ROTATIONAL FLAPS IN COMPLICATED PARTIAL FOOT
AMPUTATION: A RETROSPECTIVE REVIEW
TO ASSESS INITIAL HEALING AND FLAP SURVIVAL
ELIZABETH NEUBAUER, DPM, MSHA TROY BOFFELI, DPM, FACFAS
July 13, 2019
Regions Hospital Foot and Ankle
Surgical Residency Program
I have no financial disclosures and will not discuss off label or investigative use of products or devices 1
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Large plantar wound deficits lead to residual wound or extensive loss of foot function with amputation
Rotational flaps allow a more desirable level of amputation with complete wound closure
VALUE OF ROTATIONAL FLAPS
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Challenging micro-environment1 Tissue ischemia Immune impairment Biomechanical derangement Peripheral neuropathy
Non-healing nature of diabetes-related plantar neuropathic ulcers does not preclude successful incorporation of rotational flaps2
LITERATURE REVIEW
1. Rodrigues, Plast Reconstr Glob Open 2017 2. Boffeli & Peterson, JFAS 2013
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Full-thickness flap is the most successful approach for plantar foot wounds due to mobility, sensation, and tissue thickness3 Immediate coverage of osseous
structures and soft tissue defects4 Prompt healing by primary intention4 Limb preservation: avoid or delay
proximal amputation4 Improve delivery of antibiotic
therapy4
ADVANTAGES
3. Park et al, JFAS 1997 4. Boffeli & Peterson, JFAS 2016
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Complicated wounds requiring nontraditional closure
Delay flap until osteomyelitis but intervene before abscess or necrosis
Plan for flap failure: incisions that don’t preclude future amputation
PMMA beads when necessary Raise full-thickness flaps Limited-touch or no-touch
technique with skin hooks Hug contours of bone to minimize
neurovascular compromise
FLAP PROTOCOL
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FIRST RAY AMPUTATION FLAP
Boffeli & Peterson, JFAS 2013
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FIFTH RAY AMPUTATION FLAP
Boffeli & Peterson, JFAS 2013
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TMA WITH LPAA ROTATIONAL FLAP
Boffeli & Waverly, JFAS 2015
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V T TMA FLAP
Boffeli & Waverly, JFAS 2015
Medial Plantar Artery Angiosome + Lateral Plantar Artery Angiosome
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Assess initial flap healing & intermediate term survival of common pedal flaps when incorporated into partial foot amputation
Assess prevalence & influence of common comorbidities
Hypothesis: A high percentage of rotational flaps heal successfully despite comorbid conditions
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STATEMENT OF PURPOSE
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Level 3 retrospective Consecutive cases
identified by CPT billing history 1st ray (20) 5th ray (26) Medial/lateral plantar
artery (37) Single surgeon (TJB) 2011 – 2015 Minimum 2-year follow-
up to assess longevity Exclusion criteria: digital flap,
trauma etiology, tumor etiology, deceased, insufficient follow-up
RESEARCH METHODOLOGY
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103 total flaps were reviewed 83 flaps met inclusion criteria 71 patients (M = 55, F = 16) Age: 62.5 ± 1.2 years (range 38-94)
77 feet (L = 46, R = 31)
PRELIMINARY RESULTS
Flap Type Frequency
1st ray 20
5th ray 26
MPA TMA 13
LPA TMA 16
MPA & LPA 8
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COMORBID CONDITIONS
Comorbid Condition Prevalence
Diabetes 86.7%
Peripheral Neuropathy 95.2%
Osteomyelitis 95.2%
Obese 50.6%
Peripheral Vascular Disease 47.0%
Overweight 25.3%
Gangrene 33.7%
Heterotopic Ossification 45.8%
Charcot 4.8%
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54/83 (65.1%) were completely healed by 6 weeks 15 more healed after 6 weeks without further surgery 6 more healed following
local revision surgery for an overall success rate of 75/83 (90.4%)
8/83 (9.6%) did not heal 6 required more
proximal amputation 2 passed due to
unrelated conditions
INITIAL FLAP HEALING RESULTS
0
5
10
15
20
25
3 4 5 6 7 8 9 10 11 12 13 14 20 >20N
umbe
r of P
atie
nts
Weeks
Healing Time
Average time to healing after revision = 12.5 weeks
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21/82 (25.3%) required more proximal amputation within 2 years TMA (11) BKA (8) AKA (2)
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LONGEVITY OF FLAP
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High percentage of rotational flaps heal successfully despite comorbid conditions 69/82 (83.1%) healed uneventfully 75/82 (90.3%) healed with revision
Diabetes and peripheral neuropathy were the most prevalent comorbid conditions
Immediate flap coverage for complicated amputations avoids excessive costs associated with chronic bone exposure, long-term Vac therapy, and recurrent osteomyelitis.
CONCLUSIONS
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Bof fe l i TJ , Col l ier RC. Near Total Calcanectomy with Rotat ional F lap Closure of Large Decubi tus Heel Ulcerat ions Complicated by Calcaneal Osteomyel i t is . J Foot Ankle Surg. 51:135-140, 2012.
Bof fe l i TJ , Peterson MC. Rotat ional F lap Closure of F i rst and Fi f th Metatarsal Head Plantar Ulcers: Adjunct ive Procedure When Per forming Fi rst or F i f th Ray Amputat ion. J Foot Ankle Surg. 52 (2013):263-270.
Bof fe l i TJ , Waverly BJ . Medial and Lateral P lantar Ar tery Angiosome Rotat ional F laps for Transmetatarsal and Lisfranc Amputat ion in Pat ients With Compromised Plantar T issue. J Foot Ankle Surg. 55(2016)351-361 .
Park EY, E l l iott ED, Giacopel l i JA , Granof f DP, Salm RJ. The Use of Transposit ional Skin Flaps in Closing Plantar Defects : A Case Repor t . J Foot Ankle Surg. 36:315-321 , 1997.
Rodriguez Col lazo ER, Rathbone CR, Barnes BR. A Retrospect ive Look at Integrat ing a Novel Regenerative Medic ine Approach in Plast ic L imb Reconstruct ion. Plast ic and Reconstructive Surgery – Global Open. 2017;5:e1214.
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