Free tissue transfer in diabetic foot ulcers: A narrative review

Abstract

Diabetic foot ulcers (DFUs) represent a major cause of morbidity, hospitalisation, and lower limb amputation worldwide. Despite advances in wound care, offloading strategies, and revascularisation techniques, a subset of patients develop complex softtissue defects that are not amenable to conventional reconstructive approaches. In this context, microvascular free tissue transfer (FTT) has emerged as an important limbsalvage strategy. This narrative review synthesises contemporary evidence regarding the role of FTT in the management of complex DFUs, with a focus on reconstructive outcomes, evolving flap techniques, patient selection, and multidisciplinary care pathways. A recent systematic review and metaanalysis demonstrates encouraging outcomes following FTT for DFU reconstruction, with reported flap survival rates approaching 85–90% and acceptable rates of postoperative ambulation. However, outcomes are less favourable in higherquality studies, highlighting persistent heterogeneity in patient populations, study design, and reporting standards. While early outcomes are promising, much of the supporting evidence derives from small, retrospective series in specialised centres. Patient selection remains a critical determinant of success. Advanced comorbidities, particularly peripheral arterial disease and endstage renal disease, significantly influence limbsalvage outcomes but should not be considered absolute contraindications in isolation. Outcomes are notably poorer in the setting of acute diabetesrelated foot infections compared with chronic nonhealing ulcers, underscoring the heterogeneity of DFU presentations. Increasingly, multidisciplinary orthoplastic pathways incorporating vascular optimisation, aggressive infection control, and coordinated reconstruction have been shown to improve limbsalvage rates. In conclusion, FTT represents a powerful reconstructive option for carefully selected patients with complex DFUs within a multidisciplinary framework. Future research should prioritise prospective multicentre studies, standardised outcome reporting, and longterm functional assessment to better define the role of microsurgical reconstruction in modern diabetic foot care.