Reconstruction Using Free Flaps for Diabetic Heel Defects: Outcomes and Risk Factor Analysis
21 October 2019
23 February 2020
06 April 2020 (online)
Background Overall success rate after diabetic foot reconstruction using free flap has been acceptable, but certain parts of the foot like the heel remains more challenging.
Patients and Methods This retrospective study reviewed 37 patients reconstructed with free flaps for diabetic foot ulcer on the heel region from 2008 to 2017. Flap outcome in addition to various risk factors were analyzed; arterial status on heel, the American Society of Anesthesiologists (ASA) physical status, smoking, hypertension, hypercholesterolemia, chronic renal failure patient, hemoglobin A1c level, C-reactive protein, and osteomyelitis.
Results Overall flap survival was 73% and resulted in limb salvage and functional ambulation. Total flap loss was 27% and the majority ended up with high-level amputation. Among the risk factors evaluated, the arterial status of the heel and ASA status significantly increased the odds for failure. When both arterial branches to the heel were impaired, the odds of failure were 80 times higher to fail (p< 0.05).
Conclusion The vascularity of the surrounding tissue of the defect plays a critical role in overall success of diabetic heel reconstruction. Aggressive debridement using the angiosome concept is necessary to assure surrounding tissue has a good circulation. Despite the high chance of failure, success will lead to limb salvage and to reasonable functional ambulation whereas failure to salvage the heel will lead to higher level amputation. This warrants microsurgeons to make an effort to perform reconstruction to the heel defect after obtaining maximal vascularity after angioplasty.
- 1 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
- 2 Suh HS, Oh TS, Lee HS. , et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg 2016; 138 (04) 702e-709e
- 3 Fitzgerald O'Connor EJ, Vesely M, Holt PJ, Jones KG, Thompson MM, Hinchliffe RJ. A systematic review of free tissue transfer in the management of non-traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg 2011; 41 (03) 391-399
- 4 Colen LB. Limb salvage in the patient with severe peripheral vascular disease: the role of microsurgical free-tissue transfer. Plast Reconstr Surg 1987; 79 (03) 389-395
- 5 Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011; 128 (01) 173-180
- 6 Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using supermicrosurgery. Diabetes Metab Res Rev 2016; 32 (Suppl. 01) 275-280
- 7 Crowe CS, Cho DY, Kneib CJ, Morrison SD, Friedrich JB, Keys KA. Strategies for reconstruction of the plantar surface of the foot: a systematic review of the literature. Plast Reconstr Surg 2019; 143 (04) 1223-1244
- 8 Kallio M, Vikatmaa P, Kantonen I, Lepäntalo M, Venermo M, Tukiainen E. Strategies for free flap transfer and revascularisation with long-term outcome in the treatment of large diabetic foot lesions. Eur J Vasc Endovasc Surg 2015; 50 (02) 223-230
- 9 Carsten III CG, Taylor SM, Langan III EM, Crane MM. Factors associated with limb loss despite a patent infrainguinal bypass graft. Am Surg 1998; 64 (01) 33-37 , discussion 37–38
- 10 Younes NA, Albsoul AM, Awad H. Diabetic heel ulcers: a major risk factor for lower extremity amputation. Ostomy Wound Manage 2004; 50 (06) 50-60
- 11 Attinger C, Cooper P, Blume P, Bulan E. The safest surgical incisions and amputations applying the angiosome principles and using the Doppler to assess the arterial-arterial connections of the foot and ankle. Foot Ankle Clin 2001; 6 (04) 745-799
- 12 Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast ReconstrSurg 2006; 117 (07) 261S-293S
- 13 Clemens MW, Attinger CE. Angiosomes and wound care in the diabetic foot. Foot Ankle Clin 2010; 15 (03) 439-464
- 14 Suh HP, Jeong HH, Hong JPJ. Is early compression therapy after perforator flap safe and reliable?. J Reconstr Microsurg 2019; 35 (05) 354-361
- 15 Anthony T, Roberts J, Modrall JG. , et al. Transmetatarsal amputation: assessment of current selection criteria. Am J Surg 2006; 192 (05) e8-e11
- 16 Hong JP, Oh TS. An algorithm for limb salvage for diabetic foot ulcers. Clin Plast Surg 2012; 39 (03) 341-352
- 17 Lu J, DeFazio MV, Lakhiani C. , et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg 2019; 35 (02) 117-123
- 18 Velander E. Vascular changes in tubed pedicles. An animal experimental study. Acta Chir Scand Suppl 1964; 24 (322) 322 , 1
- 19 Burns A, Avery BS, Edge CJ. Survival of microvascular free flaps in head and neck surgery after early interruption of the vascular pedicle. Br J Oral Maxillofac Surg 2005; 43 (05) 426-427
- 20 Skrbić S, Stanec Z. Early rupture of the arterial anastomoses with free flap survival. Injury 1995; 26 (07) 494-496
- 21 Goudie EB, Gendics C, Lantis II JC. Multimodal therapy as an algorithm to limb salvage in diabetic patients with large heel ulcers. Int Wound J 2012; 9 (02) 132-138
- 22 Kwok AC, Agarwal JP. An analysis of free flap failure using the ACS NSQIP database. Does flap site and flap type matter?. Microsurgery 2017; 37 (06) 531-538
- 23 Üstün GG, Aksu AE, Uzun H, Bitik O. The systematic review and meta-analysis of free flap safety in the elderly patients. Microsurgery 2017; 37 (05) 442-450
- 24 Endara M, Masden D, Goldstein J, Gondek S, Steinberg J, Attinger C. The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control. Plast Reconstr Surg 2013; 132 (04) 996-1004
- 25 Fox CM, Beem HM, Wiper J, Rozen WM, Wagels M, Leong JC. Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis. J Reconstr Microsurg 2015; 31 (01) 59-66