Vascular surgery, microsurgery and supramicrosurgery for treatment of chronic diabetic foot ulcers to prevent amputations

Abstract

Introduction: Diabetic foot ulcers occur in approximately 2,5% of patients suffering from diabetes and may lead to major infections and amputation. Such ulcers are responsible for a prolonged period of hospitalization and co- morbidities caused by infected diabetic foot ulcers. Small, superficial ulcers can be treated by special conservative means. However, exposed bones or tendons require surgical intervention in order to prevent osteomyelitis. In many cases reconstructive surgery is necessary, sometimes in combination with revascularization of the foot. There are studies on non surgical treatment of the diabetic foot ulcer. Most of them include patients, classified Wagner 1-2 without infection. Patients presenting Wagner 3D and 4D however are at a higher risk of amputation. The evolution of microsurgery has extended the possibilities of limb salvage. Perforator based flaps can minimize the donorsite morbidity.

Patients and methods: 41 patients were treated with free tissue transfer for diabetic foot syndrome and chronic defects. 44 microvascular flaps were needed. The average age of patients was 64.3 years. 18 patients needed revascularization. 3 patients needed 2 microvascular flaps. In 6 cases supramicrosurgical technique was used.

Results: There were 2 flap losses leading to amputation. 4 other patients required amputation within 6 months postoperatively due to severe infection or bypass failure. Another 4 patients died within one year after reconstruction. The remaining patients were ambulated.

Discussion: Large defects of the foot can be treated by free microvascular myocutaneous or fasciocutaneous tissue transfer. If however, small defects, exposing bones or tendons, are not eligible for local flaps, small free microvascular flaps can be applied. These flaps cause a very low donor site morbidity. Arterialized venous flaps are another option for defect closure. Amputation means reduction of quality of life and can lead to an increased mortality postoperatively.

Figure 1. 55y.old patient with diabetes and peripheral arterial disease and defect of the heel and exposed bones.

The patient required flap and bypass. A reversed greater saphenous bypass was planned including an arterialized venous flap. The bypass supplies the flap by arterial means. 2 separate veins are anastomosed to provide venous outflow.

Figure 2. Preoperative planning of the arterialized venous flap.

Bypass is anastomosed to the popliteal artery proximally, and the medial plantar artery distally.

Figure 3. Intraoperative situs: the donor site proximally is covered with a skin graft.

The flap covers the distal defect.

Figure 4. Arterialized venous flap 6 months postoperative.

Figure 5. Donor site of the arterialized flap 6 months postoperative.

Figure 6. 60 y. old patient with diabetes after reconstruction with a parascapular flap covering exposed bone and plantar surface.

Figure 7. Same patient with a new defect on the lateral foot after reconstruction of the medial foot with a parascapular flap.

The new defect leaves a defect of bone, that requires intensive surgical debridement and coverage.

Figure 8. Intraoperative situs: the free peroneus brevis muscle flap, obliterates and closes the defect (flap anastomosis to the lateral tarsal artery).

Figure 9. 6 weeks after reconstruction.

The muscle is covered with a split thickness skin graft.