The scapular/parascapular flap in reconstruction of distal lower extremity soft tissue defects over the Achilles tendon

Open tendoachilles injuries due to squatting type of toilet seats: Five-year prospective observational study from a tertiary care center in India

BACKGROUND

Open traumatic tendoachilles injuries due to toilet seats are least reported. The exact mechanism of such injuries is debatable. None of the studies have reported associated neurovascular injuries and the need for microvascular tissue transfer.

METHODS

It is a 5-year prospective observational study from Sep 2013 - Aug 2018 at a tertiary care center on 26 patients who had sustained foot injuries due to squatting type toilet seats. All the patients were managed by thorough wound irrigation and debridement followed by repair of cut tendoachilles, other tendons and neurovascular structures. All the complications and secondary procedures required were recorded. Functional outcome was assessed by Boyden clinical outcome score. Follow up ranged from 1 to 5 years.

RESULTS

All the 26 patients reported a particular mechanism of injury. Complete transection of tendoachilles was seen in 23 (88.5%) patients and partial transection in three (11.5%) patients. Microvascular repair of cut posterior tibial artery was undertaken in three and posterior tibial nerve in two cases and microvascular parascapular flap in one case for soft tissue reconstruction. Twenty-three (88.5%) patients had good to excellent Boyden score while three patients (11.5%) had fair to poor score at 1 year. Such severe injuries due to toilet seats have never been reported in literature.

CONCLUSIONS

Squatting toilet seats can cause devastating foot injuries involving tendons and neurovascular structures and may require microvascular tissue transfer for definitive wound management. The risk of such injuries will continue unless some modifications are undertaken in the design of the seat.

Proximally based sural adipose-cutaneous/scar flap in elimination of ulcerous scar soft-tissue defect over the achilles tendon and posterior heel region: a new approach

Scar ulcers that spread over the Achilles tendon and posterior heel disturb patients by causing pain, impeding hygiene, and creating difficulty in finding appropriate shoe wear. As this region undergoes pressure, effective reconstruction is based on the flap use. The most popular flaps currently used are distally based sural fasciocutaneous flap, calcaneal artery skin flap, and free flaps. These flaps, however, are insensate, can create soft-tissue excess, and cause donor site morbidity. Ulcerous soft-tissue defects over Achilles tendon and posterior heel after burns, frost, and trauma were studied and reconstructed in 16 patients, using proximally based sural adipose-cutaneous flap, the anatomy of which was studied on lower extremities of 27 cadavers. Ulcerous soft-tissue defect consists of two parts: ulcer and surrounding pathologic scars that should be excised in one block. Resulting soft-tissue defects with exposed tendon and calcaneal bone varied from 6 to 20 cm in length and 6 cm in width. For such wound resurfacing a flap was developed that was sensate, thin, large, and having steady blood circulation. The flap was harvested from the lower third of the leg and lateral foot, consisting of skin and subcutaneous fat layer (without fascia), including the sural nerve and lesser vein. The blood supply was ensured through peroneal and anterior tibial artery perforators, which formed a vascular net in the flap. In 14 of 16 cases excellent and stable functional and good cosmetic results with acceptable donor site morbidity were achieved. In two patients the distal flap loss took place because of arteriitis obliterans (one case) and because of the cross-cutting of the sural nerve and vessels during previous surgeries (another case). Proximally based sural adipose-cutaneous/scar flap is the only flap that satisfies all requirements for Achilles tendon and posterior heel region resurfacing. The author believes that this technique, based on this flap use, is anatomically justified, clinically profitable, and should be considered as the first choice operation.