Microvascular free flap reconstruction in pediatric lower extremity trauma: A 10-year review

Background: Limb-threatening wounds of the adult distal lower extremity pose a challenge to the microvascular surgeon and are the subject of a sizable body of literature. The microsurgical management of these injuries in the pediatric population has some unique features but has not previously been the subject of a separate study. Methods: A review was performed of all pediatric patients (< 18 years of age) who received lower extremity free flaps for trauma at the University of Kentucky Medical Center between 1992 and 2002. Charts were reviewed and patients were contacted via telephone and given a standardized questionnaire. Logistic regression was used to identify factors predictive of worse outcome or complications. Results: Twenty-six patients (28 flaps) met the selection criteria. The most common mechanism of injury was all-terrain vehicle accidents (n = 6), followed by motorcycle accidents, lawnmower injuries, and gunshot wounds. The latissimus dorsi muscle flap was chosen in 15 cases, with four other muscle flaps chosen for the remaining 13 cases. There were 12 Gustillo 3B or 3C fractures of the tibia. External fixation was used in 10 cases and internal fixation was used in two. Four patients had a bone gap greater than 4 cm. Three were successfully treated with distraction osteogenesis. The postoperative complication rate was 62 percent, with infection and partial skin graft loss being the most common complications. Three flaps were lost. Growth disturbances were seen in two patients. Patients receiving free flaps within 7 days after injury were seen to have a statistically significant lower rate of complications than those undergoing the procedure beyond the first week. Follow-up ranged from 2 to 11 years, with a mean follow-up of 4.5 years. All limbs were successfully salvaged, and all patients were ambulatory at the time of the survey. Conclusions: There is a significant role for the microvascular surgeon in the management of limb-threatening injuries in children. If the unique features of this population are taken into consideration, a high rate of limb salvage and good function can be expected.