Key points

Video content accompanies this article at http://www.plasticsurgery.theclinics.com/ .

Introduction

Individuals of advanced age are the fastest growing subpopulation in many countries, such as Europe and the United States, with an increasing incidence of complex lower extremity wounds of orthopedic, oncologic, vascular, and medical origin. According to epidemiologic data, the number of people aged over 65 years is projected to increase by 135% between 2000 and 2050, and the population aged over 85 years, which is the group most likely to need health and long-term care services, is estimated to increase by 350% within that period. Centenarians may increase from 200,000 in 2020 to 500,000 to 4 million in 2050.

Historically, elderly patients were discouraged from microsurgical reconstructions because of the higher incidence of medical comorbidities and lack of organ system reserve to withstand the lengthy and physically demanding intervention. Today, microsurgical operations have become very reliable because of advances in anesthesia and operative techniques with significantly reduced perioperative morbidity and mortality. ^, Microsurgery is no longer considered to be the last resort when everything else has failed, but rather selected routinely to provide one-stage reconstructions (reconstructive elevator), for example, in orthoplastic surgery. ^{, ,} Salvage of leg function and thus preserving mobility are of essential importance for patients of advanced age who live longer, more active lives and for whom mobility is conditio sine qua non for self-subsistent autonomy. A shift of age limits can even be observed toward the “very old” (>80 years) and occasionally until the age of 100 years (centenarians).

The purpose of this article is to discuss strategies for microsurgical reconstruction of the lower extremity in the elderly population to further reduce perioperative and postoperative risks and complications providing in good functional results.

Indications

Microsurgical flaps are the procedure of choice for large soft tissue and composite tissue defects throughout the lower extremity, especially in elderly patients who often present with risk factors, such as diabetes, vascular compromise, and osteoporosis. The following indications are given:

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  High-energy lower-leg injuries

  
  
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  Open fractures of the lower extremity: grade III tibial fractures with substantial tissue loss and associated high rates of infection, nonunion, prolonged hospital stay, and sometimes amputation; in these cases, regional musculocutaneous flaps may cause functional and aesthetic deficits and may not achieve sufficient coverage

  
  
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  Chronic osteomyelitis (eg, owing to trauma or diabetes, with multiple resistant organisms, bone defects, and extensive scarring and fibrosis from previous treatment attempts, which frequently contraindicate the application of local flaps)

  
  
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  Fracture-related infection and periprosthetic joint infection

  
  
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  Foot and ankle defects (with exposed bones and tendons or loss of weight-bearing plantar surface, which may preclude local flaps, cause prolonged immobilization and hospitalization, eg, because of multiple surgeries)

  
  
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  Chronic wounds owing to vascular disease, radiation, diabetes, inflammatory disease, or infection

  
  
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  Postoncologic resections (eg, owing to soft tissue sarcoma) usually creating complex soft tissue defects

Contraindications

Microsurgical procedures may not be feasible in cases of/if

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  General inoperability (poor general health, bedridden, low life expectancy, high risk for severe morbidity/mortality)

  
  
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  Bony stabilization impossible

  
  
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  No adequate donor vessels available/reconstructable (revascularization impossible)

  
  
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  Multiresistant bacteria/no antibiotic treatment available

  
  
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  Lack of compliance (eg, drug abuse, psychiatric/mental illnesses)

Preoperative evaluation and special considerations

Surgical procedure

To minimize medical complications, any factor reducing the intraoperative strain for the elderly patient and speeding up the procedure should be identified and optimized:

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  One-stage procedure if possible

  
  
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  Debridements and biopsies in regional anesthesia

  
  
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  Vascular procedures to improve inflow (preferred as separate operation)

  
  
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  Short operative time (ideally <3 hours), for example, by careful preoperative planning (eg, by 3-dimensional imaging or CT angiography), limited incisions in a “longitudinal fashion,” intraoperative utilization of vascular coupler devices, meticulous coagulation

  
  
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  Scrupulous attention to detail yields great benefit, as elderly individuals tolerate complications poorly

  
  
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  Regional (spinal) anesthesia and sitting position (beach chair)

The surgical and anesthetic teams should be experienced in dealing with elderly patients and opt for safe and speedy reconstructions:

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  Two-team approach (simultaneous flap elevation, preparation of recipient site, donor-site closure)

  
  
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  Experienced surgical, anesthetic, and nursing staff, no teaching procedure

  
  
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  Workhorse flaps with long, reliable, and constant pedicles from the lower extremity (gracilis or anterolateral thigh [ALT] flaps) or other donor sites (groin, latissimus dorsi, parascapular, extended lateral arm flaps)

  
  
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  Primary closure of donor site

  
  
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  Avoid repositioning

  
  
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  End-to-side or flow-through anastomosis, venous bypass, or grafting if necessary

  
  
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  8-0 or 7-0 sutures with stronger needles in case of arteriosclerotic plaques

  
  
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  Punch hole for removal of plaques or use of vein grafts

  
  
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  No clamps on vessel; instead, use of tourniquet or intraluminal occlusion devices as frequently used in cardiac surgery

Special indications include composite defects and reconstruction of osteocutaneous, tendocutaneous, and extensor apparatus defects, exposed prosthesis, and foot reconstruction.

Postoperative care and expected outcome

A scheduled intensive care unit (ICU) stay is frequently necessary to assure postoperative safety and provide timely intervention in cases of postoperative complications. A trend toward increased nondirect surgery-related complications in elderly patients has been observed. Cardiac (heart infarction), pulmonary (pneumonia, embolus), and renal complications are of particular importance and require postoperative control:

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  Intensive care or immediate care unit 12 to 48 hours

  
  
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  Flap monitoring for early detection of perfusion problems

  
  
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  Restrictive fluid management

  
  
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  Maintaining body temperature

  
  
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  blood pressure management (vasoactive agents)

  
  
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  Nursing and physiotherapy

  
  
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  Nutrition

  
  
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  Early mobilization and flap dangling

  
  
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  Pain control

  
  
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  Delirium prophylaxis

  
  
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  Social service

  
  
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  Rehabilitation

Management of complications

Complication rates, mortality, and morbidity can be reduced by respecting the concepts mentioned above. Early detection is important to avoid fast deterioration of the older patient with smaller organ system reserve and complication tolerance. General complications of organ functions and mental status should be addressed in a multidisciplinary approach. Local complications at the donor and recipient site should be treated after thorough causative analysis and with short delay. In case of rare flap loss, a back-up strategy, including nonmicrosurgical concepts, should be considered to avoid repetitive major surgery, and putting the patient in jeopardy.

Case demonstrations (up to 4 cases)

Discussion

Microsurgery has revolutionized lower extremity reconstruction as in concepts of orthoplastic surgery and is increasingly required in elderly patients, a subpopulation that is continuously growing in Europe and the United States. In these patients, however, treatment decisions need careful consideration, as postoperative complications seem to become more relevant after the age of 70 years. Alternative treatment options, for example, amputation, lead to high mortalities and reduced quality of life in this patient cohort. The influence of advanced age has been discussed regarding patient survival, complication rate, and functional outcomes in the literature. An overall number of 5951 cases of free tissue transfer were controlled for comorbidities by Jubbal and colleagues, and age itself was not found to be significantly associated with complications. However, advanced chronologic age was significantly associated with increased mortality. Ustun and colleagues performed a systematic review and meta-analysis of free flaps in patients of advanced age and could not detect any difference in elderly versus young flap success rates or surgical complications; however, they did find significantly more medical complications and mortality in elderly patients. Therefore, the investigators recommend assessment of “physiologic” age instead of chronologic age in patients for free tissue reconstruction. Serletti and colleagues examined 100 patients aged older than 65 years retrospectively and found that chronologic age did not predict flap complications, but higher American Association of Anesthesiology (ASA) scores and length of operative time were significant predictors of postoperative surgical morbidity. This finding emphasizes that compared with the chronologic age, biological age is considered more relevant today, taking into account evaluation measures, such as the ASA classification. In addition to biological age, the term “frailty” describes the consequences of age-associated functional losses that lead to increased vulnerability of the entire organism regarding external and internal stressors and even permanent disability. The “frailty index” according to Rockwood and colleagues summarizes all existing deficits.

In order to reduce postoperative complications in this important patient group, preoperative multidisciplinary planning and intraoperative management are key. Interestingly, this may be especially important in the very old patient groups, as the high incidence of medical comorbidities increases beyond the age of 80 years. A large retrospective cohort study examined 211 patients 70 years or older at a single institution undergoing free tissue flap surgery and revealed significantly higher rates of medical complications in the octogenarian group when compared with septuagenarians.

Careful patient selection based on medical comorbidities and overall functional status should be taken in a multidisciplinary setting (expert board) and consulted by an expert from internal medicine (infectious disease specialist and geriatric), septic orthopedic surgeon, plastic surgeon, vascular surgeon, and interventional radiologist to individually assess opportunities to improve vascular supply of the leg. In planning complex reconstruction, especially after trauma, magnetic resonance angiography, CT angiography, or conventional angiography should be routinely performed. ^, As an alternative in cases with no further risk factors and local reconstruction, duplex ultrasound is safe and highly diagnostic to identify appropriate arterial perfusion of the recipient vessel. In the lower extremity, this may include catheter intervention, stent, bypass surgery, or venous reconstruction or AV-loop intervention.

During the microsurgical operation, not only the surgeons but also the anesthetic and nursing teams should be experienced in dealing with elderly patients, as they are more prone to have complications related to the anesthesia and the long duration of the procedure, for example, hypothermia, hyperhydration with imbalanced diuresis, or hypotonic or hypertonic episodes, which require intervention. Intraoperatively, every factor to reduce the strain for the patient and to speed up the operation should be identified and optimized, for example, by using a 2-team approach and allowing simultaneous operating at the donor and recipient sites, keeping the intervention short, successful, and safe. Vascular aging in the lower extremity demonstrates increased structural changes in the arterial system with reduction of arterial elasticity; above all, in posttraumatic damage, diabetes mellitus or peripheral neurovascular pathologic condition increases the difficulty of microsurgical reconstruction of soft tissue and limits the generalization of previous results that have been obtained from breast or head and neck reconstruction. As an example, in a study of 44 microsurgical salvages for posttraumatic leg defects of the lower leg by Xiong and colleagues , the preoperative clinical situations of the elderly cohort were characterized by high rates of peripheral neurovascular pathologic condition (diabetes mellitus, peripheral artery disease) and complex wound conditions. A relatively large proportion (36%) of this cohort had only 1 or 2 lower-leg arteries patent, which further increased the difficulty and risk of free flap transfer. Besides, most defects were located in the distal lower leg and accompanied by exposure of bone or hardware. Such problematic wound situations in geriatric patients require an individually adapted surgical procedure. Safe and speedy reconstructions by workhorse flap techniques with easy vascular access, reliable anatomy and long pedicles and vascular coupler devices should be used.

The authors share the opinion that elderly patients should at least be admitted to an intermediate care unit or to an ICU for closer postoperative monitoring and nursing postoperatively and to enable timely intervention during a minimum of 12 to 24 hours, which is performed in many microsurgical centers even for healthy patients (“flap ICU”). Further postoperative care of these patients, including mobilization, ambulation, and physiotherapy, should be initiated as early as possible.

Summary

Microsurgical reconstruction in the lower extremity can be performed safely with high success rate and manageable complications in elderly patients. The prerequisites include (i) a comprehensive preoperative interdisciplinary assessment of the patient and optimization of risk factors, (ii) meticulous preoperative planning, (iii) intraoperative adaptation of anesthesia and efficient surgical technique, and (iv) specialized postoperative monitoring and early mobilization according to the specific needs of the patient of advanced age (see Table 1 ).

Clinics care points

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  A multidisciplinary team approach makes microsurgery a safe and succesful procedure.

  
  
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  Age-related pathologies (atherosclerosis above all) demand thorough preoperative planning.

  
  
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  Intraoperative stress can be reduced by regional anaesthesia, a sitting position (beach-chair) and a short operative time through a two-team approach.

  
  
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  Reliable workhorse flaps provide easy vascular access with limited incisions, reliable anatomy and long vascular pedicles for speedy and safe soft-tissue reconstruction.

  
  
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  Postoperative intensive / intermediate care helps to detect and manage complications early, provide immediate interventions and avoid fast deterioration due to limited physiological reserve.

  
  
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  Early flap dangling, mobilization and physiotherapy minimize sequelae of prolonged immobilization and support rapid functional and social reintegration.