SLR - February 2019 - John Dresser

Free Flap Reconstruction for Diabetic Foot Limb Salvage

Reference: Sato, Tomoya, Yuichiro Yana and Shigeru Ichioka. Free Flap Reconstruction for Diabetic Foot Limb Salvage. Journal of Plastic Surgery and Hand Surgery (2017): 1–6.

Scientific Literature Review

Reviewed By: John Dresser, DPM
Residency Program: St. Francis Hospital and Medical Center, Hartford CT

Podiatric Relevance: As the prevalence of diabetes continues to rise, peripheral neuropathy and lower-extremity ulcerations are placing patients at higher risk of limb loss. Podiatrists play an integral role in limb salvage. Through a multidisciplinary approach with vascular surgery, plastics and other disciplines, outcomes can be improved. With a five-year mortality rate after a major amputation being extremely high, the present study highlights a potential approach in the surgical armamentarium. This study looks at a total of 23 free flaps for large lower-extremity tissue deficits and evaluates the relationship between free flap success and postoperative ambulation.

Methods: A total of 23 free flaps were transferred in 23 cases of diabetic foot ulcerations over a seven-year period. The indication was the presence of exposed bone or tendon after tissue debridement with the only other option being amputation. Free rectus abdominis, latissimus dorsi and anterolateral thigh flaps were used in ten, eight and five patients, respectively. A comparison was made between free flap success and postoperative independent ambulation using Fisher’s exact test.

Results: Two patients died within 14 days of the procedure due to congestive heart failure. Five flaps failed due to venous thrombosis, arterial thrombosis and infection at the anastomosis. Of the 23 flaps done, 16 had a successful reconstruction. Of the 16 successful reconstructions, 75 percent (12/16) went on to independent ambulation.  

Conclusion: The in-hospital mortality rate was 8.7 percent after free flap reconstruction, but when compared with that of lower-extremity amputations (11.6–17 percent), it was quite favorable (18–20). There are a number of limitations of this study with respect to its design. A major limitation was that the authors did not indicate where on the foot these flaps were placed and the rate of success depending on flap placement. Another limitation of this study is that no comparison is made if the patients had simply been offloaded. It would also have been interesting to compare length of surgery of free flap operation versus amputation and how it affects outcomes. Lastly, it would be interesting to see how the rate of independent ambulation compares to return to ambulation with a prosthesis.

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