Early Results of a Collaborative Multispecialty Mangled Extremity Algorithm for Acute Limb Salvage with Incorporation of Long Saphenous Arterial-Venous Loops for Free Flap Reconstruction in the Community Hospital Setting

Abstract

Salvage of the mangled lower extremity is both technically challenging and time-consuming. It requires the collaborative efforts of multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitation of a successful limb salvage program with creation of a mangled extremity algorithm. An integral part of this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Use of a long saphenous arterial-venous (AV) loop has been cited, but minimal data are available with larger inflow vessels in the acute trauma setting. We describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Since June 2016, eight patients admitted from the trauma service with mangled lower extremity injuries were identified and placed into the protocol. All eight patients sustained severe crush injuries with large tissue defects and insufficient distal runoff for healing but deemed salvageable by multispecialty assessment. Mangled Extremity Severity Scores were tabulated. Patients (seven male and one female) ranged in age from 21 to 44 years. Per protocol, repeated débridement was performed until successful sterilization of the wounds was accomplished. Eight long saphenous vein AV loops were anastomosed to the popliteal vessels for free flap reconstruction. All patients were followed up after AV loop creation for vascular complications and wound assessments. All eight patients had sterilization of the wounds with open reduction and internal fixation of the fracture site before vascular reconstruction. Mean débridement to surgical site sterilization was 4.3 washouts (range, 2-7). Successful popliteal AV loop creation with great saphenous vein was completed in 100% of patients without vascular complications or steal events (Fig 1). Free flap tissue transfers were completed using six rectus abdominis and two latissimus dorsi muscles within 7 days of the loop creation (Fig 2). Patency rate of the AV loop was 100% with eight successful flap transfers and 88% (seven of eight) amputation-free survival at 1 year. One flap did not survive because of recurrent bacterial infection of the hardware. The seven patients with successful procedures reached preoperative ambulatory status within 3 months after their final operation. Although this is a small cohort of patients, incorporation and use of our mangled extremity protocol to guide limb salvage proved successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.Fig 2Immediate postoperative rectus abdominis free flap tissue transfer to right lower extremity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)