Development of A Multispecialty Limb Salvage Protocol With Incorporation Of Long Saphenous Arterial-Venous Loops For Free Flap Reconstruction In The Mangled Lower Extremity

Abstract Background Traumatic limb salvage with free flap reconstruction versus primary amputation for lower extremity (LE) injuries remains an oft debated topic. Limb salvage has well-studied benefits and advances in microsurgery have helped reduce the complication rates. A subset of patients eventually requires secondary amputation after a failed attempt at limb salvage. A better understanding of risk factors that predict subsequent amputation after failed free flap reconstruction of LE injuries may improve operative management. Patients and Methods A retrospective study (2002–2019) was conducted on all patients who underwent free flap reconstruction of the LE within 120 days of the original inciting event at a single institution. Patient and operative factors were reviewed including comorbidities, severity of the injury, flap choice, outcomes, and complications. Predictors of subsequent amputation were analyzed. Results A total of 129 patients requiring free flap reconstructions for LE limb salvage met inclusion criteria. Anterolateral thigh flaps (70.5%) were performed most frequently. Secondary amputation occurred in 10 (7.8%) patients. Preoperative factors associated with eventual amputation include diabetes mellitus (p = 0.044), number of preoperative debridements (p = 0.013), evidence of any arterial injury/pathology (p = 0.008), specifically posterior tibial artery (p = < 0.0001), and degree of three-vessel runoff (p = 0.007). Operative factors associated with subsequent amputation include evidence of recipient artery injury/pathology (p = 0.008). Postoperative factors associated with secondary amputation include total flap failure (p = 0.001), partial flap failure (p = 0.002), minor complications (p = 0.037), and residual osteomyelitis (p = 0.028). Conclusion Many factors contribute to the reconstructive surgical team's decision to proceed with limb salvage or perform primary amputation. Several variables are associated with failed limb salvage resulting in secondary amputation. Further studies are required to better guide management during the limb salvage process.

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Outcome Analysis of End-to-End and End-to-Side Anastomoses in 131 Patients Undergoing Microsurgical Free Flap Reconstruction of the Lower Extremity

Journal of Reconstructive Microsurgery Open ◽

10.1055/s-0036-1593815 ◽

2016 ◽

Vol 02 (01) ◽

pp. e7-e14

Author(s):

Sören Könneker ◽

G.F. Broelsch ◽

J.W. Kuhbier ◽

T. Framke ◽

N. Neubert ◽

...

Keyword(s):

Lower Extremity ◽

Free Flap ◽

Statistical Significance ◽

Group Versus ◽

Outcome Analysis ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Flap Survival ◽

Anastomotic Technique ◽

End To End

Background End-to-end and end-to-side anastomoses remain the most common techniques in microsurgical free flap reconstruction. Still, there is an ongoing effort to optimize established techniques and develop novel techniques. Numerous comparative studies have investigated flow dynamics and patency rates of microvascular anastomoses and their impact on flap survival. In contrast, few studies have investigated whether the type of anastomosis influences the outcome of microvascular free flap reconstruction of a lower extremity. Patients and Methods Retrospectively, we investigated the outcome of 131 consecutive free flaps for lower extremity reconstruction related to the anastomotic technique. Results No statistical significance between arterial or venous anastomoses were found regarding the anastomotic techniques (p = 0.5470). However, evaluated separately by vessel type, a trend toward statistical significance for anastomotic technique was observed in the arterial (p = 0.0690) and venous (p = 0.1700) vessels. No thromboses were found in arterial end-to-end anastomoses and venous end-to-side anastomoses. More venous (n = 18) than arterial thromboses (n = 9) occurred in primary anastomoses undergoing microsurgical free flap reconstruction (p = 0.0098). Flap survival rate was 97.37% in the end-to-end arterial group versus 86.36% in the end-to-side group. No thromboses were found in five arterial anastomoses using T-patch technique. Conclusion For lower extremities, there is a connate higher risk for venous thrombosis in anastomotic regions compared with arterial thrombosis. We observed divergent rates for thromboses between end-to-end and end-to-side anastomoses.However, if thrombotic events are explained by anastomotic technique and vessel type, the latter carries more importance.

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