SLR - March 2020 - Nicholas D. Salerno
References: Ramanujam, C. L., & Zgonis, T. (2019). Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review. Foot & Ankle Specialist, 12(3), 286–293. https://doi.org/10.1177/1938640018803745Scientific Literature Review
Reviewed By: Nicholas D. Salerno, DPM
Residency Program: MedStar Georgetown University Hospital – Washington, DC
Podiatric Relevance: As the prevalence of Diabetes Mellitus continues to grow, so are rates of diabetic associated foot ulcerations. Neuropathy, peripheral vascular disease and biomechanical deformities all increase risk for wound formation; which is the leading cause of hospitalization, and risk factor for amputation in the diabetic population. Treating wounds of the lower extremity requires adherence to a multifactorial algorithm, involving optimizing tissue perfusion, off loading pressure prone areas, antibiotics and surgical debridement. The healthy soft tissue we are left with post debridement often leaves a varying deficit, which must be closed in the most biomechanically favorable fashion. Remembering our soft tissue ladder, local tissue and muscle flaps are a valuable and versatile treatment option in compromised lower extremity wounds. This study was preformed to evaluate the outcomes of these flaps for the closure of specifically diabetic foot wounds.
Methods: A systematic review was preformed by two independent reviewers who identified 53 studies between 1997-2017, all involving diabetic patients being treated for foot wounds with the use of local random flaps with a follow up of six months. Of those 53 studies only 25 met their inclusion criteria; 72 percent were case series and 28 percent case reports. From these studies 512 patients were extracted in which 199 had undergone 204 local flap procedures. Documentation of healing rates, complications and revisional surgery’s were included in the eligible studies. Success of these flaps was defined as complete flap take, without occurrence of any type of complications.
Results: The average follow-up period in these studies was 2.06 years. Of the 25 eligible studies, the number of flaps preformed included standard rhomboid flap; 7.35 percent, Stepladder V-Y advancement flap; 0.49 percent, Subcutaneous flap of the medial lower leg; 0.49 percent, Toe fillet flap; 1.961 percent, Transposition flap; 2.941 percent, Unilobed rotation flap; 0.49 percent, V to Y fasciocutaneous flap; 6.373 percent, and V to Y septofascuicutaneous flap; 0.98 percent. Success of each flap was based on complete take, with no complications or need for further surgery. Of 204 random local flaps 154; 75.5 percent were considered successful. While 50; 24.5 percent of flaps were considered failures due to complications. The most common complications was wound dehiscence; 33 patients, postoperative infection; 10 patients, new onset Charcot; four patients, transfer ulcer; one patient, wound recurrence; one patient and flap congestion; one patient.
Conclusions: The treatment of diabetic foot ulcerations and gangrene can be appropriately treated with accurate assessment, debridement, and cultures. Its repair is dictated by the remaining soft tissue post debridement, and its biomechanical stability. Based on the evidence found in this systemic review, local pedal flaps show a relatively high rate of success in the definitive closure of diabetic foot ulcerations at a success rate of 75.5 percent based on these studies. These local flaps listed above should be considered as a viable surgical option, once the wound has been appropriately debrided, perfusion has been optimized, and all formed of anti-infective therapy have been started.