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468
J. M. Felder and J. P. Hong
Patient Population andSelection
Ninety percent of diabetic foot reconstructions
can be accomplished by simple techniques, and
only roughly 10% require complex ap reconstruction [1]. Patients needing microsurgical
reconstruction are often those that have failed
traditional wound care or reconstruction and
therefore are at high risk for amputation.
Presenting patients are typically middle-aged
to elderly, although younger patients with severe
diabetes are becoming more common as the
global epidemic mounts. Obesity, neuropathy,
poor glucose control, peripheral vascular disease, osteomyelitis, cardiovascular disease, kidney disease, and visual and mobility impairment
are common. Thus, patient selection typically
begins within a pool of patients that are traditionally considered poor candidates for complex
or lengthy surgeries. Because of this, proper
patient selection is paramount. Unfortunately,
because the comorbidities listed above (and the
critical details of each—e.g., where exactly is
the osteomyelitis or PVD) may occur in a countless number of individual combinations, useful
algorithms to guide patient selection do not
exist.
The surgeon therefore must consider the pertinent contributions of each of these complicating
factors to create a plan with any likelihood of
success. This ability can only be gained through
experience and multidisciplinary collaboration. It
is also advisable that the surgeon be familiar with
the principles and practice of amputation surgery,
so that the role of properly performed amputations can be included in the decision-making
process.
The foremost consideration in patient selection is the current and anticipated level of function of the patient. While some scenarios are
clear-cut, such as coverage of a limited area of
bone exposure in a younger and active patient,
most require careful evaluation to determine if
an attempt at salvage will be in the best interest
of the patient. For instance, younger and highly
active patients with extensive osteomyelitis or
arthropathy in which salvage would require
sacrice of the critical bony architecture of the
foot will have better function with a transtibial
amputation. However, elderly diabetic patients
have difculties putting on a prosthesis without
support. In many cases their neuropathy has
already limited their hand and nger coordination. In addition, they suffer from diabetic retinopathy. Thus, counterintuitively, salvage to
maintain limb length for independent transfers
and minimal weight bearing is of benet to preserve independence (Fig.32.1). Unfortunately,
patients who are much older but very active and
who are highly motivated to pursue salvage
may at times be too frail to withstand complex
surgery, hospitalization, and a prolonged period
of healing and rehabilitation. The variations are
endless, such that seasoned judgment is
required.
Obesity is problematic in terms of limiting
ap selection to mostly muscle aps and increasing the difculty of surgical dissection. It also
tends to increase donor site complications such
as seroma, dehiscence, and fat necrosis. Finally,
increasing obesity tends to be associated with
poorer rehabilitation and ambulation potential.
Poor glucose control has been independently
associated with dehiscence in lower extremity
diabetic wound closures; thus, involvement of
internists and/or endocrinologists is critical [2].
Sensory neuropathy does not affect surgical success rate and is not a contraindication to salvage,
but increases the risk of ulcer recurrence [3] and
late reconstructive failure. Motor neuropathy is
of increasing signicance for rehabilitation as
involvement moves proximally from the foot into
the leg.
Osteomyelitis is a frequent indication for
microsurgical coverage but presents a wide
spectrum of considerations depending upon the
location of the involved bone(s). Skeletal deformities of the foot (e.g., Charcot arthropathy)
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469
a
d
b
e
c
Fig. 32.1 Determining candidacy for salvage may be
complex. Counterintuitively, less functional patients may
be indicated for salvage. A 78-year-old wheelchair-bound
diabetic female with ESRD presented with osteomyelitis
after failed attempts at partial calcanectomy and closure.
Although extensive calcaneal osteomyelitis with a large
soft tissue should prompt consideration for amputation in
ambulatory patients, in this elderly, debilitated patient,
salvage was indicated to preserve length for independent
transfers. (a) Wound at presentation with desiccated cal-
caneal bone at base. The patient had undergone a failed
attempt at partial calcanectomy with primary closure. (b)
Radiographs demonstrate a fractured residual calcaneus
with osteomyelitis. (c) Wound following debridement,
antibiotic therapy, and negative pressure wound therapy.
Note the granulation from the calcaneal bone, which is an
indicator of good blow ow. (d, e) Stable result at 2years
post-op after coverage with a free vastus lateralis ap and
glabrous skin graft from the instep. Anastomosis was endto- side (ETS) to the posterior tibial vessels
470
bc
J. M. Felder and J. P. Hong
a
Fig. 32.2 Underlying biomechanical abnormalities and
extent of infection must be considered before proceeding
with salvage. (a) A small wound of the midfoot appears
favorable for salvage. (b) X-ray demonstrating Charcot
arthropathy. (c) Magnetic resonance imaging (MRI) dem-
may further complicate the feasibility or advisability of salvage (Fig.32.2). It is useful to consider the foot in thirds, with osteomyelitis and
deformities of the forefoot, midfoot, and hindfoot being progressively less feasible for salvage, as destruction of bony architecture (either
by infection/debridement or bony collapse) in
critical weight bearing joints will lead to a nonfunctional foot. For these reasons, it is important to have a collaborative relationship with
orthopedic surgeons, who may be able to extend
the indications for salvage with antibiotic spacers, fusions, tendon transfers, and external
xation.
Associated peripheral vascular disease (PVD)
is more the rule than the exception for cases
onstrating extensive osteomyelitis of the midfoot. In this
case, salvage would not have been appropriate despite the
small wound. Below knee amputation was undertaken and
the patient returned to ambulation in 8weeks
requiring microsurgical reconstruction.
Classically, in diabetics, this is at the level of the
leg trifurcation vessels and is relatively amenable
to vascular intervention (Fig.32.3). However, the
high prevalence of associated physical, medical,
and social comorbidities such as age, renal failure, and tobacco abuse mean that in reality, vascular disease can be diffuse and very problematic
distally in the leg and foot. Milder PVD may be
simply an obstacle in recipient vessel selection,
but severe PVD associated with tissue loss represents a stage of disease that is much more difcult to treat and associated with high limb loss
rates independent of ap success. A close collaborative relationship with vascular surgery is
critical.
ab
cd
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471
Fig. 32.3 Peripheral vascular disease is a complicating
factor in diabetic foot reconstruction that is at play more
often than not. Diabetics typically present with trifurcation level (infrapopliteal) disease. (a, b) A 54-year-old
diabetic woman presented with a plantar forefoot ulceration leading to rst metatarsophalangeal joint infection
and underwent incision and drainage with hallux amputation. (c, d) Angiography demonstrated chronic total
occlusions of the anterior and posterior tibial arteries in
the mid-leg. (e, f) The occlusions of the anterior tibial and
posterior tibial arteries were treated with balloon angioplasty, resulting in 3 vessel runoff
472
ef
J. M. Felder and J. P. Hong
Fig. 32.3 (continued)
Pre-operative Surgical Evaluation
disease. The realistic success rate of microsurgical diabetic foot reconstruction is markedly lower
Preoperative Counseling
than in most other applications of microsurgery.
Even in successful cases, it is the rule rather than
Patients requiring microsurgical reconstruction
are often those that have failed traditional wound
care or reconstruction and therefore are at high
risk for amputation. In most cases, patients
should be frankly counseled that they may be at
the point of facing amputation if salvage is unsuccessful, and that diabetic foot infections themselves are a marker for increased risk of mortality.
Patients should understand that the wound is a
serious warning bell, and that even successful
reconstruction is not to be taken lightly. Patients
should be realistically counseled about the surgeon’s success rate in challenging cases such as
in the presence of advanced peripheral vascular
the exception that minor complications such as
areas of delayed wound healing will occur.
Because of the frequent presence of advanced
medical comorbidities, the surgeon must consider patient safety to a greater degree than in
most other applications of microsurgery. Safety
requires a thorough medical workup, as detailed
below.
Finally, the surgeon must keep in mind that
healing from microsurgical reconstruction of the
diabetic foot generally means a 6–12 week
period of non-weightbearing on the foot.
Therefore, patients should be evaluated for willingness to undergo a lengthy period of non-
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473
weightbearing, as well as for noncompliance.
Patients expected to be noncompliant with postoperative activity restrictions are not candidates
for reconstruction.
Preoperative History
A history of any prior wound or surgery (including amputations) of either lower extremity should
be sought. A history of prior vascular intervention is critical to obtain. Specic attention should
be paid to determining the patient’s level of
ambulatory function. Previous history of throm-
bophilia, stroke, unexplained miscarriages, or
venous diseases should be sought. Specic attention must be paid to use of anticoagulants and
recommendations obtained for perioperative
anticoagulant therapy. Many patients will be anticoagulated either for cardiac reasons or owing to
lower extremity vascular surgery.
Preoperative Examination
The wound is assessed carefully by measuring its
size and depth and is then photographed. A metallic probe is used to assist in the evaluation of the
depth of the wound. If the probe touches bone,
there is an 85% chance that osteomyelitis is present. If tendon is involved, the infection is very
likely to have tracked proximally or distally. Note
the presence and extent of cellulitis and differentiate from dependent rubor. Antibiotic therapy
should be initiated after deep cultures are performed [1].
A critical error to avoid is to simply consider
the wound itself. Instead, the surgeon must consider the extent of the underlying disease processes at play (vascular, bony, neuropathic,
osteomyelitis). Plastic surgeons are often called
upon to treat wounds. However, plastic surgeons may not be used to the idea that a fundamental, progressive, underlying change of the
foot is going on and must be evaluated and
treated as a whole in order to obtain meaningful
success.
Assessment for peripheral vascular disease is
paramount. Femoral, popliteal, and pedal pulses
should be palpated. Pencil Doppler examination
of blood ow to the foot is the cornerstone of vascular examination and should be performed in all
cases, even when a pulse is palpable. Specic
effort should be made to determine whether ow
is antegrade or retrograde in both the dorsal and
plantar systems, via selective occlusion of arteries [4].
Preoperative Studies
X-ray examination of the foot should be performed in all cases to assess for osteomyelitis or
biomechanical deformities such as Charcot neuroarthropathy that may impact reconstruction.
MRI may be useful when the presence of osteomyelitis is uncertain, or when `the exact extent of
osteomyelitis will have implications for salvage
(Fig.32.2). X-ray images often will also reveal
valuable information regarding the extent of arterial calcication within the foot and ankle
(Fig.32.4).
When free ap reconstruction is being planned,
and unless there are multiple palpable pulses, traditional angiography should be obtained rather
than computed tomography or magnetic resonance imaging. Traditional angiography provides
superior visualization for recipient vessel planning and avoids artifacts caused by vessel calcication, which is frequent in this population
(Fig.32.4). When pulses are palpable and there is
low concern for signicant arterial calcication,
such as in younger diabetic patients, CT angiogram is an adequate screening examination that
has the added benet of being able to visualize
perforators (e.g., anterolateral thigh, circumex
iliac) and assist with planning the ap harvest. If
abnormalities are noted on the CT angiogram,
then formal angiography should be pursued.
Ultrasound to exclude the presence of active
deep venous thromboses is advisable [5].
Duplex ultrasound should be used to map recipient vessels for perforator to perforator type
anastomoses [6].
474
J. M. Felder and J. P. Hong
Fig. 32.4 Arterial
calcication is a
common complication
factor in diabetic foot
reconstruction and can
lead to technical
difculties with
anastomosis, as well as
signal a more advanced
state of disease. Plain
radiographs should be
assessed for the presence
and extent of vascular
calcications. (a)
Calcication of the rst
dorsal metatarsal and
digital arteries can be
seen. (b) Extensive
calcications of the
anterior tibial, posterior
tibial, dorsalis pedis, and
lateral plantar arteries
can be seen
a b
In addition to standard preoperative laboratory
testing, nutrition labs (albumin, prealbumin) are
important to obtain. Hemoglobin A1C may help
dene whether the patient is likely to be compliant. In the setting of osteomyelitis, baseline and
subsequent ESR/CRP are useful to help tailor the
length of antibiotic therapy and determine suitability for delayed bony procedures such as
fusion or arthroplasty. Microbial cultures are
mandatory prior to reconstruction.
Anemia is common, due to chronic disease,
kidney disease, and other comorbidities.
Transfusion may be needed when Hgb< 10 for
cardiac reasons or if blood loss is anticipated
(e.g., in anticoagulated patients).
anesthesia. Internal medicine or endocrinology
should be involved preoperatively for tight perioperative glycemic control. Nephrology may be
needed for co-existing kidney disease, dialysis,
and adrenal insufciency. Operative planning
may need to account for hemodialysis schedules,
which can also affect administration of blood
products and antibiotics. Infectious diseases
consultation is recommended for all patients,
given the frequent need to consider drug interactions, extended courses of intravenous antibiotics, and microbial antibiotic resistance. Vascular
surgery should be consulted for angiography
and, frequently, for preoperative vascular
intervention.
Preoperative Consultations
Appropriate interdisciplinary consultations are
essential for patient safety. Safety proles for
lengthy surgery should be determined by colleagues in internal medicine, cardiology, or
Preparation forReconstruction
Before consideration of reconstruction, it is
imperative to achieve adequate debridement. All
necrotic material, foreign material, and microorganisms must be removed while delicately spar-
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475
ing intact tissue to maintain substrate for healing.
Cultures should be taken before and after debridement and used to guide antibiotic therapy. Flap
reconstruction should be delayed until negative
post-debridement cultures are obtained. Negative
pressure wound therapy, with or without uid
instillation, can be helpful in managing the
wound between debridements [1].
In cases where vascular disease has impeded
healing, vascular intervention should be pursued before debridement and reconstruction.
The periwound tissues must be capable of tolerating debridement and healing to the ap. If vascular intervention is required, the patient should
be referred to a vascular surgeon who special-
izes in distal revascularizations, as bypass surgery is clinically still superior to endovascular
revascularization. Ideally, this is the same person who performed the preoperative arteriography. Angiosome-specic reperfusion is
preferable when possible because this generally
provides better options for ap recipient vessels
adjacent to the wound. When impossible, then
revascularization should target the best outow
available [7].
After successful bypass surgery, it then takes
4–10days to maximize the periwound tissue oxygen level. If angioplasty is performed, then it may
take up to 30days for tissue oxygen saturation to
reach maximal levels. Denitive debridement
and aggressive wound care should follow as soon
as signs of revascularization occur, such as new
granulation and so forth. Wet gangrene, ascending cellulitis, and necrotizing fasciitis demand
immediate debridement.
Timing of reconstruction in relation to revascularization is critical when pursuing the supermicrosurgery or perforator to perforator
approach. Use of smaller recipient vessels near to
the wound may be dependent upon the continued
patency of a recent angioplasty. Because up to
60% of angioplasties may be occluded within
2–3 months, capitalizing on the window of
reperfusion shortly following an angioplasty is
important.
Another factor to consider is the healing
potential of the surrounding tissues in the setting
of PVD. Even with a healthy ap, failure may
occur if the surrounding tissues are inadequately
perfused. In this scenario, two adjuncts may be
helpful. The rst is preoperative hyperbaric oxygen therapy (HBOT). HBOT may be begun
immediately following reperfusion surgery
while awaiting demarcation of viable tissues.
The goal is to reach a TCP02 of 40mmHg, which
has been shown in multiple studies to promote
angiogenesis from the surrounding tissues into
the ap.
The second option is to employ aggressive
debridement according to angiosomes. This is
not necessary in well-perfused limbs. However,
in the setting of severe PVD manifesting as a
wound within a dened angiosome, the entire
ischemic angiosome surrounding the wound
should be resected, such that the remaining surrounding angiosomes are all adequately perfused
for healing. This requires judgment and condence on the part of the surgeon, as the wound
may be signicantly enlarged as a result. Failure
to completely debride the ischemic angiosome
can result in tissue edges that will not heal to the
ap or result in marginally perfused tissue that is
susceptible to infection, which can also be a
source of late ap failure.
Partial foot amputation should be considered
when approaching more extensive cases of tissue
loss or osteomyelitis. This is because good biomechanical function is the goal of reconstruction.
This is a frequent scenario in the forefoot, and
aps can often be combined with partial foot
amputations (such as the transmetatarsal amputation) for meaningful salvage (Fig.32.5).
476
J. M. Felder and J. P. Hong
a
b
c
d
Fig. 32.5 Forefoot wounds with involvement of the toes
in patients with peripheral vascular disease (PVD) should
be considered for conversion to a transmetatarsal amputation (TMA), with ap coverage if needed. This provides a
stable, denitive level of amputation that is functional for
ambulation and does not risk the formation of future toe
wounds with progression of PVD. (a–c) The patient from
Fig. 32.3 after revascularization and debridement with
rst ray resection. Although perfused, the toes have signicant wounds with tendon exposure that would require
complex coverage. They are at signicant risk of wound
e
f
recurrence. (d) Conversion to a TMA was performed, and
the rst ray amputation defect covered with a gracilis ap
anastomosed end-to-end to the rst dorsal metatarsal
artery and subcutaneous vein. The gracilis muscle ap
was chosen rather than a skin ap because the patient
required angioplasty for reperfusion of the foot. Muscle
aps provide a larger capillary bed and lower outow
resistance, which may assist with maintaining patency of
vascular interventions. (e, f) Stable, healed TMA at 1year
post-op. The patient returned to ambulation without assistive devices and had no recurrence of wounds
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Algorithmic Approach
toReconstruction
Although diabetic foot wounds can be complex
with many reconstructive considerations, a simple 3-step algorithm is a good starting point for
the advanced microsurgical approach. The algorithm assumes the operator is comfortable with
any ap type and focuses on choosing the best
reconstruction for the particular defect based on
three factors:
1. Consider the wound and the reconstructive
requirements.
2. Review angiography or other vascular imaging (e.g., ultrasound) and commit to a choice
of recipient vessels, using the best-available
vessels.
(a) If there is no signicant PVD and high-
quality vessels are available adjacent to
the wound, these should be chosen preferentially, regardless of their size, to
decrease operative morbidity.
(b) If severe PVD is present or no suitable
small vessels are adjacent to the wound,
major recipient vessels should be chosen
regardless of their distance from the
wound.
3. Choose the ap based on:
(a) The appropriate pedicle length from the
chosen recipient vessels to the wound and
(b) The reconstructive requirements of the
wound (e.g., thick/thin skin, weight bearing or not, dead space, outow resistance, etc.)
The following sections deal with each of these
considerations in turn. The presented cases will
also emphasize this algorithm.
Types ofWounds andDefectSpecic Considerations
The foot is a specialized weight bearing structure
and enough of its critical components must be
intact if functional ambulation is the goal. This
includes the bony architecture, specialized glabrous skin, protective sensation, vascular perfusion, and thin contour that allows footwear.
Diabetic foot wounds can present with an endless variety of involvement of each of these components [8]. This chapter will focus on common
examples, organized by forefoot, midfoot, hindfoot, ankle, and massive wounds. The examples
considered will be exclusively those that require
microsurgical reconstruction. It should be recognized by the reader that local ap alternatives
may exist and be preferable in some of the scenarios discussed, but their inclusion is beyond the
scope of this chapter [9, 10].
Forefoot Wounds
The forefoot is a relatively privileged area in that
signicant bony sacrice can be made while preserving good function. This is important, as many
forefoot wounds that reach the point of requiring
free tissue transfer for salvage will involve osteomyelitis. However, the forefoot also has the signicant downside of being the area most affected
by peripheral vascular disease. Thus, patients
with good blood ow are often high priority candidates for salvage despite osteomyelitis and soft
tissue loss. Conversely, patients with the same
wound and signicant PVD are generally poor
candidates for salvage.
Generally, acral forefoot wounds such as toe
infections or osteomyelitis of the toes can be
treated with limited amputation of the involved
digits, or llet aps. We have reported reconstruction of toe or webspace defects with superthin aps (e.g., supercial circumex iliac artery
perforator—SCIP, posterior interosseous artery
perforator—PIA) connected to the digital vessels (Figs.32.6 and 32.7) [11, 12]. Use of these
techniques must be carefully considered against
the more traditional options of toe amputation
or llet ap due to the reliability of these traditional procedures for resolution and prevention
of recurrence. However, the goal of “advanced
reconstruction” is to be able to provide new
solutions that are function-sparing and more
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