Early Results of a Collaborative Multispecialty Mangled Extremity Algorithm for Acute Limb Salvage with Incorporation of Long Saphenous Arterial-Venous Loops for Free Flap Reconstruction in the Community Hospital Setting

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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Limb Salvage with Microvascular Free Flap Reconstruction Using Simultaneous Polytetrafluoroethylene Graft for Inflow

Annals of Plastic Surgery ◽

10.1097/00000637-199509000-00016 ◽

1995 ◽

Vol 35 (3) ◽

pp. 310-315 ◽

Cited By ~ 4

Author(s):

Armen K. Kasabian ◽

Paul M. Glat ◽

Yosef Eidelman ◽

Nolan Karp ◽

Gary Giangola

Keyword(s):

Limb Salvage ◽

Free Flap ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Microvascular Free Flap

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Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1735835 ◽

2021 ◽

Author(s):

Joseph Lewcun ◽

Sameer Massand ◽

John Trangucci ◽

Chan Shen ◽

Timothy S. Johnson

Keyword(s):

Head And Neck ◽

Free Flap ◽

Community Hospital ◽

Medical Center ◽

Academic Medical Center ◽

Community Setting ◽

University Hospital ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

The University

Abstract Background Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting. Methods A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings. Results Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080). Conclusion Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.

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Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1726394 ◽

2021 ◽

Author(s):

Eleanor S. Lumley ◽

Jin Geun Kwon ◽

Beatriz Hatsue Kushida-Conteras ◽

Erin Brown ◽

Julian Viste ◽

...

Keyword(s):

Limb Salvage ◽

Free Flap ◽

Free Tissue Transfer ◽

Diabetic Patients ◽

Flap Reconstruction ◽

Limb Salvage Rate ◽

Free Flap Reconstruction ◽

Flap Survival ◽

Transmetatarsal Amputation ◽

Salvage Rate

Abstract Background Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. Methods Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. Results Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9–20 days). Patients were followed-up for a median of 344 days (range: 142–594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. Conclusion TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.

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