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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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  1. 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 1 I have no financial disclosures and will not discuss off label or investigative use of products or devices

  2. VALUE OF ROTATIONAL FLAPS  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 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  3. LITERATURE REVIEW  Challenging micro-environment 1  Tissue ischemia  Immune impairment  Biomechanical derangement  Peripheral neuropathy  Non-healing nature of diabetes-related plantar neuropathic ulcers does not preclude successful incorporation of rotational flaps 2 1. Rodrigues, Plast Reconstr Glob Open 2017 2. Boffeli & Peterson, JFAS 2013 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  4. ADVANTAGES  Full-thickness flap is the most successful approach for plantar foot wounds due to mobility, sensation, and tissue thickness 3  Immediate coverage of osseous structures and soft tissue defects 4  Prompt healing by primary intention 4  Limb preservation: avoid or delay proximal amputation 4  Improve delivery of antibiotic therapy 4 3. Park et al, JFAS 1997 4. Boffeli & Peterson, JFAS 2016 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  5. FLAP PROTOCOL  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 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  6. FIRST RAY AMPUTATION FLAP Boffeli & Peterson, JFAS 2013 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  7. FIFTH RAY AMPUTATION FLAP Boffeli & Peterson, JFAS 2013 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  8. TMA WITH LPAA ROTATIONAL FLAP Boffeli & Waverly, JFAS 2015 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  9. V  T TMA FLAP Medial Plantar Artery Angiosome + Lateral Plantar Artery Angiosome Boffeli & Waverly, JFAS 2015 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  10. STATEMENT OF PURPOSE  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 HealthPartners/ Regions Hospital 10 Foot & Ankle Surg ery

  11. RESEARCH METHODOLOGY  Level 3 retrospective  Consecutive cases identified by CPT billing history  1 st ray (20)  5 th 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 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  12. PRELIMINARY RESULTS Flap ap Ty Type Freq equen ency  103 total flaps were reviewed 1 st ray 20  83 flaps met inclusion criteria 5 th ray 26  71 patients (M = 55, F = 16) MPA TMA 13  Age: 62.5 ± 1.2 years (range 38-94) LPA TMA 16  77 feet (L = 46, R = 31) MPA & LPA 8 HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  13. COMORBID CONDITIONS Com omor orbid C Con ondition on 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% HealthPartners/ Regions Hospital 13 Foot & Ankle Surg ery

  14. INITIAL FLAP HEALING RESULTS  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 Healin ling T g Tim ime for an overall success rate 25 of 75/83 (90.4%) ents 20 of Patien  8/83 (9.6%) did not heal 15 er o  6 required more 10 Number proximal amputation 5 0  2 passed due to 3 4 5 6 7 8 9 10 11 12 13 14 20 >20 unrelated conditions Week eeks Average time to healing after revision = 12.5 weeks HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  15. LONGEVITY OF FLAP  21/82 (25.3%) required more proximal amputation within 2 years  TMA (11)  BKA (8)  AKA (2) HealthPartners/ Regions Hospital 15 Foot & Ankle Surg ery

  16. CONCLUSIONS  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. HealthPartners/ Regions Hospital Foot & Ankle Surg ery

  17. THANK YOU! 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 . HealthPartners/ Regions Hospital 17 Foot & Ankle Surg ery

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