From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; and Georgetown University School of Medicine.
Plast Reconstr Surg. 2022 Jul 1;150(1):197-209. doi: 10.1097/PRS.0000000000009236. Epub 2022 May 19.
Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population.
The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound.
The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort.
Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
在非愈合性伤口的情况下，下肢挽救需要多学科方法来成功进行游离组织转移。以前，患有合并症（包括糖尿病和外周血管疾病）的患者被认为是游离组织转移的不良候选人。然而，截肢会导致功能下降和死亡率大大增加。作者介绍了他们在高合并症人群中为下肢挽救而进行的 200 例游离组织转移的机构围手术期方案。
作者回顾了 2011 年至 2019 年期间进行的 200 例下肢游离组织转移的机构数据库。对前 100 例和后 100 例游离组织转移的患者的人口统计学、合并症、伤口原因和位置、术中细节、皮瓣结果和并发症进行了比较。作者记录了他们为下肢游离组织转移制定的机构方案的演变，包括标准的术前高凝状态检测、血管造影和静脉超声。
中位 Charlson 合并症指数为 3，分别有 48%和 22%的患者患有糖尿病和外周血管疾病。39%的患者检测出超过三种高凝遗传条件呈阳性。第二组 100 例游离组织转移中，有更多的患者血管流出减少（35%比 47%；p<0.05）、血管内介入治疗率（7.1%比 23%；p<0.05）和静脉反流率（19%比 64%；p<0.001）较高。第二组的皮瓣成功率（91%比 98%；p<0.05）和手术时间（500 分钟比 374 分钟；p<0.001）均有所提高。
基于标准化证据的方案和多学科方法可实现成功的肢体挽救。尽管存在学习曲线，但通过提高机构知识和能力，可在高合并症患者中实现较高水平的挽救。
临床问题/证据水平：治疗性，III 级。
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