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30 Local Flaps forReconstruction andLimb Salvage oftheFoot andAnkle
447
comes and costs for biologically based, local tissue
rearrangement, and free ap reconstruction. Plast
Reconstr Surg. 2020;145(3):608e–16e. https://doi.
org/10.1097/PRS.0000000000006589.
2. Attinger Christopher E, Kim EK, Erwin B, Peter B,
Paul C.Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction,
incisions, and revascularization. Plast Reconstr Surg.
2006;117(7S):261S–93S. https://doi.org/10.1097/01.
prs.0000222582.84385.54.
3. Shuck J, Nolan J, Kanuri A, Evans KK, Attinger
CE. The effect of positive post-debridement cultures on local muscle ap reconstruction of the lower
extremity. Plast Reconstr Surg. 2015;136(4S):9–10.
https://doi.org/10.1097/01.prs.0000472283.01460.a1.
4. Attinger CE, Ducic I, Cooper P, Zelen CM.The role
of intrinsic muscle aps of the foot for bone coverage
in foot and ankle defects in diabetic and nondiabetic
patients. Plast Reconstr Surg. 2002;110(4):1047–54.
5. Weinstein R, Larsen A. Orthoplastic foot and ankle
reconstruction part 2. In: MacGlamry ED, Southerland
JT, editors. McGlamry’s comprehensive textbook
of foot and ankle surgery. Philadelphia, PA: Wolters
Kluwer Lippincott Williams & Wilkins; 2004. p.204.
6. Ortak T, Ozdemir R, Ulusoy MG, Tiftikcioglu YO,
Karaaslan O, Kocer U, Sensoz O.Reconstruction of
heel defects with a proximally based abductor hallucis
muscle ap. J Foot Ankle Surg. 2005;44(4):265–70.
https://doi.org/10.1053/j.jfas.2005.04.001. PMID:
16012432.
7. Capobianco CM, Zgonis T.Abductor hallucis muscle
ap and staged medial column arthrodesis for the
chronic ulcerated Charcot foot with concomitant
osteomyelitis. Foot Ankle Spec. 2010;3:269–73.
8. Craig GC. Intrinsic muscle aps for coverage of
small defects in the foot. Clin Podiatr Med Surg.
2020;37(4):789–802.
9. Wang JS, Gunsch C, Thompson C, Nigam M, Evans
KK, Attinger CE.Proximally based split abductor hallucis turnover ap for medial hindfoot reconstruction:
a case report. J Foot Ankle Surg. 2019;58(6):1072–6.
10. Landi A, Soragni O, Monteleone M. The extensor digitorum brevis muscle island ap for softtissue loss around the ankle. Plast Reconstr Surg.
1985;75(6):892–7.
11. Buntic R. “MICROSURGEON.ORG.” Extensor digitorum brevis brevis ap. 2021. www.microsurgeon.
org/extensorbrevis.
12. Abdelrahman I, etal. Versatility of the extensor digitorum brevis muscle ap in lower limb reconstruction.
Plast Reconstr Surg Glob Open. 2018;6(12):e2071.
https://doi.org/10.1097/GOX.0000000000002071.
13. Bakhach J, Demiri E, Chahidi N, Baudet J.Extensor
digitorum brevis muscle ap: new renements. Plast
Reconstr Surg. 1998;102(1):103–10.
14. Hartrampf CR Jr, Schean M, Bostwick J III. The
exor digitorum brevis muscle island pedicle ap.
Plast Reconstr Surg. 1980;66(2):264–70.
15. Vincenti R, Belczyk R.Can a exor digitorum brevis
muscle ap help manage a soft tissue defect after an
open total calcanectomy? Podiatry Today. 2015;28:1.
16. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized ap: a clinical study. Plast Reconstr Surg.
1975;55(2):177–85.
17. Limthongthang R, Eamsobhana P. First dorsal metatarsal artery perforator ap to cover
great toe defect. J Orthop Surg (Hong Kong).
2017;25(3):2309499017739497. https://doi.
org/10.1177/2309499017739497. PMID: 29137568
18. Hou Z, Zou J, Wang Z, Zhong S.Anatomical classication of the rst dorsal metatarsal artery
and its clinical application. Plast Reconstr Surg.
2013;132(6):1028e–39e. https://doi.org/10.1097/
PRS.0b013e3182a97de6. PMID: 24281608.
19. Serletti JM, Moran SL.Soft tissue coverage options for
dorsal foot wounds. Foot Ankle Clin. 2001;6:839–51.
20. Vazales R, Masadeh S.First dorsal metatarsal artery
ap for coverage of soft tissue defects of the distal
foot: delayed technique, proximal and distally based
Fasciocutaneous and Adipofascial variants. Clin
Podiatr Med Surg. 2020;37(4):765–73. https://doi.
org/10.1016/j.cpm.2020.07.001. PMID: 32919603.
21. Grabb WC, Argenta LC.The lateral calcaneal artery
skin ap (the lateral calcaneal artery, lesser saphenous
vein, and sural nerve skin ap). Plast Reconstr Surg.
1981;68(5):723–30.
22. 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 Reconstr Surg.
2006;117(7S):261S–93S.
23. Koshima I, Urushibara K, Inagawa K, Hamasaki T,
Moriguchi T. Free medial plantar perforator aps
for the resurfacing of nger and foot defects. Plast
Reconstr Surg. 2001;107(7):1753–8.
24. Lee HB, Tark KC, Rah DK, Shin KS.Pulp reconstruction of ngers with very small sensate medial plantar
free ap. Plast Reconstr Surg. 1998;101(4):999–1005.
25. Amarante J, Martins A, Reis J.A distally based median
plantar ap. Ann Plast Surg. 1988;20(5):468–70.
26. Hanasono MM, et al. Handbook of reconstructive
aps. 1st ed. NewYork, NY: Thieme; 2021.
27. Gu JX, Huan AS, Zhang NC, Liu HJ, Xia SC, Regmi
S, Yang L.Reconstruction of heel soft tissue defects
using medial plantar artery island pedicle ap: clinical
experience and outcomes analysis. J Foot Ankle Surg.
2017;56(2):226–9.
28. Baker GL, Newton ED, Franklin JD.Fasciocutaneous
island ap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot. Plast
Reconstr Surg. 1990;85(1):47–58.
29. Masquelet AC, Romana MC, Wolf G.Skin island aps
supplied by the vascular axis of the sensitive supercial nerves: anatomic study and clinical experience in
the leg. Plast Reconstr Surg. 1992;89(6):1115–21.
30. Coskunrat OK, Velidedeoglu HV, Sahin U, Demir
Z. Reverse neurofasciocutaneous aps for soft-
448
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D. Z. Martin and G. Del-Corral
tissue coverage of the lower leg. Ann Plast Surg.
1999;43(1):14–20.
31. Fachinelli A, Masquelet A, Restrepo J, Gilbert A.The
vascularized sural nerve: anatomy and surgical
approach. Int J Microsurg. 1981;3:57.
32. Mahmoud WH.Foot and ankle reconstruction using
the distally based sural artery ap versus the medial
plantar ap: a comparative study. J Foot Ankle Surg.
2017;56:514–8.
33. Cheema TA, Saleh ES, De Carvalho AF.The distally
based sural artery ap for ankle and foot coverage. J
Foot Ankle Surg. 2007;46(1):40–7.
34. Herlin C, Bekara F, Bertheuil N, Carloni R, Dast
S, Sinna R, Chaput B. Venous supercharging
reduces complications and improves outcomes of
distally based sural aps. J Reconstr Microsurg.
2017;33(05):343–51.
35. Kuntscher MV, Erdmann D, Homann H-H, Steinau
H-U, Levin SL, Germann G.The concept of llet aps:
classication, indications, and analysis of their clinical value. Plast Reconstr Surg. 2001;108(4):885–96.
36. Lin CH, Wei FC, Chen HC. Filleted toe ap for
chronic forefoot ulcer reconstruction. Ann Plast Surg.
2000;44(4):412–6. https://doi.org/10.1097/00000637-
200044040- 00010. PMID: 10783098.
37. Huang X, Qu X, Li Q. Risk factors for complications of tissue expansion. Plast Reconstr Surg.
2011;128(3):787–97. https://doi.org/10.1097/
PRS.0b013e3182221372.
38. Kenny EM, Egro FM, Russavage JM, Spiess AM,
Acarturk TO.Primary closure of wide fasciotomy and
surgical wounds using rubber band-assisted external
tissue expansion: a simple, safe, and cost-effective
technique. Ann Plast Surg. 2018;81(3):344–52.
https://doi.org/10.1097/SAP.0000000000001506.
PMID: 29905602.
39. Santiago GF, Bograd B, Basile PL, Howard RT,
Fleming MDO, Valerio IL. Soft tissue injury management with a continuous external tissue expander.
Ann Plast Surg. 2012;69(4):418–21. https://doi.
org/10.1097/SAP.0b013e31824a4584.
Free Tissue Transfer inDiabetic
Limb Salvage: Lessons Learned
andBest Practices forFunctional
Salvage
PaigeK.Dekker, KevinG.Kim, KennethL.Fan,
andKarenK.Evans
31
Introduction
Reconstruction of lower extremity defects using
free tissue transfer (FTT) rst occurred in 1973
when abdominal and groin aps were used for
coverage of distal lower extremity defects [1, 2].
Flap failure rates were initially as high as 40–50%
[3] but continued advancements in microsurgery
technique, surgical microscopes, and surgical
instruments have led to success rates as high as
98–99% [4, 5], making FTT a highly reliable
reconstructive modality in various clinical scenarios. FTT is now recognized as a mainstay
reconstructive option for lower extremity reconstruction, yielding ap success rates up to 92%
[6] and limb salvage rates of 83–84% [6, 7].
Contrary to previous beliefs, diabetes and
peripheral vascular disease are not contraindications to microsurgical free ap reconstruction.
Previous thinking held that hyperglycemia, neu-
P. K. Dekker · K. G. Kim
Department of Plastic Surgery, MedStar Georgetown
University Hospital, Washington, DC, USA
e-mail: pkd15@georgetown.edu; kgk31@rwjms.
rutgers.edu
K. L. Fan · K. K. Evans (*)
Department of Plastic and Reconstructive Surgery,
MedStar Georgetown University Hospital,
Washington, DC, USA
e-mail: Kenneth.l.fan@medstar.net;
karen.k.evans@medstar.net
ropathy, and microvascular occlusive disease that
developed secondary to diabetes resulted in
impaired healing, compromising the viability of
FTT and thereby making diabetic patients poor
candidates for this reconstructive modality [7–9].
Various studies have since failed to demonstrate
increased incidence of small vessel disease or
endothelial proliferation in patients with diabetes
[10–13]. Furthermore, our research and others’
have maintained that free ap reconstruction can
be performed with high success rates in the diabetic population [7, 9].
While FTT is not always a viable option, it
offers several benets over major limb amputation in appropriate patients. First, major amputation of one lower extremity increases the risk of
contralateral amputation: nearly 50% of patients
who undergo amputation will undergo a second
amputation of the contralateral limb within two
years [9, 14–16]. Second, major limb amputation
has been shown to be associated with increased
mortality. Patients with diabetes and chronic
lower extremity wounds have a 5-year mortality
of 43–55% [17–19] but mortality may increase to
as high as 74–78% in patients who ultimately
require amputation due to increased cardiovascular demand [17, 19, 20]. Oh etal. demonstrated a
statistically signicant increase in 5-year survival
for diabetic patients undergoing FTT for lower
extremity reconstruction relative to patients
undergoing above-ankle amputation (86.8% versus 41.4%, respectively; p<0.001) [7].
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_31
449
450
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P. K. Dekker et al.
While FTT is a successful and reliable reconstructive modality for diabetic patients with
lower extremity defects, several perioperative
strategies can optimize success. Importantly,
diabetic patients undergoing FTT generally
require more debridements, have longer healing
times, and have higher rates of re-exploration,
ap failure, and local complications when compared to non-diabetic patients undergoing FTT
[9, 21]. A carefully orchestrated multidisciplinary
approach involving reconstructive, podiatric,
orthopedic, and vascular surgeons as well as
close collaboration with infectious disease, endocrinology, hematology, and nutrition colleagues
is essential to optimizing free ap outcomes in
this patient population [21]. This chapter will discuss the indications for FTT as well as strategies
to optimize outcomes in the preoperative, intraoperative, and postoperative stages of care for
patients with diabetes who are undergoing lower
extremity reconstruction with FTT.
Indications
(3) exhibit exposed joint or neurovascular structures [9, 21]. Another primary indication for FTT
is for reconstruction of areas of the foot or leg in
ischemic angiosomes where there is minimal inline blood ow. In this regard, FTT acts as a vascular bypass adding vascularized tissue to
ischemic wounds. Importantly, diabetes, peripheral vascular disease, and elderly age are not
absolute contraindications for FTT; however,
patients with these comorbidities do require special perioperative considerations as discussed
further below [21]. Importantly, FTT is contraindicated in patients who lack a suitable recipient
vessel and caution should be taken in diabetic
patients receiving dialysis [9]. Patients with endstage renal disease often have diffuse vessel calcication and impaired wound healing, while
patients on dialysis are at increased risk of both
thromboembolic events and hematoma formation
[28–30].
Preoperative Evaluation
andOptimization
The reconstructive ladder is traditionally used to
help guide the stepwise progression through
reconstructive modalities. Free ap reconstruction was considered when primary closure, skin
grafts, and local ap options were exhausted
[22]. However, certain authors advocate for a
reconstructive elevator rather than a reconstructive ladder [23, 24]. Primary closure is often precluded by the lack of soft tissue domain [9].
Robust soft tissue is required for ambulation, and
skin grafting is precluded by exposed tendon and/
or bone [9, 25, 26]. Local aps have limited reach
and may not always be a reliable reconstructive
option, particularly in distal third defects with
repetitive trauma [27, 28]. As surgeons seek to
attain superior functional and aesthetic outcomes,
FTT is often the rst choice for reconstruction
[21].
Keeping the aforementioned points in mind,
indications for microsurgical free tissue transfer
for reconstruction of lower extremity defects
include those that (1) are large (>2–3 cm), (2)
involve concurrent bone or muscle loss, and/or
The preoperative stage should focus on three
tasks: (1) evaluating whether the patient is a good
candidate for FTT, and if so, (2) early and aggressive optimization of underlying comorbidities as
well as (3) preparation of the wound bed for
FTT. Each of these steps requires multidisciplinary collaboration from both a surgery and
medicine standpoint, which may include specialist expertise from podiatric and reconstructive
surgery to cardiology, hematology, and hematology, among others. Our management algorithm is
depicted in Fig.31.1.
In addition to this multidisciplinary approach,
patients must have a clear understanding of the
reconstructive timeline as well as postoperative
expectations and guidelines in order to maximize
the chance of reconstructive success. To that end,
counseling the patient and his or her caretakers
should occur throughout the preoperative period.
Ensuring a clear understanding of postoperative
weight-bearing and ambulation progression are
particularly important, as failure to comply with
rehabilitation protocols can lead to ap failure.
31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional…
451
Fig. 31.1 Multidisciplinary approach to preoperative workup for free tissue transfer reconstruction
Medicine
than three times likely to experience wound
dehiscence and patients with a hemoglobin A1c
Preoperative evaluation of the patient should
include obtaining a thorough history that captures all pre-existing medical conditions in order
to allow for early and aggressive optimization. In
patients with diabetes, tight glycemic control in
the perioperative period is essential: patients with
blood glucose levels above 200mg/dL are more
greater than 6.5% are more than three times as
likely to undergo wound dehiscence and/or reoperation [31]. In addition to setting a target glucose level of less than 200 mg/dL, it is also
important that glucose levels are maintained in a
narrow range throughout the perioperative period,
as patients who display wide variability in
452
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P. K. Dekker et al.
glucose levels are at increased risk of reoperation
[31]. Close collaboration with endocrine specialists and patient education regarding the importance of perioperative glucose control are
essential to achieving these targets.
Surgical trauma induces a hypermetabolic
state mediated by multiple endocrine pathways,
which relies on adequate nutritional stores.
Nutritional screening should therefore be included
as a routine aspect of any preoperative workup
[32]. Retrospective review of patients undergoing
free ap reconstruction at our institution suggests
that a preoperative albumin level above 2.7g/dL
within 30days is a reasonable target for patients
undergoing FTT, as levels below this value were
associated with slower healing times and
decreased overall ap healing rates (personal
communication with Karen K.Evans, 2020).
Smoking cessation, or at the very least
decreased use leading up to surgery, can reduce
the risk of impaired wound healing, infection,
partial ap loss, and need for revision surgery
[33]. We typically encourage patients to quit or
otherwise abstain from tobacco use for at least
four to eight weeks prior to surgery.
Patients should also be screened for inherited
or acquired traits that may predispose them to
thrombosis. Patients with underlying hypercoagulability are at increased risk of microvascular
thrombosis and subsequent ap failure with high
rates of nonsalvageability [34–36]. In our institution, we employ a preoperative hypercoagulable workup for all patients undergoing FTT
including a thrombophilia panel and thorough
history taking to assess for any personal or family history of hypercoagulability [36]. As part of
this history taking, patients should be asked
about any personal or family history of clotting
disorders, autoimmune disease, purpura fulminans, miscarriage, blood clots, or use of blood
thinners [36]. Components of a thorough thrombophilia panel are outlined in Table 31.1 and
include a complete blood count (CBC), prothrombin time (PT), partial thromboplastin time
(PTT), homocysteine and factor VIII levels, testing for antiphospholipid antibodies, and measuring activity levels of protein C, protein S, and
antithrombin III. Testing should also include
Table 31.1 Components of a thorough thrombophilia
screening panel
CBC
PT, PTT
Factor V Leiden G1691A genotype
Prothrombin G20210A genotype
Homocysteine level
Factor VIII level
Antiphospholipid antibody testing
Antithrombin III activity
Protein C activity
Protein S activity
MTHFR polymorphisms (A1298C and C677T)
PAI-1 4G/5G QST
CBC complete blood count, MTHFR methylenetetrahydrofolate reductase, PAI-1 plasminogen activator inhibitor
1, PT prothrombin time, PTT partial thromboplastin time,
QST quantitative sensory testing
Adapted from Defazio MV, Hung RWY, Han KD, Bunting
HA, Evans KK. Lower Extremity Flap Salvage in
Thrombophilic Patients: Managing Expectations in the
Setting of Microvascular Thrombosis. J Reconstr
Microsurg. 2016. doi:10.1055/s-0035-1571249
genotypes for factor V Leiden G1691A and prothrombin G20210A as well as testing for the
A1298C and C677T polymorphisms of the
MTHFR gene and lastly for the 4G/5G polymorphism of the plasminogen activator inhibitor-1
(PAI-1) gene [36]. Implementation of this hypercoagulability testing protocol in our preoperative
workup algorithm revealed that 61% of patients
undergoing FTT for lower extremity reconstruction may have at least one thrombophilic trait
and that 20% of patients were found to have
three or more separate diagnoses [36].
Patients with known or newly detected
thrombophilia should receive a hematology
consult in order to assist with preoperative risk
stratication as well as have perioperative anticoagulation regimens optimized based on their
level of thrombosis risk. We consider hematologic (hypercoagulable traits identied with
thrombophilia panel), acquired (history of
venous thromboembolism, myocardial infarction, cerebrovascular accident, malignancy,
miscarriage(s), and/or use of blood thinners),
and intraoperative (thrombosis, anastomotic
revision, vascular calcications) risk factors to
stratify patients into low, moderate, and highrisk groups [34]. We use this risk stratication
31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional…
453
to guide intraoperative and postoperative antithrombotic therapy as outlined in Fig. 31.2.
Implementation of this risk-stratied anticoagulation algorithm at our institution resulted in
signicantly lower rates of total and partial ap
loss in the risk- stratied group compared to
non-stratied controls (total ap loss 3.0% versus 19.0%, p=0.06; partial ap loss 10.0% versus 37.0%, p = 0.025) [34]. Several studies
investigating patients undergoing free ap surgery have found 0% salvageability rates in the
setting of postoperative thrombosis, regardless
of anticoagulation protocol [34, 35]. Taken
together, these ndings reiterate the risk of nonsalvageability in thrombophilic patients who
develop thrombosis postoperatively and reinforce the potential benets of a risk- stratied
anticoagulation protocol.
Vascular
Flap success is highly reliant on adequate arterial
supply and venous drainage of the transferred tis-
sue, requiring thorough physical exam. The vascular supply dening the six foot and ankle
angiosomes should guide the vascular exam, as
this not only allows the surgeon to predict the
viability of a newly placed free ap but it also
allows the surgeon to plan for optimal placement
of surgical incisions since adequate blood ow
on either side of the incision is necessary for optimal healing. Furthermore, vascular exam and
imaging assist in the coordination with a vascular
surgeon for preoperative revascularization procedures, if necessary, to ensure that areas targeted
for reconstruction have adequate blood supply. In
patients with diabetes and/or peripheral vascular
disease, using the six angiosomes as a framework
to guide directional assessment of blood ow can
ensure that (1) surgical incisions will not compromise blood ow to a given area of the foot and
(2) that vascular bypass procedures will actually
revascularize ischemic angiosome(s) [25, 37].
Arterial examination can be performed via
palpation of pulses, ankle-brachial indices,
handheld doppler, catheter arteriography, or
computed tomographic (CT) angiography [38].
Fig. 31.2 Risk-stratied anticoagulation protocol for
patients undergoing free tissue transfer. ASA acetylsalicylic acid, LMWH low molecular weight heparin, POD
postoperative day, PTT partial thromboplastin time.
(Adapted from DeFazio M, Economides J, Anghel E,
Tefera E, Evans K.Lower Extremity Free Tissue Transfer
in the Setting of Thrombophilia: Analysis of Perioperative
Anticoagulation Protocols and Predictors of Flap Failure.
J Reconstr Microsurg. 2019;35(04):270–286. doi:10.105
5/s-0038-1675145)
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P. K. Dekker et al.
We employ arteriography for all patients undergoing FTT. Conventional arteriography uses
less intravenous contrast than CT angiography
and provides more meaningful clinical data
[38]. Routine use of this imaging modality in
our institution identied arterial pathology in
67.8% of patients undergoing FTT for lower
extremity reconstruction [38]. In the same
series, diabetes was associated with the need for
endovascular intervention as well as ndings of
stenosis or occlusion on angiography [38].
These ndings highlight the utility of this imaging modality not only in diagnosing peripheral
vascular disease but also in guiding recipient
vessel selection and facilitating timely endovascular intervention [38].
Insufcient venous outow resulting in ap
congestion and delayed thrombosis is a leading
cause of re-exploration and ap loss; thus,
venous studies are also a key component of preoperative workup [4, 39]. Venous studies can
identify venous insufciency as well as venous
anomalies that may predispose patients to venous
congestion with subsequent thrombosis and ap
failure. While there are many options for venous
imaging, including CT venography, magnetic
resonance (MR) venography, and catheter
venography, we recommend venous duplex
ultrasound because of its superior safety and
efcacy prole relative to alternative imaging
modalities. Importantly, duplex ultrasound is
noninvasive and does not require contrast, which
is particularly benecial in diabetic patients who
often have comorbid renal insufciency.
Utilization of venous duplex ultrasonography in
patients undergoing lower extremity free ap
reconstruction at our institution detected venous
insufciency in 39% of patients and deep vein
thrombosis requiring anticoagulation in 6.78%
of patients [40]. These ndings highlight the
utility of duplex ultrasound in detecting proximal deep venous thrombosis as well as venous
reux, making it a helpful tool in determining
whether the deep venae commitantes versus the
supercial saphenous system should be used as
the recipient veins for a given patient’s free ap
reconstruction.
Podiatric andOrthopedic Surgery
All patients should undergo biomechanical
examination in order to identify any mechanical
factors that may be contributing to wound development and recurrence. This portion of the preoperative workup is particularly important for
patients with diabetic neuropathy, as impaired
protective sensation, proprioception, balance,
and muscle strength in these patients can lead to
increased plantar pressure, prolonged stance
times, weakened dorsiexion, and claw toes [41,
42]. Gait alterations in these patients may lead to
changes in skeletal structure and muscle function, as well as loss of exibility in the joint and
Achilles tendon [42]. Reduced exibility in the
Achilles tendon impairs foot dorsiexion, which
can lead to Charcot development and subsequent
plantar ulceration [43]. For this reason, we routinely address equinus gait with Achilles tendon
lengthening, which has been shown to reduce
wound recurrence by up to 94% in this population [44]. This procedure should be supplemented
with additional measures to address other biomechanical abnormalities, including, but not limited
to, external xation for bony reconstruction in
patients requiring Charcot reconstruction as well
as appropriate corrective footwear [42].
Surgical
The next preparatory step entails achieving a
clean wound bed via serial surgical debridement
of all infected or devitalized tissue, senescent
cells, and biolm [25, 45]. Aerobic and anaerobic
cultures should be obtained prior to and after
debridement and should be collected deep to the
wound surface [45]. Culture-driven antibiotic
therapy should be given in conjunction with surgical debridements and should be maintained
until negative cultures are achieved, at which
point the patient is ready for further reconstruction from an infectious standpoint. Please refer to
Chap. 13 of this text (“Debridement of the
Diabetic Foot and Leg”) for further information
on this topic.
31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional…
455
Intraoperative Optimization
Anesthesia
Close collaboration with the anesthesiologist is
important, as they manage several factors capable
of optimizing ap outcomes. Perioperative anticoagulation is of particular importance in free
ap procedures because ap viability is so critically dependent on ap perfusion. As previously
stated, hematology should be consulted to help
devise an optimal anticoagulation regimen for
any patient with underlying thrombophilia. In
general, patients should be given aspirin or subcutaneous low-molecular-weight heparin for
antithrombotic prophylaxis. We also typically
administer 5000 U of heparin just prior to ap
inset and vessel anastomosis.
Normothermia (average temperature>37°C)
should be maintained throughout the surgery, as
lower temperatures have been associated with
increased risk of perioperative complications
including recipient site infections [46].
Vasopressors can be administered as needed for
hypotension as their use does not signicantly
increase the risk of complications, reoperation, or
ap failure [46].
Flap Choice
One of four ap compositions can be utilized for
the vast majority of lower extremity reconstructions: fasciocutaneous, muscle only, musculocutaneous, or chimeric. Fasciocutaneous aps,
which are harvested by elevating the skin along
with its underlying deep fascia, offer several benets including preservation of underlying musculature as well as being thin, pliable, and amenable
to tissue expansion [47]. Large fasciocutaneous
aps (>8cm) may require skin grafts at the donor
site [47]. Typically, we avoid fasciocutaneous
aps if subcutaneous tissue is too thick. In these
instances, we use a muscle ap with overlying
skin graft. Revision procedures including
debridement and repeat skin grafts for partial
skin graft loss are not uncommon as blood supply
may be altered in the vasculopathic population.
Musculocutaneous aps are harvested by elevating the skin and underlying muscle. These aps
are well vascularized and offer more bulk than
fasciocutaneous aps, making them more resistant to infection and more helpful for coverage of
defects requiring obliteration of dead space [47].
Chimeric aps can be helpful for patients with
tendinous or bony defects. For example, a chimeric anterolateral thigh (ALT) with rolled fascia
lata free ap can be used to reconstruct defects
that require tendinous reconstruction [48].
Chimeric aps that include vascularized bone
can be helpful for reconstruction of defects with
bony involvement [49].
In addition to ap composition, one must also
consider the aesthetic and functional needs of the
site that is being reconstructed. The subunit principle of the foot described by Hollenbeck etal.
provides a helpful framework when determining
which free ap best suits the unique needs of a
particular area of the foot or ankle [50]. Heel
ulcers (subunit 5) require reconstruction with a
ap that will provide both bulk and durability,
making either the vastus lateralis (VL) or ALT
good options (Case 31.1) [25, 50]. The dorsum of
the foot (subunits 3 and/or 4) requires a different
reconstructive approach, as use of a bulky ap
could prevent the patient from tting into shoes.
Instead, one must rely on aps with thinner paddles such as the supercial circumex iliac artery
(SCIP) ap (Case 31.2), medial sural artery perforator (MSAP) ap, or fasciocutaneous ALT
ap [25, 50]. Functional morbidity is also a key
consideration in ap donor site, particularly in
patients who may require future amputation. The
free rectus ap and the latissimus dorsi ap are
not preferable options as it is important to retain
upper body and core strength for transfers should
an amputation be required in the future.
Case 31.1 Vastus Lateralis Free Flap
A 45-year-old male with a past medical history
signicant for type I diabetes mellitus, peripheral
artery disease, left below-knee amputation
(BKA), right-sided weakness secondary to cerebrovascular accident, and right fth ray partial
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P. K. Dekker et al.
amputation initially presented with right foot
wounds. On exam, the patient was afebrile (37.1)
with stable vitals (HR 99, BP 128/72). Exam of
the right foot revealed a wound with expressible
purulence on the lateral aspect of the fth metatarsal as well as a wound on the dorsomedial
aspect of the rst metatarsal shaft and head.
Necrotic skin was noted on the plantar aspect of
the foot, spanning across all metatarsal heads
(Fig.31.3). Labs were signicant for a hemoglobin A1c of 8.8%. X-ray of the foot was negative
for gas in the extremity but was concerning for
cortical erosion of the talus and navicular bones.
Fig. 31.3 Plantar (a)
and lateral (b) surfaces
of the right foot on
initial presentation
a b
Purulence was expressed from the wound at the
bedside and cultures were sent. Broad-spectrum
intravenous antibiotics were initiated, and the
patient was admitted for surgical management of
his wounds.
The patient underwent two rounds of surgical
debridement down to fascia in the operating room
(Fig.31.4). The patient also underwent arteriogram and subsequent percutaneous transluminal
angioplasty of the right anterior tibial artery. The
patient was discharged home on the tenth day of
hospitalization with home health nursing and
wound care instructions.
Fig. 31.4 Plantar (a)
and medial (b) surfaces
of the right foot
following two rounds of
surgical debridement
a b
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