Free Tissue Transfer in Patients with Severe Peripheral Arterial Disease: Functional Outcome in Reconstruction of Chronic Lower Extremity Defects

Abstract

Chronic wounds of the lower extremity are difficult to treat, especially in patients with peripheral arterial disease (PAD). This patient population frequently suffers from multiple comorbidities, which further impairs wound healing. Local flaps are often not available, or are insufficient to cover these defects, and limbs are frequently amputated, although they could possibly be salvaged by free tissue transplantation. Although there is a growing evidence that free tissue transfer may be feasible in these patients with otherwise doomed extremities, previous studies have mostly focused on short-term flap survival, but not long-term ambulatory status and independence. Therefore, we investigated the long-term results of limb salvage, ambulatory status, and social independence in patients with PAD who underwent free tissue transfer for chronic wounds of the lower extremities.

In this study we retrospectively reviewed 38 patients who underwent free tissue transfer because of nontraumatic, chronic wounds of the lower extremities at our institution. All patients suffered from a nontraumatic occlusion of at least one major lower leg artery verified by angiography. After a mean time period of 34 months we assessed flap survival and limb preservation as well as pre- and postoperative ambulatory status and social independence. A subgroup of 14 patients with a “single-vessel-leg” was evaluated separately.

It was observed that anterolateral thigh and latissimus dorsi musculocutaneous flaps were most often used to cover the defects. Overall 29 out of the 38 flaps healed completely (9 flap failures) and 34 extremities were salvaged, including 12 out of 14 single-vessel-legs. One patient had to be amputated despite a vital free flap because of persistent calcaneal osteomyelitis. After failure of free tissue transfer, six extremities could still be salvaged by secondary procedures (two secondary free flaps, two local flaps, and two skin grafts). Total 22 out of 34 patients with salvaged limbs maintained or improved their ambulatory status. In the amputee group, two patients remained on their preoperative level of mobility, while two declined. All patients with amputated limbs required assistance in activities of daily living while this was only true for 4 out of the 34 remaining patients.

It was concluded that free tissue transfer is a valid option for salvaging lower extremities in patients with PAD. Long-term limb salvage can be achieved in a high percentage of cases, which allows the patients to ambulate freely and remain socially independent.

Keywords

microsurgery - limb salvage - amputation - peripheral arterial disease - free flap

• References

• 1 Shestak KC, Fitz DG, Newton ED, Swartz WM. Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques. Plast Reconstr Surg 1990; 85 (3) 406-411
• 2 Schmiedt W, Neufang A, Dorweiler B , et al. Krurale und pedale Bypasschirurgie bei kritischer Ischämie und nicht heilenden Fußläsionen. Gefaesschirurgie 2003; 8 (4) 252-258
• 3 Weis-Müller BT, Lippelt I, Römmler V , et al. Ergebnisse der operativen Revaskularisation beim Diabetespatienten mit arterieller Verschlusskrankheit. Der Diabetologe 2009; 5 (1) 28-36
• 4 Gutacker N, Neumann A, Santosa F, Moysidis T, Kröger K. Amputations in PAD patients: data from the German Federal Statistical Office. Vasc Med 2010; 15 (1) 9-14
• 5 Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009; 124 (6) 1965-1973
• 6 Driver VR, Fabbi M, Lavery La, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg 2010; 52 (3 Suppl) 17S-22S
• 7 Bodily KC, Burgess EM. Contralateral limb and patient survival after leg amputation. Am J Surg 1983; 146 (2) 280-282
• 8 Sarin S, Shami S, Shields DA, Scurr JH, Smith PD. Selection of amputation level: a review. Eur J Vasc Surg 1991; 5 (6) 611-620
• 9 Francis W, Renton CJ. Mobility after major limb amputation for arterial occlusive disease. Prosthet Orthot Int 1987; 11 (2) 85-89
• 10 Ducic I, Rao SSS, Attinger CECE. Outcomes of microvascular reconstruction of single-vessel lower extremities: limb salvage versus amputation. J Reconstr Microsurg 2009; 25 (8) 475-478
• 11 Wa W, Freitag MH, Wölfle KD, Bohndorf K, Kirchhof K. [Incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in the treatment of peripheral arterial occlusive disease in a German referral center 1996–2003]. RoFo 2006; 178 (9) 906-910
• 12 Christy MR, Lipschitz A, Rodriguez E, Chopra K, Yuan N. Early Postoperative Outcomes Associated With the Anterolateral Thigh Flap in Gustilo IIIB Fractures of the Lower Extremity. Ann Plast Surg 2012;
• 13 Knobloch K, Herold C, Vogt PM. Free latissimus dorsi flap transfer for reconstruction of soft tissue defects of the lower extremity]. Oper Orthop Traumatol 2012; 24 (2) 122-130
• 14 Colen LB. Limb salvage in the patient with severe peripheral vascular disease: the role of microsurgical free-tissue transfer. Plast Reconstr Surg 1987; 79 (3) 389-395
• 15 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123 (1) 230-235
• 16 Herold C, Gohritz A, Meyer-Marcotty M , et al. Is there an association between comorbidities and the outcome of microvascular free tissue transfer?. J Reconstr Microsurg 2011; 27 (2) 127-132
• 17 Kim HK, Park B, Bae TH, Kim WS. Comparative study of the postoperative complications of microvascular surgery in elderly and young patients. J Reconstr Microsurg 2011; 27 (4) 219-224
• 18 Moran SL, Illig KA, Green RM, Serletti JM. Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience. Plast Reconstr Surg 2002; 109 (3) 999-1006
• 19 Doukas WC, Hayda RA, Frisch HM , et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013; 95 (2) 138-145
• 20 Stinner DJ, Burns TC, Kirk KL, Ficke JR. Return to duty rate of amputee soldiers in the current conflicts in Afghanistan and Iraq. J Trauma 2010; 68 (6) 1476-1479
• 21 Gailey R, McFarland LV, Cooper RA , et al. Unilateral lower-limb loss: prosthetic device use and functional outcomes in servicemembers from Vietnam war and OIF/OEF conflicts. J Rehabil Res Dev 2010; 47 (4) 317-331
• 22 Fleury AM, Salih SA, Peel NM. Rehabilitation of the older vascular amputee: a review of the literature. Geriatr Gerontol Int 2013; 13 (2) 264-273
• 23 Schnall BL, Wolf EJ, Bell JC, Gambel J, Bensel CK. Metabolic analysis of male servicemembers with transtibial amputations carrying military loads. J Rehabil Res Dev 2012; 49 (4) 535-544
• 24 Homann HH, Lehnhardt M, Langer S, Steinau HU. Stumpferhalt und Stumpfverlängerung an der unteren Extremität. Der Chirurg 2007; 78 (4) 308-315
• 25 Steinberg FU, Sunwoo I, Roettger RF. Prosthetic rehabilitation of geriatric amputee patients: a follow-up study. Arch Phys Med Rehabil 1985; 66 (11) 742-745
• 26 Nehler MR, Coll JR, Hiatt WR , et al. Functional outcome in a contemporary series of major lower extremity amputations. J Vasc Surg 2003; 38 (1) 7-14
• 27 Stone PA, Flaherty SK, Aburahma AF , et al. Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations. Ann Vasc Surg 2006; 20 (2) 209-216
• 28 Culliford IV AT, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59 (1) 18-21 , discussion 21–22
• 29 Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989; 29 (8) 1086-1094
• 30 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (2) 243-250
• 31 Gonzalez MH, Tarandy DI, Troy D, Phillips D, Weinzweig N. Free tissue coverage of chronic traumatic wounds of the lower leg. Plast Reconstr Surg 2002; 109 (2) 592-600
• 32 Fischer JP, Wink JD, Nelson JA , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (6) 407-416
• 33 Perrot P, Bouffaut A-L, Perret C, Connault J, Duteille F. Risk factors and therapeutic strategy after failure of free flap coverage for lower-limb defects. J Reconstr Microsurg 2011; 27 (3) 157-162
• 34 Tukiainen E, Kallio M, Lepäntalo M. Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: Long-term outcome. Ann Surg 2006; 244 (6) 949-957 , discussion 957–958
• 35 Chien S-H, Huang C-C, Hsu H, Chiu CH, Lin CM, Tsai JP. Free tissue transfers for limb salvage in patients with end-stage renal disease on dialysis. Plast Reconstr Surg 2011; 127 (3) 1222-1228
• 36 Tan ML, Feng J, Gordois A, Wong ES. Lower extremity amputation prevention in Singapore: economic analysis of results. Singapore Med J 2011; 52 (9) 662-668
• 37 MacKenzie EJ, Jones AS, Bosse MJ , et al. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am 2007; 89 (8) 1685-1692
• 38 Parmaksizoglu F, Unal MB, Cansu E, Koprulu AS, Ince Y, Yurga E. Functional results of limb salvage in below-knee type III C open fractures or traumatic amputations. J Reconstr Microsurg 2012; 28 (9) 607-613
• 39 Aravind M, Shauver MJ, Chung KC. A qualitative analysis of the decision-making process for patients with severe lower leg trauma. Plast Reconstr Surg 2010; 126 (6) 2019-2029
• 40 Aust MC, Spies M, Kall S , et al. [Vascular interventions and reconstructive plastic surgery. Optimizing the treatment of chronic wounds]. Chirurg 2007; 78 (8) 729-736
• 41 Randon C, Jacobs B, De Ryck F, Van Landuyt K, Vermassen F. A 15-year experience with combined vascular reconstruction and free flap transfer for limb-salvage. Eur J Vasc Endovasc Surg 2009; 38 (3) 338-345