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An Innovative Application of the Free Vascularized Medial Femoral Condyle Flap in the Prevention of Recurring Neuropathic Ulcer in the Diabetic Foot: A Case Report

      Abstract

      Despite various therapy options, the prophylactic and symptomatic treatment of recurrent ulcerations in the diabetic foot are still challenging. We report the application of a free vascularized medial femoral condyle flap to prevent the recurrence of pressure ulcer in a patient with diabetic foot syndrome. Our patient had type 2 diabetes and presented with pressure ulcers and osteomyelitis of metatarsal heads 2 and 3 after a great toe amputation. We chose to use a medial femoral condyle flap as a damper in the area of the metatarsal heads because of the relatively young age and good vascularity of our patient. We shaped the graft like a ski to distribute the pressure and prevent perforation of the plantar skin. Good results were achieved for wound healing, pain reduction, and improvement of gait. No pressure ulceration had recurred after a 3-year follow-up period. The versatility of the osteomyocutaneous graft from the medial femoral condyle is an important reconstructive tool for addressing major surgical problems. We present the first use of a medial femoral condyle flap in the treatment of a pressure ulcer in a diabetic foot. In selected patients, our method could prevent premature and extended amputations, thereby providing good improvement in patients' quality of life.

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      References

        • Quebedeaux T.L.
        • Lavery L.A.
        • Lavery D.C.
        The development of foot deformities and ulcers after great toe amputation in diabetes.
        Diabetes Care. 1996; 19: 165-167
        • Lavery L.A.
        • Armstrong D.G.
        • Vela S.A.
        • Quebedeaux T.L.
        • Fleischli J.G.
        Practical criteria for screening patients at high risk for diabetic foot ulceration.
        Arch Intern Med. 1998; 158: 157
        • Lavery L.A.
        • Lavery D.C.
        • Quebedeax-Farnham T.L.
        Increased foot pressures after great toe amputation in diabetes.
        Diabetes Care. 1995; 18: 1460-1462
        • Cheer K.
        • Shearman C.
        • Jude E.B.
        Managing complications of the diabetic foot.
        BMJ. 2009; 339: b4905
        • Apelqvist J.
        Diagnostics and treatment of the diabetic foot.
        Endocrine. 2012; 41: 384-397
        • Besse J.-L.
        • Leemrijse T.
        • Deleu P.-A.
        Diabetic foot: the orthopedic surgery angle.
        Orthop Traumatol Surg Res. 2011; 97: 314-329
        • Andrews K.L.
        • Houdek M.T.
        • Kiemele L.J.
        Wound management of chronic diabetic foot ulcers: from the basics to regenerative medicine.
        Prosthet Orthot Int. 2015; 39: 29-39
        • Borkosky S.L.
        • Roukis T.S.
        Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review.
        Diabet Foot Ankle. 2012; 3
        • Chu Y.-J.
        • Li X.-W.
        • Wang P.-H.
        • Xu J.
        • Sun H.-J.
        • Ding M.
        • Jiao J.
        • Ji X.-Y.
        • Feng S.-H.
        Clinical outcomes of toe amputation in patients with type 2 diabetes in Tianjin, China: a 5-year follow-up study.
        Int Wound J. 2016; 13: 175-181
        • Brown M.L.
        • Tang W.
        • Patel A.
        • Baumhauer J.F.
        Partial foot amputation in patients with diabetic foot ulcers.
        Foot Ankle Int. 2012; 33: 707-716
        • Sakai K.
        • Doi K.
        • Kawai S.
        Free vascularized thin corticoperiosteal graft.
        Plast Reconstr Surg. 1991; 87: 290-298
        • Fei W.
        • Danmou X.
        • Dong R.
        • Wei F.
        • Eberlin K.
        • Yan C.
        • Wusheng K.
        Free vascularized medial femoral condyle corticocancellous flap for treatment of challenging upper extremity nonunions.
        J Reconstr Microsurg. 2014; 31: 124-131
        • Haddock N.T.
        • Wapner K.
        • Levin L.S.
        Vascular bone transfer options in the foot and ankle: a retrospective review and update on strategies.
        Plast Reconstr Surg. 2013; 132: 685-693
        • Rodríguez-Vegas J.M.
        • Delgado-Serrano P.J.
        Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities.
        J Plast Reconstr Aesthet Surg. 2011; 64: 515-527
        • Choudry U.H.
        • Bakri K.
        • Moran S.L.
        • Karacor Z.
        • Shin A.Y.
        The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions.
        Ann Plast Surg. 2008; 60: 174-180
        • Caterson E.J.
        • Singh M.
        • Turko A.
        • Weaver M.J.
        • Talbot S.
        The medial femoral condyle free osteocutaneous flap for osteomyelitis in pilon fractures.
        Injury. 2015; 46: 414-418
        • Fuchs B.
        • Steinmann S.P.
        • Bishop A.T.
        Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle.
        J Shoulder Elbow Surg. 2005; 14: 264-268
        • Mattiassich G.
        • Marcovici L.L.
        • Dorninger L.
        • Kerschhagl M.
        • Buerger H.
        • Kroepfl A.
        • Larcher L.
        Reconstruction with vascularized medial femoral condyle flaps in hindfoot and ankle defects: a report of two cases: MFC-flap in lower limb defects.
        Microsurgery. 2014; 34: 576-581
        • Yamamoto H.
        • Jones D.B.
        • Moran S.L.
        • Bishop A.T.
        • Shin A.Y.
        The arterial anatomy of the medial femoral condyle and its clinical implications.
        J Hand Surg Eur. 2010; 35: 569-574
        • Rahmanian-Schwarz A.
        • Spetzler V.
        • Amr A.
        • Pfau M.
        • Schaller H.-E.
        • Hirt B.
        A composite osteomusculocutaneous free flap from the medial femoral condyle for reconstruction of complex defects.
        J Reconstr Microsurg. 2011; 27: 251-260
        • Iorio M.L.
        • Masden D.L.
        • Higgins J.P.
        Cutaneous angiosome territory of the medial femoral condyle osteocutaneous flap.
        J Hand Surg. 2012; 37: 1033-1041
        • Raspovic A.
        • Landorf K.B.
        A survey of offloading practices for diabetes-related plantar neuropathic foot ulcers.
        J Foot Ankle Res. 2014; 7: 35
        • Singh N.
        Preventing foot ulcers in patients with diabetes.
        JAMA. 2005; 293: 217
        • Goodridge D.
        • Trepman E.
        • Embil J.M.
        Health-related quality of life in diabetic patients with foot ulcers: literature review.
        J Wound Ostomy Continence Nurs. 2005; 32: 368-377
        • Mueller M.J.
        • Hastings M.
        • Commean P.K.
        • Smith K.E.
        • Pilgram T.K.
        • Robertson D.
        • Jeffrey J.
        Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy.
        J Biomech. 2003; 36: 1009-1017
        • Lavery L.A.
        • Armstrong D.G.
        • Vela S.A.
        • Quebedeaux T.L.
        • Fleischli J.G.
        Practical criteria for screening patients at high risk for diabetic foot ulceration.
        Arch Intern Med. 1998; 158: 157-162
        • Wrobel J.S.
        • Najafi B.
        Diabetic foot biomechanics and gait dysfunction.
        J Diabetes Sci Technol. 2010; 4: 833-845
        • Hyer C.F.
        • Lee T.H.
        • Philbin T.M.
        • Berlet G.C.
        Diabetic neuropathy: the painful foot.
        Foot Ankle Clin. 2004; 9: 221-237
        • Weitgasser L.
        • Cotofana S.
        • Winkler M.
        • Buerger H.
        • Jamnig D.
        • Anderhuber F.
        • Gaggl A.
        Detailed vascular anatomy of the medial femoral condyle and the significance of its use as a free flap.
        J Plast Reconstr Aesthet Surg. 2016; 69: 1683-1689
        • Iorio M.L.
        • Masden D.L.
        • Higgins J.P.
        The limits of medial femoral condyle corticoperiosteal flaps.
        J Hand Surg. 2011; 36: 1592-1596
        • Rao S.S.
        • Sexton C.C.
        • Higgins J.P.
        Medial femoral condyle flap donor-site morbidity: a radiographic assessment.
        Plast Reconstr Surg. 2013; 131: 357e-362e
        • Iglay K.
        • Hannachi H.
        • Joseph Howie P.
        • Xu J.
        • Li X.
        • Engel S.S.
        • Moore L.M.
        • Rajpathak S.
        Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus.
        Curr Med Res Opin. 2016; 32: 1243-1252
        • Bowling F.L.
        • Rashid S.T.
        • Boulton A.J.M.
        Preventing and treating foot complications associated with diabetes mellitus.
        Nat Rev Endocrinol. 2015; 11: 606-616