Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene

Abstract

Symmetrical peripheral gangrene (SPG) is rare but devastating complication which is characterized by symmetrical ischemic change of the distal extremities. In this report, we describe our management protocol for SPG, focusing on surgical approaches. Between January 2007 and February 2016, 10 thoracodorsal artery perforator (TDAP) free flaps were performed in 6 patients with SPG. Three patients were male and mean age was 56 (range, 44–69) years. All the patients were in shock. The causes of shock were sepsis in 4 cases, respiratory arrest in 1 case, and hypovolemia in 1 case. Eight transmetatarsal amputations and 2 Lisfranc amputations were performed. Flap sizes ranged from 7 × 11 cm to 25 × 15 cm. There were 3 cases of partial necrosis of the flap: two healed conservatively with dressings and one required skin graft. Three of the patients were later able to walk independently at Functional Ambulation Classification (FAC) level 6, one patient could walk independently on level surfaces at FAC level 5, and 2 could walk independently using walking aids, classified at FAC level 4. The average follow-up period was 18 (range, 6–54) months. In patients with SPG, minimal bone amputation and foot salvage with TDAP flaps were successful. Separate reconstruction of bone and soft tissue had good outcomes.

Multiple free dorsal flaps for symmetrical peripheral gangrene of the extremities: A case report

“… 3 Extensive necrosis may require major amputation, but there have been reports of patients who avoided major amputation by implanting a free flap at the amputation stump. 4 , 5 …”

The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis

“…Moreover, few studies used validated scales, such as the LEFS or FAC, to report functional status in a standardized fashion. 14,44,46,50 QOL measures are even less consistently described and are often anecdotal in nature; only one study used a validated scoring system to assess QOL ratings. 37 For patients undergoing LE flap reconstruction, clinical practice has seen a growing shift in focus on long-term outcomes that are patient-centered in nature, such as ambulation and functionality.…”

“…22,72 Other standardized assessments that could be utilized in postoperative care include the FAC, the Musculoskeletal Function Assessment (MFA), and the Functional Independence Measure (FIM). 24,50,73 QOL scales can refer to various aspects of patient outcomes, including subjective wellbeing, economic burdens, and social impacts. 74 Several validated scales exist, including the Sickness Impact Profile, the SF-12, the Toronto Extremity Salvage Score (TESS) QOL survey, and the Diabetic Foot Syndrome-Short Form (DFS-SF), which is specific to diabetic foot wounds.…”

“…14,44,46,50 Ambulation rate was reported by 14 studies, with a weighted mean of 83.3% of patients ambulating postoperatively. 14,31,37,40,44,50,[52][53][54]56,58,[61][62][63] The average LEFS score, calculated from three studies, was 54.4 out of 80 points, indicating stage-4 function, or "independent community ambulation." 14,44,46 The range of LEFS scores was 46 to 65.6, with the highest score reported by Wu et al in a study of local flap outcomes for chronic osteomyelitis of long bones.…”

“…14,44,46 The only study to report FAC level, Lim et al calculated a mean level of 5.2 out of 6, corresponding to independent ambulation on level surfaces only. 50 The use of ambulation assistance devices, such as canes and walkers, was described as a functional outcome in four studies. 31,40,49,53 Kallio et al reported that 20 (48.8%) of 41 ambulatory patients in their study were restricted by a walker or cane.…”