SLR - October 2022 - Shazeb Rizvi, DPM
Reference: Chia-Yu Oua , Meng-Si Wub,e, Mei-Chen Linc,f, Chun-Ming Changde,Short-term and long-term outcomes of free flap reconstruction versus amputation for diabetic foot reconstruction in patients with end-stage renal disease
Level of evidence: Level III- Retrospective Series
Scientific Literature Review
Reviewed by Shazeb Rizvi, DPM
Residency Program: Phoenix VA (Carl T Hayden) Medical Center- Phoenix, AZ
Podiatric Relevance: Diabetic foot infections are one of the most common conditions that Podiatrist will encounter in training and even throughout their careers. It is important to have a systematic approach with multiple tools to properly assess the condition and determine if conservative or more aggressive treatment is warranted especially in cases where multiple comorbidities exist. Typical surgical interventions can include amputations or free flap reconstructions. Although there and risks and benefits with each approach, there is no clean consensus on the effects of end stage renal diseases on patients who undergo reconstruction with free flaps. The aim of this study was to determine the long-term outcomes of end stage renal disease patients undergoing diabetic foot reconstruction using free flaps.
Methods: A retrospective cohort study was done comparing the outcomes of hemodialysis patient with end stage renal disease undergoing amputation or free flap reconstruction. Data was collected from National Health Insurance Research Database for patients during 2000-2013. 86 patients were assigned to free flap recon and 344 to amputation. Patient were followed up until mortality, further loss of limb or until end of time period till 2013.
Results: 344 patients underwent amputations, and 86 free flap reconstruction. Within the free flap group that rate of flap failure related amputation was 24.1%. Overall the free flap group had significantly lower 1,3, and 5 year mortality rate compared to amputation group, but no difference seen for longer term follow up. Further, the mortality rate was higher in patients who underwent amputation after free flap recon vs those who did not get amputation.
Conclusions: The authors of this study found that patients with ESRD and diabetic foot ulcers who underwent free flap recon had higher 1,3-, and 5-year survival rate than those who got amputations. The use of free flap techniques can increase the chances of independent ambulation and long-term survival for patients. This is further supported by numerous studies that have shown mortality rates increase drastically for patients who undergo amputations such as trans-metatarsal and below/above knee amputations. Although avoiding amputation has benefits, flap procedures require longer anesthesia time and this can be problematic for patients with multiple comorbidities. Although larger studies are needed to definitively anoint one over the other it is not surprising that they yield somewhat similar long-term results. Withstanding, it is crucial that clinicians weigh risks/benefits and use prudent clinical judgment based on compliance, social history, medical comorbidities when choosing surgical options.