The flexor digitorum brevis muscle island pedicle flap: a new dimension in heel reconstruction

The "lazy-V" de-epithelialised turn-over fasciocutaneous flap in the reconstruction of skin defects after tendo Achilles repair

Few methods of closure of skin defects lying over the tendo Achilles have been described. The de-epithelialised turn-over flap is one of them but it cannot be used in the presence of a scar proximal to the defect. We describe a modification ("The Lazy-V") of the de-epithelialised turn-over flap which gives it a rotation arc, thus enhancing the versatility of the procedure. This modification is presented with an illustrative case report and a review of the literature.

Local fasciocutaneous flap skin coverage for the dorsal foot and ankle

Recalcitrant wounds of the distal leg and foot are notorious for requiring complex solutions even when deceptively small or benign in appearance. The simplicity of local flap options is always preferable, but is limited about the dorsal foot and ankle region. Inclusion of the well-defined deep fascia with the overlying integument in this area permits creation of local fasciocutaneous flaps that may be an important viable alternative. Over the past 6 years, 13 patients have had 15 such fasciocutaneous flaps for ankle or dorsal foot soft tissue reconstruction, with vascular ischemia being the most common etiology. Although four major complications occurred (27%), no limb amputation was a sequela as local wound care was satisfactory for eventual healing. Seven of these patients (54%) either declined or technically were not candidates for a complicated microvascular tissue transfer, which usually would have been preferable, but nevertheless all results proved satisfactory.

Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap

Two cases with extensive plantar avulsion injuries had their heel defects resurfaced initially with full thickness skin grafts. Two months later, reinnervation presented in areas of grafted skin innervated by medial and lateral plantar nerves. No reinnervation was found in the plantar heel region originally innervated by the medial calcaneal nerve. Heel ulceration in the non-sensate, grafted skin occurred in the first case. Reinnervated, skin-grafted flexor digitorum brevis muscle flaps were then used for reconstructing the non-sensate plantar heels. There was no breakdown of skin during the follow-up period of 8 months and 6 months respectively. This method provides sensate and durable cover for extensive plantar heel defects.

Free tissue transfer of digital food pads for reconstruction of the distal limb in the dog

Reconstructive procedures used in salvaging distal limb injuries in the dog are reviewed. Techniques employed to resurface the distal weight-bearing surface include local reconstruction using pedicle flap transposition of foot pads. The development of a previously described free microneurovascular digital foot pad flap is reviewed; the experimental results and potential for clinical use of the free flap are discussed.

Microsurgical reconstruction: the weightbearing surface of the foot

Microsurgical reconstruction in the weightbearing surface of the foot is discussed. Thirty-eight patients treated at the Mayo Clinic are reviewed as well as a review of the current literature, leaving 122 patients for analysis. Minor complication rates in the skin grafted muscle flaps were 18.5% and major complication rates requiring further surgery were found in 12.9%. Fasciocutaneous and cutaneous flaps had a 25% incidence of minor complications and a 26% incidence of major complications requiring further surgery. No definite conclusions can be drawn as to which flap is indeed the best, but the newer, thinner fasciocutaneous flaps with innervation seem to hold promise. Future considerations are also discussed.

Heel reconstruction with an iliac osteocutaneous free flap in a child

We report a case of heel reconstruction in a 13-month-old child in one stage. An iliac crest osteomyocutaneous free flap based on the deep circumflex vessels was transferred using microsurgical techniques. The apophysis of the os calcis was replaced with a portion of the iliac epiphysis to allow normal growth of the heel. At age 2 years, the patient is walking normally and wearing regular shoes of equal size. Gait analysis reveals normal ambulation.

Sensory reinnervation in reconstruction of the foot

Intact sensation constitutes an important protective mechanism for the plantar surface of the foot. For optimal functional results, sensory reinnervation in reconstruction of the heel of the plantar foot would appear to be helpful. Various techniques are presented in which both intact local tissue and distant tissue are used. The design of neurosensory fasciocutaneous flaps and musculocutaneous flaps from the foot, sensory-innervated full thickness skin grafts, and microsurgically transferred skin flaps, muscle flaps, and musculocutaneous flaps are presented. Free tissue transfer techniques can be used in combination with various sensory reinnervation techniques.

Knee joint salvage utilising a plantar musculocutaneous island pedicle flap

A young adult male presented with an open tibia-fibula fracture, extensive circumferential soft tissue loss and exposed bone. Although the fracture sites were stabilised by an external fixator, chronic infection complicated this 2-week-old wound. Treatment by amputation was elected. Local skin alone was inadequate for coverage of a preferred below-knee amputation. As an alternative to above-knee amputation, the patient underwent coverage of a below-knee amputation using a musculocutaneous island pedicle flap of sensate plantar skin and muscle.

Foot reconstruction by free flap transfer

Free skin flap transfer for foot salvage and reconstruction was done in 10 patients whose follow-up exceeded 1 year. Nine of the 10 had successful results, and generally all achieved the desired reconstructive goal in one stage, with a minimum of hospitalization and disability time. In using a free skin flap transfer in weightbearing locations, the need for cutaneous innervation of the flap should be considered, but such innervation is not necessary for success.