Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Xiaobing , LIU Hongjun , YANG Chao , XIONG Aibing , HE Xiaochuan , TIAN Xinli , LI Ying , YANG Ruqian ,  YAN Hong

Department of Plastic and Burn Surgery, Affiliated Hospital of Southwest Medical University, National Key Clinical Construction Specialty, Luzhou Sichuan, 646000, P. R. China;

Corresponding author：

YAN Hong, Email: huaxi90@126.com

Keywords：

Diabetic foot; ulcer; free anterolateral femoral flap; bone exposure; wound repair

DOI：

10.7507/1002-1892.202108110

Video：

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Objective To investigate the effectiveness of free anterolateral thigh flap (ALTF) with fascia lata in repairing diabetic foot ulcers (DFUs) with bone exposure. Methods Between January 2019 and January 2021, 20 patients with DFUs with bone exposure were admitted. There were 17 males and 3 females with a median age of 57.5 years (range, 48-76 years). There were 10 cases of Wagner grade 3 and 10 cases of grade 4. The DFUs formed 1 to 14 months, with a median time of 3 months. The patients underwent CT angiography, which showed extensive atherosclerosis in both lower limbs; 6 of them were severely narrowed or occluded and underwent percutaneous transluminal angioplasty. The size of wound ranged from 7 cm×6 cm to 27 cm×10 cm after applied first-stage debridement combined with vacuum sealing drainage treatment. In the second-stage, free ALTF with fascia lata was used to repair wounds and partial defects of tendons. The size of flap ranged from 8 cm×5 cm to 28 cm×11 cm. The wound of the donor site was sutured directly. The survival of the flap, the healing time of the wound, and the complications were recorded. The laser speckle blood flow imaging system was used to detect the blood perfusion of the flap and the skin around the flap at 2 weeks and 6 months after operation. The foot function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months after operation. Results After operation, effusion under the flap happened in 6 cases, which cured after symptomatic treatment. Flaps survived completely in 14 cases. The tissue necrosis at the edges of the flaps occurred in 3 cases and healed after dressing changes. Venous crisis of flaps occurred in 3 cases, of which 1 case was completely necrotic after exploration, and the other 2 cases were partially alive. The wounds of 3 cases were repaired with skin grafts after debridement and dressing. The flap survival rate was 95.0%, and the limb salvage rate was 100%. The wound healing time after flap transplantation was 14-30 days, with an average of 19.1 days. Two patients had recurrence of peripheral skin ulcers of the flaps within 1 month after healing, which healed after conservative dressing changes. Eighteen cases of incisions at donor site healed by first intention, 2 cases had local skin necrosis and healed by debridement and suture. All patients were followed up 6-30 months, with a median time of 11 months. The texture, appearance, and elasticity of the flaps were good. All patients could walk alone without pain. At 6 months after operation, the AOFAS score was 75.9±11.9, which was significantly different from that (44.7±18.4) before operation (t=−7.025, P=0.000). The blood perfusion value increased from (38.1±7.8) PU at 2 weeks to (42.7±10.3) PU, and the difference was significant (t=−4.680, P=0.001). Conclusion Free ALTF with fascia lata has a rich blood supply and a high survival rate. It can be used to repair DFUs with bone exposure. After the free skin flap healed, it can promote revascularization of the affected foot, reduce the probability of ulcer recurrence, and avoid amputation.

Citation： LI Xiaobing, LIU Hongjun, YANG Chao, XIONG Aibing, HE Xiaochuan, TIAN Xinli, LI Ying, YANG Ruqian, YAN Hong. Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(1): 86-91. doi: 10.7507/1002-1892.202108110 Copy

1.	Cho NH, Shaw JE, Karuranga S, et al. IDF diabetes atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract, 2018, 138: 271-281.
2.	Brownrigg JR, Schaper NC, Hinchliffe RJ. Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med, 2015, 32(6): 738-747.
3.	Skrepnek GH, Mills JL, Lavery LA, et al. Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the U. S. Diabetes Care, 2017, 40(7): 936-942.
4.	Olsson M, Järbrink K, Divakar U, et al. The humanistic and economic burden of chronic wounds: A systematic review. Wound Repair Regen, 2019, 27(1): 114-125.
5.	Xie P, Deng B, Zhang X, et al. Time in range in relation to amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers. Diabetes Metab Res Rev, 2021. doi: 10.1002/dmrr.3498.
6.	Eskelinen E, Kaartinen I, Kääriäinen M, et al. Successful foot salvage with microvascular flaps in diabetic patients. Scand J Surg, 2015, 104(2): 103-107.
7.	Lu J, DeFazio MV, Lakhiani C, et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg, 2019, 35(2): 117-123.
8.	Lakhiani C, DeFazio MV, Han K, et al. Donor-site morbidity following free Tissue harvest from the thigh: A systematic review and pooled analysis of complications. J Reconstr Microsurg, 2016, 32(5): 342-357.
9.	Niu Z, Chen Y, Li Y, et al. Comparison of donor site morbidity between anterolateral thigh and radial forearm free flaps for head and neck reconstruction: A systematic review and meta-analysis. J Craniofac Surg, 2021, 32(5): 1706-1711.
10.	Schneider W, Jurenitsch S. Normative data for the American Orthopedic Foot and Ankle Society ankle-hindfoot, midfoot, hallux and lesser toes clinical rating system. Int Orthop, 2016, 40(2): 301-306.
11.	Janhofer DE, Lakhiani C, Kim PJ, et al. The utility of preoperative arteriography for free flap planning in patients with chronic lower extremity wounds. Plast Reconstr Surg, 2019, 143(2): 604-613.
12.	Schirmer S, Ritter RG, Fansa H. Vascular surgery, microsurgery and supramicrosurgery for treatment of chronic diabetic foot ulcers to prevent amputations. PLoS One, 2013, 8(9): e74704. doi: 10.1371/journal.pone.0074704.
13.	Zhan Y, Fu G, Zhou X, et al. Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps. Int J Surg, 2017, 48: 53-58.
14.	Meloni M, Morosetti D, Giurato L, et al. Foot revascularization avoids major amputation in persons with diabetes and ischaemic foot ulcers. J Clin Med, 2021, 10(17): 3977. doi: 10.3390/jcm10173977.
15.	Ehrl D, Heidekrueger PI, Schmitt A, et al. The anterolateral thigh flap for Achilles tendon reconstruction: functional outcomes. Plast Reconstr Surg, 2019, 143(6): 1772-1783.
16.	Mennes OA, van Netten JJ, van Baal JG, et al. Assessment of microcirculation in the diabetic foot with laser speckle contrast imaging. Physiol Meas, 2019, 40(6): 065002. doi: 10.1088/1361-6579/ab2058.
17.	Tanaka K, Igari K, Kishino M, et al. The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report. Microsurgery, 2017, 37(6): 694-698.

1. Cho NH, Shaw JE, Karuranga S, et al. IDF diabetes atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract, 2018, 138: 271-281.
2. Brownrigg JR, Schaper NC, Hinchliffe RJ. Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med, 2015, 32(6): 738-747.
3. Skrepnek GH, Mills JL, Lavery LA, et al. Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the U. S. Diabetes Care, 2017, 40(7): 936-942.
4. Olsson M, Järbrink K, Divakar U, et al. The humanistic and economic burden of chronic wounds: A systematic review. Wound Repair Regen, 2019, 27(1): 114-125.
5. Xie P, Deng B, Zhang X, et al. Time in range in relation to amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers. Diabetes Metab Res Rev, 2021. doi: 10.1002/dmrr.3498.
6. Eskelinen E, Kaartinen I, Kääriäinen M, et al. Successful foot salvage with microvascular flaps in diabetic patients. Scand J Surg, 2015, 104(2): 103-107.
7. Lu J, DeFazio MV, Lakhiani C, et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg, 2019, 35(2): 117-123.
8. Lakhiani C, DeFazio MV, Han K, et al. Donor-site morbidity following free Tissue harvest from the thigh: A systematic review and pooled analysis of complications. J Reconstr Microsurg, 2016, 32(5): 342-357.
9. Niu Z, Chen Y, Li Y, et al. Comparison of donor site morbidity between anterolateral thigh and radial forearm free flaps for head and neck reconstruction: A systematic review and meta-analysis. J Craniofac Surg, 2021, 32(5): 1706-1711.
10. Schneider W, Jurenitsch S. Normative data for the American Orthopedic Foot and Ankle Society ankle-hindfoot, midfoot, hallux and lesser toes clinical rating system. Int Orthop, 2016, 40(2): 301-306.
11. Janhofer DE, Lakhiani C, Kim PJ, et al. The utility of preoperative arteriography for free flap planning in patients with chronic lower extremity wounds. Plast Reconstr Surg, 2019, 143(2): 604-613.
12. Schirmer S, Ritter RG, Fansa H. Vascular surgery, microsurgery and supramicrosurgery for treatment of chronic diabetic foot ulcers to prevent amputations. PLoS One, 2013, 8(9): e74704. doi: 10.1371/journal.pone.0074704.
13. Zhan Y, Fu G, Zhou X, et al. Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps. Int J Surg, 2017, 48: 53-58.
14. Meloni M, Morosetti D, Giurato L, et al. Foot revascularization avoids major amputation in persons with diabetes and ischaemic foot ulcers. J Clin Med, 2021, 10(17): 3977. doi: 10.3390/jcm10173977.
15. Ehrl D, Heidekrueger PI, Schmitt A, et al. The anterolateral thigh flap for Achilles tendon reconstruction: functional outcomes. Plast Reconstr Surg, 2019, 143(6): 1772-1783.
16. Mennes OA, van Netten JJ, van Baal JG, et al. Assessment of microcirculation in the diabetic foot with laser speckle contrast imaging. Physiol Meas, 2019, 40(6): 065002. doi: 10.1088/1361-6579/ab2058.
17. Tanaka K, Igari K, Kishino M, et al. The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report. Microsurgery, 2017, 37(6): 694-698.

Chinese Journal of Reparative and Reconstructive Surgery

Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure

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