Microvascular reconstruction of complex foot defects, a new anatomo-functional classification

Thin Free Perforator Flap as a Viable Option for Forefoot Reconstruction: Comprehensive Evaluation of Outcomes

BACKGROUND

Reconstruction of forefoot defects often necessitates free tissue transfer due to the limited availability of local tissue. Microsurgical reconstruction of the forefoot remains challenging, as it requires durable yet thin soft-tissue coverage for functional restoration. This study aimed to evaluate the efficacy of free thin perforator flaps for forefoot reconstruction, with a focus on functional outcomes.

METHODS

Records of patients who underwent microsurgical forefoot reconstruction between March of 2020 and September of 2023 were reviewed. Development of postoperative complications and functional outcomes were evaluated.

RESULTS

In total, 53 patients (mean age, 62.7 years) were analyzed. The most common cause of defects was oncologic surgery, followed by chronic wound, with a majority involving the plantar side. The superthin anterolateral thigh flap and superficial circumflex iliac artery perforator flap were predominantly used. The median flap thickness was 4.0 mm. Digital vessels were the most frequently used as recipients. All but one flap survived, resulting in a success rate of 98.1%. Postoperative flap site complications developed in 20 patients, the majority of which resolved with conservative treatment. The median hospital stay was 8.0 days, and the mean time for initiating weight-bearing ambulation was 12.4 days. In the postoperative Foot Function Index questionnaire survey, the overall score was 9.41, showing minimal impairment, and it did not differ according to defect size or location. A secondary debulking operation was needed in 7 patients.

CONCLUSION

Use of thin free perforator flaps might provide reliable outcomes with rapid recovery and excellent postoperative function in forefoot reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes and Complications of Sole Reconstruction Using Lateral Thoracic Free Tissue Transfer

BACKGROUND

The complex structure of the sole of the foot makes the repair of extensive defects challenging. The present study, therefore, aimed to address a gap in current research by evaluating the potential of the lateral thoracic free flap, including perforator options and chimeric configurations, to be used as an advanced solution for comprehensive sole reconstruction.

PATIENTS AND METHODS

We retrospectively collected the following data from the charts of patients with sole defects, due to various causes, who underwent lateral thoracic free tissue transfers: patient demographics; etiologies; comorbidities; flap types and dimensions; pedicle length; operative time; follow-up period; complications; and management.

RESULTS

The present study included 54 patients who underwent lateral thoracic free tissue transfer, citing infection, trauma, tumor, and posttraumatic sequelae as the major etiologies. We used the following techniques for the reconstruction of sole defects: thoracodorsal artery perforator free flap (83.3%); latissimus dorsi musculocutaneous free flap (1.9%); and various chimeric pattern flaps (14.8%). Free tissue transfer in the lateral thoracic region offers versatility for reconstruction, as well as low donor site morbidity. Complications observed in the present study included wound dehiscence (9.3%), partial necrosis (9.3%), and pressure ulcers (22.2%), although most patients healed favorably without flap loss.

CONCLUSIONS

The lateral thoracic free flap is a viable option for the reconstruction of the sole of the foot and allows for the effective reconstruction of complex defects. It contains a sustainable skin paddle, and multiple components can be easily included as a chimeric type. Further studies should seek to identify ways to prevent pressure ulcers, which was the only known long-term complication in the present study.

Functional Reconstruction of Arches of the Foot With Vascularized Fibula Flap

ABSTRACT

The skeletal integrity of the foot is as important as the soft tissue coverage of the foot. In this article, we present reconstruction of arches of foot with free fibula flap. Three patients with composite foot defects underwent reconstruction a with vascularized fibula flap. Free fibula flap was used to reconstruct the transverse arch in 2 cases and longitudinal arch in 1 case. The mean follow-up period was 3.2 years. Functional outcome was evaluated with 3-dimensional motion analyses at 12 months postoperatively. No early or late complications were encountered, and all patients were satisfied with both cosmetic appearance and functional aspects of their foot. Fibular bone showed a very healthy course without any fracture, resorption, extrusion, or migration. Three-dimensional motion analyses revealed acceptable gait capability in all cases showing successful restoration of the foot arches. As a conclusion, osteocutaneous free fibula flap can provide functional and durable reconstruction of longitudinal and transverse arches of the foot, especially if preservation of the length or the width of the foot is desired.

Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community

Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson’s chi-square test of association, Student’s t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient’s outcome.

[A systematic approach to plastic surgical foot reconstruction]

BACKGROUND

Soft tissue defects of the foot are very common sequelae after trauma and require an individual reconstructive approach.

OBJECTIVE

Recommendations for the treatment of soft tissue injuries to the foot are given.

MATERIAL AND METHODS

The criteria of soft tissue reconstruction, postoperative follow-up and complications are first discussed before the therapeutic approach is explained depending on the reconstruction site. Case examples are given for illustration.

RESULTS

Decision making for soft tissue reconstruction of the foot is based on the location, the 3‑dimensional extent of the defect, the patient requirements and concomitant diseases. Standardized treatment algorithms are usually applied that need to be adapted according to individual patient factors. Randomized and local pedicled flaps can be applied for foot reconstruction; however, these options involve a significant risk of complications. Consequently, free flaps are frequently indicated after appropriate preoperative diagnostics of the perfusion of the foot. Due to the vast variety of donor sites, free flaps allow an individualized reconstruction, which is adapted to local and patient requirements.

CONCLUSION

Precise preoperative reconstructive planning and analysis of the vascularization form the foundation for a successful soft tissue reconstruction of the foot. The aims of the individualized approach to soft tissue reconstruction of the foot are stable soft tissue coverage, resistance to weight bearing of the sole of the foot, the ability to wear normal shoes and maintenance of sensibility.

Ultrathin free flaps for foot reconstruction: impact on ambulation, functional recovery, and patient satisfaction

BACKGROUND

Plantar reconstruction is a complex procedure due to the paucity of tissue around the foot. Tissues used for reconstruction should provide similar properties, which can be accomplished by using ultra-thin flaps. Validated functional scales may provide essential information regarding patients' evolution.

METHODS

Information concerning a series of 12 cases of plantar reconstruction using ultra-thin free flaps was gathered retrospectively by the authors. Data from preoperative functional scores in Lower Extremity Functional Scale and American Orthopaedic Foot and Ankle Society scale were obtained from clinical records; these were compared to postoperative scores assigned prospectively during follow-up. Differences were determined using Student's t-test for paired samples. Objective measurements concerning evolution (ulceration, footwear usage, sensation), as well as patient satisfaction, were also explored.

RESULTS

The mean follow-up duration was 16.5 (range 12 to 24) months. The Lower Extremity Functional Scale scores mean modified from 39.1 to 60.2, p = 0.004; the American Orthopaedic Foot and Ankle Society scale mean modified from 42.2 to 53.4, p = 0.012. No patient showed plantar ulceration. Protective sensation was achieved in 75% of the patients, and 10 out of 12 could use regular footwear. All patients reported satisfaction with the surgical procedure.

CONCLUSIONS

Ultra-thin flaps for foot reconstruction are related to improvement in functional scales, high rates of patient satisfaction, and use of regular footwear as well as a limited range of complications.

Negative pressure wound therapy in the management of mine blast injuries of lower limbs: Lessons learnt at a tertiary care center

Background

Mine blast injuries of foot are devastating injuries that result in composite tissue loss or amputations. Negative pressure wound therapy has helped in the management of such combat-related wounds. The aim of this study was to report experiences gained in managing such injuries at a tertiary care center.

Methods

17 combatants who sustained mine blast injuries were included in this study. Severity of foot injury was assessed as per Foot and Ankle Severity Score. After wound debridement, negative pressure wound therapy was started and foot defect was appropriately reconstructed. Following wound healing, the foot was assessed for Foot and Ankle Severity Score in terms of impairment. The patients were then suitably rehabilitated by shoe modifications, orthosis, or custom-made prosthesis.

Results

Mean age of soldiers who sustained mine blast injuries was 30.2 years. The mean Foot and Ankle Severity Score was 3.76. Temporary wound closure was achieved using negative pressure wound therapy and it prevented local and systemic infection. The defect could be reconstructed appropriately using split skin graft, regional fasciocutaneous flap, or microvascular free flap. Mean time to definitive reconstructive procedure was 16.5 days. Mean Foot and Ankle Severity Score in terms of impairment was 4.11. All soldiers could be rehabilitated and were returned to their respective units and were able to perform sedentary duties assigned to them.

Conclusion

The negative pressure wound therapy was helpful in preventing proximal amputations due to mine blast injury and was helpful in satisfactory reconstruction of foot defects.