SLR - August 2020 - Nicholas Chang

Reverse Neurocutaneous vs Propeller Perforator Flaps in Diabetic Foot Reconstruction

Reference: E. Demiri, A. Tsimponis and L. Pavlidis, G.A. Spyropoulou, P. Foroglou, D. Dionyssiou. Reverse Neurocutaneous vs Propeller Perforator Flaps in Diabetic Foot Reconstruction. Injury. 2020 Mar 14.

Scientific Literature Review

Reviewed By: Nicholas Chang, DPM
Residency Program: VA Puget Sound Health Care System – Seattle, WA

Podiatric Relevance: Healing soft tissue defects in a timely manner is vital. A systematic approach utilizing the "reconstructive ladder," which ascends in order of technical complexity as necessary, is warranted. Reconstruction using regional flaps is an advanced option for achieving wound closure. This paper compares the use of neurocutaneous flaps, namely the reverse sural and lateral supramalleolar, and propeller flaps in reconstructing foot and ankle wounds in diabetic patients. 
Methods: A retrospective review of 54 diabetic patients who underwent regional flap reconstruction for acute or chronic diabetic foot wounds between 2005 and 2018. The first group (34 patients) received neurocutaneous flap (NCF) reconstruction. Nineteen of these cases composed of the reverse sural flap (10 at the posterior and plantar heel, six dorsal foot, two anterior ankle and one lateral ankle). Fifteen cases included reverse lateral supramalleolar flap (nine over the Achilles zone, two lateral/medial ankle, two lateral distal foot, one dorsal foot and one anterior ankle). The second group (20 patients) received propeller flap (PF) reconstruction (seven in Achilles zone, five lateral/medial ankle, four posterior heel, two dorsal foot, and two anterior ankle). All patients underwent preoperative doppler examination to confirm posterior tibial and dorsalis pedis pulses and to identify the nutrient artery of the flap. The quantitative variables for statistical analysis were age, BMI, ABI, defect size, complication rate, revision surgery, and healing time.

Results: Primary healing occurred in 58.8 percent (20/34) with NCF group and 60 percent (12/20) with PF group. Complications included complete flap loss (one NCF, one PF), flap necrosis (10 NCF, 7 PF), and delayed wound healing at either the donor or recipient sites (12 NCF, three PF). Secondary procedures that involved surgical debridement and skin grafting were performed in 15 NCF and eight PF patients. All patients, except for one leg amputation in NCF, returned to previous levels of ambulation. Statistically significant variables for NCF and PF groups were age (59.1 and 50.8), defect size (42.8 and 23 cm^2), and healing time (48.1 and 40.7 days). BMI, ABI, complications rate, and revision surgeries did not show significant differences between both groups.  

Conclusions: The nature of the study was subjected to selection bias since it is generally accepted that NCF are considered better indications for larger and more distally located defects; whereas, PF are more frequently used in younger patients with relatively smaller and more proximal wounds. Nevertheless, both techniques are effective methods to provide coverage of various lower extremity tissue loss in diabetic patients with adequate blood flow. Overall, regional flap is a feasible option in closing diabetic foot and ankle wounds with thorough preoperative physical examination and planning followed by postoperative management of recipient and donor sites.   

Educational Opportunities