Clostridium difficile induced coagulopathy: Implications for microsurgery in the setting of limb salvage

Studies have demonstrated a correlation between Clostridium difficile infection (CDI) and hypercoagulability. This study evaluates CDI in patients undergoing lower extremity (LE) free tissue transfer (FTT) and quantifies its impact on microsurgical outcomes.

A retrospective cohort study of patients receiving LE FTT from July 2011 to June 2024 was conducted. Patients who tested positive for C. difficile within 15 days of their FTT were identified and compared to those who did not.

A total of 356 LE FTT were performed. Six patients (1.7%) contracted CDI. Groups had similar comorbidity and wound profiles. Flap takeback occurred at significantly higher rates in the CDI group (66.7% vs. 6.3%; p<0.001), as did microvascular pedicle thrombosis (33.3% vs. 3.1%; p=0.017). Flap complications were also significantly higher in the CDI group (100.0% vs. 27.7%; p=0.001), specifically partial flap necrosis (50.0% vs. 3.1%; p=0.001) and infection (66.7% vs. 12.6%; p=0.004). By a median follow-up of 15.7 months, major LE amputation rates were similar between CDI and Non-CDI groups (33.3%, n=2 vs. 12.6%, n=44; p>0.05). Multivariate regression models adjusting for statistically and clinically significant covariates demonstrated CDI to be independently associated with flap takeback (OR: 46.4, 95% CI: 7.2-297.4, p<0.001) and microvascular thrombosis (OR: 26.4, CI: 3.5-197.3, p=0.001).

Our results suggest a possible association between C. Diff infection and increased risk for microvascular thrombotic complications in LE FTT. Microvascular plastic surgeons should be aware of the immediate microvascular risks associated with C. Diff infection. Further research is required to fully understand the clinical management of this population.