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

Abstract

Background: Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population. Methods: The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound. Results: The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort. Conclusions: Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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

“…31 Our study duration spanned eleven years, during which there were substantial refinements in surgical technique as well as the adoption of perioperative risk stratification protocols, including hypercoagulability screening. 27,32 Given that these changes are associated with lower rates of thrombotic events and flap loss, patients were matched based on their risk stratification status to reduce the influence of confounding variables for a more direct assessment of the interrelatedness between thrombocytosis, AP therapy, and postoperative complications. 33 The association between preoperative thrombocytosis of any etiology and postoperative complications following FTT has thus far been reported across select patient populations.…”

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

“…Patients began a progressive dangling protocol beginning POD five to seven. Patients were discharged home once the flap was deemed stable with 15 min of gravitational dependence, typically around day 10 or 11 [24]. At one month postoperatively, patients started a graduated physical rehabilitation program.…”

Ultrasound in Microsurgery: Current Applications and New Frontiers

“…CT and magnetic resonance angiography have played critical roles in flap planning, particularly for autologous breast reconstruction procedures [5][6][7][8][9]. Formal angiography has also been instrumental in microsurgical lower extremity limb salvage, particularly in patients with vascular comorbidities [10,11].…”