Outcome of arterial reconstruction and free-flap coverage in diabetic foot ulcers: long-term results.

Background: Major amputation for advanced soft tissue loss with bone and tendon exposure, can be prevented in diabetes patients with a combined arterial reconstruction and free-flap transfer. We reviewed our 15-year outcome and evaluated the feasibility to save diabetic feet by means of this aggressive strategy.

Methods: A total of 55 type II diabetes patients (42-80 years of age), hospitalized between January 1992 and December 2006 for a combined arterial reconstruction and free-flap transfer, were followed until December 2007. All would have otherwise required at least a below-knee amputation. Arterial reconstructions, preferentially with autologous vein, were performed in combination with free tissue transfer, simultaneously or staged. The rectus abdominis muscle was the most frequently used muscle graft, although in recent years a growing number of alternative muscle and perforator flaps were used.

Results: The mean follow-up was 22 months (range: 1-180 months). Major complications occurred in 37% with only one in-hospital death. Major amputations were performed in 15 patients, 5 in the early postoperative period. The 1-year and 3-year limb salvage rates were 75.8 and 64.3%, with a 1-year and 3-year amputation-free survival of 69.5% and 55.8%. The 1-year and 3-year secondary patency for graft and free flap was 78.7% and 60.2%, respectively. Renal insufficiency was a major risk factor for limb loss (Hazard Ratio [HR] 5.581 (95% Confidence Interval [CI] 1.384-22.5)). Independent ambulation was regained in 38 patients.

Conclusions: Combined arterial reconstruction and free tissue transfer provides an excellent long-term result with regard to amputation-free survival and limb salvage. It should be considered in every diabetes patient with extensive soft tissue deficits before amputation is performed.