Soft tissue coverage of lower extremity defects: pearls and pitfalls in the chronic wound population

Abstract

The incidence of chronic lower extremity (LE) wounds continues to increase. Lower limb amputations are associated with increased cardiovascular exertion, further decline in functional ability, and higher mortality rates. As such, there has been a shift towards limb salvage modalities. These include local debridement with advanced wound care, revascularization, bony reconstruction, and soft tissue reconstruction. Perioperative planning for soft tissue reconstruction requires careful consideration of several factors, including patient comorbidities, wound size and location, exposed underlying structures, and in the case of possible free flap, patency of donor and recipient vessels. This article reviews the perioperative factors that should be considered in preparation for successful soft tissue reconstruction of the LE.

Long-Term Outcomes in Patients With Peripheral Arterial Disease Who Undergo Free Flap Reconstruction for Chronic Lower Extremity Wounds

“…Our improved limb salvage rates may be attributed to improved medical management of comorbidities and technical advances in microsurgery in recent years. 14,[18][19][20] In this study, we found that patients with PAD had a higher prevalence of other comorbidities that can negatively impact vasculature and wound healing, including diabetes and end-stage renal disease. 21 Furthermore, patients with PAD had a higher prevalence of osteomyelitis in their LE wounds compared with patients without PAD.…”

“…We attribute this study's higher long-term outcomes of FTT in patients with PAD to the multidisciplinary team approach used at our institution. 18,23 Before FTT, our tertiary wound care center team requires patients to be medically optimized, most importantly including smoking cessation and tight glycemic control. During perioperative optimization, each patient is evaluated by the following specialists: a reconstructive microsurgeon, a podiatric surgeon for biomechanical foot examinations, an endocrinologist for glycemic control in diabetic patients, an infectious disease physician for appropriate antibiotic coverage, and a hematologist for anticoagulation in patients with known hypercoagulable traits.…”

“…Comparatively, among the 84 patients in our study with PAD, the limb salvage rate was 84.5%, with a 98.8% flap survival rate and a 91.7% patient survival rate. Our improved limb salvage rates may be attributed to improved medical management of comorbidities and technical advances in microsurgery in recent years 14,18–20 …”

“…We attribute this study's higher long-term outcomes of FTT in patients with PAD to the multidisciplinary team approach used at our institution 18,23 . Before FTT, our tertiary wound care center team requires patients to be medically optimized, most importantly including smoking cessation and tight glycemic control.…”

“…Long-term patency of microvascular anastomosis is dependent on the arterial and venous flow within the flap 6 . Preoperative planning with a vascular surgeon is crucial to select a patent, high-caliber recipient artery for flap anastomosis 14,18 . Previous studies have shown that flaps with abundant blood flow have higher patency of anastomosed vessels and higher resistance to infection 5,25,26 .…”