SLR - April 2023 - Marisa Mosier, DPM
Title: Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomesReference: Sayyed AA, Towfighi P, Deldar R, Attinger CE, Evans KK. Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomes. Microsurgery. 2022 Sep;42(6):538-547. doi: 10.1002/micr.30889. Epub 2022 Apr 8. PMID: 35394669
Level of Evidence: III
Scientific Literature Review
Reviewed By: Marisa Mosier, DPM
Residency Program: Eastern Virginia Medical School, Norfolk VA
Podiatric Relevance: Non healing heel ulcerations along weight bearing surfaces are unfortunately frequent pathologies that present a significant challenge when it comes to limb salvage especially when coupled with complicated comorbidities such as diabetes and PVD. Free tissue transfer reconstruction presents an opportunity to preserve function, quality of life, ambulation and mortality rates. The purpose of this study was to describe surgical and functional outcomes in patients who underwent FTT for the treatment of chronic heel ulcers.
Methods: A retrospective review was performed on a highly comorbid 44 patient population who underwent a free flap reconstruction for the treatment of chronic heel ulcerations from 2011-2021. All surgeries were performed by a single institution and operating team. Patient demographics, comorbidities, perioperative data, post operative complications and long-term outcomes were studied. Patients were placed in 2 groups to compare outcomes, either successful limb salvage or amputation. Primary outcomes included flap success, limb salvage, post operative complications, rate of reoperation and long-term function.
Results: A total of 44 patients underwent free flap reconstructions with an average age of 57.3 years and a BMI of 30.1 kg/m2. There was no significant difference in age or BMI between salvage and amputation groups. Of note, comorbidities included 86.4% with calcaneal osteomyelitis, 79.5% with diabetes and 40.9% with PVD. The immediate microsurgical success rate of FTT flaps was 95.6%. After an average follow up of 20 months, a 73.3% limb salvage rate was noted. Preoperative albumin levels were higher within the limb salvage group (3 vs 2.4 g/dL). Overall amputation rate was increased in patients with a prior stroke history and lower baseline albumin levels. The risk for amputation increased with PVD, hypoalbunemia and post operative infection. 90.7% of patients were ambulatory by the end of their follow up period. There was no significant difference in LFES (functionality scores) in limb salvage versus amputees.
Conclusions: This study demonstrated the overall effectiveness of free flap reconstruction for chronic non healing heel wounds in pursuing limb salvage. There are several benefits to FTT’s including improved ambulation and function. This study demonstrated an overall 95.6% flap success rate. Limitations of this study include its retrospective nature and small sample size of 44 patients which may be addressed by performing a higher powered, prospective study in addition to perhaps assessing functional status and post operative morbidity of FTT’s over a longer follow up time period. It is crucial to consider a multidisciplinary approach when treating these recalcitrant ulcerations from preoperative optimization. These include but are not limited to workup such as venous mapping and angioplasty intervention along with overall medical management. It is important to maintain a working relationship with a lower extremity focused plastics team to offer your patient these options for limb salvage. FTT presents with a successful means of preserving both limb function and gait.