Refining a Multidisciplinary “Vasculo-plastic” Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps

Abstract

Background: The use of free tissue transfer (FTT) is effective for chronic, non-healing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plants to optimize limb salvage. This study aims to describe our vasculo-pathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTT and the most recent 100 procedures performed. Methods: A single-institution, retrospective review of 300 LE FTTs from July 2011 to January 2023 was performed. Patients were compared between the first 200 (Group 1, July 2011 – February 2020) and last 100 flaps (Group 2, February 2020 – January 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected. Results: Group 2 patients had significantly higher rates of diabetes (67.0% vs. 48.5%, p=0.002), peripheral vascular disease (56.0% vs. 24.5%, p<0.001), history of venous thromboembolisms (13.0% vs. 6.0%, p=0.039), venous reflux (81.9% vs. 67.8%; p=0.028), and preoperative venous thromboses on venous testing (25.5% vs. 10.5%; p=0.003) compared to Group 1. Group 2 underwent more pre-FTT endovascular interventions (23.0% vs. 16.5%, p=0.039) and vascular bypasses (4.0% vs. 0.0%, p =0.012). While immediate flap success and amputation rates were similar between the groups, Group 2 had higher rates of partial flap necrosis (7% vs. 3%; p=0.012). Conclusions: The adoption of a vasculo-plastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population.