November 2017 #PRSJournalClub Wrap-Up: “Not All Gustilo Type IIIB-Fractures Are Created Equal: Arterial Injury Impacts Limb Salvage Outcomes”

by Nicole A. Phillips, MD (@DrNikkiPhillips)

The November edition of the #PRSJournalClub focused on the challenging topic of lower extremity reconstruction and offered an exciting discussion based around the article entitled “Not all Gustilo Type IIIB-Fractures are created equal: arterial injury impacts limb salvage outcomes” by Stranix et al. Click here to read the article.

Despite tremendous surgical advances, lower extremity reconstruction remains a challenging problem for today’s microsurgeon. This large. retrospective review examined the outcomes of  361 lower extremity reconstructions performed between 1979 and 2016. Inclusion criteria for the study involved the use of free tissue transfer to address Gustilo Type III injuries. The authors propose a modification of the Gustilo classification system based upon the results of this review.

Patient demographics, mechanism of injury, sublocation of injury (i.e., proximal, middle, and distal thirds of the leg), time between injury and flap coverage, Gustilo classification, associated injuries, limb vascular status, flap composition and size, recipient vessels/anastomosis, and perioperative outcomes were examined. The majority of patients were classified as having Gustilo type IIIB injuries, whereas a smaller percentage presented with an ischemic distal limb (type IIIC).

The results of the study suggested that the presence of any arterial injury, even when not used as a free flap recipient, was associated with significantly higher flap complication rates. As might be expected, the use of a damaged recipient artery was found to significantly increase flap complication rates. Injured recipient arteries doubled the risk of all complications and more than doubled the risk of vascular compromise requiring emergent take-back to the operating room. Interestingly, the risk of complications, take-backs, and total flap failures was also associated with the number of patent arteries in the lower extremity. These results demonstrated a strong association between the presence of any arterial injury and higher flap complication rates.

Introduced in 1976 and modified in 1984, the Gustilo classification system does not currently account for the presence of one- or two-vessel arterial injuries in an otherwise perfused limb. Based on the findings of the current study, the authors propose a 3-2-1 modification of the type IIIB subgroup denoting the number of intact arteries perfusing the lower leg, in which the arterial runoff number would be reported after the Gustilo type: IIIB-3 injury has three-vessel runoff, type IIIB-2 injury has two-vessel runoff, and type IIIB-1 injury has single-vessel runoff. This modification system could significantly impact reconstructive planning and allow for more accurate prognostic information regarding microvascular limb salvage.

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Jordan Frey (@JordanFreyMD), Shuja Shafqat (@shujashafqatmd), and Chad Purnell (@ChadPurnellMD), and special guest moderator Dr. David Chang. Listen to the podcast discussion below.

One of the liveliest #PRSJournalClub discussions to date was held over the weekend of November 19th-20th, with authors JT Stranix (@jtstranix) and Jamie Levine (@JamieLevineMD) answering questions covering a wide range of topics related to lower extremity reconstruction. The most popular discussion threads are highlighted below, and organized according to topic. Enjoy, and please join us for our next #PRSJournalClub on 12/17 and 12/18!

Role of preoperative imaging:

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Timing of reconstruction:

Screen Shot 2017-12-12 at 1.55.41 PMScreen Shot 2017-12-12 at 2.34.11 PM


Selection of recipient vessel, type of anastomotic connection, and getting outside the zone of injury:

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Impact of nerve injury on lower extremity reconstruction:

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Venous outflow:

Screen Shot 2017-12-12 at 2.11.24 PM.pngScreen Shot 2017-12-12 at 2.14.15 PM


Flap choice:

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Implications of a new 3-2-1 classification system:

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