title: The fate of lower extremities with failed free flaps: a single institution's experience over 25 years.
abstract: BACKGROUND
  Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure.
  
  
  METHODS
  A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis.
  
  
  RESULTS
  Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980-1992) to 3.7% (1993-2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting.
  
  
  CONCLUSIONS
  This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization.
authors.affiliation: Division of Plastic, Reconstructive and Hand Surgery, Staten Island University Hospital, Staten Island, NY 10305, USA. aculliford@yahoo.com
authors.forename: Alfred T
authors.initials: AT
authors.lastname: Culliford
authors.forename: Jason
authors.initials: J
authors.lastname: Spector
authors.forename: Alan
authors.initials: A
authors.lastname: Blank
authors.forename: Nolan S
authors.initials: NS
authors.lastname: Karp
authors.forename: Armen
authors.initials: A
authors.lastname: Kasabian
authors.forename: Jamie P
authors.initials: JP
authors.lastname: Levine
mesh_terms: D000671:Amputation, Surgical / Q000706:statistics & numerical data; D005264:Femoral Fractures / Q000453:epidemiology / Q000601:surgery; D006801:Humans; D035002:Lower Extremity / Q000601:surgery*; D008866:Microsurgery / Q000379:methods; D010019:Osteomyelitis / Q000453:epidemiology / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012189:Retrospective Studies; D013524:Surgical Flaps; D013978:Tibial Fractures / Q000453:epidemiology / Q000601:surgery; D017211:Treatment Failure