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Long-Term Limb Salvage for Diabetic Foot Ulcers: A 14-Year Single-Institution Review of Reconstructive Outcomes
Hannah Soltani, BS
1; Leila I Jones, BS
2; Rachel N. Rohrich, BS
1; Priyanka Meesa, BS
2; Jayson N. Atves, DPM
1; Richard C. Youn, MD
1; Christopher E. Attinger, MD
1; Karen K. Evans, MD
1; Stephen B. Baker, MD
1. Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA, 2. Georgetown University School of Medicine; Washington, DC, USA
Background: Diabetic foot ulcers (DFUs) are a leading cause of disability and amputation in the US. When exposed bone, tendon, or hardware preclude skin grafting or local tissue rearrangement, free tissue transfer (FTT) provides durable vascularized coverage. Long-term institutional data focused specifically on DFUs remains limited. This study evaluates reconstructive and limb salvage outcomes following flap reconstruction for DFUs over a 14-year period at a tertiary referral center.
Methods: A retrospective review was performed of adult patients undergoing lower extremity FTT for DFUs between July 2011 and December 2025 at MedStar Georgetown University Hospital. All patients were managed using a multidisciplinary limb salvage protocol including vascular assessment, revascularization, infection control, and risk-stratified anticoagulation. Primary outcomes included flap success and limb salvage.
Results: A total of 179 patients (mean age 57.9 ± 10.1 years; 77.7% male) underwent FTT for DFUs. Endovascular intervention was required in 31.8% of patients. Anterolateral thigh-based flaps (45.8%) and vastus lateralis muscle flaps (33.0%) were most common. Immediate flap success was 97.2%. Flap-related complications occurred in 42.4%, with 14.8% requiring reoperation; takeback within 7 days occurred in 6.3%, with a 90.9% salvage rate. Partial flap necrosis occurred in 10.8%, infection in 20.0%, and donor-site complications in 9.7%. Ipsilateral major amputation occurred in 19.3% at a median of 208 days. Ambulation by final follow-up was achieved in 73.7% of patients, and overall mortality during follow-up was 10.1%.
Conclusions: FTT provides durable limb salvage for DFUs in a medically complex population. Successful outcomes rely on multidisciplinary care, infection control, vascular optimization, and tailored reconstructive planning to offload pressure points. Biomechanical correction further supports high flap success and functional recovery, and is an essential component of the overall approach to limb salvage and preserved function.
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