extremity TraumaAmputation/Limb Salvage(METALS)study looked at simi
29、laroutcomes using the Short Musculoskeletal Function Assess-ment(SMFA)13.The authors found that on regressionanalysis,patients who underwent amputation reported signif-icantly lower scores(better functioning)in all domains of theSMFA compared with patients with limb salvage(p 6 h)or tibial nerve tra
30、nsection.Relative indications includepolytrauma,severe ipsilateral foot trauma or projected longrecovery course.Given the findings of Bosse et al.we wouldrecommend nerve injury only be included if transection isverified(Table 1)18.Timing of soft-tissue reconstructionTiming of definitive soft-tissue
31、reconstruction of lowerextremity trauma is determined by many factors,includingpatient condition,wound condition,fracture type andexposed structures 20.Exposed structures and infection riskare important to consider.Surgeons strive for prompt bonystabilization and soft-tissue reconstruction.More impo
32、rtantthan simply achieving soft-tissue coverage is obtaining a cleanwound free of contaminated and devitalized tissue that willinhibit healing 2123.Aggressive debridement to healthybleeding tissue is essential.If needed,additional imagingmodalities such as indocyanine green(ICG)fluorescenceangiograp
33、hy(discussed later)can be used as an adjunct toassess tissue perfusion and guide debridement.Necrotic bonedoes not heal and serves as a nidus for infection.Multipledebridements are often necessary.Adequate time for completedemarcation of the zone of injury must be allowed,which willvary by patient a
34、nd mechanism 24.However,the sooner thewound is clean,the sooner it can be reconstructed with lowerrisk of infection.The work of Marko Godina in 1986 suggested thatmicrovascular soft-tissue coverage of open extremity frac-tures should be performed within 72 h of injury to maximizefree-flap success ra
35、te 25.A time of 72 h is posited to be priorto the onset of significant bacterial colonization and fibrosis,which complicates microvascular dissection and anastomosis.For years soft-tissue coverage within 72 h of injury wasconsidered gold standard,but there is no consensus andtiming remains debated.B
36、yrd et al.26advocated definitivesoft-tissue coverage within 5 days,and Yaremchuk et al.recommended definitive soft-tissue coverage be performed 714 days after injury to allow time for adequate debridement24.Contemporary studies suggest successful reconstructioncan be performed well beyond the 72 h w
37、indow 2731.The advancement of orthopedic fixation techniques,expanded use of antibiotic impregnated cement,antibioticbeads and introduction of NPWT has extended the windowfor soft-tissue reconstruction,liberalizing constraints of the72-h period 31.Given these advances,there is a limitedrole for the
38、emergency free flap to the lower extremity.Average time to soft-tissue reconstruction increased from6.12 to 12.5 days from 2002 to 2011 32.This increase maybe attributable to NPWT,which has allowed extending theinterval to coverage without adverse effects,decreased ratesof infection and may decrease
39、 rates of flap reconstruction3336.Recent studies suggest the ideal period for earlyreconstruction can be extended to 1014 days withoutadverse effect on outcomes 30,31,37.In the absence ofdefinitive guidelines,the authors suggest reconstruction assoon as possible when the patient is medically optimiz
40、ed andthe wound clean,preferably within 2 weeks of injury.A listand brief summary of the pertinent literature on the timingof lower extremity trauma soft-tissue coverage is provided inTable 2 2530,3643.Trend of reconstructionWhen treating complex lower extremity wounds,the goal isto provide reliable
41、 soft-tissue coverage with optimal cosme-sis while minimizing morbidity.Advancements in woundcare technology such as NPWT,hydrosurgical debridementdevices like Versajet(Smith&Nephew,Watford England)Downloaded from https:/ by Shanghai Jiao Tong University user on 29 January 20234Burns&Trauma,2021,Vol
42、.9,tkab024Table 1.Indications for limb salvage vs amputation of the traumatized lower extremityIndications for limb salvageIndications for amputation Young patientAbsolute No ischemia or tibial nerve injury Complete disruption of posterior tibial nerve Good rehabilitation potential Crush injury with
43、 ischemia time6 hRelative Severe polytrauma with life-threatening injuries Severe ipsilateral foot trauma Anticipated protracted reconstruction and recovery Segmental tibia fractureTable 2.Pertinent literature regarding time to definitive soft-tissue coverage of lower extremity traumaArticleYearPati
44、entsNo.VACTime to definitivesoft-tissuecoverageFindingsByrd et al.26198118No4872 h5 d Mean 4 months to bony union Several patients with IIIA wounds excluded for coveragebeyond 5 dGodina 251986532No3 months 1 year Similar rates of flap loss,highest in 2 months 1 y(16%)35%Primary wound healing 1 d1 we
45、ek,65%additionalsoft-tissue loss or infection requiring additional procedures 85 Patients with 1 year follow-up,91%normal legfunction Chronic osteomyelitis not documentedRinker et al.362008105Yes22%17 d842 d42 d No significant difference in osteomyelitis or flap-relatedcomplications,but trends towar
46、d higher rates in 842 d group Time to bony union significantly shorter in 17 d group(4.2vs 6.5 vs 6.2 months)Subacute patients with VAC significantly lower rates ofoverall complications(35 vs 53%),infections(6 vs 18%)andflap-related complications(12 vs 21%)842 d time to bony union significantly shor
47、ter with VAC(4.9 vs 7.2 months)Starnes-Roubaud et al.282015100Yes(%notdocumented)15 d No significant difference in time to bone union,rates ofchronic osteomyelitis,or free-flap failure 4 reconstructive procedures significantly increased rate ofdelayed or nonunionLee et al.302019358Yes routine use199
48、6201690 d 72 h Superior outcomes vs 490 d Rates flap failure,major complications Multivariate analysis-no significant difference in total orpartial flap failure,take-backs-overall complications for 90%in many centers,but still carries the risk of flaploss and partial loss 5,28,46,47.A study by Wetts
49、tein etal.reported 13%partial flap loss in 197 free flaps,andSofiadellis et al.reported an 11.4%partial flap loss rate48,49.While unknown if flap loss occurred over criticalstructures,suchcomplications may require another anestheticfor debridement or additional soft-tissue coverage,possiblyanotherfr
50、ee-flap.Free-tissuetransferhasevolvedandbecomea work horse for lower extremity reconstruction.However,the use of local reconstructions combined with NPWT,otherwound care adjuncts and local flaps or dermal matricesshould not be overlooked in an era of advanced microsurgery4,50.The role of NPWTThe wid