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11 Fine-Tuning Postoperative Care ofFracture-Related Infection
165
Flap Failure
Global survival of free aps is reported to be
from 90% to 97% [5]. However, in the lower
limb, it is estimated 4–13% of free aps must
return to the operating room (OR) because of suspected vascular compromise [29, 30]. For those
that are revised surgically, a wide range of ap
salvage rates (22–100%) is reported [5, 30]. Free
ap salvage rates in recipients located in the
extremities (the most common scenario in FRI
patients) are similar to those for aps on the head
and neck region, and lower than salvage rates of
free aps in the trunk region [5]. In the limbs,
venous compromise is more likely to be successfully managed when compared to arterial compromise [5].
In the event of partial ap failure, it may not
be possible to identify the cause of the failure
precisely, but often simple techniques such as
skin grafts or locoregional aps, or even secondary healing depending on the case, sufce to
achieve wound coverage [31].
In the event of total ap failure where ap
salvage has not been possible, the underlying
problem that caused the ap failure must be
addressed before further reconstructive measures
are undertaken. For example, if the cause of the
failure was an arterial thrombosis, an angiography is appropriate to check for potential abnormalities of the recipient artery [31, 32]. If the
recipient’s ow is normal, the same recipient vessel can be used again, whereas when poor ow is
seen, a different recipient should be chosen (or a
bypass to a more proximal section with normal
ow, if no better nearby recipients are available)
[31]. If venous thrombosis occurs, another vein
from a different system (e.g., a supercial vein, if
previously a deep vein had been used) should be
selected for the new anastomosis [31]. If the
recipient pedicle presented an anatomic anomaly
or vasospasm, or was compressed extrinsically,
the deleterious condition should be addressed
when performing a second ap.
When a second free ap is performed, the
ratio of survival is lower than with the rst one
(82% success rate) [32]. The indication for limb
reconstruction with a second ap versus an
amputation must be revised. Identied risk factors for amputation after failed lower limb salvage with a free ap include residual infection, a
high number of preoperative debridements, and
comorbidities such as diabetes mellitus or arterial
pathology (especially, three-vessel injury) [33].
For more information on indications for amputation, refer to Chap. 8.
Note that when a second free ap is performed
after a primary ap failure, infection eradication,
and union rates do not change [30].
Postoperative Rehabilitation
Physical therapy and rehabilitation are fundamental to obtain good functional outcomes, preventing joint stiffness and the need for secondary
procedures [34].
Treatments are protracted, often with periods of
immobility after surgery, especially when joints
are involved since their immobilization improves
infection control [35]. Thus, without exquisite
attention to keeping joints supple, range of motion
of nearby joints will decrease [36]. Even with adequate physical therapy, it may be challenging to
maintain full range of motion, especially with
some treatments that tend to interfere with the
range of motion of adjacent joints, such as bone
transport [37]. When a joint does become stiff,
joint contracture release may be necessary [35].
The optimal time to perform it is after infection
eradication and before adjunctive procedures such
as nerve, muscle, or tendon transfers [38].
Axial Load andWeight-Bearing
The evidence to aid decision-making on when to
allow the patient to load on the affected bone is
scarce.
In the lower limb, weight-bearing will
depend strongly on the kind of treatment that was
applied. For example, cancellous bone autografts
provide little mechanical stability, so stability
will depend mostly on hardware. Generally, autografted patients are able to start partial weightbearing at 14weeks [39]. With techniques based
166
E. Armas and N. Vanaclocha
on distraction osteogenesis (acute shortening and
re-lengthening, bone transport), partial weightbearing can be started immediately, gradually
increasing the load until full weight-bearing
within the rst postoperative week or two [40]. If
bone aps are used, weight-bearing must be
delayed until bone union (three out of four cortices) is observed. In most patients, this will take
about 4 months [41]. After this time, protected
weight-bearing with a CAM walker-type boot
until adequate hypertrophy of the bone ap is
obtained is important to prevent stress fractures.
The patient should avoid jumps and plyometricstyle exercises, as well as activities in which their
lower limb must resist weight additional to their
body weight, for a full year minimum [42].
After harvesting a bula ap, it was traditionally considered necessary to splint the ankle of
the donor leg with a cast or an orthopedic boot
and forbid weight-bearing on that leg for 2weeks,
after which partial weight-bearing could be initiated [41]. More recent evidence suggests that
early weight-bearing on the rst postoperative
day is associated with a reduction in donor-site
complications and shorter length of stay [43, 44].
In the upper limb, where maintaining mobility is key for a good functional result, range of
motion exercises should generally be started in
the immediate postoperative period (for free aps
and skin grafts, a delay of a few days is wise)
[45]. Allowing axial load will depend mostly on
the strength of the osteosynthetic construct. If
sturdy internal xation was possible, it is reasonable to allow axial load once the wounds are stable (usually 2–3weeks) [45].
Limb Dangling
Free aps on the lower limb are affected by positional hemodynamic changes, which can lead to
edema, decreased perfusion, and potential compromise of the reconstruction [46]. Many
microsurgeons adopt dangle protocols to avoid
this potential outcome, these protocols being
highly heterogenic [46–48]. There is no evidence
to support any one specic dangling protocol
over another.
It has been theorized that early dangling protocols could lead to a faster patient discharge, but
there is currently insufcient evidence to support
this claim. There is evidence that patients with
diabetes, hypertension or smokers can safely tolerate early dangling protocols [48]. Some surgeons have combined early dangling at
postoperative day 3 with wrapping of the ap to
prevent edema, without increases of ap failure
rate [49–51]. If performed, elastic wrapping
should be placed with 30mmHg pressure [52].
Conclusions
Adequate postoperative care of every type of
wound is necessary to achieve a good outcome.
In general, standard care of postoperative
wounds, skin grafts, and aps is applicable. As
we move up on the reconstructive ladder, more
resources are necessary to ensure good postoperative care and a successful reconstruction.
Clinical examination by trained professionals
can provide adequate information regarding the
vascular status of free aps, but device-based
monitoring, such as NIRS or the implantable
Doppler, is becoming increasingly popular as
early evidence suggests more precise, prompt,
and user-independent detection of vascular compromise using these devices.
When free ap failure occurs, performing a
second free ap might not always be the best
strategy. Reconsider which technique will benet
the patient best in the new scenario. It is important to identify the cause(s) of failure and any factors negatively affecting ap viability.
Physical therapy is essential to achieve a good
functional outcome in every trauma patient.
When to allow mobilization, axial load, and
weight-bearing will depend on where the fracture
is located and the treatment applied. For example, in FRIs in the lower limb, many treatment
strategies allow early weight-bearing. Constructs
with bone aps are often not stable enough for
early weight-bearing, so protected weightbearing using orthopedic boots is common. In
FRIs in the upper limb, which sustain lesser
forces and in which maintaining mobility of
11 Fine-Tuning Postoperative Care ofFracture-Related Infection
167
nearby joints is especially important, controlled
range of movement and axial loading are often
started as soon as the wounds are stable.
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