Plastic and reconstructive surgery techniques can be a significant adjunct for podiatric surgeons in managing diabetic foot wounds and tissue loss. With this in mind, the panelists discuss a variety of techniques (including split-thickness skin grafting and muscle flaps) and indications for chronic ulcers, the neuropathic foot and pressure-induced heel ulcerations.
Q: When do you consider reconstructive plastic surgical techniques in the management of diabetic foot ulcers?
A: Peter Blume, DPM, says he considers plastic surgery techniques for these ulcers when offloading and conservative measures do not address the underlying soft tissue loss. Dr. Blume says you may employ local flap construction, split-thickness skin grafting, pedicle and muscle flaps including free tissue transfers in treating chronic diabetic foot ulcers as long as you address the underlying bony pathology.
Tod Storm, DPM, concurs. In cases in which surgery is indicated to fix an osseous cause of an ulcer, Dr. Storm considers plastic surgery techniques to achieve ulcer closure at the same time. He adds that adequate blood flow to the area is essential when contemplating any surgery.
It’s only a matter of time before a chronically open wound will become infected, emphasizes Dr. Storm. For this reason, Drs. Blume and Storm say they use plastic surgery closure techniques for large defects that are contracting slowly and may take several months to close on their own.
If the patient has undergone an incision and drainage procedure of the arch in addition to the medial or lateral foot, Dr. Blume says skin grafting is the primary choice for reconstruction.
Dr. Storm says he’ll also consider plastic surgery techniques on areas that have broken down several times in the past and have resulted in a significant amount of scar tissue. Employing these techniques can help replace the ulcer prone tissue and reduce recurrence, according to Dr. Storm.
Dr. Blume emphasizes that converting chronic wounds into acute wounds helps to stabilize the wound flora, which aids in facilitating desirable results. If possible, Dr. Blume says you may fully excise chronic wounds and perform reconstruction with local suprafascial random flaps, especially in the plantar arch region. If a chronic wound is localized to a metatarsal head, Dr. Blume says you can excise the metatarsal head and proceed to inset a local flap, such as a rhomboid or bilobed flap. If the sesamoids are involved, he notes that you can complete a sesamoidectomy in addition to local flap advancement.
Dr. Blume says that flaps are especially useful for reconstruction of the plantar aspect of the foot as skin grafting is not seen as a reconstructive option for weightbearing tissues. If the patient is experiencing a chronic wound to the dorsum of the foot, Dr. Blume recommends debridement and aggressive wound care with split-thickness skin grafting as the primary plastic reconstructive technique. He cautions that local flaps do not elevate and inset easily to the dorsum of the foot. Due to the fact that they are “truly nonweightbearing,” split-thickness skin grafts are the primary reconstructive option, according to Dr. Blume.
He strongly emphasizes the necessity of addressing mechanical concerns before considering plastic surgery techniques to treat chronic diabetic foot wounds.
Lawrence Karlock, DPM, says he would consider referring to a reconstructive limb salvage plastic surgeon after a failed Charcot foot reconstruction, a failed midfoot exostectomy or for needed soft tissue coverage.
Q: What plastic surgery techniques do you commonly use to treat the neuropathic foot?
A: Dr. Karlock says he commonly uses the “filet toe flap” to cover large forefoot defects.
Dr. Blume points out that patients who experience Charcot osteoarthropathy typically have loss of continuity within the mid tarsus and Lisfranc’s joint. You’ll commonly see wounds along the cuboid lateral column and talonavicular joint medial column, notes Dr. Blume. He says you’ll also see these wounds along the medial talus when patients have ankle dislocations and Charcot ankle deformities.
As far as plastic surgery techniques, Dr. Blume says the most appropriate reconstructive option for these patients is the rotational suprafascial flap, which you may rotate from medial to lateral in order to reconstruct the plantar aspect of the foot.
In the neuropathic foot, Dr. Storm also emphasizes durable soft tissue coverage since these patients are very prone to develop another ulceration. He says soft tissue flaps can provide tissue coverage that is adjacent to the defect and have a better chance of surviving. Dr. Storm adds that some flaps are designed to allow further rotation down the road if necessary.
Dr. Blume maintains that it is extremely important to address the Achilles tendon equinus with an Achilles tenotomy or tendon lengthening in addition to a fusion. “We do typically utilize external fixation with mid-foot arthrodesis in conjunction with a rotational flap and split-thickness skin grafting to the arch region, which is nonweightbearing,” notes Dr. Blume.
Q: How do you approach the pressure-induced heel ulceration?
A: Dr. Blume says the most complex foot wounds involve the heel region. He points out that many of these ulcerations occur with bedridden patients who have undergone a variety of procedures including coronary artery bypass grafting and hip open reduction internal fixation procedure. He adds that many of these patients have underlying vascular disease and diabetes.
“Tissue loss in the heel (for these patients) is extremely devastating and can lead to a major amputation,” emphasizes Dr. Blume.
Dr. Blume says patients with pressure-induced heel ulcerations commonly have “islands of ischemia” throughout the heel, and these ulcers are difficult to convert into granulating wounds. Dr. Storm notes the pressure prevents blood perfusion to the skin and the ischemia results in pain. In the neuropathic or comatose patient, there is no protective reflex and the ischemia turns into necrosis, according to Dr. Storm.
As far as treatment goes, Dr. Storm says the first step is to relieve the pressure and allow devitalized tissue to demarcate itself. He notes you would then proceed to remove all obviously necrotic tissue and address any infection. At this point, Dr. Storm says you should initiate good wound care and consider surgical intervention.
If you’re looking at an ulceration of partial thickness, Dr. Blume recommends appropriate debridement and use of VAC therapy, and following up with split-thickness skin grafting to the nonweightbearing posterior, lateral and medial apex. If the ulceration is to the plantar apex of the heel, Dr. Blume says rotation flaps and often free tissue transfers are required.
When treating a large heel ulcer of a bedridden patient, Dr. Storm says split-thickness skin grafts can provide immediate coverage and have relatively low risk, but cautions that these grafts are not very durable and will need to be protected indefinitely. For large tissue defects from the heel ulceration that extend into the Achilles tendon, Dr. Blume emphasizes broad dissection and resection with myocutaneous free tissue transfers, although he cautions that they have high morbidity and mortality rates.
Dr. Karlock says he treats heel defects with judicious bone resection and emphasizes appropriate soft tissue coverage in order to save a functional limb.
Q: What are your thoughts about new bioengineered skin equivalents? How do these compare with split thickness and full-thickness skin grafting in managing neuropathic ulcers?
A: Dr. Karlock notes he commonly uses Apligraf and has been pleased with the results. He says Apligraf is user-friendly, applicable in an office setting and you don’t have to worry about the lack of a donor site.
While bioengineered skin equivalents like Apligraf and Dermagraft can help facilitate a healthy granulating wound bed for further skin grafting, Dr. Blume says these products are not the true equivalent of a skin graft. Dr. Storm agrees. When these products are used appropriately, Dr. Storm says they provide instant biological coverage and speed ulcer closure by providing needed wound healing substrates. However, he says they do not provide the “rapid” take of a graft.
In regard to neuropathic ulcers, Dr. Storm says he rarely uses skin grafts since these ulcers are usually on weightbearing surfaces and the graft will commonly fail when the patient begins walking. While Dr. Storm says he has not used skin equivalents for these ulcers, he would consider doing so if the patient is not a surgical candidate. He adds that his experience with the skin equivalents is limited to venous stasis ulcers, and does feel that they heal the ulcers faster than dressings alone.
However, Drs. Blume and Storm concur that there is no equivalent for split-thickness skin grafting for reconstruction of foot wounds.
Dr. Blume is a Clinical Assistant Professor within the Department of Orthopaedics and Rehabilitation at the Yale School of Medicine. He is the Director of Limb Preservation at the Yale New Haven Hospital in New Haven, Ct.
Dr. Storm is a Fellow of the American College of Foot and Ankle Surgeons and is board-certified by the American Board of Podiatric Surgery. He has a private practice in Bozeman, Mt.
Dr. Karlock (pictured at the right) is a Fellow of the American College of Foot And Ankle Surgeons, and practices in Austintown, Ohio.