Suh Hyun Suk, Oh Tae Suk, Lee Ho Seung, Lee Seung Hwan, Cho Yong Pil, Park Joong Ryul, Hong Joon Pio
Seoul, Republic of Korea.
From the Departments of Plastic and Reconstructive Surgery, Orthopedic Surgery, Cardiology, Vascular Surgery, and Endocrinology, Asan Medical Center, University of Ulsan Collage of Medicine.
Plast Reconstr Surg. 2016 Oct;138(4):702e-709e. doi: 10.1097/PRS.0000000000002401.
Major vessels in the diabetic foot are often calcified and inadequate for use as recipient vessels. Thus, a supermicrosurgery technique using small branches or perforators from other collateral vessels with an adequate pulse may be an alternative method. This study evaluated outcome using the supermicrosurgery concept and the risk factors involved.
Ninety-five cases of diabetic foot reconstruction were reviewed; the average patient age was 57 years; average follow-up was 43.5 months. Débridement was performed according to the angiosome concept, and reconstruction was performed with perforator flaps using the supermicrosurgery approach. Correlation between total flap loss and 16 preoperative risk factors (age, sex, diabetes mellitus type, smoking, immunosuppression, flap size, hemoglobin A1c, ankle-brachial index, preoperative transcutaneous partial pressure of oxygen, C-reactive protein, computed tomographic angiography, amputation history, peripheral artery disease, American Society of Anesthesiologists physical status, osteomyelitis, and chronic renal failure) were analyzed.
Of 95 cases, nine cases of total loss and 12 of minor complication were noted. Among the risk factors, the odds for failure after peripheral artery disease was 10.99 (p = 0.035), and that associated with a history of amputation was 9.44 (0.0006). Other factors had no correlation with flap loss, including cases with no or one major vessel. Flap survival rate was 90.5 percent, and the overall limb salvage rate was 93.7 percent.
Despite the high risk of failure related to peripheral artery disease and history of amputation, the supermicrosurgery approach using a recipient vessel with good pulsation regardless of the source can achieve limb salvage. This approach extends the possibility for reconstruction in patients with severe ischemic diabetic foot.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
糖尿病足的主要血管常发生钙化，不适宜用作受体血管。因此，利用其他有充足搏动的侧支血管的小分支或穿支进行的超显微外科技术可能是一种替代方法。本研究评估了采用超显微外科理念的治疗结果及相关危险因素。
回顾了95例糖尿病足重建病例；患者平均年龄57岁；平均随访43.5个月。根据血管体区概念进行清创，并采用超显微外科方法用穿支皮瓣进行重建。分析了皮瓣完全坏死与16项术前危险因素（年龄、性别、糖尿病类型、吸烟、免疫抑制、皮瓣大小、糖化血红蛋白、踝肱指数、术前经皮氧分压、C反应蛋白、计算机断层血管造影、截肢史、外周动脉疾病、美国麻醉医师协会身体状况分级、骨髓炎和慢性肾衰竭）之间的相关性。
95例中，有9例皮瓣完全坏死，12例发生轻微并发症。在危险因素中，外周动脉疾病患者术后失败的几率为10.99（p = 0.035），有截肢史患者的几率为9.44（0.0006）。其他因素与皮瓣坏死无关，包括无主要血管或仅有一条主要血管的病例。皮瓣存活率为90.5%，肢体总体挽救率为93.7%。
尽管外周动脉疾病和截肢史相关的失败风险较高，但无论来源如何，使用搏动良好的受体血管的超显微外科方法可实现肢体挽救。这种方法增加了严重缺血性糖尿病足患者重建的可能性。
临床问题/证据级别：治疗性，IV级
