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

William Piwnica-Worms; John T. Stranix; Sammy Othman; Geoffrey M. Kozak; Ilaina Moyer; Amy Spencer; Saïd C. Azoury; L. Scott Levin; Stephen J. Kovach

doi:10.1055/s-0040-1710358

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2020; 36(07): 528-533
DOI: 10.1055/s-0040-1710358

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

William Piwnica-Worms

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

John T. Stranix

²Department of Plastic Surgery, University of Virginia Health System, Charlottesville, Virginia

,

Sammy Othman

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

Geoffrey M. Kozak

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

Ilaina Moyer

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

Amy Spencer

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

Saïd C. Azoury

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

L. Scott Levin

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

³Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

,

Stephen J. Kovach

¹Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

³Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania

› Author Affiliations

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.

Keywords

limb salvage - amputation - lower extremity

Full Text

References

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