Using The Dorsal Perforator Metatarsal Artery Propeller Flap To Facilitate Limb Salvage

The author presents a case in which a dorsal fasciocutaneous “propeller” flap provided soft tissue coverage of a plantar lateral ulceration and promoted limb salvage.

The incidence of diabetes mellitus worldwide has reached almost epidemic proportions with nearly 29 million affected by the disease in the United States alone.^1,2 In concert with this increased incidence, there has been a significant rise in the observed comorbidities commonly associated with the disease process in patients living with diabetes. Among these complications, lower extremity manifestations are a significant source of patient comorbidity, mortality and healthcare expense.³

Researchers have estimated that the lifetime risk of developing diabetic foot ulceration (DFU) is as high as 25 percent in patients living with diabetes.³ In addition to the development of DFUs, greater than 50 percent of these ulcerations will become infected, accounting for nearly 20 percent of all diabetes-related hospital admissions and a significant portion of healthcare related costs — nearly $11 billion in 2001.^4-7

In those patients presenting with infected DFUs, underlying osteomyelitis is present in as many as 65 percent of cases and these infected ulcers constitute a major risk factor for non-traumatic lower extremity amputation.⁸ Indeed, nearly 83 percent of all non-traumatic lower extremity amputations in the U.S. are secondary to complications associated with diabetes mellitus.⁸ It has been well documented that the consequences of major lower extremity amputation in patients with diabetes are severe with an estimated five-year postoperative survival rate of less than 50 percent.⁹ In fact, the mortality rate associated with diabetic lower extremity amputations exceeds that of most cancers.⁹

It is therefore vital to provide early and effective diagnosis and management of patients presenting with lower extremity complications of diabetes in an effort to stem the current epidemic of limb loss. Advanced wound healing modalities, bioengineered alternative tissues and advanced limb salvage techniques are all useful to progress patients through wound healing toward the ultimate aim of preservation.

A Closer Look At The Case Presentation

The patient is a 56-year-old African-American female with a 10-year history of diabetes. She presented to the wound healing center with a three-month history of a plantar lateral foot wound underlying the fifth metatarsophalangeal joint (MPJ). At the time of presentation, the wound probed to bone and subsequent magnetic resonance imaging was suggestive of osteomyelitis about the fifth metatarsal head. (see photo 1)

The patient presented to vascular surgeons and they recommended a partial fifth ray resection. The patient requested a second opinion and the limb salvage team consulted for potential salvage options.

Subsequently, the patient went to the operating room for initial surgical debridement and metatarsal head resection with a bone biopsy. The bone cultures went to pathology and there was an infectious disease consult as well. The patient started on a six-week course of parenteral antibiotics as per the infectious disease consult recommendations and completed this course without incident. During the duration of the patient’s antibiotic therapy, I utilized total contact casting and local wound care modalities. Upon the completion of her antibiotics and when the wound clinically appeared free from infection and deep wound cultures were negative, I decided to progress the patient to surgical closure of her plantar lateral foot wound.

Considering the location and size of the wound, I decided to use a dorsolateral fasciocutaneous propeller flap to facilitate lower extremity reconstruction. The distal metatarsal perforating artery was the pedicle artery to provide perfusion to the flap. Using Doppler intraoperatively, I located the perforating artery at the distal dorsal aspect of the fourth interspace, just proximal to the MPJs. I subsequently assessed the distance from the pedicle perforator and the farthest margin of the plantar lateral wound to determine the appropriate length for the flap along the dorsum of the foot (see photo 2). Utilizing an atraumatic technique, I elevated the flap and rotated it 90 degrees laterally to cover the plantar lateral soft tissue defect (see photo 3). After subsequently securing the flap in place, I took care to provide minimal tension and atraumatic technique along the margins. Upon completing flap placement, I utilized a Doppler to confirm patency of the pedicle via the dorsal perforating artery.

Upon completion of the flap elevation and transposition, I applied a dermoconductive bioengineered alterative tissue (BAT) graft to the dorsal donor site to provide for the development of granulation tissue over the now exposed extensor digitorum longus tendons (see photo 4). At this point, the patient was non-weightbearing and I initiated negative pressure wound therapy to improve BAT graft uptake. I removed the silicone layer from the dorsal dermconductive BAT graft at approximately two weeks post-op. With the development of appropriate granulation tissue, the patient returned to the operating room for placement of a split-thickness skin graft at the fasciocutaneous donor site to provide for complete wound closure (see photo 5).

Final Words

This case highlights the viability of the dorsal perforator artery propeller flap/ for the management of foot wounds. In this case, a dorsal lateral propeller flap provided wound coverage for a plantar lateral wound underlying the fifth MPJ. Anatomic considerations and the geometry of this type of fasciocutaneous flap allow for the use of this technique to provide wound closure for the management of a variety of lower extremity wound locations to promote limb preservation.^10,11

Prior to any reconstructive efforts, appropriate management of any underlying infectious process is necessary to ensure the greatest likelihood for success. Upon wound healing, it is vital to transition the patient into an appropriate offloading shoe to promote continued wound remission.

Dr. Fitzgerald practices at the GHS Center for Amputation Prevention in Greenville, SC. He is an Assistant Professor of Surgery at the University of South Carolina School of Medicine in Greenville, SC.

References

1.      Capobianco CM, Stapleton JJ. Diabetic foot infections: a team-oriented review of medical and surgical management. Diabet Foot Ankle. 2010; 1.

2.      Wendel CS, Fotieo GG, Shah JH, et al. Incidence of non-severe hypoglycaemia and intensity of treatment among veterans with Type 2 diabetes in the USA: a prospective observational study. Diabet Med. 2014; 31(12):1524-31.

3.      Ozdemir BA, Brownrigg J, Patel N, et al. Population-based screening for the prevention of lower extremity complications in diabetes. Diabetes Metab Res Rev. 2013; 29(3):173-82.

4.      Norvell DC, Turner AP, Williams RM, et al. Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes. J Vasc Surg. 2011; 54(2):412-9.

5.      Reed JF. An audit of lower extremity complications in octogenarian patients with diabetes mellitus. Int J Low Extrem Wounds. 2004; 3(3):161-4.

6.      American Public Health Association. Reducing the incidence of blindness, lower extremity amputation, and oral health complications in minority populations due to diabetes. Am J Public Health. 2001; 91(3):478-9.

7.      Maser RE, Lenhard MJ, DeCherney GS. Lower extremity complications: identifying patients with diabetes mellitus who are at risk. Del Med J. 1999; 71(6):249-54.

8.      Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg. 2007; 24(3):469-82, viii-ix.

9.      Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286-7.

10.    Hallock GG. The first dorsal metatarsal artery perforator propeller flap. Ann Plast Surg, August 29, 2014 (Epub ahead of print).

11.    Cinpolat A, Bektas G, Ozkan O, et al. Metatarsal artery perforator-based propeller flap. Microsurgery. 2014; 34(4):287-91.