Outcomes and Risk Factors in Microsurgical Forefoot Reconstruction

Abstract

Background: Defects at the forefoot frequently require microsurgical reconstruction, however reconstructive failure can lead to results inferior to primary amputation. The purpose of this study was to identify independent factors affecting surgical outcomes and hospitalization time in these patients. Methods: All patients that underwent free flap reconstruction of the forefoot between 2008 and 2019 were reviewed retrospectively. Statistical evaluation included binary logistic regression and correlation analysis. Results: A total of 93 free flap procedures were performed in 87 patients. The most common defect etiologies were acute trauma (30 cases; 32.3%), diabetic foot syndrome (20 cases; 21.5%) and infection (17 cases; 18.3%). Muscle flaps were used in 50 cases (53.8%) and fasciocutaneous flaps were used in 43 cases (46.2%). Major complications occurred in 24 cases (25.8%) including 11 total flap losses and 2 partial flap losses. Minor complications occurred in 38 cases (40.9%). Patients aged 60 years or above were at significant higher risk for major complications (p=0,029). Use of fasciocutaneous flaps (OR: 14.341; p=0.005), arterial hypertension (OR: 18.801; p=0.014) and operative time (min) (OR: 1.010; p=0.029) were identified as individual risk factors for major complications. Two venous anastomoses significantly reduced the risk for major complications (OR: 0.078; p=0.022). Multi resistant bacterial wound colonization (OR: 65.152; p<0.001) and defect size (OR: 1.007; p=0.045) were identified as independent risk factors for minor complications. The median hospital stay was 28 days (7-85 days). Age significantly correlated with the length of hospital stay (r=0.405, p<0.01). Conclusion: Our study identified independent risk factors that might help to make individual decisions whether to target microsurgical forefoot reconstruction or primary amputation. Two venous anastomoses should be performed whenever feasible, and muscle free flaps should be preferred in patients at higher risk for major surgical complications.

Combining antibiotic‐loaded bone cement‐based free vastus lateralis muscle‐sparing flap with split‐thickness skin grafts: A reliable strategy for reconstructing diabetic foot ulcers at non‐weight‐bearing areas

“… 17 , 42 , 43 Therefore, combining free muscle flaps with STSGs may be an ideal choice for DFU reconstruction. Mayr‐Riedler et al 44 found that the risk of significant complications in reconstructing the forefoot using free fasciocutaneous flaps is four times higher than that of free muscle flaps, especially in elderly patients with ischaemic defects. Therefore, they recommended using free muscle flaps as the first choice for patients at higher risk of complications.…”

“…However, there were two cases of partial loss of the STSGs, and more detailed reports on this topic are lacking. Moreover, the study by Mayr‐Riedler et al 44 showed that for every 1‐minute increase in surgical time, there is a relative 1% increase in the risk of major surgical complications (total or partial loss of >10% of flap tissue and secondary surgery). Demirtas et al 49 compared the clinical outcomes of free muscle flaps (including the rectus abdominis, latissimus dorsi and gracilis) with anterolateral thigh perforator flaps in reconstructing foot and ankle defects.…”