Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2025 Sep;45(6):e70093.
doi: 10.1002/micr.70093.

Free Tissue Transfer for the Management of Diabetic Lower Limb Ulcers: A Systematic Review and Meta-Analysis

Quillan Young Sing  1 , Tiffanie-Marie Borg  2 , Yousif F Yousif  3 , Kai Jian Chin  4 , Konstantinos Devetzis  5 , Sara Sousi  6
Affiliations
Meta-Analysis

Free Tissue Transfer for the Management of Diabetic Lower Limb Ulcers: A Systematic Review and Meta-Analysis

Quillan Young Sing et al. Microsurgery. 2025 Sep.

Abstract

Background: Diabetic foot ulcers are a major complication of diabetes, with resulting soft tissue defects increasing the risk of limb amputation and mortality. Reconstruction of defects may be in the form of local, pedicled, or free tissue transfer. This systematic review aims to confirm the role and benefit of free tissue transfer in this patient cohort.

Method: This review is registered on PROSPERO (ID: 617657). A literature search was performed using the online databases EMBASE, MEDLINE, and Web of Science to identify literature reporting use of free flaps in the management of diabetic lower limb ulcers. Mesh terms used included "diabetes," "lower limb," "ulcer," and "free tissue transfer." A random-effect meta-analysis was implemented to assess the efficacy of free flaps as a treatment based on complication and limb salvage rates.

Results: Twenty-five studies were included in this systematic review, amounting to 547 free flaps. The total complication rate was 26% (95% CI = 21%-32%, I2 = 27%, p = 0.11). Partial flap loss was noted in 6% of cases (95% CI = 3%-11%, I2 = 0%, p = 0.96) while complete loss occurred in 4% of cases (95% CI = 2%-7%, I2 = 0%, p = 1.0). The most performed flap was the anterolateral thigh (ALT) flap. Revascularization was performed prior to free flap reconstruction in 15% of cases. The amputation-free rate was 95% at the latest follow-up point of each study.

Conclusion: Free tissue transfer is a viable treatment option for patients with diabetic foot ulcers. The low complication including amputation rate supports its implementation in practice provided a myriad of factors and careful patient selection is maintained.

Keywords: diabetic foot ulcer; free tissue transfer; lower limb.

PubMed Disclaimer

References

    1. Bernadette, A., C. N. Hile, A. D. Hamdan, et al. 2004. “Major Lower Extremity Amputation: Outcome of a Modern Series.” Archives of Surgery 139: 395–399.
    1. Boulton, A. J. M., A. J. Boulton, D. G. Armstrong, et al. 2008. “Comprehensive Fool Examination and Risk Assessment: A Report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, With Endorsement by the American Association of Clinical Endocrinologists.” Physical Therapy 31: 1679–1685.
    1. Chou, C., P.‐J. Kuo, Y.‐C. Chen, et al. 2016. “Combination of Vascular Intervention Surgery and Free Tissue Transfer for Critical Diabetic Limb Salvage.” Annals of Plastic Surgery 77, no. Suppl 1: S16–S21. https://doi.org/10.1097/sap.0000000000000812.
    1. Crowe, C. S., D. Y. Cho, C. J. Kneib, S. D. Morrison, J. B. Friedrich, and K. A. Keys. 2019. “Strategies for Reconstruction of the Plantar Surface of the Foot: A Systematic Review of the Literature.” Plastic and Reconstructive Surgery 143: 1223–1244.
    1. Eskelinen, E., I. Kaartinen, M. Kääriäinen, and H. Kuokkanen. 2015. “Successful Foot Salvage With Microvascular Flaps in Diabetic Patients.” Scandinavian Journal of Surgery 104, no. 2: 103–107. https://doi.org/10.1177/1457496914524389.

LinkOut - more resources