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

Abstract

Background: The use of free tissue transfer (FTT) is efficacious for chronic, non-healing lower extremity (LE) wounds. The four pillars of managing patient comorbidities, infection control, blood flow status, and biomechanical function are critical in achieving successful limb salvage. The authors present their multidisciplinary institutional experience with a review of 300 FTTs performed for the complex LE limb salvage of chronic LE wounds. Methods: A single-institution, retrospective review of atraumatic LE FTTs performed by a single surgeon from July 2011 to January 2023 was reviewed. Data on patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, postoperative complications, and long-term outcomes were collected. Results: A total of 300 patients who underwent LE FTT were included in our retrospective review. Patients were on average 55.9 ± 13.6 years old with a median Charlson Comorbidity Index of 4 (IQR: 3). The majority of patients were male (70.7%). The overall hospital length of stay (LOS) was 27 days (IQR: 16), with a postoperative LOS of 14 days (IQR: 9.5). The most prevalent comorbidities were diabetes (54.7%), followed by peripheral vascular disease (PVD: 35%) and chronic kidney disease (CKD: 15.7%). The average operative LE FTT time was 416 ± 115 min. The majority of flaps were anterolateral thigh (ALT) flaps (52.7%), followed by vastus lateralis (VL) flaps (25.3%). The immediate flap success rate was 96.3%. The postoperative ipsilateral amputation rate was 12.7%. Conclusions: Successful limb salvage is possible in a highly comorbid patient population with a high prevalence of diabetes mellitus, peripheral vascular disease, and end-stage renal disease. In order to optimize patients prior to their LE FTT, extensive laboratory, arterial, and venous preoperative testing and diabetes management are needed preoperatively. Postoperative monitoring and long-term follow-up with a multidisciplinary team are also crucial for long-term limb salvage success.

Keywords: atraumatic; chronic wound; diabetic limb salvage; free tissue transfer; lower extremity reconstruction.

Figure 1

Limb salvage team model in a multidisciplinary wound clinic setting.

Figure 2

Multidisciplinary limb salvage: 4 critical factors to consider for successful complex soft tissue coverage for the highly comorbid patient.

Figure 3

A 53-year-old male with a past medical history of type II diabetes mellitus with peripheral neuropathy A1c 9.3% who presents to the clinic with a left foot infection, abscess, and gas gangrene. (A) Patient presents to the clinic with infection of the L foot and gangrene of the 3rd toe. Patient is admitted to the limb surgical service. Patient receives a CT scan, which confirms gas gangrene and shows changes corresponding to osteomyelitis. (B) Photograph post incision and drainage of left foot and open partial third ray amputation. Patient presents with a large plantar foot defect measuring approximately 13 × 7 cm in size, extending from second webspace anteriorly and continuing plantarly and medially to the medial aspect of calcaneal region with exposed intrinsic muscles of the foot. Post-debridement cultures are positive for polymicrobial infection. Biopsy of the left toe is taken and reported to show evidence of acute osteomyelitis. Patient receives four additional debridements prior to free flap. (C) Photograph of patient’s diagnostic angiogram showing 2-vessel run-off with widely patent anterior tibial (AT) artery, which continue onto the foot as a dorsalis pedis artery (arrow), widely patent posterior tibial (PT) artery which continues onto the foot as plantar vessels, and intact pedal arch (arrow). Return to the OR for second debridement; photograph of post-excisional debridement (obtained from chart). (D) Intraoperative photograph of recipient site dissection. Incision placed 2 cm posterior to medial malleolus where strong doppler signal is heard from the posterior tibial artery. Posterior tibial artery measures 2.5 mm in caliber with evidence of moderate calcifications throughout the vessel. (E) Intraoperative photograph of free anterolateral (ALT) flap with end-to-side anastomosis to PT. Implantable Cook Doppler and Vioptix placed for postoperative monitoring. (F) Follow-up in clinic 9.6 months post-op showing well-healed free flap. (G) Follow-up in clinic 9.6 months post-op showing patient is ambulating with regular footwear.