Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps

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This study from MedStar Georgetown University Hospital presents the institutional protocol and outcomes of 200 lower extremity free tissue transfers (FTTs) performed for limb salvage in patients with nonhealing wounds and significant comorbidities, including diabetes mellitus and peripheral vascular disease. The incidence of chronic lower extremity wounds, especially diabetic foot ulcers, is rising and often leads to amputation, which is associated with decreased mobility and high mortality. Free tissue transfer provides well-vascularized soft tissue coverage, improving limb salvage rates and 5-year survival. <br /><br />Historically, patients with comorbidities were poor candidates for FTT due to technical challenges and poor wound healing. This study shows that through a standardized, evidence-based multidisciplinary protocol—including thorough preoperative hypercoagulability screening, angiography with possible endovascular interventions, venous ultrasound, and intraoperative use of an implantable Doppler device—high flap success rates (>95%) and improved outcomes can be achieved even in high-risk populations.<br /><br />The analysis compared the first 100 FTT cases to the second 100, noting significant improvements in operative time (decreased from 500 to 374 minutes), flap success rates (from 91% to 98%), and reduced amputation rates. Despite the second cohort having higher comorbidity scores, worse vessel runoff, and more vascular disease, outcomes improved, indicating institutional learning and protocol refinement. High rates of hypercoagulable conditions were found (39% with three or more traits), underpinning the importance of preoperative screening and tailored anticoagulation.<br /><br />Preoperative angiography allowed for targeted endovascular interventions that improved distal perfusion. Venous duplex ultrasound identified venous reflux and deep vein thrombosis, guiding intraoperative and postoperative management. The use of implantable Doppler probes enhanced real-time flap monitoring and allowed early detection of vascular compromise.<br /><br />This comprehensive approach emphasizes the importance of evolving institutional expertise and multidisciplinary care in expanding limb salvage eligibility for severely comorbid patients. The study highlights that, although resource-intensive, such protocols enhance disease management, flap survival, and patient quality of life, while potentially reducing long-term costs associated with amputation and complications. Limitations include shorter follow-up for the recent cohort and lack of functional outcome data. Nevertheless, the MedStar Georgetown protocol demonstrates that successful free tissue transfer for limb salvage is feasible and effective in complex comorbid populations.

Keywords

lower extremity free tissue transfer

limb salvage

nonhealing wounds

diabetes mellitus

peripheral vascular disease

chronic wounds

diabetic foot ulcers

hypercoagulability screening

implantable Doppler monitoring

endovascular interventions