Lu Jocelyn, DeFazio Michael V, Lakhiani Chrisovalantis, Abboud Michel, Penzler Morgan, Elmarsafi Tammer, Kim Paul J, Attinger Christopher E, Evans Karen K
Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC.
Department of Plastic Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC.
J Reconstr Microsurg. 2019 Feb;35(2):117-123. doi: 10.1055/s-0038-1667363. Epub 2018 Aug 12.
Recent evidence documenting high success rates following microvascular diabetic foot reconstruction has led to a paradigm shift in favor of more aggressive limb preservation. The primary aim of this study was to examine reconstructive and functional outcomes in patients who underwent free tissue transfer (FTT) for recalcitrant diabetic foot ulcers (DFUs) at our tertiary referral center for advanced limb salvage.
Between June 2013 and June 2016, 29 patients underwent lower extremity FTT for diabetic foot reconstruction by the senior author (K.K.E.). In all cases, microsurgical reconstruction was offered as an alternative to major amputation for the management of recalcitrant DFUs. Overall rates of flap survival, limb salvage, and postoperative ambulation were evaluated. The lower extremity functional scale (LEFS) score was used to assess functional outcomes after surgery.
Overall rates of flap success and lower limb salvage were 93 and 79%, respectively. Flap failure occurred in two patients with delayed microvascular compromise. Seven patients in this series ultimately required below-knee amputation secondary to recalcitrant infection ( = 5), intractable pain ( = 1), and limb ischemia ( = 1). The average interval between FTT and major amputation was 8 months (, 0.2-15 months). Postoperative ambulation was confirmed in 25 patients (86%) after a mean final follow-up of 25 months (, 10-48 months). The average LEFS score for all patients was 46 out of 80 points (, 12-80 points), indicating the ability to ambulate in the community with some limitations.
FTT for the management of recalcitrant DFUs is associated with high rates of reconstructive success and postoperative ambulation. However, several patients will eventually require major amputation for reasons unrelated to ultimate flap survival. These data should be used to counsel patients regarding the risks, functional implications, and prognosis of microvascular diabetic foot reconstruction.
近期有证据表明，微血管糖尿病足重建术后成功率很高，这导致了一种范式转变，即更倾向于积极保肢。本研究的主要目的是在我们的三级高级肢体挽救转诊中心，检查接受游离组织移植（FTT）治疗顽固性糖尿病足溃疡（DFU）患者的重建和功能结果。
2013年6月至2016年6月期间，29例患者由资深作者（K.K.E.）接受了下肢FTT进行糖尿病足重建。在所有病例中，显微外科重建被作为治疗顽固性DFU的主要截肢替代方案。评估了皮瓣存活、肢体挽救和术后行走的总体发生率。采用下肢功能量表（LEFS）评分评估术后功能结果。
皮瓣成功和下肢挽救的总体发生率分别为93%和79%。2例患者出现皮瓣失败，伴有微血管延迟受损。本系列中有7例患者最终因顽固性感染（n = 5）、顽固性疼痛（n = 1）和肢体缺血（n = 1）而需要进行膝下截肢。FTT与主要截肢之间的平均间隔时间为8个月（范围，0.2 - 15个月）。平均末次随访25个月（范围，10 - 48个月）后，25例患者（86%）证实可术后行走。所有患者的平均LEFS评分为80分中的46分（范围，12 - 80分），表明在社区中行走有一定限制。
FTT治疗顽固性DFU与较高的重建成功率和术后行走率相关。然而，一些患者最终仍会因与最终皮瓣存活无关的原因而需要进行主要截肢。这些数据应用于向患者咨询微血管糖尿病足重建的风险、功能影响和预后。
