Wound Healing Society

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Hyunsuk Peter Suh, Professor
Korea University Medical Center, Seoul, South Korea

Background: Diabetic foot ulcers can occur because of a combination of neuropathy, microvascular angiopathy, mechanical stress, and uncontrolled blood glucose levels. In addition to causing severe morbidities, they are the most common non-traumatic cause of amputations. Since microsurgery for diabetic foot reconstruction is no longer considered contraindicated, the use of free flaps for toe resurfacing after diabetic ulcers or reconstruction of defects secondary to toes amputation is an effective approach to maintain the length of the foot and preserve the ankle power generation in normal mechanics of gait. We propose that through this approach we avoid transmetatarsal amputation to ensure closure of the defect and decrease the healing time of patients in which secondary intention closure is the proposed option.

Methods: Retrospective data of 43 patients were evaluated according to their surgical method. . When required, toes amputations were performed by the orthopedic surgeon, sparing healthy surrounding tissue and metatarsal heads. Metatarsophalangeal joints were preserved when was possible.

Results: Preoperative percutaneous transluminal angioplasty (PTA) was performed in 10 patients (23.25%) of which in 9 cases were successful. Toes amputations were performed in 26 cases; big toe only in 8 cases (30.76 percent), big and lesser toes in 1 case (3.8 percent), single lesser toe in 10 cases (38.46 percent), multiple lesser toes in 7 cases (26.92 percent). Among big toe amputation cases, 6 cases were at metatarso-phalangeal level (66.7 percent) and 3 cases were distal phalangeal amputation (33.3 percent). Microsurgical reconstruction for toe resurfacing and after toes amputation was performed in 43 patients; big toe only in 22 cases (51.16 percent), big and lesser toes in 3 cases (6.97 percent), single lesser toe in 10 cases (23.25 percent), multiple lesser toes in 8 cases (18.6 percent). Major reamputation rate after microsurgical flap reconstruction was 6.97 percent (3 cases) with 35.42 months of free major amputation time (range, 0.66 to 54.8). Minor amputation after reconstruction was performed in 6 cases (13.9 percent). Limb salvage rate was 93.03% with a mean follow-up of 1029.32 days (range, 25 to 3330 days).

Conclusions: We strongly believe that avoiding transmetatarsal amputation by doing free flap reconstruction, allows maintaining the normal mechanics of gait and preventing new episodes of ulceration and therefore reamputation.

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