How To Prevent Plastic Surgery Failures In Lower Extremity Reconstruction

Author(s): 
Samir S. Rao, MD, and Christopher E. Attinger, MD

Whether it is diabetes, biofilms, biomechanical abnormalities or inadequate wound debridement, there are a number of factors that can lead to plastic surgery complications in lower extremity reconstruction. Accordingly, these authors emphasize a proactive
approach to managing patient comorbidities, reducing technical errors in surgery and
facilitating solid post-op protocols.

With advances in orthopedic, podiatric and plastic surgical technology and techniques over the past 30 years, we now have the ability to save limbs that previously would have been destined for amputation. However, our ability to save these limbs comes at the cost of more complex surgeries and more complications.

   Today’s patients are at higher risk for complications due to the rising incidence of morbid obesity and diabetes as well as the greater resistance of bacteria to antibiotics both in their planktonic form and within biofilm. Complication rates in lower extremity salvage and reconstruction surgery for acute wounds range from 18 to 50 percent depending on the timing of reconstruction.1

   Patient factors that contribute to complications include medical comorbidities (diabetes mellitus, renal failure, connective tissue disorders, coagulopathies, morbid obesity, malnutrition, etc.) and biomechanical abnormalities. The surgeon has little control over these factors, especially when facing an acute situation such as trauma or an infected wound. Our primary role in the management of these conditions is to facilitate subspecialist involvement to ensure these conditions are optimized prior to beginning the reconstructive process.

   Surgeon factors that contribute to complications include inadequate debridement, poor surgical decision making or planning, technical errors during surgery, and inadequate offloading or immobilization postoperatively. As surgeons, we have complete control over these factors and our goal should be to eliminate errors in these areas.

How Medical Comorbidities Can Spur Complications

Diabetes mellitus. The impact of diabetes on wound healing and lower extremity reconstruction is the subject of countless books, articles and even conferences. Regarding the lower extremity, it is the resultant neuropathy, vascular disease and advanced glycosylation of collagen in tendons and joints that are responsible for the great part of our challenges. The end-organ effects on the heart, kidneys and brain create systemic disease that make operating on the diabetic patient population even more challenging.

   In our practice, the management of diabetes is generally limited to tracking our patients’ blood sugars and hemoglobin A1C levels. When these levels are outside the normal range, we refer patients to a diabetes specialist if they are not already under the care of one. When our patients are hospitalized, we use a combination of their home diabetic medication regimens with sliding scale insulin and, when necessary, insulin drips. We have a low threshold for involving internists or endocrinologists in the management of diabetes in patients in whom we are unsuccessful controlling the disease ourselves.

   Renal failure. Renal disease causes many metabolic disturbances that have a negative impact on wound healing and increase the complication risk in reconstructive procedures. The uremia that results from renal failure decreases cell-mediated immunity and granulation tissue formation in open wounds. Renal disease also impacts the clotting process and can lead to problems with excessive bleeding and hematoma formation.2

   When operating on patients with renal failure, it is critical to ensure that a nephrologist is adequately managing their condition and that they are on a regular dialysis schedule. Any acute worsening of their renal status is grounds for delaying elective procedures until their condition has stabilized. Postoperatively, when it comes to patients with chronic renal insufficiency, we leave sutures in place for an additional two weeks in order to compensate for the delayed wound healing.

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