Free Tissue Transfer for the Management of Diabetic Lower Limb Ulcers: A Systematic Review and Meta-Analysis

Diabetic foot ulcers are a major complication of diabetes, with resulting soft tissue defects increasing the risk of limb amputation and mortality. Reconstruction of defects may be in the form of local, pedicled, or free tissue transfer. This systematic review aims to confirm the role and benefit of free tissue transfer in this patient cohort.

This review is registered on PROSPERO (ID: 617657). A literature search was performed using the online databases EMBASE, MEDLINE, and Web of Science to identify literature reporting use of free flaps in the management of diabetic lower limb ulcers. Mesh terms used included "diabetes," "lower limb," "ulcer," and "free tissue transfer." A random-effect meta-analysis was implemented to assess the efficacy of free flaps as a treatment based on complication and limb salvage rates.

Twenty-five studies were included in this systematic review, amounting to 547 free flaps. The total complication rate was 26% (95% CI = 21%-32%, I² = 27%, p = 0.11). Partial flap loss was noted in 6% of cases (95% CI = 3%-11%, I² = 0%, p = 0.96) while complete loss occurred in 4% of cases (95% CI = 2%-7%, I² = 0%, p = 1.0). The most performed flap was the anterolateral thigh (ALT) flap. Revascularization was performed prior to free flap reconstruction in 15% of cases. The amputation-free rate was 95% at the latest follow-up point of each study.

Free tissue transfer is a viable treatment option for patients with diabetic foot ulcers. The low complication including amputation rate supports its implementation in practice provided a myriad of factors and careful patient selection is maintained.