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The "Double Hit": Free Tissue Transfer Is Often Necessary In Comorbid Population With Irradiated Wounds For Successful Limb Salvage
Romina Deldar, MD1, Cara K. Black, BA2, Elizabeth G. Zolper, BS1, Peter Wirth, BS2, Kyle Luvisa, MPH2, Kenneth L. Fan, MD1, Karen K. Evans, MD1.
1MedStar Georgetown University Hospital, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA.

Purpose: Radiation therapy is an integral adjunct to cancer treatment today. While effectively causing tumor death, it also imparts histopathologic changes on tissue, including fibrosis, loss of tissue planes, and vascular damage. These sequelae can lead to chronic wound formation. When patients with comorbidities, such as diabetes and peripheral vascular disease (PVD), undergo radiation, they suffer a "double hit" to the microvasculature, which leads to significant delays in wound healing. Local wound care and skin grafts are commonly insufficient; wide excision of the wound and free tissue transfer (FTT) is necessary. There is a paucity of data on the surgical management of chronic irradiated lower extremity (LE) wounds in patients with multiple comorbidities. In this study, we evaluated limb salvage outcomes and long-term complications after FTT in patients with chronic, irradiated leg wounds.
Methods: We retrospectively reviewed patients with irradiated LE wounds who underwent FTT from 2012 to 2017 at a single academic medical center. Patient demographics included age, sex, body mass index (BMI), comorbidities, and tobacco use. Primary outcomes included flap survival, limb salvage, ambulatory status, and complications such as infection, hematoma, seroma, dehiscence, reoperation, and flap necrosis. Reconstruction involved complete excision of irradiated tissue and coverage with well-vascularized tissue.
Results: Six patients were found to have lower extremity wounds resulting from radiation treatment for malignancy. One patient underwent two separate free flaps over one year apart for a large leg wound, for a total of seven flaps. That patient required an additional flap due to incomplete excision in the index case, leading to prolonged wound healing at the flap / radiated skin junction. Average age was 68.4 years and BMI was 27.8 kg/m2. Comorbid conditions included hypertension (57.1%), PVD (57.1%), underlying hypercoagulability disorder (42.9%), diabetes (14.3%), and tobacco use (14.3%). Patients had the wounds for an average of 25.5 months prior to FTT. Wounds were located in the lower leg, including the anterior calf (28.6%), medial calf (28.6%), lateral calf (14.3%), and ankle (28.6%). Donor sites included anterolateral thigh (71.4%), vastus lateralis (14.3%), and latissimus dorsi (14.3%). Overall flap success rate was 100% with one patient requiring reoperation for dehiscence. Limb salvage rate was 85.7% with one patient undergoing elective amputation due to pain. All patients were able to ambulate (one used a prosthesis) at a mean follow-up time of 1.4 years. There were no cases of post-operative clotting or flap necrosis requiring reoperation.
Conclusions: Radiation therapy in a comorbid population leads to formation of chronic non-healing wounds. Radical excision of non-healing tissue and FTT is necessary. We advocate for earlier consideration of FTT to provide healthy vascularized tissue, thereby avoiding prolonged wound care and patient burden. Successful limb salvage outcomes can be achieved.


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