Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma

The timing of soft tissue reconstruction for severe open lower limb trauma is critical to its successful outcome, particularly in the setting of exposed metalware and pre-existing wound infection. The use of negative pressure wound therapy (NPWT) may allow a delay in soft tissue coverage without adverse effects. This study evaluated the impact of delayed free-flap reconstruction, prolonged metalware exposure, pre-flap wound infection, and the efficacy of NPWT on the success of soft tissue coverage after open lower limb injury.

Retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009.

103 patients underwent 105 free-flap reconstructions. Compared with patients who were reconstructed within 3 days of injury, the cohort with delayed reconstruction beyond 7 days had significantly increased rates of pre-flap wound infection, flap re-operation, deep metal infection and osteomyelitis. Pre-flap wound infection independently predicted adverse surgical outcomes. In the setting of exposed metalware, free-flap transfer beyond one day significantly increased the flap failure rate. These patients required more surgical procedures and a longer hospital stay. The use of NPWT significantly lowered the rate of flap re-operations and venous thrombosis, but did not allow a delay in reconstruction beyond 7 days from injury without a concomitant rise in skeletal and flap complications.

Following open lower limb trauma, soft tissue coverage within 3 days of injury and immediately following fracture fixation with exposed metalware minimises pre-flap wound infection and optimises surgical outcomes. NPWT provides effective temporary wound coverage, but does not allow a delay in definitive free-flap reconstruction.