Foot and Ankle Reconstruction: Pedicled Muscle Flaps versus Free Flaps and the Role of Diabetes

Background: The effectiveness of pedicled muscle flaps versus microsurgical free flaps in patients with diabetes mellitus for complex foot and ankle reconstruction has not been well defined. Methods: The Georgetown Wound Registry identified all patients who underwent pedicled muscle flap or free flap reconstruction from 1990 to 2000 with 8.1 +/- 3.1-year follow-up. Thirty-eight diabetic and 42 nondiabetic patients were identified. Flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone, with pedicled muscle flaps always selected for smaller defects. Results: Thirty-two patients received 34 pedicled muscle flaps for 34 wounds, whereas 48 received 52 free flaps for 51 wounds. Thirty-one of 34 wounds covered with pedicled muscle flaps went on to heal, for a 91 percent success rate, a 94 percent limb salvage rate, and a 78 percent patient survival rate. There were 15 complications among 45 reconstructive procedures, for an overall 33 percent complication rate. Forty-eight of the 51 wounds covered with free flaps went on to heal, for a 94 percent healing rate, a 96 percent limb salvage rate, and a 77 percent patient survival rate. There were 17 complications among 93 reconstructive procedures, for an 18 percent complication rate. Conclusions: Diabetes does not appear to affect the success of pedicled muscle flap or free flap reconstruction except for requiring more debridements, longer healing times, and decreased long-term survival. When compared with historical diabetic controls with amputation, however, limb salvage appears to prolong survival of diabetic patients. Pedicled muscle flaps appear to be as effective as free flaps for the coverage of small complex foot and ankle defects, despite the postoperative complication rate. Diabetes is not a contraindication to either type of flap reconstruction for limb salvage. (Plast. Reconstr. Surg. 128: 173, 2011.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.