Limb salvage and vascular augmentation by microsurgical free flap transfer for treatment of neuropathic diabetic foot ulcers

Background : Neuropathic diabetic foot ulcers are generally deep and infectious wounds extending to the bone or joint. We performed microsurgical free flap transfer for limb salvage and vascular augmentation of feet with diabetic neuropathy. Methods : Angiography was performed to identify any significant arterial disease. The free flaps were transplanted after resection of the damaged skin and infected bone. Flow-through or end-to-side anastomosis to the dorsalis pedis artery was performed to preserve the arterial blood flow to the residual foot. Results : An anterolateral thigh flap and free flaps based on the subscapular artery system were transplanted in 1 and 10 patients, respectively. All flaps survived. Arterial flow on the distal side of the anastomosis was postoperatively confirmed in all patients. During a mean follow-up period of 52 months, the long-term complications observed were recurrent ulcers in 4 patients. The limb salvage rate was 100%, and 82% of patients achieved functional ambulation. Conclusions : Microsurgical flap transplantation is a safe and useful technique for minimal amputation of a diabetic neuropathic foot. Postoperative protection of the feet is important in order to avoid recurrence of foot ulceration. The use of protective footwear custom-tailored for each patient is strongly recommended

Flap Monitoring by TcPCO2

Background: Measurement of transcutaneous oxygen pressure (TcPO2) and transcutaneous carbon dioxide pressure (TcPCO2) has been used for free flap monitoring. Because these values are obtained with sensor probes heated to 44°C, there is potential for low-temperature burns on skin flaps. We measured TcPO2 and TcPCO2 at 37°C in both animals and humans to determine the feasibility and safety of the procedure as a postoperative flap monitoring method. Methods: Twelve epigastric island flaps were elevated in rabbits, and TcPO2 and TcPCO2 were measured at 37°C before and after ligation of the pedicles. In addition, TcPO2 and TcPCO2 at 37°C were measured in healthy men. Subsequently, the method was applied to postoperative monitoring of free flaps in 49 clinical cases. Results: TcPO2 and TcPCO2 values were significantly affected by the experimental flap elevation. A rapid increase in TcPCO2 was observed with both arterial and venous occlusion. In the healthy men, TcPO2 and TcPCO2 were measurable at all skin surface sites. In the clinical cases of free flap transfer, TcPO2 values remained very low for at least 72 hours. TcPCO2 values ranged from 40 to 70 mmHg for 72 hours in more than 80% of cases. In 2 cases, TcPCO2 values increased to more than 90 mmHg, and exploration surgery was performed. These compromised flaps were saved by reanastomosis of the veins. Conclusions: Continuous monitoring of TcPCO2 at 37°C can provide objective information and alert doctors and nurses to the need for checking the free flap

Three-dimensional sodium chloride (NaCl) model for simulated mandibular reconstruction surgery : a new environmentally friendly material

Background : Mandibular reconstruction using a fibular graft is a difficult procedure that requires technical expertise to enable adequate occlusal function and restore an aesthetic appearance. Here we used three-dimensional (3D) sodium chloride (NaCl) models for simulated mandibular reconstruction surgery. This study aimed to reveal the accuracy of mandibular reconstruction with fibular grafts using this model. Methods : Mandibular reconstructions using 3D NaCl models were performed in 5 cases. The maxilla, mandible, and fibular models were developed using computed tomography (CT) data. We performed preoperative cutting and simulation surgery using this model. Angles between the body of the corpus and symphysis were measured from the axial view (n = 4). Angles between the ramus and the body of the corpus were measured from the lateral and axial views (n = 6). These angles were measured on simulated models and postoperative CT images were compared. Results : Differences between the angles measured on the simulated models and postoperative CT images were 0-5°(mean, 1.9°). Conclusions : We were able to reproduce the neomandibles with precise osteotomies using the 3D NaCl models. We believe that simulated mandibular reconstruction surgery using this model might help reduce the number of intraoperative neomandibular segment adjustments

Transcutaneous PCO2 Measurement at Low Temperature for Reliable and Continuous Free Flap Monitoring : Experimental and Clinical Study

Background: Measurement of transcutaneous oxygen pressure (TcPO2) and transcutaneous carbon dioxide pressure (TcPCO2) has been used for free flap monitoring. Because these values are obtained with sensor probes heated to 44°C, there is potential for low-temperature burns on skin flaps. We measured TcPO2 and TcPCO2 at 37°C in both animals and humans to determine the feasibility and safety of the procedure as a postoperative flap monitoring method. Methods: Twelve epigastric island flaps were elevated in rabbits, and TcPO2 and TcPCO2 were measured at 37°C before and after ligation of the pedicles. In addition, TcPO2 and TcPCO2 at 37°C were measured in healthy men. Subsequently, the method was applied to postoperative monitoring of free flaps in 49 clinical cases. Results: TcPO2 and TcPCO2 values were significantly affected by the experimental flap elevation. A rapid increase in TcPCO2 was observed with both arterial and venous occlusion. In the healthy men, TcPO2 and TcPCO2 were measurable at all skin surface sites. In the clinical cases of free flap transfer, TcPO2 values remained very low for at least 72 hours. TcPCO2 values ranged from 40 to 70 mmHg for 72 hours in more than 80% of cases. In 2 cases, TcPCO2 values increased to more than 90 mmHg, and exploration surgery was performed. These compromised flaps were saved by reanastomosis of the veins. Conclusions: Continuous monitoring of TcPCO2 at 37°C can provide objective information and alert doctors and nurses to the need for checking the free flap

Transcutaneous PCO2 Measurement at Low Temperature for Reliable and Continuous Free Flap Monitoring: Experimental and Clinical Study

Background: Measurement of transcutaneous oxygen pressure (TcPO2) and transcutaneous carbon dioxide pressure (TcPCO2) has been used for free flap monitoring. Because these values are obtained with sensor probes heated to 44°C, there is potential for low-temperature burns on skin flaps. We measured TcPO2 and TcPCO2 at 37°C in both animals and humans to determine the feasibility and safety of the procedure as a postoperative flap monitoring method. Methods: Twelve epigastric island flaps were elevated in rabbits, and TcPO2 and TcPCO2 were measured at 37°C before and after ligation of the pedicles. In addition, TcPO2 and TcPCO2 at 37°C were measured in healthy men. Subsequently, the method was applied to postoperative monitoring of free flaps in 49 clinical cases. Results: TcPO2 and TcPCO2 values were significantly affected by the experimental flap elevation. A rapid increase in TcPCO2 was observed with both arterial and venous occlusion. In the healthy men, TcPO2 and TcPCO2 were measurable at all skin surface sites. In the clinical cases of free flap transfer, TcPO2 values remained very low for at least 72 hours. TcPCO2 values ranged from 40 to 70 mm Hg for 72 hours in more than 80% of cases. In 2 cases, TcPCO2 values increased to more than 90 mm Hg, and exploration surgery was performed. These compromised flaps were saved by reanastomosis of the veins. Conclusions: Continuous monitoring of TcPCO2 at 37°C can provide objective information and alert doctors and nurses to the need for checking the free flap