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Factors Associated with Failed Hardware Salvage in High Risk Patients following Microsurgical Lower Extremity Reconstruction
Ketan M. Patel, M.D., Mitch Seruya, M.D., Brenton Franklin, Margaret Gatti, M.D., M.P.H, Ivica Ducic, M.D., Ph.D..
Georgetown University Hospital, Washington, DC, USA.

BACKGROUND:
Lower extremity hardware salvage remains a difficult challenge in patients with multiple, complex co-morbidities. Surgeons must weigh the benefit of lower extremity stabilization against the costs of compromised wound healing and potential limb loss. Presently, guidelines are lacking with regard to suitable/unsuitable conditions for attempted hardware salvage. The purpose of this study was to identify factors associated with failed hardware salvage following microsurgical lower extremity reconstruction
METHODS:
The authors performed a retrospective, IRB-approved review of all patients who underwent lower extremity hardware salvage via free tissue transfer by the senior author (I.D.) from 2004-2010. Patient demographics, wound characteristics, microbiology, and pathology were reviewed for each patient. Outcomes were binarized into successful versus failed hardware salvage, with failure defined as the absence of hardware at latest follow-up. Univariate analysis was used for comparison of associations between patient factors and the outcome of interest, with a p value < 0.05 considered statistically significant.
RESULTS:
34 patients underwent lower extremity hardware salvage via free tissue transfer, with an average follow-up time of 2.6 years (range 0.3 - 7.0 years). Fifteen patients had successful hardware salvage; 19 patients eventually required hardware removal, representing a 55.9% rate of failed hardware salvage. Comparison of patient demographics revealed similar surgical age, BMI, and co-morbidities (end-stage renal disease, diabetes, peripheral vascular disease, hypertension, and coronary artery disease) between successful versus failed hardware salvage groups. Analysis of wound characteristics revealed a significantly longer time to hardware coverage and longer duration of IV antibiotic coverage in failed versus successful hardware salvage patients (38.9 versus 9.3 weeks, p = 0.02; and 6.5 versus 4.1 weeks, p = 0.03, respectively). Initial wound cultures demonstrated a significantly higher frequency of positive growth in patients with failed versus successful hardware salvage (100.0% versus 57.1%, p = 0.003); the distribution of microbial flora on initial and final cultures was similar for the two groups. Initial pathology revealed a borderline-significantly higher frequency of chronic osteomyelitis in failed versus successful hardware salvage patients (66.7% versus 33.3%, p = 0.08); absence of osteomyelitis and presence of acute osteomyelitis were similar for the two groups.
CONCLUSIONS:
Based on this retrospective review of microsurgical lower extremity reconstruction, factors associated with failed hardware salvage included: longer time to hardware coverage; longer duration of IV antibiotics; positive initial wound cultures; and presence of chronic osteomyelitis on initial pathology. These findings underscore the need for early and timely hardware coverage, as the likelihood of salvage is inversely related to wound chronicity.


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