Soft tissue reconstruction pyramid in the diabetic foot

Staged management of a large ischemic heel ulcer in a diabetes patient: a case report

Heel ulcer is one of the severe complications of patients with diabetes mellitus, which poses a high risk for foot infection and amputation, especially in patients with peripheral arterial disease and neuropathy. Researchers have searched for new treatments for treating diabetic foot ulcers in recent years. In this case report, we demonstrated the treatment of large ischemic ulcers for the first time in a diabetic patient. The overall treatment goal of this patient was designed to improve blood supply to her diseased lower extremities and close the ulcer. This two-stage reconstruction approach resulted in an ulcer-free, stable, plantigrade foot at postoperative follow-up.

Local Random Flaps for the Diabetic Foot

Diabetic foot wounds should be treated in a timely fashion to prevent infection and potential limb loss. When local wound care and traditional off-loading fails, surgeons may consider local random flaps for definitive closure. Wound size, location, and type are characteristics that should be considered for selection of the best flap. This article reviews the application of local random flaps in the treatment of diabetic foot wounds.

A Two-Stage Diabetic Foot Salvage Using Synthetic Bone Void Filler and Lesser Toe Fillet Flap: A Case Report

CASE

A 54-year-old type 2 diabetic man with a diabetic forefoot ulcer and osteomyelitis successfully underwent a staged reconstruction to salvage his foot. An antibiotic-carrying bone void filler was used to decrease the infection burden after initial debridement. The fifth toe fillet flap was performed to cover the large soft-tissue defect. The patient returned to baseline ambulation at the 1-year follow-up with a well-incorporated flap.

CONCLUSION

This case highlights the utility of combining an antibiotic-carrying bone void filler and a toe fillet flap in a two-stage approach to salvage complex diabetic foot ulcers.

Modification of the abductor digiti minimi muscle flap for soft tissue coverage of the diabetic foot

The local intrinsic abductor digiti minimi muscle flap is ideal for lateral, plantar lateral traumatic or diabetic foot wounds following adequate surgical debridement to eradicate any soft tissue and/or osseous infection. Although the indications and surgical technique have been well-described in the literature, the authors present a unique modification of tunnelling the harvested muscle flap directly from the donor site to the plantar recipient foot wound by maintaining the intact overlying skin island at the surface of the fifth metatarsal base. This modification allows preservation of the patient's skin integrity in this area, thereby minimising potential morbidity at the major pedicle site. After the harvested muscle is tunnelled through the intact skin island, an adjacent local random flap mobilisation, autogenous or allogeneic skin graft can then be used for coverage over the muscle inset if primary wound closure is not feasible. Simultaneous soft tissue or osseous surgical procedures and/or surgical offloading with external fixation at the time of index surgery may be necessary to achieve optimal outcomes. The authors present a modified surgical technique for the abductor digiti minimi muscle flap that can be performed in the surgical reconstruction of a soft tissue wound in patients with diabetic Charcot neuroarthropathy.

Surgery for the diabetic foot: A key component of care

Surgery for acute and chronic diabetic foot problems has long been an integral component of care. While partial foot amputations remain as important diabetic limb-salvaging operations, foot-sparing reconstructive procedures have become equally important strategies to preserve the functional anatomy of the foot while addressing infection, chronic deformities, and ulcerations. A classification of types of diabetic foot surgery is discussed in accordance with the soft tissue status and acuity of the presenting foot problem. This brief overview from the Association for Diabetic Foot Surgeons describes common conditions best treated by surgical interventions, as well as specific indications. While techniques and indications continue to evolve, effective surgical management of the diabetic foot remains an integral component of care as well as for the prevention of recurrent ulceration.

Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review

"A systematic review was undertaken to assess the outcomes of local random flaps in diabetic foot wound closure. The review was conducted using the following databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica dataBASE, Google Scholar, MEDLINE, Ovid, and PubMed. Search terms were local random flap, diabetes, foot, wound, ulceration, neuropathy, tissue transfer, V-Y, bilobed, monolobed, rotational, advancement, transpositional, rhomboid, and Limberg. English language studies, studies published from 1997 to 2017, patients with diabetes mellitus treated for foot wounds, use of local random flaps, follow-up period of 6 months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery were included. Isolated literature reviews and descriptions of only surgical technique and/or cadaveric studies were excluded. The initial search identified 53 eligible studies with 28 being excluded. The remaining 25 studies used for data extraction had a total of 512 patients in which 199 of these underwent 204 local random flap procedures. Average follow-up for the flaps was approximately >2 years, and successful wound closure at last follow-up was demonstrated in 75.5% of the studied population. Studies were found to be of generally low quality, with the majority composed of retrospective case series. Based on current available evidence found in this systematic review, local random flaps demonstrated a relatively high success rate when utilized for the definitive closure of diabetic foot wounds. However, because of a lack of high-quality evidence and substantial heterogeneity among the studies, the results should be interpreted with caution. Levels of Evidence: Level III: Systematic review.

The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity

BACKGROUND

Small (<30 cm) soft tissue defects of the distal leg, foot, and ankle pose a complicated issue with regard to wound healing. Multiple flaps have been proposed for reconstruction of these wounds with varying levels of success. The medial femoral condyle flap is a free bone flap supplied by the descending geniculate artery. It is currently used in the treatment of fracture nonunion, infected bone defects, avascular necrosis, and osteoradionecrosis. This study proposes the use of the periosteal portion of the medial femoral condyle (PMFC) flap for soft tissue reconstruction of the distal leg, foot, and ankle.

METHODS

We performed a single-center, retrospective series of 6 patients with distal leg, foot, and ankle wounds. All patients underwent reconstruction using the PMFC flap.

RESULTS

Of the 6 patients, 5 had chronic wounds. There were no incidences of flap loss. Five patients healed without complication, four of which had undergone immediate skin grafting, whereas one had concomitant skin paddle reconstruction. The remaining patient required a second surgery with a rotation flap for recurrent osteomyelitis and wound infection 2 months after the initial surgery. Mean operative time decreased after a 2-case learning curve.

CONCLUSIONS

Small wounds of the distal extremity can be difficult to treat, with many requiring free or rotational flap coverage. We propose novel use of the PMFC flap for reconstruction of small soft tissue defects of the distal leg, foot, and ankle. In our series, we demonstrated no donor site morbidity, with excellent cosmetic and functional outcomes.

Soft Tissue Reconstruction Pyramid for the Diabetic Charcot Foot

Foot and ankle ulcerations in patients with diabetic Charcot neuroarthropathy (DCN) occur frequently and can be challenging to address surgically when conservative care fails. Patients with acute or chronic diabetic foot ulcers (DFU) are at continued risk for development of osteomyelitis, septic arthritis, gas gangrene, and potential lower extremity amputation. Concurrent vasculopathy and peripheral neuropathy as well as uncontrolled medical comorbidities complicate the treatment approach. In addition, pathomechanical forces left untreated may contribute to DFU recurrence in this patient population. This article outlines in detail the stepwise approach and options available for durable soft tissue coverage in the DCN patient.

Literature review on the management of diabetic foot ulcer

Diabetic foot ulcer (DFU) is the most costly and devastating complication of diabetes mellitus, which affect 15% of diabetic patients during their lifetime. Based on National Institute for Health and Clinical Excellence strategies, early effective management of DFU can reduce the severity of complications such as preventable amputations and possible mortality, and also can improve overall quality of life. The management of DFU should be optimized by using a multidisciplinary team, due to a holistic approach to wound management is required. Based on studies, blood sugar control, wound debridement, advanced dressings and offloading modalities should always be a part of DFU management. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management in some cases. Also, hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bio-engineered skin and growth factors could be used as adjunct therapies for rapid healing of DFU. So, it’s suggested that with appropriate patient education encourages them to regular foot care in order to prevent DFU and its complications.

Diabetic foot ulcers: Part II. Management

The management of diabetic foot ulcers can be optimized by using an interdisciplinary team approach addressing the correctable risk factors (ie, poor vascular supply, infection control and treatment, and plantar pressure redistribution) along with optimizing local wound care. Dermatologists can initiate diabetic foot care. The first step is recognizing that a loss of skin integrity (ie, a callus, blister, or ulcer) considerably increases the risk of preventable amputations. A holistic approach to wound assessment is required. Early detection and effective management of these ulcers can reduce complications, including preventable amputations and possible mortality.

Current therapies for diabetic foot infections and osteomyelitis

Treatment of the patient with a diabetic foot infection and underlying osteomyelitis is currently an evolving process, often complicated by neuropathy, peripheral vascular disease, and renal insufficiency. Understanding which patients require hospitalization, intravenous antibiotic therapy, and urgent operative intervention may ultimately prevent the spread of infection or major limb amputation. The treating surgeon should focus on accurate and early diagnosis, proper antibiosis, and appropriate surgical debridement to eradicate infection while preserving function with a plantar-grade foot.

Aggressive early reconstruction in open foot trauma: a case report

Open fracture-dislocation of the lower extremity poses a serious risk, has a high incidence of complications, and necessitates prompt surgical intervention. Patients need to be evaluated on presentation to the emergency department for neurovascular injury, soft-tissue insult, stability of the fracture, concomitant injuries, and overall medical/nutritional status. Implementation of a specific treatment protocol will decrease time to operative management and increase the overall success rate. Success after treatment of lower-extremity trauma should be defined as a noninfected, functional limb with optimal tissue preservation allowing ambulation. We present a case of open fracture-dislocation of the first ray treated with prompt debridement, skeletal stabilization, and immediate soft-tissue reconstruction.

Diabetic Lisfranc fracture-dislocations and Charcot neuroarthropathy

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.

The use of split-thickness skin grafts on diabetic foot ulcerations: a literature review

Diabetic foot ulcerations are historically difficult to treat despite advanced therapeutic modalities. There are numerous modalities described in the literature ranging from noninvasive topical wound care to more invasive surgical procedures such as primary closure, skin flaps, and skin grafting. While skin grafting provides faster time to closure with a single treatment compared to traditional topical wound treatments, the potential risks of donor site morbidity and poor wound healing unique to the diabetic state have been cited as a contraindication to its widespread use. In order to garner clarity on this issue, a literature review was undertaken on the use of split-thickness skin grafts on diabetic foot ulcers. Search of electronic databases yielded four studies that reported split-thickness skin grafts as definitive means of closure. In addition, several other studies employed split-thickness skin grafts as an adjunct to a treatment that was only partially successful or used to fill in the donor site of another plastic surgery technique. When used as the primary closure on optimized diabetic foot ulcerations, split-thickness skin grafts are 78% successful at closing 90% of the wound by eight weeks.

Surgical soft tissue closure of severe diabetic foot infections: a combination of biologics, negative pressure wound therapy, and skin grafting

Creative surgical strategies are often warranted for long-term closure of diabetic foot wounds. This article provides a case report describing the successive use of negative pressure wound therapy, advanced biologics, and split thickness skin grafting for healing an extensive surgical wound. Although the success of these therapies is enticing, their use should be based on careful patient selection in a multidisciplinary setting.