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Iterative “Vasculo-plastic” Protocol Refinement Enables Limb Salvage In A Growing Vasculopathic Population: Practice Patterns From 400 Free Flaps In 14 Years And Future Directions
Rachel N. Rohrich, BS, Hannah Soltani, BS, Karen R. Li, MD, Lelia Jones, BS, Meghan Currin, BS, Christopher E. Attinger, MD, Cameron M. Akbari, MD, MBA, Richard C. Youn, MD, Karen K. Evans, MD.
Medstar Georgetown University Hospital, Washington, DC, USA.
BACKGROUND: Advancements in microsurgery have allowed for limb salvage in increasingly comorbid patients. Over 14 years, our institution has performed 400 lower extremity (LE) free tissue transfers (FTT), implementing iterative refinements. This study quantifies the longitudinal impact of protocol evolution on patient selection, technique, and outcomes.
METHODS: LE FTT from 2011-2025 was stratified into four sequential 100-case eras: (1) initial practice (2011-2017), (2) early established (2017-2020), (3) late established (2020-2023), and (4) current practice (2023-2025).
RESULTS: Annual case volume increased from 4.3 to 33.3 yearly cases (p=0.003). Patient complexity increased: diabetes prevalence rose from 41.0% to 56.0% (p=0.003), peripheral vascular disease from 39.0% to 58.0% (p=0.001), and medial arterial calcification from 3.0% to 16.0% (p=0.015). Use of saphenous vein interposition grafts increased from 1.0% to 16.0% (p=0.001). Median operative duration decreased from 491 to 404 minutes (p<0.001). Immediate flap success improved (93.0% to 99.0%, p=0.050), with a 29.6-fold higher adjusted odds of success in the current practice era (p=0.030). Minor flap complications increased: partial flap necrosis from 1.0% to 15.0% (p<0.001) and dehiscence from 15.0% to 30.0% (p=0.007). Median time to independent ambulation decreased from 304 to 57 days (p<0.001). Limb salvage rates remained ≥88.0% across eras (p=0.069) at a median follow-up of 16.9 (IQR: 26.4) months.
CONCLUSIONS: In the most recent era marked by the highest burden of comorbidities and vasculopathy, flap-related complications became more common, yet flap success and limb salvage were not compromised. As we continue expanding indications to patients once considered inoperable we must continue iterative change and evolution.
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