Massachusetts Chapter of the American College of Surgeons

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Vascular Interventions and Free Flaps Are Associated with Prolonged Length of Stay Among Patients Undergoing Traumatic Lower Extremity Reconstruction
Scott R. Levin, MD, MSc, Daniel S. Roh, MD, PhD
Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA

Background:
Salvaging limbs with extensive soft tissue loss requires reconstruction with pedicled or free flaps. We aimed to evaluate patient/procedural characteristics associated with traumatic lower extremity (LE) reconstruction outcomes.

Methods:
We queried the National Trauma Data Bank (2015-18) for patients undergoing traumatic LE reconstructions. Univariable/multivariable analysis evaluated associations with outcomes.

Results:
There were 13,000 patients undergoing traumatic LE reconstructions free (87%) and local (26%) flaps. Most underwent free skin grafting (83%) followed by local muscle (11%), subcutaneous (9%), and skin grafting (8%). Mean age was 4417 years and most were male (75%), white (67%), non-obese (59%), non-smokers (69%), and non-diabetic (91%). Patients typically presented after blunt trauma (89%) to Level I trauma centers (77%) with mean total injury severity scores of 1311. Injuries included ipsilateral LE fractures (45%), vascular injuries (11%), and traumatic amputations (2%). LE interventions were vascular interventions (9%), fasciotomies (7.5%), and major amputations (4%). Surgical site infections (SSI) (2%) and post-reconstruction ipsilateral amputations (1.2%) occurred. Among inpatient survivors (98%), mean length of stay (LOS) was 2220 days and 43% were discharged to rehab. On multivariable analysis, LE vascular interventions was associated with increased SSI (OR 2.2), amputation (OR 4.3), and discharge to rehab (OR 1.1) (all P<.001). LE vascular interventions (OR 1.9) and free flaps (OR 1.9) were associated with increased LOS (all P<.001).

Conclusion:
Traumatic LE reconstructions were frequently free skin grafts. Patients receiving LE vascular interventions or free flaps experienced prolonged LOS. Future prospective studies should investigate causes of increased healthcare utilization among these subgroups.


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