Short-term and long-term outcomes of free flap reconstruction versus amputation for diabetic foot reconstruction in patients with end-stage renal disease

Abstract

In Taiwan, the prevalence of diabetes mellitus complicated by end-stage renal disease (ESRD) has been increasing and diabetes-related foot amputation is commonplace. In recent years, limb salvage has become top priority. The long-term outcomes of patients on hemodialysis undergoing diabetic foot reconstruction using free flaps remain unknown. Data from the National Health Insurance Research Database on hemodialysis patients with type 2 diabetes who received amputation or free flap reconstruction surgery for diabetic foot ulcer were analyzed from 2000 to 2013 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. After 1:4 propensity score matching, 86 and 344 patients were assigned to the free flap reconstruction and amputation groups, respectively. The 5-year survival rate was significantly higher in patients who received free flap compared to the amputated group (1-year survival rate=80.0% vs. 67.6%, p=0.030; 3-year survival rate=49.7% vs. 35.5%, p=0.024; 5-year rate=30.1% vs. 19.9%, p=0.018; however, after 5 years, the overall long-term survival rate was similar in both groups (p=0.064). Patients who had lower limb amputation after flap reconstruction were susceptible to mortality (adjusted HR=1.39; p=0.069). Peripheral arterial disease was a dependent risk factor (HR=1.45; p=0.037) for long-term survival, whereas old age (> 75 years; HR=1.65; p=0.004), cerebrovascular disease (adjusted HR=1.36; p=0.011), and sepsis (adjusted HR=1.85; p=0.035) served as independent risk factors. Hemodialysis patients with diabetic foot ulcer who had limb salvaged showed a higher 5-year survival rate as compared to the amputated group.