Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps

Refining a Multidisciplinary "Vasculoplastic" Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps

BACKGROUND

The use of free tissue transfer (FTT) is effective for treatment of chronic nonhealing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plans to optimize limb salvage. The authors describe their vasculopathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTTs and the most recent 100 procedures performed.

METHODS

A single-institution, retrospective review of 300 LE FTTs from July of 2011 to January of 2023 was performed. Patients were compared between the first 200 (group 1; July of 2011 through February of 2020) and last 100 flaps (group 2; February of 2020 through January of 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected.

RESULTS

Group 2 patients had significantly higher rates of diabetes (67.0% versus 48.5%; P = 0.002), peripheral vascular disease (56.0% versus 24.5%; P < 0.001), history of venous thromboembolism (13.0% versus 6.0%; P = 0.039), venous reflux (81.9% versus 67.8%; P = 0.028), and preoperative venous thromboses on venous testing (25.5% versus 10.5%; P = 0.003) compared with group 1. Group 2 patients underwent more pre-FTT endovascular interventions (23.0% versus 16.5%; P = 0.039) and vascular bypasses (4.0% versus 0.0%; P = 0.012). Immediate flap success and amputation rates were similar between the groups, but group 2 had higher rates of partial flap necrosis (7% versus 3%; P = 0.012).

CONCLUSION

The adoption of a vasculoplastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Prevalence of Popliteal Artery Variants in Free Tissue Transfer for Limb Salvage: A 12-Year Vasculoplastic Experience

Popliteal artery variants (PAVs) are anatomical deviations of the popliteal artery's branching pattern and should be considered in microsurgical planning for patients undergoing lower extremity (LE) free tissue transfer (FTT). However, there is a significant lack of FTT literature in this patient population. Thus, this study presents our 12-year experience with LE FTT in patients with PAV.Patients receiving LE FTT reconstruction from July 2011 to March 2024 were reviewed. Preoperative angiograms were reviewed by a single vascular surgeon, and the presence of PAV was identified and classified as IIIA, IIIB, or IIIC. Primary outcomes were flap success and limb salvage.A total of 339 LE FTT were performed in 331 patients. A total of 32 patients (9.4%) had PAV, accounting for a total of 34 LE FTT. Class IIIA was the most common category (n = 20, 58.8%) followed by IIIB (n = 8, 23.5%) and IIIC (n = 6, 11.7%). Median age and body mass index were 63.5 (interquartile range [IQR]: 22.5) years and 27.4 (IQR: 10.3) kg/m2. The median Charlson Comorbidity Index was 5 (IQR: 2.5), with prevalent rates of diabetes (n = 18/32, 56.3%) and peripheral artery disease (n = 16/32, 50.0%). Median wound area was 71.0 (IQR: 80.0) cm2. Flap success rate was 100% (n = 34/34). At a median follow-up of 12.8 (IQR: 22.6) months, limb salvage was 97.1% (n = 33/34) and mortality was 6.3% (n = 2/32).In this large population of LE FTT, PAV occurs in almost 1 out of 10 patients. Essential to flap success and limb salvage is appropriate preoperative vascular imaging with arteriography, as the presence of PAV changes microsurgical intraoperative planning and technical considerations.

Regional anaesthesia-based free flap reconstruction for limb salvage in high-risk patients with refractory lower limb infections

Background

Patients with severe comorbidities and refractory lower leg and foot infections face high risks from prolonged anaesthesia and complex soft tissue reconstruction. Our institution collaborates with anaesthetists to perform limb salvage using free flaps, primarily under combined spinal-epidural anaesthesia (CSE) without general anaesthesia (GA). This study aimed to evaluate the treatment outcomes of our limb salvage algorithm in high-risk patients.

Materials and methods

Between January 2020 and December 2023, we included patients with ASA class III or higher undergoing limb salvage for chronic osteomyelitis or diabetic gangrene, who desired limb preservation, had palpable main arteries and no urgent cardiovascular conditions. We investigated 12 patients with 13 limbs and 14 free flaps who underwent infection control and free flap reconstruction under CSE without GA.

Results

Among the 14 free flaps, 9 were ASA class III and 5 were class IV. The median anaesthesia time was 562 min and median surgical time was 479 min. All flap surgeries, except for one, required no vasopressor usage to control intraoperative hypotension. Partial necrosis occurred in 2 flaps, but all flaps survived. One limb with recurrent osteomyelitis required a vascularised fibula graft. No severe systemic complications were observed, and all limbs were preserved with weight-bearing function in 11 of 13 limbs (85%).

Conclusions

Our treatment algorithm using CSE without GA for severe lower limb infections demonstrates that limb salvage can be safely achieved by preventing flap necrosis and systemic complications.

Understanding the Prevalence of Medial Arterial Calcification Among Complex Reconstructive Patients: Insights from a Decade of Experience at a Tertiary Limb Salvage Center

Background: Medial arterial calcification (MAC), a distinct form of vascular pathology frequently coexisting with peripheral arterial disease (PAD), poses unique challenges in limb salvage among patients with diabetes, chronic kidney disease, and end-stage renal disease. This study examines the incidence of MAC and its impact on limb salvage outcomes over a decade of experience at a tertiary limb salvage center. Methods: A retrospective review of all complex lower extremity (LE) reconstructions using local flap (LF) or free tissue transfer (FTT), performed from July 2011 to September 2022, was conducted. Patients were classified into MAC and No MAC groups based on pedal radiography evaluations using the Ferraresi MAC scoring system. The primary outcomes were major lower extremity amputation (MLEA), the need for postoperative vascular intervention, major adverse limb events (MALE; defined as the composite of any unplanned reoperation, MLEA, or postoperative revascularization attempt), and mortality. Results: During the study period, a total of 430 LE reconstructions were performed with LF or FTT. A total of 323 cases (75.1%) demonstrated no MAC while the remaining 107 (24.9%) demonstrated MAC. The MAC group exhibited significantly higher rates of diabetes, PAD, and renal disease. With a follow-up duration of 17.0 (IQR: 33.9) months, the MAC group demonstrated a significantly higher rate of MLEA (24.3% vs. 13.0%, p = 0.006), postoperative vascular intervention (23.4% vs. 8.7%, p < 0.001), MALE (57.0% vs. 25.7%, p < 0.001), and mortality (28.0% vs. 9.9%, p < 0.001). Multivariate analysis identified MAC as independently predictive of MALE (OR: 1.8, CI: 1.1-3.0, p = 0.033). Conclusion: MAC is prevalent among surgical candidates for limb salvage. Patients with MAC represent a significant medical and reconstructive challenge. Radiographic screening for MAC should be considered in all limb salvage candidates with LE wounds, especially in those with diabetes and kidney disease. Assessing MAC is important for better evaluating risk factors and surgical options so as to optimize outcomes in this challenging population.

The Role of Local Flaps in Foot and Ankle Reconstruction: An Assessment of Outcomes across 206 Patients with Chronic Wounds

BACKGROUND

Reconstructive surgery has experienced a paradigm shift in favor of free flaps. Yet local flaps may be of particular use in foot and ankle reconstruction among comorbid patient populations. Thus, the authors sought to better characterize long-term outcomes in this setting.

METHODS

A single-center, retrospective cohort study of patients undergoing local muscle and fasciocutaneous flaps of the foot and ankle from January of 2010 through November of 2022 was performed. Flaps were performed on wounds measuring 3 × 6 cm or smaller; flap selection depended on preoperative vascular assessment, Doppler findings, comorbidity profile, and wound location, depth, and geometry.

RESULTS

A total of 206 patients met inclusion criteria. Their median age was 61.0 years (interquartile range, 16.8), and comorbidities included diabetes mellitus ( n = 149 [72.3%]) and peripheral arterial disease ( n = 105 [51.0%]). Presentations included chronic, nonhealing wounds ( n = 77 [39.1%]) or osteomyelitis ( n = 45 [22.8%]) and most frequently extended to the bone ( n = 128 [62.1%]). Eighty-seven patients (42.2%) received muscle flaps; 119 (57.8%) received fasciocutaneous flaps. Six patients (2.9%) needed return to the operating room, with thrombosis occurring in 2 cases (1.0%). The flap success rate was 98.1%. By a median follow-up duration of 21.7 months (interquartile range, 39.0), 21.8% of patients ( n = 45) required ipsilateral amputation, 73% ( n = 145 of 199) were ambulatory, and 2 deaths related to the surgical wound occurred (2 of 49 [4.1%]). Multivariate analysis revealed that positive predictors of complications included diabetes mellitus, end-stage renal disease, and history of venous thromboembolism or smoking.

CONCLUSION

Local flaps remain a reliable option to reconstruct smaller defects of the foot and ankle in a highly comorbid population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Extreme Limb Salvage: The Thin SCIP Flap for Distal Amputation Coverage in Highly Comorbid Patients

BACKGROUND

Limb length preservation is correlated with overall survival. Successful free flap coverage of forefoot, midfoot, and hindfoot amputations can prevent more proximal below-knee amputations but is challenging in patients with multiple comorbidities. The thin superficial circumflex iliac artery perforator (SCIP) flap is well-suited for these patients, as it provides thin, pliable tissue from a favorable donor site.

METHODS

A retrospective review of all patients with distal amputations requiring coverage with a thin SCIP flap between 2016 to 2022 was performed. Patient demographics, amputation levels, and wound characteristics in addition to flap and microsurgery details were analyzed. The primary outcome was limb salvage. Secondary outcomes included partial flap necrosis, flap revision rate, and additional postoperative complications.

RESULTS

Thirty-two patients (mean age, 57.3 years) underwent reconstruction of forefoot, midfoot, and hindfoot amputations with thin SCIP flaps (mean follow-up, 36 months). Twenty-eight patients (87.5%) had diabetes, 27 (84.4%) had peripheral artery disease, and 15 (46.9%) were dialysis-dependent. Average flap size was 59.5 cm 2 and average flap thickness was 5.7 mm. Successful limb salvage was achieved in 27 patients (84.3%). Three cases (9.4%) had total flap loss. Twenty-one flaps (65.6%) had partial necrosis, of which 12 (57.1%) healed with conservative management and 7 (33.3 %) healed after late revision.

CONCLUSIONS

The thin SCIP flap is a useful option for coverage of distal pedal amputations in patients with significant comorbidities. Despite higher rates of partial flap necrosis, free flap reconstruction allowed for high rates of limb salvage in a challenging patient population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ultrasound in Microsurgery: Current Applications and New Frontiers

Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.

A Multidisciplinary Approach to End-Stage Limb Salvage in the Highly Comorbid Atraumatic Population: An Observational Study

Background: The use of free tissue transfer (FTT) is efficacious for chronic, non-healing lower extremity (LE) wounds. The four pillars of managing patient comorbidities, infection control, blood flow status, and biomechanical function are critical in achieving successful limb salvage. The authors present their multidisciplinary institutional experience with a review of 300 FTTs performed for the complex LE limb salvage of chronic LE wounds. Methods: A single-institution, retrospective review of atraumatic LE FTTs performed by a single surgeon from July 2011 to January 2023 was reviewed. Data on patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, postoperative complications, and long-term outcomes were collected. Results: A total of 300 patients who underwent LE FTT were included in our retrospective review. Patients were on average 55.9 ± 13.6 years old with a median Charlson Comorbidity Index of 4 (IQR: 3). The majority of patients were male (70.7%). The overall hospital length of stay (LOS) was 27 days (IQR: 16), with a postoperative LOS of 14 days (IQR: 9.5). The most prevalent comorbidities were diabetes (54.7%), followed by peripheral vascular disease (PVD: 35%) and chronic kidney disease (CKD: 15.7%). The average operative LE FTT time was 416 ± 115 min. The majority of flaps were anterolateral thigh (ALT) flaps (52.7%), followed by vastus lateralis (VL) flaps (25.3%). The immediate flap success rate was 96.3%. The postoperative ipsilateral amputation rate was 12.7%. Conclusions: Successful limb salvage is possible in a highly comorbid patient population with a high prevalence of diabetes mellitus, peripheral vascular disease, and end-stage renal disease. In order to optimize patients prior to their LE FTT, extensive laboratory, arterial, and venous preoperative testing and diabetes management are needed preoperatively. Postoperative monitoring and long-term follow-up with a multidisciplinary team are also crucial for long-term limb salvage success.

Is Diabetes a Contraindication to Lower Extremity Flap Reconstruction? An Analysis of Threatened Lower Extremities in the NSQIP Database (2010-2020)

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.

Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis

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.

Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19

Background

Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19.

Methods

We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes.

Results

Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002).

Conclusions

In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.