Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
4/5/2014
1
Soft Tissue Coverage for the Diabetic Foot
Scott L. Hansen, M.D.Chief, Plastic and Reconstructive Surgery
San Francisco General Hospital
Diabetic foot wounds/ulcers• Neuropathy
– Sensory: loss of protective sensation– Motor: alteration in foot mechanics– Autonomic: dry, cracked skin
• Decreased immune response– Infection
• Peripheral vascular disease– Local hypoxia– **Can’t reconstruct until adequate
perfusion!
Hansen 2014
General Management
• Staged debridement's with Vascular, Orthopaedic and Podiatric Surgery• Assess components of defect• Continue until wound clean • Amt. of debridement depends on perfusion
• Wound VAC used as bridge• Amputation vs. Limb salvage vs. preservation
of length
Hansen 2014
What we are trying to avoidHansen 2014
4/5/2014
2
What we are trying to avoidHansen 2014
Result = Amputation
Wound Analysis• Location
• Hindfoot/Midfoot/Forefoot
• Wound size• Components of wound
– Skin -Nerve- Subcutaneous tissue -Cartilage– Muscle -Bone– Vessels
• Etiology• Pressure, non-compliance
Hansen 2014
Reconstructive LadderHansen 2014
Healing / Secondary Intention
• Advantage– pulls “like” tissue into wound
• Disadvantage– duration of healing
• Consider for smaller wounds
Hansen 2014
4/5/2014
3
Split-Thickness Skin GraftHansen 2014
Indications for Flap Coverage
• Skin graft cannot be used– Exposed cartilage, tendon (without
paratenon), bone, open joints, metal implants
• Flap coverage is preferable– Exposed nerves or vessels, durability
required, multiple tissues required, dead space present
Hansen 2014
Principles• The final
reconstruction should be functional– Durable– Maintain Sensation– Contour (not bulky)
Hansen 2014Reconstructive options depend on
location of wound
Hindfoot/Heel/Malleolus
Forefoot
Mid plantar
Hansen 2014
4/5/2014
4
Hindfoot & Mid Plantar• Goal is to provide sensate coverage by using like
tissue from non-weight bearing midsole area• <1/3 of heel
• Split & full thickness skin grafts• Sural Flap: Suprafascial rotation flap
• 1/3 to 2/3 of heel• Flexor digitorum brevis muscle turnover flap• Instep island flap
Hansen 2014
Hindfoot & Mid Plantar• >2/3 of heel
• Free tissue transfer• Non-weight bearing heel, instep, malleoli
• Skin graft• Rotation flaps• Reverse pedicled fasciocutaneous flaps• Extensor digitorum brevis flap• Abductor hallucis & abductor digiti minimi muscle flap• Free muscle or fasciocutaneous flap if deep
Hansen 2014
HindfootCalcanectomy & closure
Hansen 2014 HindfootFlexor digitorum brevis flap
Hansen 2014
4/5/2014
5
HindfootFlexor digitorum brevis flap
Blood Supply: Branches of Medial and Lateral Plantar artery
Hansen 2014 Hindfoot Reconstruction Hansen 2014
Hindfoot Reconstruction
Flexor digitorum brevis flap
Hansen 2014 Hansen 2014
4/5/2014
6
HindfootInstep island flap
Hansen 2014
Based on branches of the medial plantar artery
Hansen 2014
Local rotational flap, Length:Width ratio 2:1
Hansen 2014
V to Y AdvancementHansen 2014
4/5/2014
7
Lateral Supramalleolar FlapHansen 2014
*Supplied by a perforating branch of the peroneal artery
Hansen 2014Lateral Calcaneal Artery Flap
Hansen 2014Lateral Calcaneal Artery Flap Hansen 2014Lateral Calcaneal Artery Flap
4/5/2014
8
Neurocutaneous Flap
• Sural artery flap• Small artery and vein
supplying the suralnerve
• Pivot point is 5cm proximal to lateral malleolus (peronealartery)
Hansen 2014 Sural FlapHansen 2014
Sural FlapHansen 2014 MidfootV-Y advancement island flaps
Hansen 2014
4/5/2014
9
MidfootV-Y advancement flaps
Hansen 2014 Hansen 2014
Plantar rotation flaps• Based on the vascular plexus superficial to the
plantar fascia• Donor site is skin grafted
Hansen 2014
Microvascular Transplantation (MVT)• Myriad of Flaps Available
• Muscle• Skin• Combination
• Dead space present• Osteomyelitis• Local tissues not available
Hansen 2014
4/5/2014
10
Muscle and Musculocutaneous Flaps
• Latissimus dorsi• Rectus abdominis• Gracilis
Hansen 2014
Fasciocutaneous and Perforator Flaps• Radial Forearm Flap• Anterolateral Thigh Flap
Hansen 2014
Heel ReconstructionHansen 2014
Muscle vs. fasciocutaneous flap coverage
Hansen 2014
4/5/2014
11
Heel ReconstructionHansen 2014 Hindfoot
Latissimus flapHansen 2014
HindfootLatissimus flap
Hansen 2014 HindfootLatissimus free flap
Hansen 2014
4/5/2014
12
Perforator FlapHansen 2014
Perforator FlapHansen 2014
Anterolateral thigh flap (ALT): Blood supply- Descending branch of the lateral circumflex
Perforator FlapHansen 2014
Forefoot• Plantar flaps cannot be mobilized distally due
to tethering effect by plantar nerves• Sensate toe flap; unfavorable donor defect• Free tissue transfer provide most stable,
durable coverage– Latissimus dorsi muscle flap
Hansen 2014
4/5/2014
13
ForefootRay amputation +STSG
Hansen 2014 ForefootTransmetatarsal amputation
Hansen 2014
ForefootTransmetatarsal amputation
Hansen 2014 ForefootTransmetatarsal amputation
Hansen 2014
4/5/2014
14
ForefootToe filet flaps
Hansen 2014 ForefootNeurovascular island flaps
Hansen 2014
ForefootNeurovascular island flaps
Hansen 2014 ForefootV-Y advancement flaps
Hansen 2014
4/5/2014
15
ForefootV-Y advancement flaps
Hansen 2014
Large DefectsHansen 2014
Large DefectsHansen 2014
Large DefectsHansen 2014
4/5/2014
16
Hansen 2014 MidfootAmputation Salvage
Hansen 2014
MidfootAmputation Salvage
Hansen 2014
Foot Dorsum• Skin grafts• Direct exposed tendon or bone
– Free flaps• Radial forearm/ALT flap• Latissimus muscle• Gracilis flap
Hansen 2014
4/5/2014
17
Hansen 2014
Post-op Management• Foot immobilization post-op
– Consider ex-fix• Protect pressure points• Continue to optimize medical management• Close follow-up
Hansen 2014
Conclusions• Team approach = more chance of success• Reconstructive ladder helpful in choosing
reconstruction• Limb salvage prolongs survival of diabetic
patients• Diabetes is NOT a contraindication to local or
free flap reconstruction
Hansen 2014