Free Tissue Transfer Optimizes Stump Length and Functionality Following High-Energy Trauma

Abstract

Background Advances in medicine and surgery have allowed patients, who in the past would have required more aggressive amputations, to maintain longer stump lengths. Microvascular free tissue transfer has become increasingly popular to preserve limb length and optimize functionality. We present our experience using microvascular free flap reconstruction to preserve lower extremity limb length in the setting of high-energy trauma.

Methods We conducted an Institutional Review Board-approved retrospective review of patients at three San Francisco hospitals who underwent free flap reconstruction after high-energy trauma between 2003 and 2015. We included all patients who underwent free flap reconstruction for lower extremity limb length preservation. We reviewed patient demographics, preoperative variables, intraoperative details, and postoperative outcomes, including complications, functional status, reoperation rates, and need for revision amputation.

Results Twelve patients underwent microvascular free tissue transfer for limb length preservation. Overall, the patients had similar preoperative comorbidities and a mean age of 44. Six patients had postoperative complications: three minor complications and three major complications. Seven patients had additional surgeries to improve the contour of the flap. One patient required revision amputation, while the remaining 11 patients preserved their original limb length. The majority of patients were fully ambulatory, and four used a prosthesis.

Conclusion Microvascular free tissue transfer can be used to effectively maintain lower extremity stump length following trauma. Although these patients often require multiple surgeries and face lengthy hospital courses, this technique enables preservation of a functional extremity that would otherwise require a more proximal amputation.

Keywords

limb salvage - limb length preservation - extremity reconstruction

• References

• 1 Lister G. Microsurgical transfer of the second toe for congenital deficiency of the thumb. Plast Reconstr Surg 1988; 82 (04) 658-665
• 2 Erdmann D, Sundin BM, Yasui K, Wong MS, Levin LS. Microsurgical free flap transfer to amputation sites: indications and results. Ann Plast Surg 2002; 48 (02) 167-172
• 3 Hallock GG. Evidence-based medicine: lower extremity acute trauma. Plast Reconstr Surg 2013; 132 (06) 1733-1741
• 4 Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am 1993; 75 (10) 1431-1441
• 5 Hansen Jr ST. The type-IIIC tibial fracture. Salvage or amputation. J Bone Joint Surg Am 1987; 69 (06) 799-800
• 6 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 (02) 138-145
• 7 Gonzalez EG, Corcoran PJ, Reyes RL. Energy expenditure in below-knee amputees: correlation with stump length. Arch Phys Med Rehabil 1974; 55 (03) 111-119
• 8 Penn-Barwell JG. Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis. Injury 2011; 42 (12) 1474-1479
• 9 Tukiainen EJ, Saray A, Kuokkanen HOM, Asko-Seljavaara SL. Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps. Scand J Plast Reconstr Surg Hand Surg 2002; 36 (02) 85-90
• 10 McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A. ; LEAP study group. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am 2003; 85-A [phone]
• 11 Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am 1976; 58 (01) 42-46
• 12 Peng YP, Lahiri A. Spare-part surgery. Semin Plast Surg 2013; 27 (04) 190-197
• 13 Lin CH, Webb K, Neumeister MW. Immediate tissue transplantation in upper limb trauma: spare parts reconstruction. Clin Plast Surg 2014; 41 (03) 397-406
• 14 Riah Y, Balaguer T, Médard de Chardon V, Chignon-Sicard B, Dannan E, Lebreton E. [The use of the “spare-parts tissue bank” concept in emergency hand surgery]. Chir Main 2010; 29 (01) 23-31
• 15 Russell RC, Neumeister MW, Ostric SA, Engineer NJ. Extremity reconstruction using nonreplantable tissue (“spare parts”). Clin Plast Surg 2007; 34 (02) 211-222 , viii
• 16 Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: classification, indications, and analysis of their clinical value. Plast Reconstr Surg 2001; 108 (04) 885-896
• 17 Aderibigbe K, Fletcher JW, Barta RJ, Hill BW, Cole PA. Staged calcaneus osteocutaneous filet flap for salvage of transtibial amputation. Foot Ankle Int 2014; 35 (01) 71-79
• 18 Van Nesc CP. ; VAN NESC. Transplantation of the tibia and fibula to replace the femur following resection: turn-up plasty of the leg. J Bone Joint Surg Am 1964; 46: 1353-1355
• 19 Tronzo RG, Janek AM. The “turn-up” plasty: one solution to a complex problem. Orthop Nurs 1995; 14 (03) 41-47
• 20 Ghali S, Harris PA, Khan U, Pearse M, Nanchahal J. Leg length preservation with pedicled fillet of foot flaps after traumatic amputations. Plast Reconstr Surg 2005; 115 (02) 498-505
• 21 Machol IV JA, Fang RC, Matloub HS. The free fillet flap after traumatic amputation: a review of literature and case report. Hand (N Y) 2013; 8 (04) 487-490
• 22 Bosse MJ, MacKenzie EJ, Kellam JF. , et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002; 347 (24) 1924-1931