Microsurgical reconstruction for post—traumatic defects of lower leg in the elderly: A comparative study

ABSTRACTS

Background

Lower leg microsurgical reconstruction in the elderly is challenging, especially for post − traumatic defects. The present study aimed to evaluate the risk factors, management and outcome of free tissue transfer in patients older than 65 years of post-traumatic defects.

Methods

Retrospective chart review was performed for all patients older than 18 years undergoing free tissue transfer for post–traumatic lower leg reconstruction from April 2000 to November 2014. A comparative study was designed to identify risk factors and outcome.

Results

In total, 197 patients (ages 18–64) and 44 patients (ages ≥65, average 71.7 ± 6.3) were included and allocated into cohort 1 and 2, respectively. Cohort 2 had a higher rate of diabetes mellitus and/or peripheral artery disease (46.6%, P < 0.01). There was no significant difference in major flap complications, donor site complications and amputation rates (P > 0.05). A higher rate of intensive care unit (ICU) admission was observed in cohort 2 (37.8%, P < 0.01). Comparable limb salvage rates were recorded (97.1% and 95.6%, P = 0.59) with an average follow-up of 25.9 ± 30.1 months in cohort 1 and 23.7 ± 16.6 months in cohort 2.

Conclusion

Post-traumatic microsurgical free tissue transfer to the lower leg can be performed safely in patients older than 65 years with high success rate and manageable complications.

Introduction

Populations in most of the developed countries are continually becoming older. Logically, plastic surgeons will be faced more and more with defects requiring microsurgery in elderly patients, especially in the lower extremity.

Microsurgical reconstruction has been established as the gold standard for the treatment of complex soft tissue defects in the lower extremity [1]. However, its clinical employment in elderly patients is still a measure of risk stratification [2], [3]. There is also an ongoing controversy, whether limb salvage after complex microsurgical reconstruction is resource – efficient and justifiable with regard to an increase or maintenance of quality of life [4]. Many factors must be considered in the planning of reconstruction, e.g. multiple general and microsurgery – related comorbidities, such as diabetes mellitus (DM) [5], [6], age – related pathologies of peripheral nerves and arteries (PND/PAD) [7], [8], and patient’s ability to tolerate such extensive reconstructions [9].

There are only a few clinical studies on free tissue reconstruction in the elderly [3], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]. They demonstrated that advanced age is not a risk factor for free tissue transfer in the breast and head and neck regions. However, microsurgical reconstruction of post – traumatic lower extremity defects in the elderly seems to be more challenging with high rates of total flap loss [3]. There is still a lack of sufficient clinical data regarding lower extremity microsurgical reconstruction and the ongoing debate on limb salvage by free tissue transfer versus amputation and concomitant prosthetic fitting. In the present study, the aim was to evaluate the surgical outcome in post – traumatic complex lower extremity reconstruction in the elderly, while the lower leg was chosen as target region to achieve a high degree of statistical comparability.