Limb salvage despite extensive tissue loss. Free tissue transfer combined with distal revascularization
J. L. Cronenwett, M. D. McDaniel, R. M. Zwolak, D. B. Walsh, J. R. Schneider, W. F. Reus and L. B. Colen
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, NH 03756.
Extensive lower-extremity tissue loss may preclude limb salvage despite
successful arterial reconstruction. We attempted to avoid limb loss in such
patients by combining arterial bypass with microvascular free tissue
transfer. Fourteen patient (12 diabetic), 33 to 74 years of age, presented
with extensive tissue loss in 15 lower extremities, exposing bone or tendon
on the heel, ankle, lower part of the leg, or hindfoot. Mean ulcer size was
5 X 8 cm. Four patients had had previous contralateral below-knee
amputations. Femorodistal (seven), popliteal-distal (three), or
femoropopliteal (four) bypass, or tibial angioplasty (one), was performed
to provide sufficient inflow for free tissue transfer. Serratus anterior,
scapular, latissimus dorsi, rectus abdominis, gracilis, ulnar, or
temporalis free flaps were used. One free flap failed due to venous
thrombosis and was corrected with a second flap. Limb salvage was achieved
in 14 (93%) of 15 limbs during a mean follow-up of 24 months. The single
amputation occurred due to severe foot ischemia in a patient whose
femorodistal bypass remained patent only to the viable free flap. The
remaining 13 patients (14 limbs) became ambulatory, including those with
free flaps to weight-bearing regions.
