Can Great Toe Pedicle Flaps Have An Impact For Complicated DFUs?

Karen Shum, DPM, Ronald Belczyk, DPM, Lee C. Rogers, DPM, George Andros, MD, and Larissa Lee, MD

   The lateral hallux is the first choice of donor site since it has a larger flap area and digital vessels. Other typical donor sites include the other digits. The next commonly utilized site besides the great toe is the second toe. The depth of tissue involvement can include fasciocutaneous or osteocutaneous tissue. The clinical indication for harvesting bone is an osseous defect or exposed joint. Vascularized bone graft is helpful for wound closure of deep defects or when performing an arthrodesis in complex or revisional cases.

   The clinical indication for harvesting bone is usually when there is an osseous defect or exposed joint in which vascularized bone is helpful for wound closure of deep defects or arthrodesis.

   Close the donor site primarily by skin graft, local flap or syndactylization of toes. The flap can be based on the dorsal or plantar circulation. Advantages to the flap based from the plantar arterial network include potentially less functional abnormality since the dissection does not require transection of the deep transverse metatarsal ligament. Typically, this ligament supports the metatarsals in the transverse plane.

   A pedicle flap is limited by the arc of rotation so one must carefully measure the location of the donor site in relation to the recipient site. Too much tension or stretch on the pedicle flap can lead to flap failure. Measuring and tracing the ulceration with a paper template can allow one to outline the flap dimensions on the donor toe. The nail and nail bed are not included. It is helpful to perform an intraoperative Doppler exam of the digital artery. One surgical pearl to prevent injury to the digital vessels during dissection is to include a layer of protective padding and preserve the fat pad or subcutaneous tissue encasing the neurovascular bundle.

   One can close the donor site primarily by skin graft, local flap or by syndactylization of toes. If necessary, the surgeon can achieve tissue laxity by undermining the tissue at the recipient site, which then permits for secondary motion.

A Guide To Postoperative Care

A non-adherent dressing covers the wound. For the graft to successfully take, the amount of apposition to the recipient site is important.

   The more apposition the great toe pedicle flap has, the higher the chances of graft survival. Carefully secure the flaps down to the recipient site. Ensure adequate hemostasis prior to securing the flap. The use of drains can prevent hematoma and seroma formation, both of which can contribute to graft failure. Elevation of the lower extremity reduces fluid collection and edema, which may impair healing.

   Consider general offloading principles to protect the site from pressure and shear forces. This can be in the form of splinting and immobilization. Immobilizing the affected area to prevent these forces for four to six weeks is typical.

   After grafting, resume proper wound care and infection control to ensure flap survival. An infected wound or flap can lead to necrosis and ultimately failure of flap take.

   Currently, evaluation of flap perfusion relies on close postoperative physical examination. Clinical signs to watch out for include skin color, temperature, turgor and capillary refill time. The use of an arterial Doppler can assess direct flow to the flap over a specific region. One can investigate the patency of the vascular supply or whether there is thrombosis of the digital artery supplying the flap.

In Summary

A successful pedicle flap requires comprehensive pre- and postoperative care, proper patient selection, a strong understanding of anatomy, and recognition and management of complications. Plastic surgery techniques like the great toe fillet flap are an effective tool for podiatric surgeons for coverage of tissue defects.

Add new comment