Reconstruction Using Free Flaps for Diabetic Heel Defects: Outcomes and Risk Factor Analysis

Kim, Hyung Bae; Altiparmak, Mehmet Rıza; Pak, Changsik John; Suh, Hyunsuk Peter; Hong, Joon Pio

doi:10.1055/s-0040-1709477

Cited by 13 publications

(23 citation statements)

References 22 publications

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“…There is still lacking evidence on independent factors influencing the outcome in free flap transfer to the forefoot. Only three studies limited to diabetic foot defects investigated possible risk factors for postoperative complications [21][22][23] . Oh et al 21 investigated 121 cases of microsurgical diabetic foot reconstruction and identified peripheral arterial disease, a history…”

Section: Discussionmentioning

confidence: 99%

“…In the study of Las et al 25 reviewing possible risk factors in 330 microsurgical lower extremity reconstructions arterial hypertension trended towards significancy in univariate analysis while no significance was shown in multivariate analysis. Other previous studies focusing on microsurgical extremity reconstruction could not find an association of hypertension with flap failure 22,26,31 or did not include arterial hypertension in their risk factor analysis 23,32,33 .…”

Section: Accepted Manuscriptmentioning

confidence: 95%

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Outcomes and Risk Factors in Microsurgical Forefoot Reconstruction

Mayr-Riedler

Wacker

Gedrich

et al. 2022

J Reconstr Microsurg

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Accepted Manuscriptmentioning

confidence: 95%

Outcomes and Risk Factors in Microsurgical Forefoot Reconstruction

Mayr-Riedler

Wacker

Gedrich

et al. 2022

J Reconstr Microsurg

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“…The subsequent cycle of progressive infection and deformity eventually result in crippling LE morbidity in these patients (Kadam & Microsurg, 2016;Kallio et al, 2015). Delayed healing may lead to higher amputation rates, with diabetic patients accounting for 40%-70% of all lower limb amputations (Eskelinen et al, 2015;Kim et al, 2020). Goals of surgical management of heel ulcers should include early intervention to (1) control infection, (2) promote ulcer healing, and (3) prevent future recurrences (Younes et al, 2004); we highlight the role of reconstruction during early intervention to prevent morbidity such as amputation.…”

Section: Introductionmentioning

confidence: 99%

“…The heel serves a vital purpose in functionality as the most important weight-bearing region of the foot and the key point for ambulation (Kim et al, 2020). Therefore, salvage of the heel is critical in preservation of gait and ambulation.…”

Section: Introductionmentioning

confidence: 99%

Free flap reconstruction of plantar weight‐bearing heel defects: Long‐term functional and patient‐reported outcomes

et al. 2022

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Purpose Non‐healing plantar weight‐bearing heel ulcers are a challenging problem to treat. Free tissue transfer (FTT) reconstruction of the heel is an opportunity for limb salvage to preserve gait and ambulation. The aim of this study is to describe surgical and functional outcomes in patients who underwent FTT to treat chronic heel ulcers. Methods A retrospective review of patients who underwent FTT for plantar heel ulcers from 2011 to 2021 was conducted. Patient demographics, comorbidities, perioperative data, postoperative complications, and long‐term outcomes were recorded. Primary outcomes included flap success, complications, postoperative ambulation, patient‐reported outcome measures and limb salvage, with patients stratified into limb salvage or eventual amputation groups. RESULTS Forty‐four patients underwent 45 heel reconstructions. Average age and BMI were 57.3 years and 30.1 kg/m2, respectively. Thirty‐eight patients (86.4%) had calcaneal osteomyelitis, 35 patients (79.5%) had diabetes, and 18 patients (40.9%) had peripheral vascular disease (PVD). Immediate microsurgical success rate was 95.6%. At mean follow‐up of 19.6 ± 20.9 months, overall limb salvage rate was 73.3% (n = 33). Preoperative albumin levels were higher in limb salvage group compared to the amputation group (3.0 vs. 2.4 g/dl, p = .018). Prior stroke history and hypoalbuminemia were significantly higher in the amputation group compared to limb salvage group (p = .012 and p = .018, respectively). Risk for eventual amputation was associated with PVD (OR 4.0, p = .053), hypoalbuminemia (OR 4.9, p = .020), and postoperative infection (OR 6.3, p = .013). Of the 12 amputations that occurred, the most common indication for amputation was infection (n = 8, 66.7%), which most often occurred at the original wound location (62.5%). At most recent follow‐up, 90.7% of patients (n = 39) were ambulatory. CONCLUSION FTT is an effective alternative to amputation in patients with chronic heel ulcers. Proper patient selection, preoperative optimization, and postoperative care are imperative to the success of this limb salvage procedure.

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“…Diabetes is a common, chronic, neurovascular disease that is challenging to treat because patients can have many serious complications, including diabetic foot ulcers (DFU) (1,2). site of DFU which are characterized by wounds that reach the deep anatomical layers, a long disease course, and repair difficulties (4). Advancements in microscopic techniques have promoted the widespread clinical application of different perforator flaps for the treatment of DFU.…”

Section: Introductionmentioning

confidence: 99%