ROTATIONAL FLAPS IN COMPLICATED PARTIAL FOOT AMPUTATION: A - - PowerPoint PPT Presentation

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ROTATIONAL FLAPS IN COMPLICATED PARTIAL FOOT AMPUTATION: A - - PowerPoint PPT Presentation

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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

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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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

 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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

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

  • f rotational flaps2

LITERATURE REVIEW

  • 1. Rodrigues, Plast Reconstr Glob Open 2017
  • 2. Boffeli & Peterson, JFAS 2013
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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

Complicated wounds requiring nontraditional closure Delay flap until osteomyelitis but intervene before abscess

  • r 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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

FIRST RAY AMPUTATION FLAP

Boffeli & Peterson, JFAS 2013

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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

FIFTH RAY AMPUTATION FLAP

Boffeli & Peterson, JFAS 2013

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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

TMA WITH LPAA ROTATIONAL FLAP

Boffeli & Waverly, JFAS 2015

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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

V  T TMA FLAP

Boffeli & Waverly, JFAS 2015

Medial Plantar Artery Angiosome + Lateral Plantar Artery Angiosome

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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

 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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

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 ap Ty Type Freq equen ency 1st ray 20 5th ray 26 MPA TMA 13 LPA TMA 16 MPA & LPA 8

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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery 13

COMORBID CONDITIONS

Com

  • mor
  • rbid C

Con

  • ndition
  • n

Prevalence ce 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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

 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

  • f 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

5 10 15 20 25 3 4 5 6 7 8 9 10 11 12 13 14 20 >20 Number er o

  • f Patien

ents Week eeks

Healin ling T g Tim ime Average time to healing after revision = 12.5 weeks

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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

 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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

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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HealthPartners/ Regions Hospital

Foot & Ankle Surg ery

elizabeth.f.neubauer@healthpartners.com

 Boffeli TJ, Collier RC. Near Total Calcanectomy with Rotational Flap Closure of Large Decubitus Heel Ulcerations Complicated by Calcaneal Osteomyelitis. J Foot Ankle Surg. 51:135-140, 2012.  Boffeli TJ, Peterson MC. Rotational Flap Closure of First and Fifth Metatarsal Head Plantar Ulcers: Adjunctive Procedure When Performing First or Fifth Ray

  • Amputation. J Foot Ankle Surg. 52 (2013):263-270.

 Boffeli TJ, Waverly BJ. Medial and Lateral Plantar Artery Angiosome Rotational Flaps for Transmetatarsal and Lisfranc Amputation in Patients With Compromised Plantar Tissue. J Foot Ankle Surg. 55(2016)351-361.  Park EY, Elliott ED, Giacopelli JA, Granoff DP, Salm RJ. The Use of Transpositional Skin Flaps in Closing Plantar Defects: A Case Report. J Foot Ankle Surg. 36:315- 321, 1997.  Rodriguez Collazo ER, Rathbone CR, Barnes BR. A Retrospective Look at Integrating a Novel Regenerative Medicine Approach in Plastic Limb

  • Reconstruction. Plastic and Reconstructive Surgery – Global Open. 2017;5:e1214.

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THANK YOU!