Risk Factors for Lower Extremity Amputation Following Attempted Free Flap Limb Salvage

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.

Predicting the Outcome of Open Type IIIC Tibial Fractures Regarding Union, Osteomyelitis, and Amputation

“…A signi cantly higher amputation rate was noted for patients with DM compared to those without DM (4.3%). Piwnica-Worms et al [32] found a signi cant relationship between DM and the amputation rate in 129 patients with lower extremity trauma who required free ap reconstruction, which is compatible with our ndings.…”

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review

“…This highlights the importance of a multidisciplinary approach before embarking on lower limb salvage surgery. 11 The low number of trunk and visceral flaps within our sample may reflect the fact that they are not often performed and hence explain the relatively higher proportion of failure.…”

Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients

“…29 Although various different risk factors will influence the outcome, obtaining the best possible flow should be considered as an essential prerequisite for successful reconstruction. 30,31 In this series, relatively large flaps, such as anterolateral thigh (ALT) flaps, were used with the all flaps being large with average of 187.5 cm 2 to reconstruct the defect ensuring tensionless closure of the defect. Unlike the high percentage leading to higher level amputation after TMA either by secondary intension healing or primary closure, there were only two cases that led to higher level amputation in this study.…”