SLR - December 2016 - Nisha N. Shah

A New Approach for Reconstruction of Diabetic Foot Wounds Using the Angiosome and Supermicrosurgery Concept

Reference: Suh HS, Oh TS, Lee HS, Lee SH, Cho YP, Park JR, Hong JP. A New Approach for Reconstruction of Diabetic Foot Wounds Using the Angiosome and Supermicrosurgery Concept. Plast and Reconstr Surg. 2016 Oct; 138(4): 702–709

Scientific Literature Review

Reviewed By: Nisha N. Shah, DPM
Residency Program: Grant Medical Center

Podiatric Relevance: Foot and ankle surgeons routinely address diabetic ulcerations and vascular insufficiency. Major vessels of the lower extremity are often compromised due to calcifications. The concept of supermicrosurgery, defined as using vessels smaller than 0.8 mm in diameter, has a new role in reconstruction of the diabetic foot. Previous studies show that a free flap survival rate is about 92 percent and limb salvage is 83.4 percent. There are many risk factors that play a part in wound and flap healing, one being adequate blood flow. With the concept of supermicrosurgery, smaller collateral perforators can be used to provide perfusion to flaps even if the major vessel is compromised. The authors’ purpose of this study was to evaluate the outcomes and preoperative risk factors with the surgical results with this technique. As surgeons, it is important we address the underlying vascular status to give our patients the best chance for limb salvage.

Methods: This was a retrospective study that looked at 95 cases of diabetic foot reconstruction with an average age of 57 years. The mean follow-up was 43.5 months. Vascular status was assessed prior to surgery, and patients were referred to endovascular surgeons if they needed an angiogram with intervention or bypass. Once adequate blood flow was detected on noninvasive testing, debridement was performed according to the angiosome concept. The supermicrosurgery approach was then utilized for the reconstruction. Sixteen preoperative risk factors, including age, sex, diabetes mellitus type, smoking, immunosuppression, flap size, hemoglobin A1c, ankle-brachial index, preoperative transcutaneous partial pressure of oxygen, C-reactive protein, computed tomographic angiography, amputation history, peripheral artery disease, physical status, osteomyelitis and chronic renal failure, were also analyzed.

Results:
Ninety-five cases were reviewed. There were 12 minor complications, such as secondary wound healing, which was addressed with negative pressure therapy or simple dressing changes. Nine cases had partial to total loss of the site. Looking at the 16 preoperative risk factors, only two of them had significant impact. Peripheral artery disease had an odds for failure of 10.99, and a history of amputation had an odds for failure of 9.44. The others had no correlation. Overall, there was a limb salvage rate of 93.7 percent and a flap survival rate of 90.5 percent.

Conclusions: There are many factors related to a patient’s ability to heal a reconstruction for a diabetic wound. With the high rate of peripheral vascular disease in people living with diabetes and calcifications of major vessels of the leg, the supermicrosurgery concept allows perforator flaps to provide well-vascularized tissue to cover diabetic foot defects. This article found that there is a high overall limb salvage rate with this technique and one that should be further investigated to provide the best outcome possible. Newer surgeons can keep this method in the back of their minds when presented with extensive diabetic foot defects with partially ischemic tissue. 

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