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Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction
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Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction ✩ Efterpi Demiri∗, Antonios Tsimponis, Leonidas Pavlidis, Georgia-Alexandra Spyropoulou, Periclis Foroglou, Dimitrios Dionyssiou Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
a r t i c l e
i n f o
a b s t r a c t
Article history: Accepted 7 March 2020 Available online xxx
Introduction Reverse neurocutaneous and propeller perforator flaps are both used to reconstruct diabetic distal lower limb defects. Our study aims to compare outcomes between these two groups of flaps with an emphasis on indications and complication rates.
Keywords: Diabetic foot Skin defects Reverse neurocutaneous flaps Propeller flaps
Method A retrospective analysis was conducted, reviewing data from 54 diabetic patients who underwent reconstruction of acute or chronic wounds of the foot and ankle between 2005-2018. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF): nineteen sural and fifteen lateral supramalleolar flaps. Twenty patients (Group B) had a propeller flap (PF) based on peroneal (n = 13) or posterior tibial artery perforators (n = 7). All patients had a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients’ demographics, characteristics of the defect, postoperative complications and time to heal. Follow-up ranged from 6 to 59 months. Student’s t-test and chi-squared test were used for statistical analysis. Results Mean patients’ age was 59.1 and 50.8 years for Group A and B, respectively. Defects were located at the Achilles zone (n = 16), posterior heel (n = 14), foot dorsum (n = 9), lateral and medial malleolar areas (n = 8), anterior ankle (n = 5) and lateral foot (n = 2). Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B. Uneventful healing was recorded in 20/34 neurocutaneous flaps and in 12/20 propeller flaps; complications included two complete flap losses (one NCF, one PF), seventeen distal flap necroses (10 NCFs, 7 PFs), fifteen delayed wound healing events over the donor or recipient site (12 NCFs, 3 PFs). Secondary surgeries were required in 15 NCF and 8 PF patients. Mean healing time was 48.1 and 40.7 days for Group A and B, respectively. All patients, except one NCF case, which resulted in leg amputation, returned to previous levels of ambulation. Conclusion Reverse neurocutaneous and propeller flaps may provide stable reconstruction of diabetic lower limb defects; neurocutaneous flaps are specially indicated for larger and more distally located defects, although they might be associated with longer healing time and additional revision surgeries. Propeller flaps were more frequently used in younger patients for smaller and more proximally located defects. © 2020 Elsevier Ltd. All rights reserved.
Introduction Reconstruction of soft tissue defects of the foot and ankle in diabetic patients has always been a challenging problem. Increased morbidity including angiopathy, neuropathy, immunopathy and in-
✩ This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) ∗ Corresponding author. E-mail address: [email protected] (E. Demiri).
fection susceptibility, combined with the limited availability of local tissues in the proximity, are all negative predictive factors that should be seriously considered. Nonetheless, surgical management of those patients has improved a lot, as a result of the introduction and use of various regional flaps of the lower leg, based on perforator or fasciocutaneous vascular axes [1–4]. The aim of the current study is to compare the results obtained from using the distally based neurocutaneous flaps, namely the reverse sural and lateral supramalleolar flap [5], and the propellertype perforator skin island flaps in reconstructing soft tissue defects of the ankle and foot in diabetic patients.
https://doi.org/10.1016/j.injury.2020.03.014 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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Table 1 Summarized demographic and clinical data of the two groups and statistical analysis results. BMI: Body Mass Index, ABI: Ankle Brachial Index Group B Propeller perforator flaps 20 patients 13 peroneal a. perforator flaps 7 posterior tibial a. perforator flaps
P value
N
Group A Neurocutaneous flaps 34 patients 19 reverse sural flaps15 lateral supramalleolar flaps
Age (mean) BMI (mean) ABI (mean) Defect size (mean) Complications rate Revision surgeries Healing time (mean)
59.1 years 27.8 0.98 42.8 cm2 14/34 (41,2%) 15/34 (44.1%) 48.1 days
50.8 years 26.3 1.02 23 cm2 8/20 (40%) 8/20 (40%) 40.7 days
0.007 0.345 0.659 0.000 0.322 0.097 0.000
Patients and methods We conducted a retrospective analysis of 54 diabetic patients, who underwent reconstruction of acute or chronic wounds of the ankle and foot, between 2005-2018, using regional vascularized pedicle skin flaps from the leg. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF); in nineteen cases a reverse sural flap was used, while in fifteen patients a reverse lateral supramalleolar flap. Twenty patients (Group B) underwent a propeller-type skin flap reconstruction (PF) based on perforators of the peroneal (n = 13) or posterior tibial artery (n = 7). All procedures were performed in a single institution by the same senior surgeons. The vascular status of the involved lower limb was assessed clinically, by palpation of the posterior tibial and dorsalis pedis pulsation, and confirmed by Doppler flowmeter; further radiological investigation, i.e. CT angiography, was only performed when needed. All patients underwent a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients’ characteristics, i.e. age, Body Mass Index (BMI) and Ankle-Brachial Index (ABI), aetiology, size and location of the defect, postoperative complications, time to heal and secondary revision surgeries. Statistical analysis was conducted through SPSS (edition 26) software package. Shapiro Wilk was used to test normality for the quantitative variables (defect size, age, BMI, ABI and total healing time). Data was thoroughly examined and Student’s t test and Mann-Whitney U test were used to elaborate the statistically significant difference. Qualitative parameters were examined through Chi-square test and Fishers exact test. The level of statistical significance was determined to pvalues < 0.05. Patients with large and complex tissue losses requiring free tissue reconstruction and cases with insufficient data were not included in the study. Results Our series of 54 diabetic patients included forty-four males and ten females, aged between 42 and 83 years, with a follow-
up ranging from 6 to 59 months. Regarding patients’ demographics, mean age in Group A was 59.1 years ± 8.329 and in Group B 50.8 years ± 8.97, difference which was found statistically significant (p = 0.007). Mean Body Mass Index (BMI) was 27.8 in the NCF group and 26.3 in the PF group, while Ankle-Brachial Index (ABI) was found 0.98 and 1.02 for Group A and B, respectively; non-statistically significant difference was depicted in both parameters (p = 0.345 & p = 0.659) as shown in Table 1. Aetiology of the defect included trauma in 21 cases (39%), chronic ulcer in 26 cases (48%) and previous surgery in 7 cases (13%), with equal distribution in both groups. Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B (p < 0.001). Location of the defects concerned the Achilles zone in 16 cases, the posterior heel in 14 patients, the foot dorsum in 9, the medial and lateral malleolar areas in 8, the anterior ankle and lateral distal foot in 5 and 2 cases, respectively. Neurocutaneous flaps were used in 9 defects of the Achilles area (26.47%), 10 defects over the posterior and plantar heel (29.41%), 7 of the foot dorsum (20.59%), 3 defects over the lateral aspects of the ankle (8.82%), 3 defects over the anterior ankle (8.82%) and 2 ulcers over the lateral distal foot area (5.88%), as shown in Table 2. More specifically, reverse sural flaps were harvested to cover 10 defects over the posterior heel and plantar area, 6 wounds over the foot dorsum, one wound over the lateral ankle and 2 ulcers over the anterior ankle (Fig. 1). From those flaps, three reverse sural flaps were used in a pure adipofascial fashion; a skin graft was used to cover the flap (Fig. 2). Lateral supramalleolar flaps were used to cover 9 wounds over the Achilles zone, 2 defects of the lateral and medial malleolus, 2 defects over the lateral distal foot, one defect over the foot dorsum and one over the anterior ankle. One of our lateral supramalleolar flaps was “delayed” and transferred to the wound at a second stage, one week after the primary procedure. Propeller-type flaps were used to cover 7 tissue losses of the Achilles zone (35%), 4 of the posterior heel (20%), 2 over the foot dorsum (10%), 2 over the anterior ankle (10%) and 5 over the medial or lateral malleolar areas of the foot (25%) (Fig. 3). Table 3 illustrates the distribution of Group B defects’ location.
Fig. 1. 69-year-old diabetic patient presenting an extensive chronic ulcer over the posterior heel (a); After wound debridement and reverse sural flap harvesting, the final result 15 months after reconstruction was satisfactory (b)
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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Table 2 Distribution of defects’ location in Group A (neurocutaneous flaps)
Fig. 2. 80-year-old man presenting a post-traumatic complex tissue loss (a); coverage with an adipofascial reverse sural flap, primarily grafted with stable final result after uneventful healing, one year post-operatively (b)
Fig. 3. Design of the peroneal artery perforator propeller flap in a 77-year-old man with a chronic ulcer over the lateral malleolus (a); 6-month-postoperative result with the donor site covered with a skin graft (b)
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx Table 3 Distribution of defects’ location in Group B (propeller flaps)
Fig. 4. 65-year-old diabetic patient with a chronic ulcer over the Achilles tendon, planned to be covered with a lateral supramalleolar flap (a); Although there were initial signs of partial flap ischemia, post-operative result was stable three years post-operatively (b)
Fig. 5. Post-traumatic soft tissue defect over the medial malleolus in a 54-year-old patient and design of a posterior tibial artery perforator propeller flap (a); immediate result after reconstruction (b); distal flap necrosis (c); final result after skin grafting (d)
Uneventful primary healing was recorded in 20 out of 34 neurocutaneous flaps (58,8%) and in 12 out of 20 propeller flaps (60%). In Group A, complications occurred in 14 out of 34 operated wounds (41,2%) and included one complete loss of a lateral supramalleolar flap and ten partial flap necroses, due to venous insufficiency, that required secondary skin grafting (Fig. 4); delayed healing was recorded in three recipient sites and nine donor sites of the flaps. Overall, secondary surgeries (surgical debridement, skin grafting) were performed in 15 NCF patients (44.1%). In Group B, complications occurred in 8 flaps (40%) including one complete propeller flap necrosis and seven distal skin island necroses; six cases were managed surgically with secondary skin grafting (Fig. 5) and one patient was treated conservatively with dressings. Delayed wound healing was recorded in three flap
donor sites. Revisional surgeries were required in 8 PF patients (40%). The overall success rate including the revisional surgeries was at 97% for Group A and 95% for Group B, with a mean time to heal 48.1 and 40.7 days for Group A and B, respectively. The case that presented complete loss of the propeller flap, although re-operated and successfully reconstructed with a free ALT flap, was not considered successful regarding the original reconstructive procedure. Statistical analysis did not show any significant difference regarding occurrence of complications and revision surgeries between the two groups (p = 0.322); however, mean healing time was significantly higher in Group A (p < 0.001). Table 1 summarizes mean values of recorded parameters and statistical analysis results. All patients, except one NCF case, which resulted in leg
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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amputation following the flap loss, returned to previous levels of ambulation. None of our patients had a recurrence of the reconstructed ulcer during the follow-up period. Discussion Development of foot ulcers in patients suffering from diabetes mellitus is considerably high. It is estimated that 12 percent of diabetic patients may develop some foot ulceration during their lifetime [6,7]. Glucose control, management of co-morbidities, as well as successful reconstruction of diabetic foot defects have been shown to decrease lower limb amputation rates and prolong survival in this multi-morbid population [7]. Several reconstructive modalities are being used including skin grafting, loco-regional or free flaps. For complex wounds, selection of the right technique should be based on the safer flap according to the vascularity of the limb and patient’s comorbidities [4]. Free tissue transfer is extensively used during the recent years, mainly for large and/or more complicated tissue defects; despite the high success rates of free flaps even in diabetic patients, careful case selection and pronounced microsurgical skills are required for performing those demanding procedures [6,8,9]. Among loco-regional flaps, the distally based neurocutaneous flaps have been successfully used for soft tissue reconstruction in diabetic foot ulcers during the last two decades [1,10–12]. Salmon first reported that the superficial nerves of the leg (sural, saphenous and superficial peroneal nerves) are accompanied by arterial axes delivering multiple vascular branches to the overlying skin and anastomotic vessels to the suprafascial and deep vascular networks of the leg [13]. In 1992, Masquelet et al, based on their anatomical studies, confirmed these observations and pointed out similar characteristics in the vascular supply of these “neurocutaneous” skin island flaps, namely the sural artery and the lateral supramalleolar flap, both supplied by vascular axes of sensitive superficial nerves [5]. Advantages of these distally based cutaneous flaps include the avoidance of microsurgical procedures and the preservation of major arterial axes of the extremities, the latter being extremely important in lower limbs with insufficient blood circulation [12]. Indications of those flaps in reconstructing foot and ankle wounds are quite similar, with the lateral supramalleolar flap being mostly indicated for covering the medial malleolar area, the Achilles zone and the distal areas of the foot; [10,14] the reverse sural flap is more frequently used for covering the posterior and weight-bearing heel and the lateral malleolar areas [1,15]. Parallel advanced studies on the vascular anatomy of the lower leg, resulted in the description and harvesting of new pedicled skin island flaps supplied by perforator vessels, emerging from the major arterial axes of the leg, i.e. the anterior and posterior tibial, and the peroneal arteries [16]. Even in diabetic patients with compromised circulation, a major vascular axis -most commonly the peroneal artery- remains patent with viable perforators to supply a perforator flap [17]. Georgescu et al, published a series of 25 diabetic lower limb wounds that were successfully reconstructed with propeller-type skin flaps mainly based on perforators of the peroneal and posterior tibial artery [3]. Interestingly, results of our retrospective study showed high and comparable success rates in both groups of reconstructive methods, with 97% and 95% for neurocutaneous and propeller flaps, respectively. Although our analysis did not show any significant difference regarding overall success or complication rates between the two groups, mean time to heal was significantly higher in Group A. Need for revision surgeries was also found higher in the NCF patients, but without statistically significant difference. An explanation to these findings might be the fact that neurocutaneous flaps were more frequently used in a significantly older patients’ population and for covering significantly larger tissues defects.
5
Regarding location of the defects, our results showed that propeller flaps were used in 14 out of 20 cases (70%), for covering more proximally located wounds, i.e. the Achilles tendon, the medial, lateral and anterior aspect of the ankle. In contrary, neurocutaneous flaps were used in 19 out of 34 cases for reconstructing more distal defects, i.e. the posterior heel and plantar area, the dorsum and lateral side of the foot (55.9%). Obviously, the large rotation arc of both types of neurocutaneous flaps allowed for covering more distal areas of the foot; the lateral supramalleolar flap reached, not only the Achilles zone, but also the distal dorsum and lateral aspect of the foot, while the reverse sural flap was a better indication for covering the posterior heel and plantar defects. Delaying the transfer of neurocutaneous flaps has also been reported in order to improve the chances of flap transfer success, especially in more complex cases of diabetic foot wounds [10,15]. Delay phenomenon is well known to increase functional blood flow to the flap and, therefore, to enhance the survival of critically vascularized skin islands. In our series, one patient who presented a composite tissue loss over the distal lateral side of the foot, was treated with a delayed lateral supramalleolar flap that successfully reconstructed the defect in a two-staged procedure. One of the major disadvantages of using the reverse neurocutaneous flaps comparing to the propeller perforator flaps, is the donor site morbidity including sensory disturbances over the lateral aspect of the foot and unpleasant scarring over the flap’s donor site which is usually skin grafted. Healing of the donor site was problematic in nine NCF cases of our series, due to “nontake” of primary skin grafts, resulting in even poorer cosmetic outcome. In only three cases of adipofascial reverse sural flaps, donor site was directly closed and a skin graft was primarily applied to cover the flap. As already reported, pure adipofascial neurocutaneous flaps provide thin reconstruction and fine contour over the recipient zone with minor aesthetic alterations of the donor site, that does not need to be grafted [18,19]. None of our Group A patients reported any functional troubles resulting from harvesting a superficial sensitive nerve. Considering these parameters and in order to reduce donor site morbidity, we selected a propeller-type reconstruction when feasible, especially in our younger patients and for limited sized defects. In all but three of our PF patients, donor site was primarily sutured, leading to inconspicuous scarring and better lower leg contour.
Limitations of the study This study has potential limitations. The location and the size of the defect has played an important role in selecting the appropriate flap; therefore, a selection bias may have influenced our study. This could not have been avoided, since it is generally accepted that neurocutaneous flaps can cover more extended defects, especially when located in more distal areas of the foot.
Conclusions Results of our study showed that reverse neurocutaneous and propeller-type skin flaps are safe and reliable alternative reconstructive options for diabetic lower limb defects; both methods provided successful coverage of various tissue losses over diabetic feet and ankles, reducing the need for microsurgical procedures. Neurocutaneous flaps, although associated with more revision surgeries and significantly longer healing times, were considered better indications when facing large and distally located defects of the foot and ankle. Propeller flaps were most frequently used in younger patients for smaller and more proximal defects.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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Declaration of Competing Interest None References [1] Yildirim S, Akan M, Akoz T. Soft-tissue reconstruction of the foot with distally based neurocutaneous flaps in diabetic patients. Ann Plast Surg 2002;48:258–64. [2] Ignatiadis IA, Georgakopoulos GD, Tsiampa VA, Polyzois VD, Arapoglou DK, Papalois AE. Distal posterior tibial artery perforator flaps for the management of calcaneal and Achilles tendon injuries in diabetic and non-diabetic patients. Diabet Foot Ankle 2011;2. doi:10.3402/dfa.v2i0.7483. [3] Georgescu AV, Matei IR, Capota IM. The use of propeller perforator flaps for diabetic limb salvage: a retrospective review of 25 cases. Diabet Foot Ankle 2012;3. doi:10.3402/dfa.v3i0.18978. [4] Akhtar S, Ahmad I, Khan AH, Khurram MF. Modalities of soft-tissue coverage in diabetic foot ulcers. Adv Skin Wound Care 2015;28:157–62. [5] Masquelet A, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115–21. [6] Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013;66:243–50. [7] Ducic I. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011;128:173–80. [8] Hong JP. Reconstruction of the diabetic foot using the anterolateral thigh perforator flap. Plast Reconstr Surg 2006;117:1599–608. [9] Fitzerald O’Connor EJ, Vesely M, Holt PJ, Jones KG, Thompson MM, Hinchliffe RJ. A systematic review of free tissue transfer in the management of non– traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg 2011;41:391–9.
[10] Demiri E, Foroglou P, Dionyssiou D, Antoniou A, Kakas P, Pavlidis L, et al. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast Surg Hand Surg 2006;40:106–10. [11] Dhamangaonkar AC, Patankaar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthopaed Traumatol 2014;15:225–9. [12] Sonmez E, Silistireli OK, Karaaslan O, Kamburoglu HO, Safak T. Ehnancement of venous drainage with vein stripper for reverse pedicled neurocutaneous flaps. J Reconstr Microsurg 2013;29:249–54. [13] Salmon M. Les artères de la peau (Arteries of the skin). Paris: Manson; 1936. [14] Voche P, Merle M, Stussi JD. The lateral supramalleolar flap: experience with 41 flaps. Ann Plast Surg 2005;54:49–54. [15] Tosun Z, Ozkan A, Karacor Z, Savaci N. Delaying the reverse sural flap provides predictable results for complicated wounds in diabetic foot. Ann Plast Surg 2005;55:169–73. [16] Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008;122:161–70. [17] Hansen T, Wilkstrom J, Johansson LO, Lind L, Ahlstrom H. The prevalence and quantification of atherosclerosis in an elderly population assessed by whole-body magnetic resonance angiography. Arterioscler Thromb Vasc Biol 2007;27:649–54. [18] Demirtas Y, Ayhan S, Sariguney Y, Findikcioglu F, Cukurluoglu O, Latifoglu O, et al. Distally based lateral and medial leg adipofascial flaps: need for caution with old, diabetic patients. Plast Reconstr Surg 2006;117:272–6. [19] Lee YH, Rah SK, Choi SJ, Chung MS, Baek GH. Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle. Plast Reconstr Surg 2004;114:1478–85.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
JID: JINJ
[m5G;March 14, 2020;13:30]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction ✩ Efterpi Demiri∗, Antonios Tsimponis, Leonidas Pavlidis, Georgia-Alexandra Spyropoulou, Periclis Foroglou, Dimitrios Dionyssiou Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, Papageorgiou Hospital, Thessaloniki, Greece
a r t i c l e
i n f o
a b s t r a c t
Article history: Accepted 7 March 2020 Available online xxx
Introduction Reverse neurocutaneous and propeller perforator flaps are both used to reconstruct diabetic distal lower limb defects. Our study aims to compare outcomes between these two groups of flaps with an emphasis on indications and complication rates.
Keywords: Diabetic foot Skin defects Reverse neurocutaneous flaps Propeller flaps
Method A retrospective analysis was conducted, reviewing data from 54 diabetic patients who underwent reconstruction of acute or chronic wounds of the foot and ankle between 2005-2018. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF): nineteen sural and fifteen lateral supramalleolar flaps. Twenty patients (Group B) had a propeller flap (PF) based on peroneal (n = 13) or posterior tibial artery perforators (n = 7). All patients had a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients’ demographics, characteristics of the defect, postoperative complications and time to heal. Follow-up ranged from 6 to 59 months. Student’s t-test and chi-squared test were used for statistical analysis. Results Mean patients’ age was 59.1 and 50.8 years for Group A and B, respectively. Defects were located at the Achilles zone (n = 16), posterior heel (n = 14), foot dorsum (n = 9), lateral and medial malleolar areas (n = 8), anterior ankle (n = 5) and lateral foot (n = 2). Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B. Uneventful healing was recorded in 20/34 neurocutaneous flaps and in 12/20 propeller flaps; complications included two complete flap losses (one NCF, one PF), seventeen distal flap necroses (10 NCFs, 7 PFs), fifteen delayed wound healing events over the donor or recipient site (12 NCFs, 3 PFs). Secondary surgeries were required in 15 NCF and 8 PF patients. Mean healing time was 48.1 and 40.7 days for Group A and B, respectively. All patients, except one NCF case, which resulted in leg amputation, returned to previous levels of ambulation. Conclusion Reverse neurocutaneous and propeller flaps may provide stable reconstruction of diabetic lower limb defects; neurocutaneous flaps are specially indicated for larger and more distally located defects, although they might be associated with longer healing time and additional revision surgeries. Propeller flaps were more frequently used in younger patients for smaller and more proximally located defects. © 2020 Elsevier Ltd. All rights reserved.
Introduction Reconstruction of soft tissue defects of the foot and ankle in diabetic patients has always been a challenging problem. Increased morbidity including angiopathy, neuropathy, immunopathy and in-
✩ This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) ∗ Corresponding author. E-mail address: [email protected] (E. Demiri).
fection susceptibility, combined with the limited availability of local tissues in the proximity, are all negative predictive factors that should be seriously considered. Nonetheless, surgical management of those patients has improved a lot, as a result of the introduction and use of various regional flaps of the lower leg, based on perforator or fasciocutaneous vascular axes [1–4]. The aim of the current study is to compare the results obtained from using the distally based neurocutaneous flaps, namely the reverse sural and lateral supramalleolar flap [5], and the propellertype perforator skin island flaps in reconstructing soft tissue defects of the ankle and foot in diabetic patients.
https://doi.org/10.1016/j.injury.2020.03.014 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx
Table 1 Summarized demographic and clinical data of the two groups and statistical analysis results. BMI: Body Mass Index, ABI: Ankle Brachial Index Group B Propeller perforator flaps 20 patients 13 peroneal a. perforator flaps 7 posterior tibial a. perforator flaps
P value
N
Group A Neurocutaneous flaps 34 patients 19 reverse sural flaps15 lateral supramalleolar flaps
Age (mean) BMI (mean) ABI (mean) Defect size (mean) Complications rate Revision surgeries Healing time (mean)
59.1 years 27.8 0.98 42.8 cm2 14/34 (41,2%) 15/34 (44.1%) 48.1 days
50.8 years 26.3 1.02 23 cm2 8/20 (40%) 8/20 (40%) 40.7 days
0.007 0.345 0.659 0.000 0.322 0.097 0.000
Patients and methods We conducted a retrospective analysis of 54 diabetic patients, who underwent reconstruction of acute or chronic wounds of the ankle and foot, between 2005-2018, using regional vascularized pedicle skin flaps from the leg. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF); in nineteen cases a reverse sural flap was used, while in fifteen patients a reverse lateral supramalleolar flap. Twenty patients (Group B) underwent a propeller-type skin flap reconstruction (PF) based on perforators of the peroneal (n = 13) or posterior tibial artery (n = 7). All procedures were performed in a single institution by the same senior surgeons. The vascular status of the involved lower limb was assessed clinically, by palpation of the posterior tibial and dorsalis pedis pulsation, and confirmed by Doppler flowmeter; further radiological investigation, i.e. CT angiography, was only performed when needed. All patients underwent a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients’ characteristics, i.e. age, Body Mass Index (BMI) and Ankle-Brachial Index (ABI), aetiology, size and location of the defect, postoperative complications, time to heal and secondary revision surgeries. Statistical analysis was conducted through SPSS (edition 26) software package. Shapiro Wilk was used to test normality for the quantitative variables (defect size, age, BMI, ABI and total healing time). Data was thoroughly examined and Student’s t test and Mann-Whitney U test were used to elaborate the statistically significant difference. Qualitative parameters were examined through Chi-square test and Fishers exact test. The level of statistical significance was determined to pvalues < 0.05. Patients with large and complex tissue losses requiring free tissue reconstruction and cases with insufficient data were not included in the study. Results Our series of 54 diabetic patients included forty-four males and ten females, aged between 42 and 83 years, with a follow-
up ranging from 6 to 59 months. Regarding patients’ demographics, mean age in Group A was 59.1 years ± 8.329 and in Group B 50.8 years ± 8.97, difference which was found statistically significant (p = 0.007). Mean Body Mass Index (BMI) was 27.8 in the NCF group and 26.3 in the PF group, while Ankle-Brachial Index (ABI) was found 0.98 and 1.02 for Group A and B, respectively; non-statistically significant difference was depicted in both parameters (p = 0.345 & p = 0.659) as shown in Table 1. Aetiology of the defect included trauma in 21 cases (39%), chronic ulcer in 26 cases (48%) and previous surgery in 7 cases (13%), with equal distribution in both groups. Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B (p < 0.001). Location of the defects concerned the Achilles zone in 16 cases, the posterior heel in 14 patients, the foot dorsum in 9, the medial and lateral malleolar areas in 8, the anterior ankle and lateral distal foot in 5 and 2 cases, respectively. Neurocutaneous flaps were used in 9 defects of the Achilles area (26.47%), 10 defects over the posterior and plantar heel (29.41%), 7 of the foot dorsum (20.59%), 3 defects over the lateral aspects of the ankle (8.82%), 3 defects over the anterior ankle (8.82%) and 2 ulcers over the lateral distal foot area (5.88%), as shown in Table 2. More specifically, reverse sural flaps were harvested to cover 10 defects over the posterior heel and plantar area, 6 wounds over the foot dorsum, one wound over the lateral ankle and 2 ulcers over the anterior ankle (Fig. 1). From those flaps, three reverse sural flaps were used in a pure adipofascial fashion; a skin graft was used to cover the flap (Fig. 2). Lateral supramalleolar flaps were used to cover 9 wounds over the Achilles zone, 2 defects of the lateral and medial malleolus, 2 defects over the lateral distal foot, one defect over the foot dorsum and one over the anterior ankle. One of our lateral supramalleolar flaps was “delayed” and transferred to the wound at a second stage, one week after the primary procedure. Propeller-type flaps were used to cover 7 tissue losses of the Achilles zone (35%), 4 of the posterior heel (20%), 2 over the foot dorsum (10%), 2 over the anterior ankle (10%) and 5 over the medial or lateral malleolar areas of the foot (25%) (Fig. 3). Table 3 illustrates the distribution of Group B defects’ location.
Fig. 1. 69-year-old diabetic patient presenting an extensive chronic ulcer over the posterior heel (a); After wound debridement and reverse sural flap harvesting, the final result 15 months after reconstruction was satisfactory (b)
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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Table 2 Distribution of defects’ location in Group A (neurocutaneous flaps)
Fig. 2. 80-year-old man presenting a post-traumatic complex tissue loss (a); coverage with an adipofascial reverse sural flap, primarily grafted with stable final result after uneventful healing, one year post-operatively (b)
Fig. 3. Design of the peroneal artery perforator propeller flap in a 77-year-old man with a chronic ulcer over the lateral malleolus (a); 6-month-postoperative result with the donor site covered with a skin graft (b)
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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E. Demiri, A. Tsimponis and L. Pavlidis et al. / Injury xxx (xxxx) xxx Table 3 Distribution of defects’ location in Group B (propeller flaps)
Fig. 4. 65-year-old diabetic patient with a chronic ulcer over the Achilles tendon, planned to be covered with a lateral supramalleolar flap (a); Although there were initial signs of partial flap ischemia, post-operative result was stable three years post-operatively (b)
Fig. 5. Post-traumatic soft tissue defect over the medial malleolus in a 54-year-old patient and design of a posterior tibial artery perforator propeller flap (a); immediate result after reconstruction (b); distal flap necrosis (c); final result after skin grafting (d)
Uneventful primary healing was recorded in 20 out of 34 neurocutaneous flaps (58,8%) and in 12 out of 20 propeller flaps (60%). In Group A, complications occurred in 14 out of 34 operated wounds (41,2%) and included one complete loss of a lateral supramalleolar flap and ten partial flap necroses, due to venous insufficiency, that required secondary skin grafting (Fig. 4); delayed healing was recorded in three recipient sites and nine donor sites of the flaps. Overall, secondary surgeries (surgical debridement, skin grafting) were performed in 15 NCF patients (44.1%). In Group B, complications occurred in 8 flaps (40%) including one complete propeller flap necrosis and seven distal skin island necroses; six cases were managed surgically with secondary skin grafting (Fig. 5) and one patient was treated conservatively with dressings. Delayed wound healing was recorded in three flap
donor sites. Revisional surgeries were required in 8 PF patients (40%). The overall success rate including the revisional surgeries was at 97% for Group A and 95% for Group B, with a mean time to heal 48.1 and 40.7 days for Group A and B, respectively. The case that presented complete loss of the propeller flap, although re-operated and successfully reconstructed with a free ALT flap, was not considered successful regarding the original reconstructive procedure. Statistical analysis did not show any significant difference regarding occurrence of complications and revision surgeries between the two groups (p = 0.322); however, mean healing time was significantly higher in Group A (p < 0.001). Table 1 summarizes mean values of recorded parameters and statistical analysis results. All patients, except one NCF case, which resulted in leg
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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amputation following the flap loss, returned to previous levels of ambulation. None of our patients had a recurrence of the reconstructed ulcer during the follow-up period. Discussion Development of foot ulcers in patients suffering from diabetes mellitus is considerably high. It is estimated that 12 percent of diabetic patients may develop some foot ulceration during their lifetime [6,7]. Glucose control, management of co-morbidities, as well as successful reconstruction of diabetic foot defects have been shown to decrease lower limb amputation rates and prolong survival in this multi-morbid population [7]. Several reconstructive modalities are being used including skin grafting, loco-regional or free flaps. For complex wounds, selection of the right technique should be based on the safer flap according to the vascularity of the limb and patient’s comorbidities [4]. Free tissue transfer is extensively used during the recent years, mainly for large and/or more complicated tissue defects; despite the high success rates of free flaps even in diabetic patients, careful case selection and pronounced microsurgical skills are required for performing those demanding procedures [6,8,9]. Among loco-regional flaps, the distally based neurocutaneous flaps have been successfully used for soft tissue reconstruction in diabetic foot ulcers during the last two decades [1,10–12]. Salmon first reported that the superficial nerves of the leg (sural, saphenous and superficial peroneal nerves) are accompanied by arterial axes delivering multiple vascular branches to the overlying skin and anastomotic vessels to the suprafascial and deep vascular networks of the leg [13]. In 1992, Masquelet et al, based on their anatomical studies, confirmed these observations and pointed out similar characteristics in the vascular supply of these “neurocutaneous” skin island flaps, namely the sural artery and the lateral supramalleolar flap, both supplied by vascular axes of sensitive superficial nerves [5]. Advantages of these distally based cutaneous flaps include the avoidance of microsurgical procedures and the preservation of major arterial axes of the extremities, the latter being extremely important in lower limbs with insufficient blood circulation [12]. Indications of those flaps in reconstructing foot and ankle wounds are quite similar, with the lateral supramalleolar flap being mostly indicated for covering the medial malleolar area, the Achilles zone and the distal areas of the foot; [10,14] the reverse sural flap is more frequently used for covering the posterior and weight-bearing heel and the lateral malleolar areas [1,15]. Parallel advanced studies on the vascular anatomy of the lower leg, resulted in the description and harvesting of new pedicled skin island flaps supplied by perforator vessels, emerging from the major arterial axes of the leg, i.e. the anterior and posterior tibial, and the peroneal arteries [16]. Even in diabetic patients with compromised circulation, a major vascular axis -most commonly the peroneal artery- remains patent with viable perforators to supply a perforator flap [17]. Georgescu et al, published a series of 25 diabetic lower limb wounds that were successfully reconstructed with propeller-type skin flaps mainly based on perforators of the peroneal and posterior tibial artery [3]. Interestingly, results of our retrospective study showed high and comparable success rates in both groups of reconstructive methods, with 97% and 95% for neurocutaneous and propeller flaps, respectively. Although our analysis did not show any significant difference regarding overall success or complication rates between the two groups, mean time to heal was significantly higher in Group A. Need for revision surgeries was also found higher in the NCF patients, but without statistically significant difference. An explanation to these findings might be the fact that neurocutaneous flaps were more frequently used in a significantly older patients’ population and for covering significantly larger tissues defects.
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Regarding location of the defects, our results showed that propeller flaps were used in 14 out of 20 cases (70%), for covering more proximally located wounds, i.e. the Achilles tendon, the medial, lateral and anterior aspect of the ankle. In contrary, neurocutaneous flaps were used in 19 out of 34 cases for reconstructing more distal defects, i.e. the posterior heel and plantar area, the dorsum and lateral side of the foot (55.9%). Obviously, the large rotation arc of both types of neurocutaneous flaps allowed for covering more distal areas of the foot; the lateral supramalleolar flap reached, not only the Achilles zone, but also the distal dorsum and lateral aspect of the foot, while the reverse sural flap was a better indication for covering the posterior heel and plantar defects. Delaying the transfer of neurocutaneous flaps has also been reported in order to improve the chances of flap transfer success, especially in more complex cases of diabetic foot wounds [10,15]. Delay phenomenon is well known to increase functional blood flow to the flap and, therefore, to enhance the survival of critically vascularized skin islands. In our series, one patient who presented a composite tissue loss over the distal lateral side of the foot, was treated with a delayed lateral supramalleolar flap that successfully reconstructed the defect in a two-staged procedure. One of the major disadvantages of using the reverse neurocutaneous flaps comparing to the propeller perforator flaps, is the donor site morbidity including sensory disturbances over the lateral aspect of the foot and unpleasant scarring over the flap’s donor site which is usually skin grafted. Healing of the donor site was problematic in nine NCF cases of our series, due to “nontake” of primary skin grafts, resulting in even poorer cosmetic outcome. In only three cases of adipofascial reverse sural flaps, donor site was directly closed and a skin graft was primarily applied to cover the flap. As already reported, pure adipofascial neurocutaneous flaps provide thin reconstruction and fine contour over the recipient zone with minor aesthetic alterations of the donor site, that does not need to be grafted [18,19]. None of our Group A patients reported any functional troubles resulting from harvesting a superficial sensitive nerve. Considering these parameters and in order to reduce donor site morbidity, we selected a propeller-type reconstruction when feasible, especially in our younger patients and for limited sized defects. In all but three of our PF patients, donor site was primarily sutured, leading to inconspicuous scarring and better lower leg contour.
Limitations of the study This study has potential limitations. The location and the size of the defect has played an important role in selecting the appropriate flap; therefore, a selection bias may have influenced our study. This could not have been avoided, since it is generally accepted that neurocutaneous flaps can cover more extended defects, especially when located in more distal areas of the foot.
Conclusions Results of our study showed that reverse neurocutaneous and propeller-type skin flaps are safe and reliable alternative reconstructive options for diabetic lower limb defects; both methods provided successful coverage of various tissue losses over diabetic feet and ankles, reducing the need for microsurgical procedures. Neurocutaneous flaps, although associated with more revision surgeries and significantly longer healing times, were considered better indications when facing large and distally located defects of the foot and ankle. Propeller flaps were most frequently used in younger patients for smaller and more proximal defects.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014
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Declaration of Competing Interest None References [1] Yildirim S, Akan M, Akoz T. Soft-tissue reconstruction of the foot with distally based neurocutaneous flaps in diabetic patients. Ann Plast Surg 2002;48:258–64. [2] Ignatiadis IA, Georgakopoulos GD, Tsiampa VA, Polyzois VD, Arapoglou DK, Papalois AE. Distal posterior tibial artery perforator flaps for the management of calcaneal and Achilles tendon injuries in diabetic and non-diabetic patients. Diabet Foot Ankle 2011;2. doi:10.3402/dfa.v2i0.7483. [3] Georgescu AV, Matei IR, Capota IM. The use of propeller perforator flaps for diabetic limb salvage: a retrospective review of 25 cases. Diabet Foot Ankle 2012;3. doi:10.3402/dfa.v3i0.18978. [4] Akhtar S, Ahmad I, Khan AH, Khurram MF. Modalities of soft-tissue coverage in diabetic foot ulcers. Adv Skin Wound Care 2015;28:157–62. [5] Masquelet A, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115–21. [6] Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013;66:243–50. [7] Ducic I. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011;128:173–80. [8] Hong JP. Reconstruction of the diabetic foot using the anterolateral thigh perforator flap. Plast Reconstr Surg 2006;117:1599–608. [9] Fitzerald O’Connor EJ, Vesely M, Holt PJ, Jones KG, Thompson MM, Hinchliffe RJ. A systematic review of free tissue transfer in the management of non– traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg 2011;41:391–9.
[10] Demiri E, Foroglou P, Dionyssiou D, Antoniou A, Kakas P, Pavlidis L, et al. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast Surg Hand Surg 2006;40:106–10. [11] Dhamangaonkar AC, Patankaar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthopaed Traumatol 2014;15:225–9. [12] Sonmez E, Silistireli OK, Karaaslan O, Kamburoglu HO, Safak T. Ehnancement of venous drainage with vein stripper for reverse pedicled neurocutaneous flaps. J Reconstr Microsurg 2013;29:249–54. [13] Salmon M. Les artères de la peau (Arteries of the skin). Paris: Manson; 1936. [14] Voche P, Merle M, Stussi JD. The lateral supramalleolar flap: experience with 41 flaps. Ann Plast Surg 2005;54:49–54. [15] Tosun Z, Ozkan A, Karacor Z, Savaci N. Delaying the reverse sural flap provides predictable results for complicated wounds in diabetic foot. Ann Plast Surg 2005;55:169–73. [16] Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008;122:161–70. [17] Hansen T, Wilkstrom J, Johansson LO, Lind L, Ahlstrom H. The prevalence and quantification of atherosclerosis in an elderly population assessed by whole-body magnetic resonance angiography. Arterioscler Thromb Vasc Biol 2007;27:649–54. [18] Demirtas Y, Ayhan S, Sariguney Y, Findikcioglu F, Cukurluoglu O, Latifoglu O, et al. Distally based lateral and medial leg adipofascial flaps: need for caution with old, diabetic patients. Plast Reconstr Surg 2006;117:272–6. [19] Lee YH, Rah SK, Choi SJ, Chung MS, Baek GH. Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle. Plast Reconstr Surg 2004;114:1478–85.
Please cite this article as: E. Demiri, A. Tsimponis and L. Pavlidis et al., Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction, Injury, https://doi.org/10.1016/j.injury.2020.03.014