ORIGINAL PAPER

Abductor digiti minimi muscle flap in reconstructionof diabetic foot ulcers: A case series

S. S. Shirol & Geeta Nimbaragi & Mahesh Prabhu &

Jaideep Ratkal

Received: 12 October 2013 /Accepted: 19 December 2013 /Published online: 14 February 2014# Springer-Verlag Berlin Heidelberg 2014

AbstractBackground Diabetic foot ulcers (DFUs), a leading cause ofamputations, affect 15 % of people with diabetes. Woundcoverage in these patients is changelling due to concurrentinfection, neuropathy and vascular compromise. Though localmuscle flaps were described by Ger et al. and popularized byAttinger et al., these small muscle flaps should be moreroutinary than they are now.Methods A retrospective review of all patients with DFUswith exposed bone and osteomyelitis reconstructed by abduc-tor digiti minimi muscle flaps and free skin grafting betweenJanuary 2010 and December 2011 was conducted.Results This study included eight patients. Six patients hadulcers over the heel and two on the lateral aspect of theforefoot. All flaps survived well with no donor site complica-tions. There was partial loss of skin graft in three cases andinfection and total loss in one other case.Conclusions Abductor digiti minimi is a safe and reliable flapthat provides a durable cover.Level of evidence: Level IV, therapeutic study.

Keywords Diabetic foot . Abductor digiti minimi . Footreconstruction . Intrinsic muscle . Local flaps . Diabetic footulcer . DFU

Introduction

Diabetic foot ulcer (DFU) reconstruction continues to be achallenge, considering the varying and complex effects of thedisease on the foot. Local muscle flaps for diabetic foot recon-struction were pioneered by Ger et al. in late 1960s and contin-ued to be used for foot and ankle reconstruction till late 1970s[1–7]. With evolution of microsurgery, free flaps became themethods of choice. However, there is renewed interest in theusage of local muscle flaps of the foot, considering their safety,reliability and operating quickness [8, 9]. Abductor digiti minimi(ADM) is a small intrinsic muscle of the foot, located on thelateral aspect of foot, between flexor digitorum brevis mediallyand fifth metatarsal and cuboid laterally, that derives type IIblood supply from the branches of medial and lateral plantararteries [10]. Here we retrospectively analyze eight cases ofchronic non-healing ulcers managed with ADM muscle flaps.

Materials and methods

All patients with DFUs measuring less than 2.5 cm in diam-eter, located over the lateral aspect of the foot and heel, withexposed bone and osteomyelitis, and reconstructed with ADMmuscle flaps and free skin grafting between Jan 2010 andDecember 2011 were retrospectively analyzed in this study.Patients treated conservatively with VAC (vacuum assistedclosure), skin grafts, or other local, regional or free flaps were

S. S. Shirol (*) : J. RatkalDepartment of Plastic Surgery, K.I.M.S Hubli,Hubli, Karnataka, Indiae-mail: ssshirol@yahoo.co.uk

G. NimbaragiDepartment of Plastic Surgery, Hospital Administrator SampigeSuper-specialty Clinic, Hubli, Karnataka, India

M. PrabhuDepartment of Plastic Surgery, KLE University Belgaum,Karnataka, India

Eur J Plast Surg (2014) 37:227–232DOI 10.1007/s00238-013-0923-3

(a) (e)

(f)

(g)

(b)

(c)

(d)

Fig. 1 aPre-operative view showing chronic diabetic ulcer over the heel.bRadiograph revealing osteomyelitis of calcaeum. cand d Intra-operativeview demonstrating the raising of the standard ADM flap. ePostoperative

view at 6 weeks demonstrating complete healing. fPostoperative view at6 months demonstrating complete healing and no recurrence. gFollow-upradiograph at 6 months revealing bony healing

228 Eur J Plast Surg (2014) 37:227–232

(a)

(d)

(e)

(f)

(b)

(c)

Fig. 2 a Pre-operative view showing chronic diabetic ulcer over thelateral aspect of forefoot. b Radiograph revealing osteomyelitis of fifthmetatarsal bone. c Intra-operative view demonstrating the raising of thedistally based ADM flap. d Intra-operative view demonstrating the inset

of the distally based ADM flap and primary closure of the donor site. ePostoperative view at 6 months demonstrating complete healing and norecurrence. f Follow-up radiograph at 6 months revealing bony healing

Eur J Plast Surg (2014) 37:227–232 229

excluded from this study. All patients were primarily treatedby either general or orthopedic surgeons and were also clini-cally assessed for local angiopathy and neuropathy. Dopplerexamination of lower limbs revealed moderate to severe triplevessel disease while x-ray examination revealed osteomyelitisof calcaneum in six patients and head of fifth metatarsal in twopatients. Euglycemia was maintained and supervised in allcases by a diabetologist.

Technical details of the surgical procedure have been de-scribed in detail elsewhere [8]. During the first stage, a thor-ough debridement of the DFU is carried out. Aweek later, theADM muscle flap is harvested from the lateral aspect of thefoot, with an incision over a non-weight bearing area, andtransposed to provide coverage. When it is needed, the flap iscovered with a small split-thickness skin graft. The donor siteis closed primarily over a suction drain that is usually removedon the second post-operative day. Donor site sutures areremoved on the tenth day. All patients are allowed to bearweight at 6 weeks after complete wound healing using pro-tective footwear.

Results

This study included eight patients. Six patients had ulcersover the heel and underwent standard ADM flap (Fig. 1).The remaining two has DFUs on the lateral aspect of theforefoot and were treated with a distally based ADM flap(Fig. 2). Free skin grafting was always required. Allprocedures were carried out under spinal anesthesia bythe first author (S.S.S.). All flaps survived well with nodonor site complications. There was partial loss of skingraft in three cases and infection and total loss in another

one. In these cases, wounds healed with dressing withoutany further surgical intervention. Average time for com-plete wound healing was 24 days. Follow-up ranged from9 to 30 months (average of 19.5 months). All patientswere ambulating comfortably with shoes padded withsilicone insoles. Coverage over the bone was stable inall cases and no recurrence was detected. Patients’ demo-graphics and results are summarized in Table 1.

Discussion

A variety of complex and interrelated factors are respon-sible for diabetic ulceration. In addition to peripheralneuropathy, diabetics are also susceptible for peripheralangiopathy as well as impaired granulocyte chemotaxisand phagocytosis. The breaking strength of the woundsin diabetes is also impaired. Diabetic neuropathy in-volves both impaired sensory and motor functions.Motor neuropathy causes atrophy of the intrinsic muscles offoot leading to imbalance in the arches of foot, and sensoryloss makes the patients unaware of skin necrosis and ulcera-tion [11].

Eighty to 85 % of amputations in diabetics are preceded bynon-healing ulcers in diabetics with neuropathy, and usingflaps for limb salvage affects the long term survival andquality of life of these patients [12–14]. One of the mainreasons for amputation is limited availability of soft tissuecover. Glycemic control, drainage of abscesses, aggressivedebridement, local wound care, and systemic antibiotics arebasic steps before a plan is made for a definitive cover.

Though the use of local muscle flaps was first intro-duced by Ger et al. [1–7], it was popularized by others

Table 1 Patients demographicsand results Sr. no. Age (years) Stages Location Complications

1 46 1 Heel Infection+complete graft loss

2 54 2 Heel Partial graft loss

3 57 2 Heel None

4 60 2 Heel Partial graft loss

5 58 2 Heel None

6 52 2 Heel None

7 53 2 Lateral forefoot Partial graft loss

8 47 2 Lateral forefoot None

230 Eur J Plast Surg (2014) 37:227–232

[15, 16]. Microsurgical free flaps should be consideredfor larger defects with exposed bones, joints, orneurovascular structures. Free flaps require general an-esthesia, cardiac clearance, longer operative time, andmicrosurgical skills and may require debulking or re-contouring of these flaps [9]. On the contrary, the dis-section of intrinsic muscles is simple and rapid, anddonor site closure is always primary. In their retrospec-tive study, Attinger et al. reported a healing rate of84 % [15, 16]. Altindas et al. reported 17 cases ofdiabetic foot ulcers reconstructed with ADM flap withtotal healing and no recurrence during follow-up [8]. Inour study, patients undergoing previous debridement andflap coverage and skin grafting at a second stage 1week later, healed completely within 3 weeks. Onepatient, who underwent debridement and flap coveragein a single stage, had recipient site infection with 100% graft loss, and complete healing after 6 weeks ofregular wound dressings.

Muzaffer et al. proposed the ADM muscle flap as amajor workhorse for reconstruction of small to moderatesize defects that have exposed bone, joint, or tendons inthe hind foot and lateral plantar midcourt [8]. Yoshimoraet al. were the first to describe a distally based ADMmuscle flap in a frostbite case of the fifth toe [17]. In ourstudy we successfully used a distally based flap in twocases for covering the head of an osteomyelitic fifthmetatarsal.

The mere presence of diabetes does not seem toaffect the survival of the flaps [8]. The adequate bloodsupply to the foot is a significant determinant of successof ADM muscle flaps. It is also believed that musclestissues have the ability to absorb and redistribute theshearing forces along the foot [8]. As ADM muscleflaps do bear stress and shearing forces very well, theyshould be the first choice for covering DFUs. The onlydisadvantage of this flap is its limited size being onlysuitable for small to moderate size defects.

According to our experience, a thorough debridementduring a previous stage seems to prevent wound infectionand skin graft loss. Although skin grafts tend to contractover a period of time, ADM muscle flaps continue toprovide good cushioning. We believe that excellent resultscan be obtained by proper patient selection, good glycemiccontrol, thorough debridement, meticulous tissue handling,good hemostasis, suction drain use for the donor site,regular follow-up by a multispecialty team, and with goodfoot care.

Conclusions

ADM muscle flap is a safe, reliable, and durable flap forcoverage of small to moderate size defects of the lateral footand heel. Even in the era of microsurgery with high successrates, ADM remains as our first choice for such defects. Withmagnification and good hemostasis flap dissection is rapidand simple. Donor site can be closed primarily healing un-eventfully in all cases. Considering all of these, we feel thatthe ADM muscle flap should be used more routinely indiabetic ulcers over lateral aspect of forefoot and heel.

Conflict of interest None declared.

Ethical standards This study has been approved by the appropriateethics committee and have therefore been performed in accordance withthe ethical standards laid down in the 1964 Declaration of Helsinki and itslater amendments.

All persons gave their informed consent prior to their inclusion in thestudy.

References

1. Ger R (1966) The operative treatment of the advanced stasis ulcer: apreliminary communication. Am Surg 111:659–663

2. Ger R (1968) The management of pre-tibial skin loss. Surgery 63:757–763

3. Ger R (1970) Operative treatment of the advanced stasis ulcerusing muscle transposition: a follow-up study. Am J Surg 120:376–380

4. Ger R (1971) The techniques of muscle transposition in the operativetreatment of traumatic and ulcerative lesions of the leg. J Trauma 11:502–510

5. Ger R (1975) The surgical management of ulcers of the heel. SurgGynecol Obstet 140:909–911

6. Ger R (1996) The management of chronic ulcers of the dorsum of thefoot by muscle transposition and free skin grafting. Br J Plast Surg29:199–204

7. Ger R et al (2005) Prevention of major amputations in non-ischemiclower limb lesions. J Am Coll Surg 201:898–905

8. Altindas M, Ceber M, Kilic A et al (2013) A reliable method fortreatment of nonhealing ulcers in the hindfoot and midfoot region indiabetic patients: reconstruction with abductor digiti minimi muscleflap. Ann Plast Surg 70(1):82–87

9. Ducic I, Attinger CE (2011) Foot and ankle reconstruction: pedicledmuscle flaps versus free flaps and the role of diabetes. Plast ReconstrSurg 128(1):173–80

10. Stephen JM, Foad N (1997) Reconstructive surgery, principles, anat-omy, & technique 2:1515–1526

11. Kenneth O, Richard MG (1999) Arterial disease. Principles ofSurgery 1:964

Eur J Plast Surg (2014) 37:227–232 231

12. Aulivola B, Hile CN, Hamdan AB et al (2004) Major lower legamputation: outcome of a modern series. Arch Surg 139:395–399,discussion 399

13. Ikonen TS, Sund R, Venermo M, Winell K (2010) Fewer majoramputations among individuals with diabetes in Finland in 1997–2007: a population-based study. Diabetes Care 33:2598–2603

14. Mayfield JA, Reiber GE, Maynard C, Czerniecki JM, Caps MT,Sangeorzan BJ (2000) Trend in lower limb amputation in the

Veterans Health Administration, 1989–1998. J Rehab Res Dev 37:23–30

15. Attinger C, Cooper P (2001) Soft tissue reconstruction for calcanealfractures or osteomyelitis. Orthop Clin North Am 32:135–170

16. Attinger CE, Ducic I, Zelen C (2000) The use of local muscle flaps infoot and ankle reconstruction. Clin Podiatr Med Surg 17:681–711

17. Yoshimora Y, Nakajima T, Kami T (1985) Distally based abductordigiti minimi flap. Ann Plast Surg 14(4):375–377

232 Eur J Plast Surg (2014) 37:227–232