Title: Diabetic foot salvage using anterolateral thigh ...



Diabetic Foot Salvage Using Anterolateral Thigh Perforator Flap

Joon Pio Hong, MD, PhD; Yoon Kyu Chung, MD, PhD

Treatment of diabetic foot remains to be difficult and challenging problem. When complicated with ulcerations, infections, and osteomyelitis, patients are subjected to proximal-level amputations. It is reported that 3-year survival rate in diabetic patients after first amputation is approximately 61%.1 Diabetic patients with foot ulcers and infections have decreased quality of life not to mention survival. Despite the recent advances in microsurgery, its application to reconstruct wounds in diabetic patients has been low. The concerns regarding flap viability, occlusion of flow to distal limb, general condition, and economic burden for the patient still remains to be a problem. The use of fasciocutaneous flaps and muscle flaps with skin grafts for reconstruction of the feet has been successfully applied. But controversy still remains on which kind of flap should be the most reliable choice. The ideal flap for reconstruction of diabetic foot should provide a well vascularized tissue to control infection, adequate contour for footwear, durability, and solid anchorage to resist shearing forces. This paper reviews the efficacy of anterolateral thigh perforator flap as another armament and to approach closer toward the ideal flap to reconstruct the diabetic foot.

Patients and Methods: This is a retrospective study of 32 (9 female and 23 male) diabetic patients with infected foot ulcers reconstructed with anterolateral thigh perforator flap from June of 2000 to January of 2004. Ages ranged from 33 to 68 years, with an average of 48.3 years of age. After complete medical and physical examination, the patients underwent debridement and reconstruction with anterolateral thigh perforator flap when feasible (Figure 1).

Results: Total of 32 anterolateral thigh perforator flaps were performed in patients with diabetic foot ulcers. Follow-up ranged from 3 to 43 months with an average of 19 months. Complete survival of the flap was noted in 30 cases and partial loss in 2 cases. All patients achieved bipedal gait and ambulation without assistance. The dimension of the flap ranged from 5 x 9 cm. to 8x 19 cm. with an average of 94 cm2. The arterial anastosmosis was performed in the manner not to alter the distal flow. An end-to-end anastomosis was performed in only 6 cases where the pedal arteries terminated as a stump. Among the 3 patients with minor complications, two showed partial wound dehiscence of the flap but healed without surgical management. In one patient, dehiscence and infection of the donor site was noted. Debridement, irrigation and repair were required to achieve wound healing. Partial flap loss was noted in two cases. One case required secondary skin graft procedure and eventually healed but the other case required partial foot amputation despite of the remaining flap due to exposure of vital structures of the distal foot. Both patients, 4 weeks prior to the reconstruction, underwent angioplasty on the popliteal region of the artery. Recurrence of ulceration on the flap was noted in one case. The patient had visual impairment due to diabetic complications and was unable to perform visual examinations the foot. The ulcerations on the flap were healed with conservative care but repetitive ulceration was noted despite periodic follow-up.

Conclusion: Microsurgical reconstruction of the diabetic foot should follow strict guidelines and preparation. Angiogram is required to analyze the vascular patency of the foot, systemic condition should allow the patient to undergo general anesthesia and recovery, and patient motivation and education to continue with ambulation and prevent recurrence. When decided for reconstruction, complete debridement of infected tissue and bone is essential. Anterolateral thigh perforator flaps is thin and durable and can be combine with vastus lateralis muscle to provide additional bulk. Whenever possible, major arteries should not be sacrificed which may decrease the vascular supply to the diabetic foot. Experience with anterolateral thigh perforator flaps in diabetic foot has shown to be successful with low recurrences after a vigorous patient education and rehabilitation program. A salvage procedure would benefit patients who are ambulatory. In this study, all patients were able to ambulate without assistance. After stabilization of the incorporated flap, the patient was referred to the rehabilitation department for special custom designed shoes and rehabilitation program. The patient was educated to inspect the flap and foot on daily basis and was asked to make regular visit to the clinic for medical and physical exam. The patient compliance is one of the key factors in preventing late complications.

The anterolateral thigh perforator flap provides new advantages and also the advantages seen from both muscle and fasciocutaenous flaps and in what I believe as a step further toward an ideal flap to reconstruct the diabetic foot; a well vascularized tissue to control infection, a thin flap for simple contouring and less shearing, a skin paddle to resist pressure and improve durability. It would not be practical to categorize this flap into a preexisting anatomical classification of flaps to reconstruct the foot either as fasciocutaneous flap or muscle flap with skin graft but rather compare as a different entity. The anterolateral thigh perforator flaps can be used to achieve acceptable function and aesthetical result for diabetic foot reconstruction.

Fig 1.

A 65-year-old male with diabetes and ulcerations on the right foot is shown (A). After debridement, an 8 x 17 cm. anterolateral thigh perforator flap was used to wrap the remaining first toe and the medial aspect of the foot (B). The foot at 4 months shows good contour without evidence of recurrence (C, D).

[pic]A [pic] B

[pic]C [pic] D

References

1. Faglia, E., Clelia, P., Favales, F., et al. Angiographic evaluation of peripheral arterial occlusive disease and its role as a prognostic determinant for major amputation in diabetic subjects with foot ulcers. Diabetes Care. 21:625, 1998

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