burns 49 (2023) 1103–1112

Available online at www.sciencedirect.com

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Predictors for limb amputation and reconstructive

management in electrical injuries
]]
]]]]]]
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Nadine Pedrazzi a,b, Holger Klein a,b, Tony Gentzsch a, Bong-Sung Kim a,
⁎
Matthias Waldner a, Pietro Giovanoli a, Jan Plock a,b, Riccardo Schweizer a,
a
Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zürich, Switzerland
b
Department of Plastic Surgery and Hand Surgery, Kantonsspital Aarau, Switzerland

a rt i cl e in fo ab strac t

Article history: Background: Electrical injuries follow a specific pathophysiology and may progressively
Accepted 9 August 2022 damage both skin and deeper tissues, frequently ending in amputations. Type and timing
of soft tissue reconstruction after electrical burns is crucial for proper outcome. The aim of
Keywords: this study was to assess surgical management and outcome of patients with electrical
Electrical burn injuries treated at the Zurich Burn Center over the last 15 years, with emphasis on risk
High-voltage factors for amputation and reconstructive strategy.
Amputation Methods: Patient charts were reviewed retrospectively to identify cases admitted at the
Reconstruction Zurich Burns Center (2005–2019). Patient characteristics and surgical management, with a
Free flap special focus on amputations, reconstruction and outcome were analyzed and risk factors
for amputation were assessed.
Results: Eighty-nine patients were identified and a total of 522 operations were performed.
Escharotomy and fasciotomies were performed in 40.5% and 24.7% of cases, respectively, mainly
at admission. The total amputation rate was 13.5% (23 amputations, 12 patients). Development
of compartment syndrome, rhabdomyolysis, high myoglobin and CK blood levels, kidney failure,
sepsis and respiratory complications during the course were related to higher risk of amputation
(p < 0.001). Sixty-six flap-based reconstructions were performed (25% cases): 49 loco-regional
flaps, 3 distant pedicled flaps, 14 free flaps. Two flaps were lost (flap failure rate 14%). Both flap
losses occurred in cases of early reconstruction (within 5–21 days).
Conclusions: Electrical injuries are still cause of elevated morbidity and mortality, with high
amputation rate. Predictors for amputation can support physicians in the surgical care and
decision-making. Reconstruction remains challenging in this type of injury: the surgical
management with early decompression, serial necrectomies and delayed early re-
construction remains the procedure of choice at our unit.
© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC
BY license (http://creativecommons.org/licenses/by/4.0/).

Abbreviations: ABSI, Abbreviated Burn Severity Index; CI, Confidence interval; CK-MB, Creatinine kinase myocardial band; CK,
Creatinine kinase; COPD, Chronic obstructive pulmonary disease; ICU, Length of intensive care unit stay; IQR, Interquartile range; LOR,
Length of rehabilitation; LOS, Total length of hospital stay; TBSA, Total Body Surface Area
⁎
Correspondence to: Universitätsspital Zürich, Klinik für Plastische Chirurgie und Handchirurgie, Rämistrasse 100, 8091 Zürich,
Switzerland.
E-mail addresses: nadine.pedrazzi@ksa.ch (N. Pedrazzi), riccardo.schweizer@gmail.com (R. Schweizer).

https://doi.org/10.1016/j.burns.2022.08.007
0305-4179/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creative-
commons.org/licenses/by/4.0/).
1104 burns 49 (2023) 1103–1112
1. Introduction
Electrical burn injuries account for 3–7% of all burn patients
[1–6]. Nevertheless, this type of injury may be destructive, se-
quentially damaging both skin and deeper tissues, endangering
the limb function and frequently ending in amputation. Patho-
physiology of electrical injuries is different from thermal burns.
Non-thermally mediated tissue damage can occur when elec-
tricity produces pores in the cellular lipid bilayer membranes
(electroporation), that may contribute to progressive muscle
necrosis, often resulting in amputation [7,8]. Limb loss re-
presents a devastating repercussion of electrical injury. Accu-
rately predict the outcome of electrical burns is very challenging
[9]. Literature analyzing the predictive factors of amputation
specifically in electrical burns is scarce, however, it has been
proposed that any element related with the amount of muscle
injury can potentially be used to predict the need of limb am-
putation [8,10].
The type and timing of soft tissue reconstruction after
electrical burns is an additional important aspect that is
crucial for proper outcome and matter of debate. Because of
the pathophysiology of electrical burns, characterized by
progressive tissue necrosis and denaturation of blood vessels
[7], a debate about the timing of reconstruction still open [11].
The aim of this study was to assess surgical management
and outcome of patients with electrical injuries treated at the
Zurich Burn Center, one of two national burn centers in
Switzerland, over the last 15 years, with emphasis on risk
factors for amputation and reconstructive strategies.
2. Methods
This retrospective chart analysis was performed in accordance
with the Declaration of Helsinki and approved by the local Ethics
Commission (KEK Nr. 2019–00856, June 13, 2019). Informed con-
sent was retrieved from patients where necessary. Patients
equal or older than 16 years admitted at the burns unit at the
University Hospital of Zurich due to electrical injury between
January 2005 and December 2019 were extracted from in our
digital patient database and their charts reviewed. All available
charts were analyzed for following criteria: age at admission,
gender, Total Body Surface Area (TBSA), Abbreviated Burn
Severity Index (ABSI), degree and localization of burn, injury
type, surgical management, complications, length of stay, am-
putations, reconstructive surgery and outcome. Risk factors for
amputation were analyzed. We included patient’s character-
istics, including pre-existing medical diagnosis presented at the
time of admission not caused by the accident. Thousand volts
were defined as cut-off between low and high-voltage [3]. Acute
respiratory distress syndrome (ARDS), infections (pneumonia,
bronchitis), pulmonary embolisms, and pleural complications
have been included as pulmonary complications. Traumatic
brain injuries, hypoxic encephalopathy, septic encephalopathy,
cerebral edema, intracranial hypertension and cerebral hemor-
rhage were included as neurological complications. Diagnosis of
renal failure based on a combination of reduced glomerular fil-
tration rate and urine output, elevation of serum creatinine and
uremia.
Acute renal failure was defined according to the classification
of RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease)
and AKIN (Acute Kidney Injury Network), which assesses the
degree of damage based on the presence of one of the following
parameters: an increase in serum creatinine level, a decrease in
glomerular filtration rate, or a change in the volume of urine
output [12]. Rhabdomyolysis was identified by combining clinical
assessment with blood tests confirming a marked acute peak in
serum creatine kinase (CK) and myoglobin. As part of our stan-
dard admission protocol, patients with relevant skin burns re-
ceived a first debridement, consisting of whole-body disinfection
with iodine soap, debridement of all blisters and shaving. TBSA
was calculated using Lund-Browder Charts after initial debride-
ment. Fluid resuscitation occurred according to University of
Utah protocol [13]. Decision for decompression was made
mainly by clinical evaluation, while compartment pressure was
checked in distinct unclear cases. With the aim of minimizing
pressure-related tissue damage, prophylactic fasciotomies have
been performed in all patients with severe high voltage ex-
tremity injuries since 2014 [14]. Amputation was evaluated in
presence of gangrene, septic complications, destruction of vital
structures such as nerves and vessels, precluding functional
salvage of the limb; in addition, general medical condition, age
and willingness of the patient to go through a reconstructive
path were considered. The reconstruction timing after electrical
burn was classified into primary reconstruction (performed
within the accident and 6 weeks after the injury) and secondary
reconstruction (performed 6 weeks or later after the injury)
[11,15]. The primary reconstruction was itself subdivided into
immediate (< 5 days after trauma), delayed early (within
5–21 days) and intermediate (within 21 days and 6 weeks). After
free flap reconstruction, patients received initially prophylactic
anticoagulation with heparin (controlled through anti-Xa factor).
If no signs of bleeding were encountered after 24 h, the dose was
adjusted to therapeutic.
Discrete values were expressed as counts with percen-
tages, while continuous variables were presented as mean ±
standard deviation (SD) or median with interquartile range
(IQR) as appropriate. Log10-transformation was performed to
achieve Gaussian distribution for skewed continuous vari-
ables. Continuous baseline characteristics were compared
between groups (no limb loss vs. limb loss) using ANOVA.
Contingency tables with Chi-Square test and risk parameters
were used to demonstrate associations between baseline
characteristics/complications and the status of limb ampu-
tation. Binomial logistic regression models with receiver op-
erating characteristic (ROC) curves were used to predict the
outcome no limb loss vs. limb loss. All tests were two tailed;
p < 0.05 was considered significant. Data were analyzed
using Jamovi (The Jamovi Project 2020, version 1.2) and
GraphPad Prism version 6.00 for Macintosh (GraphPad
Software, La Jolla California USA).
3. Results
3.1. Patient characteristics and injuries
Eighty-nine patients with electrical injuries were identified,
with an average of 6 patients per year. The patient and injury
 burns 49 (2023) 1103–1112 1105

Table 1 – Patient characteristics and injuries. ABSI, the patients with renal failure (n = 9, 50%) fully recovered
abbreviated burns severity index; N, number; Q1, renal function, while the other half died during the course.
quartile 1; Q3, quartile 3; TBSA, total body surface area. As a matter of redundancy, we have avoided describing
Characteristics N (%) / results again, that have been published previously. We refer
Median (Q1;Q3) to our previous publication focusing on clinical outcome:
Age 34.0 (23.0;47.0) Schweizer R, Pedrazzi N, et al. Risk Factors for Mortality and
Gender Prolonged Hospitalization in Electric Burn Injuries. J Burn
Male 77 (86.5%)
Care Res Off Publ Am Burn Assoc 2020 [7].
Female 12 (13.5%)
Context
Work-related 59 (66.3%) 3.2. Initial surgical management
Non work-related 30 (33.7%)
Suicide 10 (11.2%) A total of 522 operations were performed, of which 456 during
Voltage the first hospitalization (87.4%), 54 during elective read-
High-Voltage 66 (74.2%) missions (10.3%) and 12 after emergency readmissions (2.3%).
Low-Voltage 23 (25.8%)
A median of 3 operations (IQR 2.0; 8.0) were done per patient.
Type of injury
Three patients (3.4%), with superficial hand burns, did not
Arc 43 (48.3%)
Contact 38 (42.7%) undergo any operation. Patients affected by low-voltage cur-
Unknown mechanism 8 (9%) rent had less surgeries (n = 79; median 2.0; IQR 1.5, 3.0)
TBSA (%) 12.5 (4.6;36.0) compared to patients with high-voltage injuries (n = 443;
ABSI 5.0 (4.0;7.0) median 4.0; IQR 2.0, 10.8). Patients between 41% and 60%
Concomitant injuries TBSA underwent most operations (median 12; IQR 7.0, 15.5).
Fractures 15 (16.8%)
Escharotomy and fasciotomies were performed in 36 (40.5%)
Traumatic Brain Injury 16 (18%)
Inhalation Injury (bronchoscopy 8 (9%)
and 22 patients (24.7%), respectively, mainly at admission.
confirmed) Out of the 35 circumferential lesions mentioned above, 13
(37.1%) benefited from an escharotomy, while 15 a fas-
ciotomy (42.9%). Further surgical care included reiterated
debridements/ necrectomies (n = 53; 59.5%).
characteristics are provided in Table 1. From the various
anatomical regions involved, the most commonly afflicted
3.3. Amputation and risk factors
were the upper extremities (81 cases; 91%), followed by lower
extremities (53 cases; 59.5%), trunk (46 cases; 51.7%), head (46
The total amputation rate was 13.5%, with 23 amputations
cases; 51.7%), neck (35 cases; 39.3%) and gluteal and genital
performed in 12 patients (Table 2). All the amputated pa-
region (17 cases; 19.1%) (Fig. 1). Sixty-two patients (69.7%) had
tients had high-voltage traumas. Fifteen amputations af-
at least one hand injured: 29 one hand (32.6%) and 33 both
fected the upper extremities (finger, n = 5; hand, n = 1;
hands (37.1%). Thirty-five circumferential burns were found
forearm, n = 3; upper arm, n = 6) and 8 the lower extremities
in 17 patients: 17 circumferential burns affected the legs
(lower leg, n = 6; thigh, n = 2). Five patients (41.7% of all am-
(48.6%), 11 the arms (31.4%), five the hands (14.3%), one the
putees) had single amputation while 7 (58.3%) had the am-
trunk (2.9%) and one the neck (2.9%). Among the electrical
putation of multiple anatomical parts. Furthermore, 2
burn patients included, 18 (20.2%) experienced renal failure
women (2.2%) had bilateral mastectomies. Of 23 amputations
during the course, of whom 12 (67%) received dialysis. Half of
performed, 18 were preceded by fasciotomy (78.3%) as sal-
vage procedure. In 2 cases (16.7%) a limited amputation
(fingers or hand only) was attempted for salvage before
whole extremity amputation. On average, amputations were
performed on the tenth day after admission (median 4 days;
IQR 3.0, 9.0).
Blood creatinine kinase (CK) and myoglobin median va-
lues during the first 3 days increased from 465.5 to 2′130 U/l
and from 388 to 1′123 µg/l, respectively. Patients with high-
voltage lesions had higher median CK and myoglobin mean
values than patients with low-voltage lesions (Fig. 2A-B). We
compared the patient collective with and without amputa-
tion (Table 3). The two groups showed no significant differ-
ence in age, gender, co-morbidities and TBSA. Among
amputated patients, 83% developed rhabdomyolysis during
the initial course, compared to only 21% of non-amputated
patients (p < 0.001). Fig. 3A and B depict the probability of a
necessary subsequent amputation according to the level of
Fig. 1 – Burned body region. Number of patients (y-axis), by CK and myoglobin during the first 3 days upon admission
burned body region (x-axis), per type of burn (circular vs. using estimated marginal means derived from binomial lo-
non-circular burn). gistic regression models. Overall, at admission amputated
1106 burns 49 (2023) 1103–1112

Table 2 – Amputated patient characteristics. II, partial-thickness burn; IIb, deep partial-thickness burn; III, full thickness
burn; F, female; M, male; N, number; TBSA, total body surface area.
Age / Gender TBSA (%) / Voltage / Mechanism / Local injury and degree N of Amputation / Days after admission
Amputated area

44/M 58 / High / Contact n=1 2

Leg right IIb, foot right III Distal lower leg right
22/M 4 / High / Contact n=1 7
Arm and hand left III Hand left
26/M 32 / High / Arc n=2
Arm right II, hand right III Upper arm right 3
Arm and hand left III Upper arm left 3
18/M 30 / High / Contact n=1 33
Arm left II, hand left III Upper arm left
24/M 6 / High / Unknown n=2
Arm left III, hand left III circular Upper arm left 5
Arm right IIb, Hand right IIb Phalanx Finger 2 right 77
23/M 26 / High / Contact n=2
Arm and hand right III circular Upper arm right 1
Leg right III circular Thigh right 5
28/M 32 / High / Contact n=1 0
Arm and hand right III Forearm right
22/M 10 / High / Contact n=5
Arm and hand right III Fingers 1–4 right 4
Forearm right 11
37/M 70 / High / Contact n=2
Both legs and feet III Lower leg right 5
Lower leg left 5
26/F 62 / High / Arc n=2
Both legs and feet III Lower leg left 14
Lower leg right 16
52/F 77 / High / Unknown n=1 16
Leg left III Lower leg left
48/M 27.5 / High / Unknown n=3
Arm and hand right III circular Forearm right 1
Leg right III circular Upper arm right 3
Thigh right 3

patients presented a median myoglobin level of 25′965 µg/l
(7′127 µg/l on day 2, 2′515 µg/l on day 3), while non-ampu-
tated had 242 µg/l (491 µg/l day 2, 581 µg/l day 3) (p < 0.001)
(Fig. 3A). Similarly, admission blood CK was 30′045 µg/l
(22′067 µg/l day 2, 11,483 µg/l day 3) compared to non-ampu-
tated cases with 326 µg/l (673 µg/l day 2, 515 µg/l day 3)
(p < 0.001) (Fig. 3B). Fifty-eight percent of the amputees pre-
sented renal failure during the stay, compared to 14% among
non-amputated cases (p < 0.001). Fifty percent of the ampu-
tees presented a compartment syndrome, compared to 17%
among non-amputated cases (p < 0.01). Seventy-five percent
of the amputated patients presented a lung complication and
67% a sepsis during the follow-up, compared to 27% and 16%
among non-amputated cases (p < 0.001 for both complica-
tions).
3.4. Reconstruction
Sixty-two patients received split-thickness skin grafts (69.7%).
Sixty-six flap-based reconstructions were performed in 23
patients (25.8%), with a total of 49 loco-regional flaps, 3
distant pedicled and 14 free microvascular tissue transfers.
Forty-nine locoregional flaps were performed on 21 patients
(23.6%), 28 of them during the acute phase and first hospi-
talization, while 21 during further hospital stays, for sec-
ondary correction of scars or defects. Most of the patients
(n = 16, 76.2%) who benefited from this type of reconstruction
had high-voltage lesions (Table 4). Local reconstructions in-
cluded muscle flaps (n = 7, 14.3%), mucosal flaps for re-
construction of the oral area (n = 8, 16.3%), and a wide variety
of cutaneous and fasciocutaneous local flaps (n = 34, 69.4%).
Three patients (3.4%) had a pedicled groin flap to cover de-
fects in the hand and distal forearm. Twelve patients (13.5%)
underwent free microvascular tissue transfer, mostly after
high-voltage injury (n = 10, 83.3%). Free microvascular tissue
transfers consisted primarily in arterialized venous flaps
(n = 4), followed by latissimus dorsi (LD) flaps (n = 3) and
anterolateral thigh (ALT) flaps (n = 3), gracilis (n = 2), serratus
(n = 1) and sural (n = 1) flaps (Fig. 4A, Table 4). The majority of
microvascular tissue transfers (n = 12, 85.7%) were primary
reconstruction (< 6 weeks after accident), while a minority
(n = 2, 14.3%) were secondary reconstruction (> 6 weeks)
 burns 49 (2023) 1103–1112
Fig. 2 – Blood myoglobin and creatinine kinase median
values during the first three days after admission. A.
Myoglobin median value (ug/l) in blood (y-axis) during the
first three days after admission (x-axis), per voltage. B.
Creatinine kinase median value (U/l) in blood (y-axis) during
the first three days after admission (x-axis), per voltage.
(Fig. 4 B). Among the primary reconstructions, five (35.7% of
all free flaps) were early reconstructions (within 5 and 21
days), while seven (50%) were intermediate reconstructions
(within 22 days and 6 weeks). No immediate reconstructions
before 5 days were performed. The total flap failure rate was
14.3% (n = 2). Five of the free flaps (35.7%) presented a vas-
cular complication, but only 2 (14.3%) resulted in flap loss
(Table 4). One flap presented venous insufficiency and was
removed 4 days later, despite the venous revision. Three
other flaps presented ischemia due to an arterial thrombosis.
Two of them recovered an optimal state after local throm-
bolysis and arterial re-anastomosis. The third had massive
thrombosis and could not be saved. A venous flap needed
revision of the arteriovenous and venous anastomosis and
recovered an excellent vascularization. All the vascular
complications of these free microvascular tissue transfers
took place within the first 24 h after surgery. Both flap losses
occurred after an early reconstruction, while no vascular
complication occurs in secondary reconstructions.
4. Discussion
Herein we found that initial development of compartment
syndrome, rhabdomyolysis and kidney failure, in addition to
septic and respiratory complications during hospitalization,
are related to higher risk of amputation after electrical
1107
injury. Indeed, high myoglobin and CK levels during the first
3 days correlated to significantly higher chance for ex-
tremity amputation, which is in line with other reports
identifying initial serum CK values as a prognostic para-
meter for the assessment of amputation risk [8,16,17].
Hsueh et al. set a cut-off value for CK-MB of 80 ng/ml and CK
of 7233 U/l above which the risk of amputation is extremely
high [8] and Kopp et al. states that in these patients blood
CK represents muscle injury much better than TBSA [17]. No
significant correlation between TBSA and amputation risk
was found in our analysis. Conversely, in Bartley et al. and
Tarim et al. TBSA seems to correlate significantly with am-
putation risk [10,18]. Also myoglobinuria was found in-
dicator of muscle damage and predictor for amputation [19],
[20]. In our analysis, no significant correlation was found
between patients' pre-existing diseases and their risk of
limb loss. In contrast, Thornburg et al. reported that some
co-morbidities, such as diabetes, cardiovascular, renal and
liver diseases but also alcohol abuse and smoking history
were associated with higher amputation risk [21]. In the
study of Bartley et al. for each point increase in Charlson
Comorbidity Index (CCI) score, the odds for amputation in-
creased by 29% [18]. The amputation rate in our cohort was
13.5% and involved mostly the upper extremity, as described
by others [2,10,22–24]. In the literature amputation rate
varies considerably between the series, ranging from 11% to
49.4% and depending on different factors like patient’s
condition, team’s experience and infrastructural resources
[4,16]. The average rate of amputation is higher in patients
with high-voltage injury compared to low-voltage [25] which
is in line with our results. In Handschin et al., a previous
study at our burn center, emphasized that the amputation
rate (13.5% vs 1.5%), as well as the escharotomy and fas-
ciotomy rate (47.2% vs. 21%) in electrical burned patients are
significantly higher than in thermal burns [16]. This analysis
included 19 cases with high-voltage burns, which were in-
cluded also in the current study.
Surgical strategy for high-voltage injuries treatment can
be very heterogeneous [4]. After initial patient stabilization,
the majority of acute burns should receive a proper debride-
ment, followed by the application of a skin graft [15,26,27]. At
the initial stage, early decompression with escharotomy or
fasciotomy can be necessary to avoid compartment syn-
drome and this has proven resulting in favorable outcome [4].
In our study, 66 flap-based reconstructions were performed in
a quarter of patients, with a total of 49 loco-regional flaps, 3
groin flaps and 14 free microvascular tissue transfers. The
introduction of free microvascular tissue transfer has al-
lowed the preservation of otherwise unsalvageable deeply
burned limbs [15,26,27]. Patients with electrical burns benefit
more frequently from free microvascular tissue transfer than
patients with thermal burns [16]. However, free tissue
transfers are reserved for a small number of selected cases
[11,28,29], presenting complex wounds, with exposed bone,
tendon or neurovascular structures [29]. This is also reflected
in our study. At our burns unit the treatment consists in re-
peated debridements within the initial vulnerable phase,
1108 burns 49 (2023) 1103–1112

Table 3 – Risk factors for limb loss. AUC, area under the curve; CK, creatinine kinase; d, day; N, number; Q, quartile; TBSA,
total body surface area.
No limb loss Limb loss Significance (p) Odds (95%-CI) Relative Risk (95%-CI) AUC
(n, % or median) (n, % or median) (median, Q1;Q3) (median, Q1;Q3)

Patient’s characteristics
Age 35 26 0.265
Gender Man = 67 Man = 10 0.728 1.34 (0.25; 7.02) 1.04 (0.79; 1.36)
Female = 10 Female = 2
TBSA 10 28.75 0.097
Diabetes 3 0 0.487 0.85 (0.04; 17.50) 0.86 (0.79; 0.94)
Cardiovascular disease 8/77 (10%) 0/12 (0%) 0.243 0.32 (0.02; 6.03) 0.85 (0.77; 0.93)
Blood values
Myoglobin d0 242 25,965 <0.001** 91%
Myoglobin d1 83 11,738 <0.001** 89%
Myoglobin d2 491 7127 <0.001** 84%
Myoglobin d3 581 2515 0.061 70%
CK d0 326 30,045 <0.001** 94%
CK d1 345 37,489 <0.001** 91%
CK d2 673 22,067 <0.001** 84%
CK d3 515 11,483 0.001** 81%
Complications
Rhabdomyolysis 16/77 (21%) 10/12 (83%) <0.001** 19.06 (3.79; 95.84) 1.57 (1.16; 2.14)
Compartment Syndrome 13/77 (16.9%) 6/12 (50%) 0.009** 4.92 (1.37; 17.69) 1.34 (0.98; 1.83)
Renal failure 11/77 (14%) 7/12 (58%) <0.001** 8.40 (2.26; 31.23) 1.52 (1.05; 2.21)
Cardiovascular 15/77 (19%) 4/12 (33%) 0.276 2.06 (0.54;7.78) 1.21 (0.87; 1.44)
Neurological 19/77 (25%) 6/12 (50%) 0.069 3.05 (0.88; 10.60) 1.19 (0.94; 1.50)
Abdominal 20/77 (26%) 4/12 (33) 0.593 1.43 (0.39; 5.24) 1.05 (0.86; 1.29)
Pulmonary 21/77 (27%) 9/12 (75%) <0.001** 8.00 (1.97; 32.43) 1.36 (1.06; 1.73)
Thromboembolism 5/77 (6%) 6/12 (50%) <0.001** 14.40 (3.38; 61.38) 2.03 (1.06; 3.89)
Sepsis 12/77 (16%) 8/12 (67%) <0.001** 10.83 (2.81; 41.75) 1.57 (1.09; 2.26)

with flap coverage in most cases within the first 6 weeks. In
the present cohort, flap failure rate is relatively high (14%),
and consistent with literature, which describes failure rates
up to 24% [30]. Complications with surgical revision occurred
in 5 flaps, resulting in 2 flap losses. In one case of lower leg
defect after the failure of a latissimus dorsi free flap, wound
closure was achieved using repeated debridements, vacuum
assisted closure device and coverage with pedicled gastro-
cnemius muscle flap. In the other case, a sural flow through
flap used to cover a forearm defect was lost. The wound was
subsequently covered with a groin flap. All flaps having suf-
fered from complications were performed at different time-
points and the problem occurred in 2 cases after an early
reconstruction (18 and 19 days after the accident) and in 3
cases after an intermediate reconstruction (22, 33 and 39 days
after trauma). However, both flap losses occurred in cases of
early reconstruction. No flap failure was observed after 6
weeks after trauma. In the study of Jabir et al., the timing of
reconstruction did not appear to affect flap survival [11]. The
author argues that free flap failure after early reconstruction
are more probably related to poor initial debridement prior to
free tissue transfer than timing per se [11]. However, the ideal
timing for free microvascular tissue transfers in electrical
burns remains an ongoing debate [16]. Some authors claim
that all tissue damage occurs at the time of accident and
immediately after, promoting immediate reconstruction in-
cluding free flaps [31]. The rationale is that early re-
construction allows to rescue part of borderline damaged
tissues and may result in lower tissue loss. Karimi et al. de-
monstrated that early flap coverage within 3 weeks could
reduce the length of stay by 65%, the amputation rate by 54%
and also the wound infection rate [31]. Dega et al. found that
early reconstruction results in a better outcome and limb
function, inversely proportional to the time elapsed since
admission [4]. Other authors argue that progressive tissue
necrosis follows the initial trauma [16]. In this case an early
coverage may results in fluids collection, infection and flap
loss [31]. Baumeister, Ofer and Sauerbier et al. found that free
flap reconstructions performed between 5 and 21 days after
the trauma had a higher risk of flap failure [30,32,33]. When
reconstructions were performed in the first 5 days after the
injury no failures developed and when performed after 21
days the failure rates were much lower. However, performing
free flaps at such an early stage can be difficult because of
patient instability [15]. According to this two-step damage
theory, serial debridement with removal of all necrotic tissue
would be necessary and wound coverage is performed when
progression of tissue necrosis is over [16].
 burns 49 (2023) 1103–1112 1109

Fig. 3 – Blood myoglobin and creatinine kinase as risk factor for limb loss. A. Probability of limb loss as a function of the
estimated marginal means with 95%-CI of blood myoglobin (myoglob) level at day (d) 0, 1, 2, 3. B. Probability of limb loss as a
function of the estimated marginal means with 95%-CI of creatinine kinase (CK) blood myoglobin level at day (d) 0, 1, 2, 3.
 1110

Table 4 – Patients with free microvascular reconstructions. ALT, anterolateral thigh flap; d, day after admission; F, female; LD, latissimus dorsi flap; M, male; TBSA, total
body surface area.
Age at burn / TBSA (%) / Voltage / Indication Free flap Recipient vessel Days after Complications (days after free flap)
Gender Mechanism admission
57/M 2 / Low / Contact Left hand defect ALT Radial artery 16 None
22/M 10 / High / Arc Right elbow defect ALT Branch of brachial artery 33 Arterial insufficiency (d1), recovery after
arterial reanastomosis
18/M 40 / High / Contact Right forearm defect LD Radial artery 36 None
22/M 51.5 / High / Unknown Right lower leg defect LD Anterior tibial artery 75 None
40/M 1 / High / Arc Nose, forehead and ALT Superficial temporal 38 None
periorbital defect artery
23/M 26 / High / Contact Lower lip defect Gracilis Superior thyroid artery 30 None
Left wrist defect Serratus flow-through Radial artery 22 Arterial insufficiency (d1) and recovery after
arterial and venous reanastomosis
36/M 35 / High / Unknown Exposed right knee LD Superficial femoral artery 19 Venous insufficiency (d1) and flap loss (d5)
after venous reanastomosis
49/M < 1 / Low / Contact Index defect on the Arterialized venous flap Radiopalmar digital 12 None
burns 49 (2023) 1103–1112

right hand from right forearm artery finger 2

20/M 60 / High / Arc Cranial defect on the Gracilis Branch of superficial 176 None
right side temporal artery
32/M 0.5 / Low / Contact Defect of the proximal Arterialized venous flap Princeps pollicis artery 5 None
left thumb from right forearm
22/F 39 / High / Contact Right ankle and foot Arterialized venous flap Anterior tibial artery 39 Ischemia (d1), recovery after arterial and
defect venous reanastomosis
Left ankle and foot Arterialized venous flap Anterior tibial artery 39 None
defect
48/M 27.5 / High / Contact Left forearm defect Sural flow through Radial artery 18 Arterial insufficiency (d1) and flap loss (d1)
 burns 49 (2023) 1103–1112
Fig. 4 – Type and timing of free microvascular tissue
transfer reconstruction. A. Percentage of different type of
free flaps performed. ALT, anterolateral thigh; LD,
latissimus dorsi. B. Number of free flaps (y-axis) per timing
reconstruction category (x-axis).
5. Conclusion
Electrical injuries are still cause of elevated morbidity and
mortality, with a high amputation rate compared to other
types of burns. Predictors for amputation can support phy-
sicians in the surgical management and include initial ele-
vated blood values of CK and myoglobin representing
rhabdomyolysis, but also other complications in the course,
such as renal failure, compartment syndrome and sepsis.
The surgical management with early decompression, serial
necrectomies and delayed early reconstruction has shown
positive outcome and remain the procedure of choice for
patients at our unit.
Author disclosure and Ghostwriting
No competing financial interests exist. The content of this
article is original and was expressly written by the authors
listed.
Funding
None to declare.
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