Strategies for Free Flap Transfer and Revascularisation with Long-term Outcome in the Treatment of Large Diabetic Foot Lesions (original) (raw)

2015, European Journal of Vascular and Endovascular Surgery

WHAT THIS PAPER ADDS A major proportion of large chronic tissue defects in the foot treated with free flap transfer are of diabetic origin with either neuro-ischaemic or predominantly neuropathic aetiology. Revascularisation in conjunction with free flap transfer may be necessary. This paper describes for the first time, the strategies for free flap transfer in both neuro-ischaemic and predominantly neuropathic large diabetic foot defects, as well as the long-term outcome in different treatment groups. Objective/Background: To analyse the impact of ischaemia and revascularisation strategies on the long-term outcome of patients undergoing free flap transfer (FFT) for large diabetic foot lesions penetrating to the tendon, bone, or joint. Methods: Foot lesions of 63 patients with diabetes (median age 56 years; 70% male) were covered with a FTT in 1991e2003. Three groups were formed and followed until 2009: patients with a native in line artery to the ulcer area (n ¼ 19; group A), patients with correctable ischaemia requiring vascular bypass (n ¼ 32; group B), and patients with uncorrectable ischaemia lacking a recipient vessel in the ulcer area (n ¼ 12; group C). Results: The respective 1, 5, and 10 year amputation free survival rates were 90%, 79%, and 63% in group A; 66%, 25%, and 18% in group B; and 50%, 42%, and 17%, in group C. The respective 1, 5, and 10 year leg salvage rates were 94%, 94%, and 87% in group A; 71%, 65%, and 65% in group B; and 50%, 50%, and 50% in group C. In 1 year, 43%, 45%, and 18% of the patients in groups A, B, and C, respectively, achieved stable epithelisation for at least 6 months. The overall amputation rate was associated with smoking (relative risk [RR] 3.09, 95% confidence interval [CI] 1.8e5.3), heel ulceration (RR 2.25, 95% CI 1.1e4.7), nephropathy (RR 2.24, 95% CI 1.04e4.82), and an ulcer diameter of >10 cm (RR 2.08, 95% CI 1.03e4.48). Conclusion: Despite diabetic comorbidities, complicated foot defects may be covered by means of an FFT with excellent long-term amputation free survival, provided that a patent native artery feeds the ulcer area. Ischaemic limbs may also be salvaged with combined FFT and vascular reconstruction in non-smokers and in the absence of very extensive heel ulcers. Occasionally, amputation is avoidable with FFT, even without the possibility of direct revascularisation.