The role of local flap reconstruction for limb salvage in patients with moderate to severe medial arterial calcification.

The medial arterial calcification (MAC) scoring system (Figure 1) predicts adverse limb events. This study applies MAC scoring to patients undergoing local flap reconstruction. To do so, we reviewed patients that underwent foot and ankle local flaps from January 2010 to November 2022. Radiographs were used to assign MAC scores: absent (MAC=0-1), moderate (MAC=2-3), or severe (MAC≥4). 182 patients underwent local flap reconstruction: 104 (57.1 %) absent MAC, 32 (17.6 %) moderate MAC, and 46 (25.3 %) severe MAC. Patients with severe MAC demonstrated significantly higher rates of diabetes mellitus (p = 0.001), end-stage renal disease (p < 0.001), and peripheral neuropathy (p < 0.001), and more often required a vascular intervention before reconstruction (p = 0.001). Flap-related outcomes and major limb amputation rates were statistically comparable among MAC groups. By a median of 16.5 (IQR: 36.6) months, limb salvage was 84.1 % and not independently associated with MAC on multivariable analysis. Postoperative vascular intervention (absent: 10.7 % vs. moderate: 28.1 % vs. severe: 17.4 %; p = 0.054), podiatric reoperation (absent: 35.6 % vs. moderate: 40.6 % vs. severe: 56.5 %; p = 0.056), and mortality (absent: 19.4 % vs. moderate: 34.4 % vs. 32.6 %; p = 0.102) were not independently associated with MAC on multivariable analysis. Given these results, local flaps are a viable option in patients with MAC. If utilizing a vasculo-plastic approach, severe MAC should not prevent limb salvage efforts via local flap reconstruction.