FREE TISSUE TRANSFER TO EXTEND THE LIMITS OF LIMB SALVAGE FOR LOWER-EXTREMITY TISSUE LOSS

BACKGROUND: The extent of tissue loss amenable to primary healing afte r revascularization is unknown. Salvage of limbs with large soft-tissu e defects with exposed tendon, joint, or bone lies beyond the limits o f conventional techniques, We report our results using free tissue tra nsfer as an adjunct to lower extremity vascular reconstruction in pati ents with complex ischemic or infected wounds. METHODS: Retrospective chart review of patient and wound characteristics. RESULTS: From Janua ry 1992 to June 1996, 585 procedures were performed in 544 patients, i ncluding 27 free flaps in 26 patients: 17 free flaps combined with dis tal bypass (7 staged, 10 simultaneous) and 10 isolated free flaps. Fla p donor sites included radial forearm (8), latissimus dorsi (7), rectu s abdominus (9), and scapula (3). Surgical indications included extens ive ischemic/neurotrophic ulcers, and nonhealing vein graft harvest in cision or transmetatarsal amputation site. Mean area of tissue loss wa s 70 cm(2), mean ulcer duration was 5 months, and 92% of patients had exposed tendon, joint, or bone. During a mean follow-up of 14 months, 2 patients died of cardiopulmonary disease and 3 flaps failed, resulti ng in below-knee amputation. Six flaps were revised for graft stenosis (1), venous thrombosis (1), or flap edge necrosis (4). Limb salvage r ate was 70% at 24 months by life-table analysis. Functional ambulation was achieved in 21 of 24 (88%) patients, including 7 of 8 with diabet es, end-stage renal disease, and heel ulcers. CONCLUSION: In select am bulatory patients with large soft-tissue defects and exposed deep stru ctures, functional limb salvage is obtainable in more than 80% of pati ents. For lesions not amenable to vascular reconstruction with convent ional methods of wound coverage, free tissue transfer extends the limi ts of limb salvage and is a viable alternative to amputation. (C) 1997 by Excerpta Medica, Inc.