Lower extremity free tissue transfer (LE FTT) expands limb salvage options for patients with chronic wounds. Infected wounds require serial debridement to optimize the wound bed before reconstruction, but the role of qualitative microbiological cultures in guiding surgical wound closure timing remains unclear. This study evaluates the impact of final preoperative culture results on postoperative outcomes, including flap success, infection rates, and limb salvage. A retrospective review of 344 patients undergoing LE FTT at a single institution was conducted. All patients underwent serial debridement, with final cultures obtained from the final debridement prior to flap reconstruction. Patients were stratified into positive and negative final culture groups. Subgroup analyses assessed the impact of polymicrobial colonization and comorbidity burden (Charlson Comorbidity Index [CCI] >6) on outcomes. Primary outcome was flap infection, defined as any documented clinical concern for infection, including cellulitis, purulent drainage, abscess formation, or initiation of targeted antibiotic therapy. Polymicrobial final cultures were associated with increased infection (p = 0.003) and flap complications (p = 0.041). Among patients with CCI >6, positive final culture was associated with significantly higher infection rates (p = 0.032), but not among those with CCI ≤6. In the total cohort, comparing positive final culture to negative final culture, flap outcomes were similar between groups. Final culture positivity alone does not predict poor outcomes, but polymicrobial cultures and host factors may increase flap infection risk. A risk-stratified approach should guide surgical decision-making, with additional debridement and/or wound bed optimization considered for polymicrobial wounds and polymorbid patients (CCI >6).

BACKGROUND:Achilles tendon injury with extensive soft tissue loss presents challenges to lower extremity (LE) reconstruction with functionally favorable results. The use of a free anterolateral thigh (ALT) flap incorporating a tubularized fascia lata (FL) segment offers a reconstructive option for these complex cases. This study evaluates the early outcomes of microsurgical reconstruction for Achilles tendon and soft tissue defects. METHODS:A retrospective review of patients requiring LE free tissue transfer (FTT) between 2012 and 2023 was performed. All patients included had Achilles tendon defects and underwent reconstruction using an ALT flap with tubularized FL. Demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics were collected. Primary outcomes were flap success, return to functional ambulation, and complication rate. RESULTS:Twenty-two patients underwent single-stage FTT for both soft tissue coverage and Achilles tendon reconstruction. The average age was 46.9 ± 16.1 years, with a median Charlson Comorbidity Index of 0 (IQR: 2). Average wound size was 80.6 ± 40.1 cm2. All patients (n = 22, 100.0%) were ambulatory preoperatively. Flap success rate was 95.5% (n = 21). Twelve patients (55%) had long-term physical therapy follow-up. At a median of 7.6 months (IQR: 5.2), median ankle active range of motion (AROM) was 15 degrees (IQR: 7) for dorsiflexion (DF) and 43.5 degrees (IQR: 10) for plantarflexion (PF). Eleven (50%) patients had normal DF AROM (91.7%), and 9 (81.8%) patients had normal PF AROM. At a median of 2.3 months (IQR: 2.8), all 22 patients (100.0%) returned to full weightbearing and ambulation. Median follow-up time was 6.9 months (IQR: 16.5). These findings reflect early functional outcomes, with a median follow-up period of less than 1 year. CONCLUSION:The ALT free flap with an attached FL is a functional reconstructive technique for Achilles tendon injury in the setting of large soft tissue defects. The composite free flap provides consistent operative success with robust early patient return to ambulation and weightbearing. Further evaluation into patient-reported outcomes can provide additional understanding of functionality.

BACKGROUND:Obstructive sleep apnea (OSA) is an underdiagnosed and undertreated disease that has been significantly associated with diabetes, cardiovascular disease, peripheral arterial disease, and poor wound healing. OBJECTIVE:To determine whether or not OSA is an independent risk factor for split-thickness skin graft (STSG) failure in patients with chronic lower extremity (LE) wounds, given OSA's disease burden to common comorbidities in the LE wound population. METHODS:A retrospective chart review of chronic LE wounds managed with STSG between December 2014 and December 2022 was conducted. Patients with a diagnosis of OSA ("OSA") were compared with patients without an OSA diagnosis ("Non-OSA"). RESULTS:Overall, 14.9% of patients had OSA (n = 25) and 85.1% (n = 143) did not have OSA. Patients with OSA had a significantly higher median body mass index than the Non-OSA group (32.9 and 28.2, respectively; P = .013) and a higher rate of chronic obstructive pulmonary disease (16.0% and 4.2%, respectively; P = .043). Compared with patients without OSA, patients with OSA had more superficial wounds (P = .027) and received thinner skin grafts (P = .016). Compared with the Non-OSA group, wounds in the OSA group had significantly higher rates of graft failure (OSA 30.6% vs Non-OSA 15.9%; P = .034), infection (OSA 27.8% vs Non-OSA 10.6%; P = .005), and reoperation (OSA 52.8% vs Non-OSA 31.1%; P = .010). On multivariate logistic regression, OSA remained a significant risk factor for graft failure, increasing the odds of graft failure by 8.6 times (P = .040). CONCLUSION:OSA is an independent predictor of graft failure in a highly comorbid population with chronic LE wounds. Preoperative identification of these high-risk patients should be undertaken by anesthesia, sleep medicine, and surgical teams to improve outcomes.

BACKGROUND:Lower extremity (LE) muscle free flaps (MFF) require split-thickness skin grafts (STSG) for coverage. Medically comorbid patients undergoing MFFs have demonstrated surprisingly high rates of skin graft failure over the MFF. This study therefore characterizes the risks for STSG failure and the effect of staging STSG on graft outcomes in medically comorbid patients. METHODS:A retrospective review of patients undergoing STSG for LE MFF coverage between 2011 and 2023 was performed. Demographics, comorbidities, MFF details, STSG details, and complications were collected. The primary outcome was graft failure. RESULTS:Ninety-one patients underwent MFF and STSG, with 65 (71.4%) undergoing immediate STSG and 26 (28.6%) undergoing delayed STSG, at a median of 12 days (IQR = 9) after MFF. The delayed group had a significantly higher Charlson Comorbidity Index (5.6 vs. 3.7, p < 0.001). The overall graft failure rate was 31.5%, with no differences between groups (immediate: 27% vs. delayed: 42.3%, p = 0.157). On multivariable analysis, elevated preoperative HbA1c (OR: 1.5, CI = 1.1-1.9), low levels of albumin preoperatively (OR: 0.3, CI: 0.1-0.9), and a history of Charcot arthropathy (OR: 8.6, CI: 1.3-55.2) were independent predictors of graft failure. CONCLUSION:Little evidence exists to help guide the decision to perform immediate versus delayed skin grafting of MFFs in a highly comorbid population undergoing limb salvage. Delaying skin grafts in patients with significant comorbidities that threaten flap viability and wound healing capacity may improve graft take. Patient comorbidities, nutritional status, and intraoperative factors should also be considered when determining the timing of skin grafts over MFF.

BACKGROUND:Patients with only peroneal artery blood supply to the foot, known as peronea arteria magna (PAM), represent a rare cohort and a unique challenge in the setting of complex lower free (LE) tissue transfer (FTT). The present study aims to leverage a high volume lower extremity reconstruction center to determine the incidence and microsurgical considerations in PAM. METHODS:A retrospective cohort study was conducted at a single tertiary limb salvage center, reviewing all patients who underwent lower LE FTT from July 2011 to January 2024. Patients were included if they had preoperative arteriography and underwent LE FTT for atraumatic wounds. Patient demographics, vascular anatomy, microsurgical technique, and postoperative outcomes were analyzed. RESULTS:Arteriograms for a total of 334 patients who underwent lower extremity FTT were reviewed, of which 34 patients (10.2%) had Kim-Lippert Class III variant patterns, and six patients (1.8%) had Class IIIc (PAM). Of these, all six anastomoses were performed in an end-to-side fashion. There were no instances of postoperative lower extremity devascularization or ischemia. There were no flap losses. One of the six patients required immediate return to the operating room for venous thrombosis with successful flap salvage after clot evacuation and a second venous anastomosis. CONCLUSION:PAM is a rare yet important anatomic variant that is occasionally observed in the lower extremity FTT population. The following features are important in managing patients with PAM undergoing FTT: the routine use of preoperative arteriography, an understanding of venous anatomic variability, the use of a smaller target window for microsurgery given the majority of vessels residing in the deep posterior compartment, the preservation of all peroneal side branches, and the use of ETS anastomosis when possible.

Background:The use of vasopressors during microsurgical reconstruction is debated. Their effect on the comorbid lower extremity (LE) wound population is unstudied. This study characterizes the impact of intraoperative vasopressor use in LE free tissue transfer (FTT) for limb salvage. Methods:A review of LE FTT from February 2017 to June 2024 was conducted. Flap outcomes within 7 and 42 days were evaluated, as well as long-term limb salvage. Results:Of 258 LE FTT performed, vasopressors were used in 177 cases (68.6%). Most vasopressors were administered via intermittent bolus only (75.7%) or combined with continuous infusion (23.7%). American Society of Anesthesiologists Class was significantly higher in the vasopressor group compared with controls (p = 0.001). The vasopressor group trended to have higher median Charlson Comorbidity Indices (4, interquartile range [IQR]: 3 vs. 3, IQR: 3; p = 0.055), and rates of diabetes (65.0% vs. 54.3%, p = 0.103), peripheral vascular disease (63.8% vs. 51.9%, p = 0.068), and chronic kidney disease (14.7% vs. 6.2%, p = 0.063). The rate of reoperation, microvascular thrombosis, or flap success at 7 and 42 days did not differ between groups. By a median long-term follow-up of 24.5 (IQR: 39.2) months, rates of major limb amputation (vasopressor: 10.7% vs. control: 7.4%, p = 0.402) and mortality (6.8% vs. 2.5%, p = 0.237) were similar between groups. Conclusion:In this complex population, intraoperative use of vasopressors does not appear to negatively impact flap viability or limb salvage.

SIGNIFICANCE:The Wound Healing Foundation recognized the need for consensus-based unbiased recommendations for the treatment of wounds. Consensus statements on the treatment of chronic wounds and acute wounds have been developed and published previously. The current publication on diabetic wounds represents the next step in this process. Diabetic wounds constitute a major problem. Population-based and meta-analytic studies indicate that the presence of foot wounds in patients with diabetes increases their mortality risk by more than twofold. The management of diabetic wounds requires consistent and evidence-driven intervention to achieve optimal clinical outcomes. This consensus statement provides the clinician with the necessary foundational approaches to the causes, diagnosis, and therapeutic management of diabetic wounds. Presented in a structured format, this is a useful guide for clinicians and learners in all patient care settings. RECENT ADVANCES:Continuous glucose monitoring and other new tools have facilitated better diabetes management and the management of associated wounds. Diabetic limb salvage should focus on achieving and optimizing function for the patient with diabetes rather than preserving limb tissue at all costs. CRITICAL ISSUES:Successful management of diabetic wounds requires a multidisciplinary approach encompassing comprehensive assessment, timely intervention, and collaborative care by the wound clinician with providers who can address critical aspects to achieve healing, including careful management of blood glucose levels, optimization of off-loading and physical therapy, assessment and treatment of limb ischemia, control and prevention of wound infection, and optimal pain management. FUTURE DIRECTIONS:Emerging treatments offer hope and promise, but the heterogenicity of diabetic wounds poses a challenge to performing good studies, which will be necessary to advance new treatments for diabetic wounds.

BACKGROUND:Split-thickness skin grafts (STSG) over tendon or bone often fail. In such cases, an attempt to create a neo-dermis or restore a dermal-like covering is indicated. This study compared the outcomes of dermal regeneration template (DRT) use in lower extremity (LE) wound closure when combined with STSG procedures. METHODS:Medical records of patients with chronic LE wounds who underwent STSG from 2014 to 2022 were reviewed. Wounds that were treated with DRT prior to STSG ("DRT") were compared those that were not ("non-DRT"). Both groups were acquired concurrently over the 8-year period. All outcomes evaluated were in relation to the STSG procedure. RESULTS:A total of 387 wounds in 261 patients were identified. One hundred seventy-three (43.5%) wounds were treated with DRT and 214 (55.3%) were not. No demographic differences were observed between the 2 groups. Prevalent comorbidities included diabetes (54.4%) and peripheral vascular disease (40.0%). Median wound size (28 cm2, interquartile range: 55) and depth were similar between the groups. The DRT group demonstrated significantly less graft failure than the non-DRT group (5.2% vs. 19.2%, respectively; P < .001) and higher rates of postoperative ambulation within 30 days (48.7% vs. 36.0%, respectively; P = .040) and 60 days (63.6% vs. 42.6%, respectively; P = .006). In a multivariate model, DRT independently reduced STSG failure and infection but not reoperation or amputation. Mortality trended to be lower in the DRT group (12.4% vs. 18.6%, P = .172). CONCLUSIONS:DRT plays a key role as a temporizing measure to significantly enhance STSG take and promote ambulation in patients with chronic wounds but does not decrease the need for future major limb amputation.

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.

BackgroundAmong patients with critical limb ischemia and tissue loss, revascularization is an essential component for limb salvage. Local flaps of the foot and ankle remain a versatile tool in reconstructive limb salvage but is dependent on adequate arterial flow. In patients with arterial occlusive disease requiring revascularization, there is a lack of evidence in the current literature investigating on the necessity of direct arterial flow to the respective angiosome for local flaps reconstruction. Our study thereby compares the outcomes of direct (DR) and indirect (IR) revascularization for local flap success.MethodsPatients who received endovascular revascularization (ER) prior to local flap reconstruction for chronic wounds in the foot and ankle were retrospectively reviewed. IR was performed in patients where DR could not be performed. DR was defined as an intervention on the same pedicle used for the local flap. IR was defined as an intervention performed on a different angiosome than the pedicle used for the local flap. Patient demographics, Charlson Comorbidity Index (CCI), angiographic details, postoperative complications, and long-term outcomes were collected.ResultsA total of 33 patients underwent 43 local flap reconstruction with preoperative ER: 58.1% (n = 25) received DR and 41.2% (n = 18) received IR. Patients had a mean CCI of 6.7 +/- 1.8, with a high prevalence of diabetes mellitus (93.9%), peripheral arterial disease (90.9%), and end-stage renal disease (33.3%) with no significant differences between groups. In the immediate postoperative period (postoperative day 0 to 12), there were no significant differences in immediate flap success (DR: 100% vs IR: 88.9%, P = 0.169) or partial flap necrosis between (DR: 0.0% vs IR: 16.7%, P = 0.066). Rates of major complications from infection (DR: 28.2% vs IR: 22.2%, P = 0.736), ischemia (DR: 4.0% vs IR: 11.1%, P = 0.562), or dehiscence (DR: 8.0% vs IR: 16.7%, P = 0.634) requiring reoperation were similar between 2 groups. Overall limb salvage rate was 84.9%, and comparable between groups (DR: 78.6% vs IR: 89.5%, P = 0.628).ConclusionsDR and IR achieve similar rates of limb salvage and flap success after local flap reconstruction. A multidisciplinary vasculo-plastic approach that incorporates preoperative arteriogram and revascularization should be utilized for this highly comorbid patient population to achieve optimal success and limb salvage.

BACKGROUND:Studies have demonstrated a correlation between Clostridium difficile infection (CDI) and hypercoagulability. This study evaluates CDI in patients undergoing lower extremity (LE) free tissue transfer (FTT) and quantifies its impact on microsurgical outcomes. METHODS:A retrospective cohort study of patients receiving LE FTT from July 2011 to June 2024 was conducted. Patients who tested positive for C. difficile within 15 days of their FTT were identified and compared to those who did not. RESULTS:A total of 356 LE FTT were performed. Six patients (1.7%) contracted CDI. Groups had similar comorbidity and wound profiles. Flap takeback occurred at significantly higher rates in the CDI group (66.7% vs. 6.3%; p<0.001), as did microvascular pedicle thrombosis (33.3% vs. 3.1%; p=0.017). Flap complications were also significantly higher in the CDI group (100.0% vs. 27.7%; p=0.001), specifically partial flap necrosis (50.0% vs. 3.1%; p=0.001) and infection (66.7% vs. 12.6%; p=0.004). By a median follow-up of 15.7 months, major LE amputation rates were similar between CDI and Non-CDI groups (33.3%, n=2 vs. 12.6%, n=44; p>0.05). Multivariate regression models adjusting for statistically and clinically significant covariates demonstrated CDI to be independently associated with flap takeback (OR: 46.4, 95% CI: 7.2-297.4, p<0.001) and microvascular thrombosis (OR: 26.4, CI: 3.5-197.3, p=0.001). CONCLUSION:Our results suggest a possible association between C. Diff infection and increased risk for microvascular thrombotic complications in LE FTT. Microvascular plastic surgeons should be aware of the immediate microvascular risks associated with C. Diff infection. Further research is required to fully understand the clinical management of this population.

Popliteal artery variants (PAVs) are anatomical deviations of the popliteal artery's branching pattern and should be considered in microsurgical planning for patients undergoing lower extremity (LE) free tissue transfer (FTT). However, there is a significant lack of FTT literature in this patient population. Thus, this study presents our 12-year experience with LE FTT in patients with PAV.Patients receiving LE FTT reconstruction from July 2011 to March 2024 were reviewed. Preoperative angiograms were reviewed by a single vascular surgeon, and the presence of PAV was identified and classified as IIIA, IIIB, or IIIC. Primary outcomes were flap success and limb salvage.A total of 339 LE FTT were performed in 331 patients. A total of 32 patients (9.4%) had PAV, accounting for a total of 34 LE FTT. Class IIIA was the most common category (n = 20, 58.8%) followed by IIIB (n = 8, 23.5%) and IIIC (n = 6, 11.7%). Median age and body mass index were 63.5 (interquartile range [IQR]: 22.5) years and 27.4 (IQR: 10.3) kg/m2. The median Charlson Comorbidity Index was 5 (IQR: 2.5), with prevalent rates of diabetes (n = 18/32, 56.3%) and peripheral artery disease (n = 16/32, 50.0%). Median wound area was 71.0 (IQR: 80.0) cm2. Flap success rate was 100% (n = 34/34). At a median follow-up of 12.8 (IQR: 22.6) months, limb salvage was 97.1% (n = 33/34) and mortality was 6.3% (n = 2/32).In this large population of LE FTT, PAV occurs in almost 1 out of 10 patients. Essential to flap success and limb salvage is appropriate preoperative vascular imaging with arteriography, as the presence of PAV changes microsurgical intraoperative planning and technical considerations.

Wound care centres offer opportunities to assess and compare treatment strategies and experiences across different sites through clinical research, with the ultimate goal of optimising patient care. However, recruitment of eligible participants is critical to successful and timely study completion. In this article, the authors describe the implementation of a patient-initiated approach to patient-reported outcome measure research in hard-to-heal (chronic) lower extremity wounds. The approach uses quick-response (QR) codes and automated patient identification. This process enables recruitment of patients without the need for in-person research personnel, results in minimal disruptions to clinic workflow, and captures an important dimension of wound care during under-used time in patient waiting rooms.

Background: Medial arterial calcification (MAC), a distinct form of vascular pathology frequently coexisting with peripheral arterial disease (PAD), poses unique challenges in limb salvage among patients with diabetes, chronic kidney disease, and end-stage renal disease. This study examines the incidence of MAC and its impact on limb salvage outcomes over a decade of experience at a tertiary limb salvage center. Methods: A retrospective review of all complex lower extremity (LE) reconstructions using local flap (LF) or free tissue transfer (FTT), performed from July 2011 to September 2022, was conducted. Patients were classified into MAC and No MAC groups based on pedal radiography evaluations using the Ferraresi MAC scoring system. The primary outcomes were major lower extremity amputation (MLEA), the need for postoperative vascular intervention, major adverse limb events (MALE; defined as the composite of any unplanned reoperation, MLEA, or postoperative revascularization attempt), and mortality. Results: During the study period, a total of 430 LE reconstructions were performed with LF or FTT. A total of 323 cases (75.1%) demonstrated no MAC while the remaining 107 (24.9%) demonstrated MAC. The MAC group exhibited significantly higher rates of diabetes, PAD, and renal disease. With a follow-up duration of 17.0 (IQR: 33.9) months, the MAC group demonstrated a significantly higher rate of MLEA (24.3% vs. 13.0%, p = 0.006), postoperative vascular intervention (23.4% vs. 8.7%, p < 0.001), MALE (57.0% vs. 25.7%, p < 0.001), and mortality (28.0% vs. 9.9%, p < 0.001). Multivariate analysis identified MAC as independently predictive of MALE (OR: 1.8, CI: 1.1-3.0, p = 0.033). Conclusion: MAC is prevalent among surgical candidates for limb salvage. Patients with MAC represent a significant medical and reconstructive challenge. Radiographic screening for MAC should be considered in all limb salvage candidates with LE wounds, especially in those with diabetes and kidney disease. Assessing MAC is important for better evaluating risk factors and surgical options so as to optimize outcomes in this challenging population.

BACKGROUND:Diabetic foot ulcer (DFU) care is a challenge in reconstructive surgery. Artificial intelligence (AI) tools represent a new resource for patients with DFUs to seek information. OBJECTIVE:To evaluate the efficacy of ChatGPT-3.5 in responding to frequently asked questions related to DFU care. METHODS:Researchers posed 11 DFU care questions to ChatGPT-3.5 in December 2023. Questions were divided into topic categories of wound care, concerning symptoms, and surgical management. Four plastic surgeons in the authors' wound care department evaluated responses on a 10-point Likert-type scale for accuracy, comprehensiveness, and danger, in addition to providing qualitative feedback. Readability was assessed using 10 readability indexes. RESULTS:ChatGPT-3.5 answered questions with a mean accuracy of 8.7±0.3, comprehensiveness of 8.0±0.7, and danger of 2.2±0.6. ChatGPT-3.5 answered at the mean grade level of 11.9±1.8. Physician reviewers complimented the simplicity of the responses (n=11/11) and the AI's ability to provide general information (n=4/11). Three responses presented incorrect information, and the majority of responses (n=10/11) left out key information, such as deep vein thrombosis symptoms and comorbid conditions impacting limb salvage. CONCLUSIONS:The researchers observed that ChatGPT-3.5 provided misinformation, omitted crucial details, and responded at nearly 4 grade levels higher than the American average. However, ChatGPT-3.5 was sufficient in its ability to provide general information, which may enable patients with DFUs to make more informed decisions and better engage in their care. Physicians must proactively address the potential benefits and limitations of AI.

PURPOSE:Understanding gait as a measure of functionality in patients with nontraumatic lower extremity (LE) amputations across different racial groups is important for limb salvage outcomes. This study assesses gait parameters among Black and White individuals with LE amputations. METHODS:Adults without open wounds who could safely ambulate without pain were offered inclusion in this study from June 2021 to August 2024. Participants completed a standardized 120-second walk test with wearable sensors. RESULTS:Overall, 74 patients provided racial backgrounds and completed a gait test. Amputation type was comparable between Black and White patients. Black patients were significantly younger than White patients (58.8 ± 8.5 vs 65.3 ± 12.6 years, P = 0.009). Average body mass index (31.3 ± 7.2 kg/m2) and Charlson Comorbidity Index (5.4 ± 2.5) were similar between groups (P = 0.591 and P = 0.349, respectively). Rates of diabetes mellitus type II (n = 51, 68.9%) and end-stage renal disease (n = 7, 9.5%) were also similar. Gait speed (0.8 ± 0.2 m/s, P = 0.134), cadence (97.2 ± 11.2 steps/min, P = 0.089), and double limb support (29.3 ± 5.3%, P = 0.079) were comparable. Black patients had significantly lower elevation at midswing (1.4 ± 0.9 vs 2.0 ± 1.8 cm, P = 0.045), longer step duration (0.7 ± 0.1 vs 0.6 ± 0.1 s, P = 0.042), and lower single limb support (34.7 ± 3.1% vs 36.6 ± 2.2%, P = 0.005). On multivariate analysis controlling for comorbidities and socioeconomic factors, race was an independent and significant predictor of lower elevation at midswing (β = -0.039, P = 0.041). CONCLUSIONS:Our results suggests that Black patients demonstrate a more pathologic gait following LE amputation, which is likely reflective of underlying disparities in access to care, delayed diagnoses, or differences in disease severity. While the influence of race on health outcomes is well-known, this study provides the first objective evidence of a more pathologic gait among Black patients following atraumatic LE amputation. Thus, timely intervention with physical therapy and extended follow-up become even more important in this population.

BACKGROUND:Medial arterial calcification (MAC) is emerging as a tool to predict adverse limb events, but its effects on microsurgery are unknown. This study evaluates the effects of MAC on microsurgical limb salvage outcomes. METHODS:Patients receiving lower extremity free tissue transfer from 2011 through 2024 were reviewed. Radiographs were used to classify cases as no, moderate, or severe MAC. End points included major amputation, unscheduled surgical reintervention, postoperative revascularization, major adverse limb events, defined as the composite of major amputation or surgical reintervention, and survival. RESULTS:Among 320 cases, 12 (3.8%) had moderate and 32 (10.0%) had severe MAC. The median follow-up was 22.2 months. On univariate analysis, patients with moderate or severe MAC demonstrated significantly higher rates of the following: flap complications (25.7% [no MAC], 33.3% [moderate MAC], and 56.3% [severe MAC] [ P = 0.033]), major adverse limb events (42.0%, 75.0%, and 84.4% [ P < 0.001]), surgical reintervention (41.3%, 66.7%, and 81.3% [ P < 0.001]), postoperative vascular intervention (6.9%, 8.3%, and 31.3% [ P < 0.001]), major amputation (12.0%, 25.0%, and 31.3% [ P = 0.009]), and 5-year mortality (5.4%, 8.3%, and 18.8% [ P < 0.001]). On multivariable analysis, severe MAC independently increased the odds of major adverse limb events ( P = 0.009) and unscheduled reintervention ( P = 0.015). CONCLUSIONS:Microsurgical free tissue transfer can achieve limb salvage in patients with severe MAC but is associated with significant morbidity, and more than 80% of cases will require additional surgical management. Microsurgeons should be aware of the association of MAC with adverse events.

BACKGROUND:The use of free tissue transfer (FTT) is effective for treatment of chronic nonhealing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plans to optimize limb salvage. The authors describe their vasculopathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTTs and the most recent 100 procedures performed. METHODS:A single-institution, retrospective review of 300 LE FTTs from July of 2011 to January of 2023 was performed. Patients were compared between the first 200 (group 1; July of 2011 through February of 2020) and last 100 flaps (group 2; February of 2020 through January of 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected. RESULTS:Group 2 patients had significantly higher rates of diabetes (67.0% versus 48.5%; P = 0.002), peripheral vascular disease (56.0% versus 24.5%; P < 0.001), history of venous thromboembolism (13.0% versus 6.0%; P = 0.039), venous reflux (81.9% versus 67.8%; P = 0.028), and preoperative venous thromboses on venous testing (25.5% versus 10.5%; P = 0.003) compared with group 1. Group 2 patients underwent more pre-FTT endovascular interventions (23.0% versus 16.5%; P = 0.039) and vascular bypasses (4.0% versus 0.0%; P = 0.012). Immediate flap success and amputation rates were similar between the groups, but group 2 had higher rates of partial flap necrosis (7% versus 3%; P = 0.012). CONCLUSION:The adoption of a vasculoplastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.