Use of a combined pedicled toe fillet flap

A Two-Stage Diabetic Foot Salvage Using Synthetic Bone Void Filler and Lesser Toe Fillet Flap: A Case Report

CASE

A 54-year-old type 2 diabetic man with a diabetic forefoot ulcer and osteomyelitis successfully underwent a staged reconstruction to salvage his foot. An antibiotic-carrying bone void filler was used to decrease the infection burden after initial debridement. The fifth toe fillet flap was performed to cover the large soft-tissue defect. The patient returned to baseline ambulation at the 1-year follow-up with a well-incorporated flap.

CONCLUSION

This case highlights the utility of combining an antibiotic-carrying bone void filler and a toe fillet flap in a two-stage approach to salvage complex diabetic foot ulcers.

A Systematic Review on the Outcomes of the Fillet Flap in Treating Diabetic and Ischemic Forefoot Ulcers

Background

Diabetic and ischemic foot ulcers are difficult to heal, and the mastering of numerous treatment methods is imperative to achieve healing. One of these methods is the fillet toe flap used to cover specific diabetic wounds of the forefoot associated with toe osteomyelitis. Instead of amputating the infected toe, phalanges are removed while keeping the viable surrounding soft tissue.

Methods

A systematic review was performed searching electronic databases up to October 2019 to identify relevant articles reporting the outcomes of the fillet flap in forefoot ulcers of patients with diabetes or peripheral artery disease. All study designs were included. The healing rate was the primary outcome. Secondary outcomes were the time to heal, ulcer recurrence, and complication rates of such infection, partial necrosis, and total necrosis.

Results

The 8 studies that met the inclusion criteria were all case series or case reports, with a total of 28 patients including 29 flaps. The mean healing rate was 92.8% (2/29); in both cases, total necrosis was due to infection (7.2%). No ulcer recurrence or partial necrosis was noted.

Conclusions

Though having limited indications, the fillet flap illustrates the full optimization of the available resources for wound coverage. The consistent presence of an axial vessel makes the fillet flap a reliable local flap to be used in specific circumstances where the loss of a toe is unavoidable. Further research is needed with large prospective controlled trials to support the findings of the review.

A review of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap for wound coverage during ray amputations of the toes

INTRODUCTION

Exposure of the adjacent Metatarsal-Phalangeal Joint (MTPJ) commonly occurs after application of Topical Negative Pressure Wound Therapy (TNPWT) for a ray amputation wound. This is due to mechanical soft tissue erosion or trauma to the adjacent digital artery from direct pressure effect. This results in toe gangrene requiring a ray amputation and ultimately a larger wound bed. We describe the use of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap - a filleted toe flap to protect the adjacent MTPJ capsule combined with a novel Negative Pressure Wound Therapy with instillation and dwell-time (NPWTi-d) dressing technique. The flap protects the adjacent joint capsule and reduces the wound burden whilst allowing the wound to benefit from TNPWT, thereby accelerating wound healing.

MATERIAL AND METHODS

A retrospective review was conducted of patients with toe gangrene requiring ray amputation that underwent the TOPHAT flap on in our institution from 2019 and 2020. Complications such as wound dehiscence, hematoma, flap necrosis and secondary infection were recorded. Other outcomes recorded were time taken to final skin grafting and time taken for complete wound epithelialization.

RESULTS

9 patients underwent treatment with the TOPHAT flap. 2 patients had flap necrosis. 7 patients progressed to definitive skin coverage with skin grafting. One patient subsequently had progressive arterial disease despite successful skin grafting and required above knee amputation. The mean time to final skin grafting and complete wound epithelialization was 49.5 days and 107.5 days respectively. All patients were satisfied with the outcomes and were able to return to their pre-morbid function.

CONCLUSIONS

The TOPHAT flap has a consistent vascular supply that provides durable soft tissue coverage. It is a robust and easily reproducible technique to accelerate wound healing after ray amputations even in patients with peripheral vascular disease.

Utility of the Digital Fillet Flap

The digital fillet flap provides a good option for coverage of forefoot soft tissue deficits. Understanding of the anatomy, coupled with careful patient selection, improves surgical outcomes. Similar to other fasciocutaneous flaps, the surgeon needs to be familiar with delay techniques and proper inset to minimize complications.

Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review

"A systematic review was undertaken to assess the outcomes of local random flaps in diabetic foot wound closure. The review was conducted using the following databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica dataBASE, Google Scholar, MEDLINE, Ovid, and PubMed. Search terms were local random flap, diabetes, foot, wound, ulceration, neuropathy, tissue transfer, V-Y, bilobed, monolobed, rotational, advancement, transpositional, rhomboid, and Limberg. English language studies, studies published from 1997 to 2017, patients with diabetes mellitus treated for foot wounds, use of local random flaps, follow-up period of 6 months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery were included. Isolated literature reviews and descriptions of only surgical technique and/or cadaveric studies were excluded. The initial search identified 53 eligible studies with 28 being excluded. The remaining 25 studies used for data extraction had a total of 512 patients in which 199 of these underwent 204 local random flap procedures. Average follow-up for the flaps was approximately >2 years, and successful wound closure at last follow-up was demonstrated in 75.5% of the studied population. Studies were found to be of generally low quality, with the majority composed of retrospective case series. Based on current available evidence found in this systematic review, local random flaps demonstrated a relatively high success rate when utilized for the definitive closure of diabetic foot wounds. However, because of a lack of high-quality evidence and substantial heterogeneity among the studies, the results should be interpreted with caution. Levels of Evidence: Level III: Systematic review.

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or "spare parts technique") has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the "spare parts". The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap. The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound. In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.

Modified toe pulp fillet flap coverage: Better wound healing and satisfactory length preservation

BACKGROUND

Amputation is commonly performed for toe necrosis secondary to peripheral vascular diseases, such as diabetes mellitus. When amputating a necrotic toe, preservation of the bony structure is important for preventing the collapse of adjacent digits into the amputated space. However, in the popular terminal Syme's amputation technique, partial amputation of the distal phalanx could cause increased tension on the wound margin. Herein, we introduce a new way to resect sufficient bony structure while maintaining the normal length, based on a morphological analysis of the toes.

METHODS

Unlike the pulp of the finger in the distal phalanx, the toe has abundant teardrop-shaped pulp tissue. The ratio of the vertical length to the longitudinal length in the distal phalanx was compared between the toes and fingers. Amputation was performed at the proximal interphalangeal joint level. Then, a mobilizable pulp flap was rotated 90° cephalad to replace the distal soft tissue defect. This modified toe fillet flap was performed in 5 patients.

RESULTS

The toe pulp was found to have a vertically oriented morphology compared to that of the fingers, enabling length preservation through cephalad rotation. All defects were successfully covered without marginal ischemia.

CONCLUSIONS

While conventional toe fillet flap coverage focuses on the principle of length preservation as the first priority, our modified method takes both wound healing and length into account. The fattiest part of the pulp is advanced to the toe tip, providing a cushioning effect and enough length to substitute for phalangeal bone loss. Our modified method led to satisfactory functional and aesthetic outcomes.

Digital Fillet Flaps: A Systematic Review

Digital fillet flaps have a consistent vascular supply and provide durable soft-tissue coverage. Despite their readily available nature, their use in the foot remains limited. This systematic review was undertaken to determine the size defect that could be covered, the potential postoperative complications, and the durability of a digital fillet flap. Studies were eligible for inclusion if they involved use of the entire digit for soft-tissue coverage of defects of any etiology, reported complications, and had any length of follow-up time. A total of 9 studies met all the inclusion criteria, for a total of 34 patients with a combined mean age of 47.1 years and a combined mean follow-up time of 9.3 months. Complications consisted of continued infection and partial or total necrosis of the flap. Digital fillet flaps were able to cover defects up to a combined mean size of 15.6 cm2. Coverage was found to be best for forefoot ulcerations. The flaps had limited donor site morbidity and provided full coverage of exposed vital and osseous structures that was able to withstand forces applied during weight bearing, The procedure is simple and straightforward, reducing operating time and the need for more complex soft-tissue reconstructive procedures.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Systematic review.

The lateral lesser toe fillet flap for diabetic foot soft tissue closure: surgical technique and case report

Wound closure for the diabetic foot can be challenging and often involves amputation or reconstruction. The authors describe a surgical technique and a case report of lateral lesser toe fillet flap in the management of a diabetic foot wound. The lateral lesser toe fillet flap reconstruction is a reproducible technique that incurs comparatively minimal technical complexity and provides a favorable option in the management of diabetic foot wounds where soft tissue coverage is required.

Primary Closure With a Filleted Hallux Flap After Transmetatarsal Amputation of the Big Toe for Osteomyelitis in the Diabetic Foot

In the diabetic foot, osteomyelitis of the first metatarsal head adjacent to a malum perforans may require resection of the metatarsophalangeal joint. This results in a dysfunctional great toe and large tissue defects that take a long time to heal. The authors postulated that transmetatarsal amputation followed by primary closure with a filleted hallux flap would be feasible in selected cases. Patients that required surgery for diffuse bone destruction of the first metatarsal head were included in the study. Transmetatarsal amputation was performed only if tissue removal rendered the hallux functionless. Primary closure with a filleted hallux flap was attempted in four out of sixteen patients. The developed skin flaps invariably were long enough to cover the plantar tissue defect; no flap necrosis or recurrent infection was noted. Mean healing time was 44 days (range 9-69). Long-term results were disappointing due to ulcer recurrences under the remaining metatarsal heads.

V-Y advancement flap coverage of toe-tip injuries

Toe-tip injury presents a challenging problem. There are few techniques that provide cover for distal toe defects, and most injuries are usually treated with terminalization or a skin graft. In patients with toe-tip injuries where there is preservation of the plantar toe pulp, V-Y flap advancement is a therapeutic option. In this article, we describe the surgical technique used and present the results of 10 patients with dorsal oblique or transverse toe injuries that underwent V-Y flap advancement for defect coverage. Eight patients had distal great toe injuries, 1 had a dorsal oblique amputation of the third toe, and 1 had a transverse amputation at the metatarsophalangeal joint level. Mean follow-up was 5 months, at which time all patients had returned to their previous activity level, and showed acceptable levels of scarring. The V-Y advancement flap, commonly used in fingertip injuries, when indicated and carefully performed gives excellent contour and padding, maintains toe length, and provides good cosmesis for treatment of toe amputations.

LEVEL OF CLINICAL EVIDENCE

4.

Recurrent pedal hobnail (Dabska-retiform) hemangioendothelioma with forefoot reconstructive surgery using a digital fillet flap

An 8-year-old female presented with a recurrent hobnail (Dabska-retiform) hemangioendothelioma of her right foot. After initial tumor excision and subsequent recurrence, the patient underwent a successful tumor resection and forefoot reconstruction using a fillet of second digit flap. In an attempt to create a plantigrade foot, while sufficiently removing this rare pedal tumor, the authors employed the use of a fillet of second digit flap. Specific surgical techniques and the histopathological assessment of this rare vascular neoplasm are discussed.

LEVEL OF CLINICAL EVIDENCE

4.