Limb preservation with suprafascial and thin perforator flaps: salvaging osteomyelitis, Charcot collapse and critical limb ischemia

Abstract

Aim: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine patient and flap related outcomes in advanced lower extremity disease. Methods:The authors conducted a retrospective review of fasciocutaneous free flaps of variable thickness for lower extremity salvage. Osteomyelitis and non-osteomyelitis patients were compared according to our primary outcome measures: functional ambulation, bone healing and complications to flap and patient. Subgroups with critical limb ischemia, Charcot collapse and diabetic foot were analyzed separately.Results: Fifty-nine patients underwent free flap reconstruction: osteomyelitis (n = 20, 34%), Charcot collapse (n = 22, 37%), and/or critical limb ischemia (n = 12, 20%). All patients underwent anterolateral thigh flaps tailored for defectspecific thicknesses: 17 superthin, 25 suprafascial, 17 subfascial. There were no significant differences between groups in terms of partial and complete flap loss (P = 1.000 and P = 0.108). Ninety-one percent of patients were ambulatory at follow up. Eighty-five percent of individuals with osteomyelitis cleared their infection demonstrating radiographic bone healing. Two patients developed recalcitrant deep space infections ultimately requiring amputation. Subgroup analysis did not show any differences in flap related complications within the diabetic Charcot population. In multivariate regression, preoperative revascularization was independently associated with failure of limb salvage. Conclusion:Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limb ischemia, osteomyelitis, and the Charcot foot -expanding their role in the armamentarium for lower extremity care.

Short and long-term follow-up results of soleus muscle rotation flap for coverage of soft tissue defects of proximal and middle leg

“…The decision to choose the best out of many available options depends on multiple factors like aetiology of defect, size and shape of the defect, clinical condition of the patient, presence of comorbidities, available health facilities, and experience of the surgeon. 3 The option of free tissue transfer to cover a defect requires a team approach, long operative time, prolonged hospital stay, and involves donor site morbidity and a definitive risk of total failure compared to local rotation flaps. 4 For soft tissue coverage in legs, a soleus muscle rotation flap (SMRF) is among many options.…”

Response to Letter to the Editor: Nomenclature of Thin and Super-Thin Flaps—Comment on: Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity

“…As published, we find the thinned ALT flaps ideal in circumstances for lower extremity reconstruction and, in particular, use during limb salvage. 3 At the time of writing our article, Narushima et al were yet to publish their 2018 article in the Journal of Plastic and Reconstructive Surgery which in turn resulted in conflicting language. 4 We do not disagree, a consistent nomenclature is paramount.…”