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The Effect of Variation in Intraoperative Technique on Outcomes in Lower Extremity Free Flap Reconstruction

PURPOSE: Chronic wounds of the lower extremity (LE) are often complicated by infection. Definitive treatment of wounds resistant to conservative management often entails major amputation and/or reconstruction. For severely infected chronic wounds, a guillotine amputation performed before definitive amputation can help control infection and maximize success of subsequent major amputation. A recent study demonstrated that this two-stage approach may decrease short-term complications; however long-term outcomes are yet to be evaluated. 1 This study aims to assess the effect of guillotine amputation on rates of long-term success of major amputation. METHODS: A retrospective review of all major LE amputations performed between January 2017 and July 2020 at our tertiary wound center was conducted. Major amputation was performed in the setting of chronic and/or infected LE wounds that were not amenable to limb salvage. Patients who were lost to follow up or who expired during the study period, as well as patients undergoing amputation for trauma, chronic pain, a non-infected limb deformity, or cancer, were excluded. Patient characteristics, preoperative labs, and amputation data were collected. Postoperative complications assessed included rates of hematoma, dehiscence, infection, and infection requiring takeback to the operating room. Other outcomes of interest included stump revision, time


CONCLUSIONS:
The NSQIP Universal Surgical Risk Calculator aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the Risk Calculator are perhaps most pronounced where complex, multidisciplinary reconstructions are needed 2 . Future efforts should identify targets for improving Risk Calculator reliability in order to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation. BACKGROUND: Free flap failure rates are higher in the lower extremity than other areas of the body. Although many studies have investigated the effect of particular intraoperative technical variables, these studies include small case series or are not contemporary cohorts, more closely reflecting current practice with wide availability and acceptance of instruments such as venous couplers and perforator flap techniques.

PURPOSE:
Investigate the effect of variation in intraoperative techniques and flap selection on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage at multiple institutions.

METHODS:
Consecutive patients undergoing free flap reconstruction of the lower extremity distal to the hip at two level-1 trauma centers from January 1, 2002 to January 1, 2020 were identified using CPT codes followed by review of electronic medical records to collect patient and treatment characteristics. Data were collected regarding patient demographics and comorbidities, indication for operation, intraoperative technical details (including recipient artery and vein, number of venous anastomoses, superficial or deep venous system, coupler use and coupler size, end-to-end and end-to-side anastomosis techniques, use of vein grafts or AV loops), and complications. The primary outcome of interest was flap failure, and secondary outcomes included unplanned return to the operating room, arterial thrombosis, venous thrombosis, and partial flap failure. Bivariate analysis and multivariable logistic regression were performed.

PURPOSE:
Chronic wounds of the lower extremity (LE) are often complicated by infection. Definitive treatment of wounds resistant to conservative management often entails major amputation and/or reconstruction. For severely infected chronic wounds, a guillotine amputation performed before definitive amputation can help control infection and maximize success of subsequent major amputation. A recent study demonstrated that this two-stage approach may decrease short-term complications; however long-term outcomes are yet to be evaluated. 1 This study aims to assess the effect of guillotine amputation on rates of long-term success of major amputation.

METHODS:
A retrospective review of all major LE amputations performed between January 2017 and July 2020 at our tertiary wound center was conducted. Major amputation was performed in the setting of chronic and/or infected LE wounds that were not amenable to limb salvage. Patients who were lost to follow up or who expired during the study period, as well as patients undergoing amputation for trauma, chronic pain, a non-infected limb deformity, or cancer, were excluded. Patient characteristics, preoperative labs, and amputation data were collected. Postoperative complications assessed included rates of hematoma, dehiscence, infection, and infection requiring takeback to the operating room. Other outcomes of interest included stump revision, time to complete healing, and amputation failure, which was defined as failure to heal or need for more proximal amputation. Patients were separated into guillotine and no guillotine amputation groups. Statistical analysis was performed to compare patient characteristics and amputation outcomes between groups. Student t-test and Mann-Whitney U-test were used to analyze continuous variable while Chi-square test and Fisher exact test were used to analyze binary variables, as appropriate.

CONCLUSIONS:
The results of this study suggest that guillotine amputation prior to definitive major amputation play a significant role in limiting the spread of infection, resulting in decreased infectious complications and improved success rates following major amputation, compared with single-stage major amputations. A two-stage approach is also advantageous in decreasing the need to return to the operating room for infection or stump revision. Guillotine amputations should be considered in the setting of infected chronic lower extremity wounds to improve long-term patient outcomes.