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Huffman SS, Bovill JD, Li K, Spoer DL, Berger LE, Bekeny JC, Akbari CM, Fan KL, Evans KK. Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction. J Reconstr Microsurg 2024; 40:384-391. [PMID: 37751882 DOI: 10.1055/a-2181-7149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO. METHODS Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status. RESULTS A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups. CONCLUSION This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.
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Affiliation(s)
- Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Georgetown University School of Medicine, Washington, District of Columbia
| | - John D Bovill
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Karen Li
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Olsson SE, Amado I, Fijany A, Soleimani S, Troia T, Washington KL, Sanchez HB, Kurapati S, Pekarev M. Vastus Lateralis Muscle Flap for High-Risk Patients Undergoing Orthopaedic Hip Surgery. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00021. [PMID: 38661556 PMCID: PMC11049743 DOI: 10.5435/jaaosglobal-d-23-00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Chronic infections and soft-tissue defects are serious complications after total hip arthroplasties (THAs) that may require hip disarticulation (HD). HD is a relatively high-risk procedure with poor long-term outcomes and survival. This is the first study to analyze the effect of an ipsilateral, pedicled vastus lateralis (VL) muscle flap in preventing HD in patients with recurrent complications after THA. METHODS This retrospective case review analyzed the 6-month postoperative outcomes of 14 patients who underwent soft-tissue hip reconstruction with a VL muscle flap by a single surgeon. RESULTS Most (86%) patients fully recovered after 6 months with preserved hip range of motion, no pain, and no weakness on ambulation. Two (14%) patients ultimately required HD despite introducing a VL flap. DISCUSSION A VL muscle flap is an effective treatment of nonhealing THA and prophylactic intervention for patients at high risk for HD. The VL muscle is optimal because of its large size allowing reduction of soft-tissue dead space, its local anatomical location to the hip, and its exceptional vascularity. Additional prospective studies are necessary to determine the most appropriate population for this technique.
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Affiliation(s)
- Sofia E. Olsson
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Isabella Amado
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Arman Fijany
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Shirin Soleimani
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Thomas Troia
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Kimberly L. Washington
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Hugo B. Sanchez
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Srikanth Kurapati
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
| | - Maxim Pekarev
- From the Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX (Ms. Olsson, Ms. Amado, Dr. Fijany, Ms. Soleimani, Mr. Troia, Dr. Washington and Dr. Kurapati); the Texas Health Orthopedic Specialists, Fort Worth, TX (Dr. Sanchez); and the MP Plastic Surgery, Fort Worth, TX (Dr. Pekarev)
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Chen A, Garvey SR, Saxena N, Bustos VP, Jia E, Morgenstern M, Nanda AD, Dowlatshahi AS, Cauley RP. Is Diabetes a Contraindication to Lower Extremity Flap Reconstruction? An Analysis of Threatened Lower Extremities in the NSQIP Database (2010-2020). Arch Plast Surg 2024; 51:234-250. [PMID: 38596146 PMCID: PMC11001455 DOI: 10.1055/a-2233-2617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 11/30/2023] [Indexed: 04/11/2024] Open
Abstract
Background The impact of diabetes on complication rates following free flap (FF), pedicled flap (PF), and amputation (AMP) procedures on the lower extremity (LE) is examined. Methods Patients who underwent LE PF, FF, and AMP procedures were identified from the 2010 to 2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP®) database using Current Procedural Terminology and International Classification of Diseases-9/10 codes, excluding cases for non-LE pathologies. The cohort was divided into diabetics and nondiabetics. Univariate and adjusted multivariable logistic regression analyses were performed. Results Among 38,998 patients undergoing LE procedures, 58% were diabetic. Among diabetics, 95% underwent AMP, 5% underwent PF, and <1% underwent FF. Across all procedure types, noninsulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were associated with significantly greater all-cause complication rates compared with absence of diabetes, and IDDM was generally higher risk than NIDDM. Among diabetics, complication rates were not significantly different across procedure types (IDDM: p = 0.5969; NIDDM: p = 0.1902). On adjusted subgroup analysis by diabetic status, flap procedures were not associated with higher odds of complications compared with amputation for IDDM and NIDDM patients. Length of stay > 30 days was statistically associated with IDDM, particularly those undergoing FF (AMP: 5%, PF: 7%, FF: 14%, p = 0.0004). Conclusion Our study highlights the importance of preoperative diabetic optimization prior to LE procedures. For diabetic patients, there were few significant differences in complication rates across procedure type, suggesting that diabetic patients are not at higher risk of complications when attempting limb salvage instead of amputation.
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Affiliation(s)
- Amy Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R. Garvey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nimish Saxena
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Emmeline Jia
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Monica Morgenstern
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Asha D. Nanda
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan S. Dowlatshahi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan P. Cauley
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Deldar R, Huffman SS, Bovill JD, Gupta N, Truong BN, Haffner ZK, Sayyed AA, Fan KL, Evans KK. Clinical utility of the modified frailty index in predicting adverse outcomes in patients undergoing lower extremity free flap reconstruction. Microsurgery 2024; 44:e31135. [PMID: 38124444 DOI: 10.1002/micr.31135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/30/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Identifying at-risk patients for complications remains challenging in patients with chronic lower extremity (LE) wounds receiving free tissue transfer (FTT) for limb salvage. The modified-5 frailty index (mFI-5) has been utilized to predict postoperative complications, yet it has not been studied in this population. The aim of this study was to determine the utility of the mFI-5 in predicting adverse postoperative outcomes. METHODS Patients ≥60 years, who underwent LE FTT reconstruction at a single institution from 2011 to 2022, were retrospectively reviewed. Patient characteristics, mFI-5, and postoperative outcomes were collected. Cohorts were divided by an mFI-5 score of <2 or ≥2. RESULTS A total of 115 patients were identified, of which 71.3% (n = 82) were male, 64.3% (n = 74) had a mFI-5 score of ≥2, and 35.7% (n = 41) had a score <2. The average age and body mass index were 67.8 years and 28.7 kg/m2 , respectively. The higher mFI-5 cohort had lower baseline albumin levels (3.0 vs. 4.0 g/dL, p = .015) and higher hemoglobin A1c levels (7.4 vs. 5.8%, p < .001). The postoperative length of stay was longer in the higher mFI-5 cohort (18 vs. 13.4 days, p = .003). The overall flap success was 96.5% (n = 111), with no difference between cohorts (p = .129). Postoperative complications were comparable between cohorts (p = .294). At a mean follow-up of 19.8 months, eight patients (7.0%) underwent amputation, and 91.3% (n = 105) were ambulatory. CONCLUSION High microsurgical success rates can be achieved in comorbid patients with high frailty indexes who undergo FTT for limb salvage. A multidisciplinary team approach may effectively mitigate negative outcomes in elderly, frail patients.
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Affiliation(s)
- Romina Deldar
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - John D Bovill
- Georgetown University School of Medicine, Washington, DC, USA
| | - Nisha Gupta
- Georgetown University School of Medicine, Washington, DC, USA
| | - Brian N Truong
- Georgetown University School of Medicine, Washington, DC, USA
| | - Zoë K Haffner
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Adaah A Sayyed
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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Berger LE, Huffman SS, Bovill JD, Spoer DL, Shin S, Truong BN, Gupta N, Attinger CE, Akbari CM, Evans KK. Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis. J Reconstr Microsurg 2024; 40:40-49. [PMID: 36928902 DOI: 10.1055/a-2056-1561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. METHODS A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. RESULTS Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. CONCLUSION Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.
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Affiliation(s)
- Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - John D Bovill
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Stephanie Shin
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Brian N Truong
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Nisha Gupta
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Shimbo K, Kawamoto H, Koshima I. Muscle/musculocutaneous versus fasciocutaneous free flap reconstruction in the lower extremity: A systematic review and meta-analysis. Microsurgery 2022; 42:835-847. [PMID: 36134744 DOI: 10.1002/micr.30961] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Free flaps for soft tissue coverage of the lower extremity can be broadly divided into muscle/musculocutaneous and fasciocutaneous flaps. The purpose of this systematic review and meta-analysis was to assess their different post-operative outcomes. METHODS A systematic search was performed in PubMed, Scopus, and the Web of Science from their inception to February 2022. Non-randomized comparative studies, which describe any post-operative outcome of muscle/musculocutaneous and fasciocutaneous free flaps reconstruction in the lower extremity were included. Articles with duplicate titles, editorials, review articles, case series, case reports, and publications lacking an abstract, those reporting pediatric patients, those describing only muscle/musculocutaneous or fasciocutaneous free flaps, those with incomplete or incomparable post-operative outcomes, and studies involving <10 muscle/musculocutaneous or fasciocutaneous free flaps were excluded. A comparative meta-analysis was conducted on muscle/musculocutaneous and fasciocutaneous free flaps outcomes, comprising vascular thrombosis, partial or complete flap necrosis, infection, donor-site complications, non-union, and primary or recurrent osteomyelitis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was identified. RESULTS Twenty-two articles with a total of 2711 flaps (1584 muscle/musculocutaneous flaps and 1127 fasciocutaneous flaps) were included in the qualitative and quantitative assessment. The rates of any flap necrosis (12.0% vs. 7.4%; p = 0.007) and donor-site complications (16.7% vs. 6.7%; p < 0.0001) were significantly higher for muscle/musculocutaneous flaps than for fasciocutaneous flaps. There were no significant differences in the rates of vascular thrombosis (10.5% vs. 10.7%; p = 0.98), complete flap necrosis (6.2% vs. 4.7%; p = 0.30), infection (19.4% vs. 14.7%; p = 0.18), non-union (18.9% vs. 14.8%; p = 0.33), and primary or recurrent osteomyelitis (14.7% vs. 12.4%; p = 0.69). CONCLUSION This meta-analysis revealed no significant difference in long-term post-operative outcomes, but suggested that fasciocutaneous flaps should be preferred to avoid flap necrosis and donor-site complications.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan.,International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
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Sayyed AA, Towfighi P, Deldar R, Attinger CE, Evans KK. Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomes. Microsurgery 2022; 42:538-547. [PMID: 35394669 DOI: 10.1002/micr.30889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/28/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE Non-healing plantar weight-bearing heel ulcers are a challenging problem to treat. Free tissue transfer (FTT) reconstruction of the heel is an opportunity for limb salvage to preserve gait and ambulation. The aim of this study is to describe surgical and functional outcomes in patients who underwent FTT to treat chronic heel ulcers. METHODS A retrospective review of patients who underwent FTT for plantar heel ulcers from 2011 to 2021 was conducted. Patient demographics, comorbidities, perioperative data, postoperative complications, and long-term outcomes were recorded. Primary outcomes included flap success, complications, postoperative ambulation, patient-reported outcome measures and limb salvage, with patients stratified into limb salvage or eventual amputation groups. RESULTS Forty-four patients underwent 45 heel reconstructions. Average age and BMI were 57.3 years and 30.1 kg/m2 , respectively. Thirty-eight patients (86.4%) had calcaneal osteomyelitis, 35 patients (79.5%) had diabetes, and 18 patients (40.9%) had peripheral vascular disease (PVD). Immediate microsurgical success rate was 95.6%. At mean follow-up of 19.6 ± 20.9 months, overall limb salvage rate was 73.3% (n = 33). Preoperative albumin levels were higher in limb salvage group compared to the amputation group (3.0 vs. 2.4 g/dl, p = .018). Prior stroke history and hypoalbuminemia were significantly higher in the amputation group compared to limb salvage group (p = .012 and p = .018, respectively). Risk for eventual amputation was associated with PVD (OR 4.0, p = .053), hypoalbuminemia (OR 4.9, p = .020), and postoperative infection (OR 6.3, p = .013). Of the 12 amputations that occurred, the most common indication for amputation was infection (n = 8, 66.7%), which most often occurred at the original wound location (62.5%). At most recent follow-up, 90.7% of patients (n = 39) were ambulatory. CONCLUSION FTT is an effective alternative to amputation in patients with chronic heel ulcers. Proper patient selection, preoperative optimization, and postoperative care are imperative to the success of this limb salvage procedure.
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Affiliation(s)
- Adaah A Sayyed
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Parhom Towfighi
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Romina Deldar
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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Ferry AM, Gimenez AR, Abu-Ghname A, Xue EY, Pederson WC, Lazo DÁA, Maricevich M. Reconstruction of Complex Lower Extremity Defects. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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