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CC BY 4.0 · Arch Plast Surg 2024; 51(02): 234-250
DOI: 10.1055/a-2233-2617
Extremity/Lymphedema
Original Article

Is Diabetes a Contraindication to Lower Extremity Flap Reconstruction? An Analysis of Threatened Lower Extremities in the NSQIP Database (2010–2020)

Amy Chen 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Shannon R. Garvey 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Nimish Saxena 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Valeria P. Bustos 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Emmeline Jia 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Monica Morgenstern 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Asha D. Nanda 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Arriyan S. Dowlatshahi 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Ryan P. Cauley 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
› Author Affiliations Funding None.
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Abstract

Background The impact of diabetes on complication rates following free flap (FF), pedicled flap (PF), and amputation (AMP) procedures on the lower extremity (LE) is examined.

Methods Patients who underwent LE PF, FF, and AMP procedures were identified from the 2010 to 2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP®) database using Current Procedural Terminology and International Classification of Diseases-9/10 codes, excluding cases for non-LE pathologies. The cohort was divided into diabetics and nondiabetics. Univariate and adjusted multivariable logistic regression analyses were performed.

Results Among 38,998 patients undergoing LE procedures, 58% were diabetic. Among diabetics, 95% underwent AMP, 5% underwent PF, and <1% underwent FF. Across all procedure types, noninsulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were associated with significantly greater all-cause complication rates compared with absence of diabetes, and IDDM was generally higher risk than NIDDM. Among diabetics, complication rates were not significantly different across procedure types (IDDM: p = 0.5969; NIDDM: p = 0.1902). On adjusted subgroup analysis by diabetic status, flap procedures were not associated with higher odds of complications compared with amputation for IDDM and NIDDM patients. Length of stay > 30 days was statistically associated with IDDM, particularly those undergoing FF (AMP: 5%, PF: 7%, FF: 14%, p = 0.0004).

Conclusion Our study highlights the importance of preoperative diabetic optimization prior to LE procedures. For diabetic patients, there were few significant differences in complication rates across procedure type, suggesting that diabetic patients are not at higher risk of complications when attempting limb salvage instead of amputation.

Keywords

diabetes - lower extremity - flap reconstruction

Authors' Contributions

Conceptualization, A.C., S.R.G., V.P.B., E.J., M.M., A.D.N., and R.P.C.; Methodology, A.C., S.R.G., V.P.B., E.J., M.M., A.D.N., and R.P.C.; Investigation, A.C., V.P.B., and R.P.C.; Formal Analysis, A.C., V.P.B., and R.P.C.; Writing - Original Draft, A.C., N.S., V.P.B., and R.P.C.; Writing - Review & Editing, A.C., S.R.G., A.S.D., and R.P.C.; Supervision, R.P.C.


Ethical/IRB Approval

None.




Publication History

Received: 19 February 2023

Accepted: 30 November 2023

Accepted Manuscript online:
20 December 2023

Article published online:
24 January 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Centers for Disease Control and Prevention. Prevalence of both diagnosed and undiagnosed diabetes. 2022 . Accessed November 30, 2022 at: https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html
    PubMedGoogle Scholar
  • 2 American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care 2018; 41 (05) 917-928
    CrossrefPubMedGoogle Scholar
  • 3 Goldmann DR. Surgery in patients with endocrine dysfunction. Med Clin North Am 1987; 71 (03) 499-509
    CrossrefPubMedGoogle Scholar
  • 4 Alfonso AR, Kantar RS, Ramly EP. et al. Diabetes is associated with an increased risk of wound complications and readmission in patients with surgically managed pressure ulcers. Wound Repair Regen 2019; 27 (03) 249-256
    CrossrefPubMedGoogle Scholar
  • 5 Sudhakaran S, Surani SR. Guidelines for perioperative management of the diabetic patient. Surg Res Pract 2015; 2015: 284063
    CrossrefPubMedGoogle Scholar
  • 6 McMurry Jr JF. Wound healing with diabetes mellitus. Better glucose control for better wound healing in diabetes. Surg Clin North Am 1984; 64 (04) 769-778
    CrossrefPubMedGoogle Scholar
  • 7 Nigam M, Zolper EG, Sharif-Askary B. et al. Expanding criteria for limb salvage in comorbid patients with nonhealing wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps. Plast Reconstr Surg 2022; 150 (01) 197-209
    CrossrefPubMedGoogle Scholar
  • 8 Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower extremity reconstruction. Plast Reconstr Surg 2008; 121 (4, Suppl) 1-7
    CrossrefPubMedGoogle Scholar
  • 9 Okonkwo UA, DiPietro LA. Diabetes and wound angiogenesis. Int J Mol Sci 2017; 18 (07) 1419
    CrossrefPubMedGoogle Scholar
  • 10 Bekeny JC, Zolper EG, Steinberg JS, Attinger CE, Fan KL, Evans KK. Free tissue transfer for patients with chronic lower extremity wounds. Clin Plast Surg 2021; 48 (02) 321-329
    CrossrefPubMedGoogle Scholar
  • 11 Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011; 128 (01) 173-180
    CrossrefPubMedGoogle Scholar
  • 12 Kucan JO, Robson MC. Diabetic foot infections: fate of the contralateral foot. Plast Reconstr Surg 1986; 77 (03) 439-441
    CrossrefPubMedGoogle Scholar
  • 13 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
    CrossrefPubMedGoogle Scholar
  • 14 Fitzgerald O'Connor EJ, Vesely M, Holt PJ, Jones KG, Thompson MM, Hinchliffe RJ. A systematic review of free tissue transfer in the management of non-traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg 2011; 41 (03) 391-399
    CrossrefPubMedGoogle Scholar
  • 15 Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open 2017; 5 (08) e1461
    CrossrefPubMedGoogle Scholar
  • 16 Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index using American College of Surgeons NSQIP data. J Am Coll Surg 2018; 226 (02) 173-181.e8
    CrossrefPubMedGoogle Scholar
  • 17 Frisch A, Chandra P, Smiley D. et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010; 33 (08) 1783-1788
    CrossrefPubMedGoogle Scholar
  • 18 Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011; 128 (01) 173-180
    CrossrefPubMedGoogle Scholar
  • 19 Serio S, Clements JM, Grauf D, Merchant AM. Outcomes of diabetic and nondiabetic patients undergoing general and vascular surgery. ISRN Surg 2013; 2013: 963930
    CrossrefPubMedGoogle Scholar
  • 20 Bower WF, Jin L, Underwood MJ. et al. Overt diabetes mellitus adversely affects surgical outcomes of noncardiovascular patients. Surgery 2010; 147 (05) 670-675
    CrossrefPubMedGoogle Scholar
  • 21 Sinkin JC, Reilly M, Cralley A. et al. Multidisciplinary approach to soft-tissue reconstruction of the diabetic Charcot foot. Plast Reconstr Surg 2015; 135 (02) 611-616
    CrossrefPubMedGoogle Scholar
  • 22 Koga M, Murai J, Morita S, Saito H, Kasayama S. Comparison of annual variability in HbA1c and glycated albumin in patients with type 1 vs. type 2 diabetes mellitus. J Diabetes Complications 2013; 27 (03) 211-213
    CrossrefPubMedGoogle Scholar
  • 23 Xu G, Liu B, Sun Y. et al. Prevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: population based study. BMJ 2018; 362: k1497
    CrossrefPubMedGoogle Scholar