Early results of a collaborative multispecialty mangled extremity algorithm for acute limb salvage with incorporation of long saphenous arterial-venous loops for free-flap reconstruction in the community hospital setting
Robert S Brumberg, Lawerence D Kaelin, Chris Derosier
Florida State University/Tallahassee Memorial Hospital, Tallahassee, FL
Background: The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts amongst multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort amongst these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of a long saphenous arterial-venous loop has been cited with minimal data available with using larger inflow vessels in the acute trauma setting. We describe our early experience using our protocol with arteriovenous loop creation with free flap reconstruction to salvage traumatic leg injuries.
Methods: Since June 2016, eight patients admitted from the trauma service with mangled lower extremities injuries were identified and placed into the protocol. All eight patients sustained severe crush injuries with large tissue defects and insufficient distal runoff for healing but deemed salvageable by multispecialty assessment. MESS scores were tabulated. Patients age ranged from 21-44 with 7 males and 1 female. Per protocol, repeated debridement until successful sterilization of the wounds was accomplished. Eight long saphenous vein arteriovenous loops were anastomosed to the popliteal vessels for free flap reconstruction. All patients were followed post AV loop creation for vascular complications and wound assessments.
Results: All eight patients had sterilization of the wounds with ORIF of the fracture site prior to vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (Range 2-7). Successful popliteal AV loop creation with great saphenous vein was completed in 100% of patients without vascular complications nor steal events (Figure 1). Free flap tissue transfers were completed using 6 rectus abdominis and 2 latissimus dorsi within 7 days of the loop creation (Figure 2). Patency rates of the AV loop was 100% with 8 successful flap transfers and 88% (7/8) amputation free survival at one year. One flap did not survive due to recurrent bacterial infection of the hardware. The seven patients with successful procedures reached pre-operative ambulatory status within 3 months after their final surgery.
Conclusion: Although a small patient cohort, incorporation and utilization of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long term data needs to be complied to assess patency of the free flap transfer and quality of life outcomes.
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