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

Abstract

Sir: We sincerely appreciate the authors’ interest in our recent article and the efforts to highlight important limitations with our study.1 This discussion brings an important point that our data are limited to the perioperative period and immediate free flap outcomes because of our long study period and inconsistent long-term follow-up. We do agree that we cannot form any definitive conclusions about potential differences in rates of bony union, infection, and amputation for reconstructions less than or equal to 3 days versus 4 to 9 days after injury. However, the purpose of our study was to examine the relevance of the 72-hour cutoff set forth by Godina related to flap complication rates, as his landmark article has long been cited as proof for worse flap outcomes for reconstructions performed after 72 hours after injury. By providing evidence for extending this “acute” phase of reconstruction to 10 days, we feel that this allows reconstructive surgeons to perform adequate serial débridements, especially in injuries with large zones of injury, and to arrange for triage to specialized limb salvage centers. We hope that our study encourages less experienced surgeons to transfer patients and also provides some flexibility for the accepting surgeon to plan and perform reconstruction beyond the initial 72 hours after injury without having to wait 3 months for definitive treatment, as has been traditionally suggested according to the Godina paradigm. The authors raise a controversial issue regarding the evidence for the beneficial effects of negative-pressure wound therapy on severe open lower extremity fractures. They cite the Wound Management of Open Lower Limb Fractures trial as evidence that negative-pressure wound therapy has questionable benefits for treating lower extremity open fractures.2 This study demonstrated no difference in self-rated functional outcomes at 1 year between negative-pressure wound therapy and standard wound dressing for patients with severe open lower extremity fractures. However, this study does not specifically examine the impact of negative-pressure wound therapy on timing of free flap reconstruction in the immediate injury period. It is relatively well-accepted that negative-pressure wound therapy can reduce edema and lessen the degree of wound contamination especially for large wounds. Although we were not able to directly examine the impact of negative-pressure wound therapy on timing of reconstruction, we hypothesize that it may play a role in safely delaying reconstruction beyond the initial 3 days after injury as increasing edema, inflammation, and fibrosis begin to set in. However, further studies are needed to evaluate its relationship to reconstructive timing and influence on early flap-related and late functional outcomes. The point that the authors make regarding the complex nature of lower extremity reconstruction is highly valid. Timing of reconstruction is merely one variable among many (i.e., patient factors, injury severity, operative technique, and flap type) that likely influence both immediate and long-term outcomes. In our cohort, there were no significant differences between the less than or equal to 3-day and 4- to 9-day timing groups in terms of patient age, presence of arterial injury, flap type, number of venous anastomoses, and type of arterial anastomosis. In addition, all of these variables were controlled for in our multivariable analysis. Finally, there is no doubt a need for future studies that specifically assess the impact of timing on long-term outcomes, including union rates, osteomyelitis, and overall long-term function. Ultimately, our goals for patients with lower extremity trauma remain unchanged—to provide care in the safest manner and to ensure optimal outcomes. We agree wholeheartedly with the authors that as reconstructive surgeons, we must strive to provide definitive treatment as promptly as possible. However, we do recognize that logistical constraints (i.e., time to transfer to limb salvage centers) sometimes do not always allow for complex free flap transfer within 3 days of injury. Our study attempts to provide evidence that reconstruction can be performed within 10 days of injury without compromising immediate flap outcomes. We do sincerely appreciate the comments and observations by Dr. Chou et al. DISCLOSURE Neither of the authors has a financial interest in relation to this communication.