Optimization of Free-Flap Limb Salvage and Maximizing Function and Quality of Life Following Oncologic Resection: 12-Year Experience

A knowledge gap exists regarding factors to optimize limb salvage and function following oncologic resection.

We conducted a retrospective review of all free flaps performed for upper extremity (UE) and lower extremity (LE) salvage from 2000 to 2012.

Overall, 220 patients underwent free-flap reconstruction for limb salvage (UE: 64, and LE: 156). Flaps were classified as muscle-only (n = 77), myocutaneous (MC; n = 67), or fasciocutaneous (FC; n = 76). Smoking, diabetes, peripheral vascular disease, and prior chemotherapy or radiation had no impact on complications, while osteomyelitis significantly increased the risk of infection (odds ratio [OR] 19.5, confidence interval [95 % CI] 3.77–100.64; p = 0.0004), wound healing complications (OR 7.51, 95 % CI 2.21–25.49; p = 0.001), and amputation (OR 4.63, 95 % CI 1.41–15.19; p = 0.01). Hardware increased the risk for flap loss (OR 4.92, 95 % CI 1.33–18.23; p = 0.017). MC and FC flaps had increased risks for hematoma (p = 0.02) and reoperation for microvascular complications (p = 0.005) but were at lower risk for infection (OR 0.14, 95 % CI 0.02–0.87; p = 0.03) compared with muscle-only flaps. There were a total of seven total flap losses (3.2 %), with significantly increased risks for MC/FC flaps (OR 2.58, 95 % CI 1.06–6.26; p = 0.03). For LE, 103 patients (66.3 %) were fully ambulatory, while 23 (14.7 %) were ambulatory with assistance (mean Musculoskeletal Tumor Society score (MSTS) 80.2, and Karnofsky score 84.0). For UE, 49 patients (76.6 %) were able to perform their activities of daily living independently (mean MSTS 80.2, and Karnofsky score 86.0). Overall, 190 patients (86.4 %) were successfully salvaged.

Free flaps can be performed reliably for limb salvage following tumor extirpation. While MC/FC flaps demonstrated improved postoperative function, they were at significantly higher risk for take-backs and total flap loss.