Analysis of multiple risk factors affecting the result of free flap transfer for necrotising soft tissue defects of the lower extremities in patients with type 2 diabetes mellitus

Lee, Yung Ki; Park, Keun Yung; Koo, Youn Taek; Baek, Rong Min; Heo, Chan Yeong; Eun, Seok Chan; Lee, Tae Seung; Lee, Kyoung Min; Kim, Baek Kyu

doi:10.1016/j.bjps.2014.01.047

Cited by 39 publications

(35 citation statements)

References 20 publications

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“…28 In one report of 33 diabetic patients undergoing lower extremity flaps, it was the patients' renal function that impacted their risk of flap failure such that patients with a preoperative creatinine greater than 1.28 were at a higher risk of failure. 29 In this series, neither smoking nor diabetes was significantly associated with flap failure. This is likely due to a limitation of this study, namely lack of appropriate power to determine if a significant association exists.…”

Section: Discussionmentioning

confidence: 53%

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty

et al. 2017

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Revision total knee arthroplasty (rTKA) is a challenging problem in the setting of soft tissue defects. The purpose of this study was to evaluate patients who underwent rTKA requiring flap coverage and determine patient factors that predisposed them to failure. Forty-three consecutive patients (mean follow-up, 46.5 months) who underwent rTKA requiring flap coverage were retrospectively reviewed between January 1, 2000 and December 31, 2010. Sixteen of 43 patients experienced failure requiring either flap revision ( = 2) or above the knee amputation ( = 14). Patients with heart failure ( = 0.008), cancer ( = 0.049), or infection with ( = 0.002) had greater rates of failure. Smoking ( = 0.287), diabetes ( = 0.631), and flap type ( = 0.634, = 0.801) were not associated with increased failure. Mean survival was 46.4 months. Survival of patients with a history of cancer (34.3 months) was less ( = 0.033) than those without (49.2 months). Flap coverage in rTKA is a viable limb salvage option for patients with soft tissue defects; however, failure rates are much higher than in patients not requiring flap coverage.

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Section: Discussionmentioning

confidence: 53%

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty

et al. 2017

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“…The correlation between calcified arteriosclerosis and flap failure has been reported previously in the lower limb salvage population. 38,39 Intimal separation during passage of transmural sutures and pedicle kinking from loss of vascular compliance are among the purported factors that contribute to anastomotic failure in calcified vessels. 38,39 For these reasons, microvascular anastomoses should be avoided in regions of severe calcific sclerosis, whenever possible.…”

Section: Discussionmentioning

confidence: 99%

“…38,39 Intimal separation during passage of transmural sutures and pedicle kinking from loss of vascular compliance are among the purported factors that contribute to anastomotic failure in calcified vessels. 38,39 For these reasons, microvascular anastomoses should be avoided in regions of severe calcific sclerosis, whenever possible. If diffuse calcification is encountered, intraoperatively, technical modifications to minimize intimal flap formation (i.e., meticulous vessel preparation, atraumatic "inside-to-outside" anastomosis using smallcaliber, double-needle, tapered microsuture) and thoughtful geometric arrangement of the vascular pedicle will optimize chances for successful reconstruction.…”

Section: Discussionmentioning

confidence: 99%

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

DeFazio

Economides

Anghel

et al. 2018

J reconstr Microsurg

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Background No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols. Methods Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods. Results Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified (n = 27) or risk-stratified (n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p < 0.001). Lower rates of total (3 vs. 19%, p = 0.06) and partial (10 vs. 37%, p = 0.025) flap loss were observed among risk-stratified patients, paralleling a significant reduction in the prevalence of postoperative thrombotic events (1.2 vs. 12.3%, p = 0.004). While therapeutic versus low-dose heparin infusion was associated with improved flap survival following intraoperative microvascular compromise (86 vs. 25%, p = 0.04), salvage rates in the setting of postoperative thrombosis remained 0%, regardless of protocol. On multivariate analysis, recipient-vessel calcification (odds ratio [OR]: 16.7, p = 0.02) and anastomotic revision (OR, 3.3; p = 0.04) were independently associated with total flap failure. Conclusion Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.

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“…Diabetes negatively affects the microvasculature causing changes in compliance, elasticity, and ultimately the blood flow through the vessel. These damaged vessels are used for the anastomosis in a free flap [15][16][17] . Lee et al [15] demonstrated that patients with serum Creatinine greater than 1.28 mg/dL had significantly higher post-operative complication rates including, partial and total necrosis.…”

Section: Discussionmentioning

confidence: 99%

“…These damaged vessels are used for the anastomosis in a free flap [15][16][17] . Lee et al [15] demonstrated that patients with serum Creatinine greater than 1.28 mg/dL had significantly higher post-operative complication rates including, partial and total necrosis. Flap reconstruction to previously radiated tissues has been shown to have complication rates between 8%-39%, likely due to reduction in vascularization and mean capillary lumen [18,19] .…”

Section: Discussionmentioning

confidence: 99%

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Kovar¹,

Diamond²,

Iorio³

2019

PAR

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Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure. Methods: A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution. Flaps that utilized skin grafting for closure were compared to those closed primarily. Adjunct operative procedures, demographics, and complications were evaluated. Results: A total of 71 patients fulfilled the inclusion criteria. The 11 flaps in 10 patients underwent skin grafting over the pedicle. The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group. Flap area, operative time, and anastomosis technique were comparable between the two groups. There was no significant difference in the rates of post-operative complications including partial flap loss, complete flap loss, infection. Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group. Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.

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Analysis of multiple risk factors affecting the result of free flap transfer for necrotising soft tissue defects of the lower extremities in patients with type 2 diabetes mellitus

Cited by 39 publications

References 20 publications

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty

Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

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