title: Strategies for free flap transfer and revascularisation with long-term outcome in the treatment of large diabetic foot lesions.
abstract: OBJECTIVE
  To analyse the impact of ischaemia and revascularisation strategies on the long-term outcome of patients undergoing free flap transfer (FFT) for large diabetic foot lesions penetrating to the tendon, bone, or joint.
  
  
  METHODS
  Foot lesions of 63 patients with diabetes (median age 56 years; 70% male) were covered with a FTT in 1991-2003. Three groups were formed and followed until 2009: patients with a native in line artery to the ulcer area (n = 19; group A), patients with correctable ischaemia requiring vascular bypass (n = 32; group B), and patients with uncorrectable ischaemia lacking a recipient vessel in the ulcer area (n = 12; group C).
  
  
  RESULTS
  The respective 1, 5, and 10 year amputation free survival rates were 90%, 79%, and 63% in group A; 66%, 25%, and 18% in group B; and 50%, 42%, and 17%, in group C. The respective 1, 5, and 10 year leg salvage rates were 94%, 94%, and 87% in group A; 71%, 65%, and 65% in group B; and 50%, 50%, and 50% in group C. In 1 year, 43%, 45%, and 18% of the patients in groups A, B, and C, respectively, achieved stable epithelisation for at least 6 months. The overall amputation rate was associated with smoking (relative risk [RR] 3.09, 95% confidence interval [CI] 1.8-5.3), heel ulceration (RR 2.25, 95% CI 1.1-4.7), nephropathy (RR 2.24, 95% CI 1.04-4.82), and an ulcer diameter of >10 cm (RR 2.08, 95% CI 1.03-4.48).
  
  
  CONCLUSIONS
  Despite diabetic comorbidities, complicated foot defects may be covered by means of an FFT with excellent long-term amputation free survival, provided that a patent native artery feeds the ulcer area. Ischaemic limbs may also be salvaged with combined FFT and vascular reconstruction in non-smokers and in the absence of very extensive heel ulcers. Occasionally, amputation is avoidable with FFT, even without the possibility of direct revascularisation.
authors.affiliation: Department of Plastic Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland; Vascular Surgery, HUH Abdominal Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 Helsinki, Finland. Electronic address: milla.kallio@hus.fi.
authors.forename: M
authors.initials: M
authors.lastname: Kallio
authors.affiliation: Vascular Surgery, HUH Abdominal Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 Helsinki, Finland.
authors.forename: P
authors.initials: P
authors.lastname: Vikatmaa
authors.affiliation: Vascular Surgery, HUH Abdominal Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 Helsinki, Finland.
authors.forename: I
authors.initials: I
authors.lastname: Kantonen
authors.affiliation: Vascular Surgery, HUH Abdominal Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 Helsinki, Finland.
authors.forename: M
authors.initials: M
authors.lastname: Lepäntalo
authors.affiliation: Vascular Surgery, HUH Abdominal Center, University of Helsinki and Helsinki University Hospital, PL 340, 00029 Helsinki, Finland.
authors.forename: M
authors.initials: M
authors.lastname: Venermo
authors.affiliation: Department of Plastic Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland.
authors.forename: E
authors.initials: E
authors.lastname: Tukiainen
mesh_terms: D000328:Adult; D000368:Aged; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D015897:Comorbidity; D017719:Diabetic Foot / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D058752:Free Tissue Flaps / Q000009:adverse effects; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D016491:Peripheral Vascular Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D014945:Wound Healing
keywords: Diabetic foot ulcer; Flap transfer; Peripheral arterial disease; Vascular surgical procedure