Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study

[The value of the medial plantar flap in the repair of loss of soft tissue in the distal quarter of the leg]

OBJECTIVE

Soft tissue repair of the distal leg is a challenge for the surgeon. The objective of our work is to evaluate the interest of medial plantar flaps in the repair of soft tissue loss in the distal quarter of the leg, by highlighting the advantages and disadvantages of this technique.

METHODS

We conducted a retrospective study over 4 years in the Department of Plastic, Reconstructive and Burn Surgery of the Mohammed V Military Teaching Hospital of Rabat, including 8 patients admitted for coverage of a distal quarter of the leg with a medial plantar flap.

RESULTS

Eight patients were included, 5 men and 3 women with an average age of 45.5 years. All patients received coverage with a medial plantar flap. The functional and aesthetic results were very good with a low complication rate.

CONCLUSION

The medial plantar flap should no longer be reserved for covering loss of substance of the foot only, but should be integrated into the therapeutic arsenal of reconstruction of the distal quarter of the leg.

Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries

BACKGROUND

Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes.

METHODS

Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up.

RESULTS

Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis.

CONCLUSION

APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction

Heel ulceration in patients with diabetes mellitus (DM) is a major clinical challenge, manifesting with a protracted and uncertain healing process. The prefer treatment of heel ulceration is still controversial. This study aims at describing a newly alternative surgical method with the proximal transverse tibial bone transport technique, as an attempt to achieve wound healing in diabetic patients with large heel ulceration. Retrospective clinical study. A total of 21 diabetic patients with large heel ulceration were enrolled and followed up at least 6 months. The following parameters were assessed: Visual analogue scale (VAS), healing time, ulcer healing rate, ulcer recurrence rate and limb salvage rate. All patients got fully follow-up and achieved wound healing uneventfully. Eighteen patients returned to independent walking without any helper while three patients walked using a crutch. Limb salvage was achieved in all 21 patients (100%). The mean wound area was 67.43 ± 13.31 cm2 (range: 46-97 cm2 ). The mean healing time was 128.62 ± 16.76 days (range: 91-160 days). 16 out of 21 patients without calcaneal osteomyelitis achieved ulcer healing with a mean duration of 124.69 ± 14.42 days (range: 91-143 days), while the other five patients with calcaneal osteomyelitis were 141.20 ± 19.12 days (range: 110-160 days). 2 out of 21 patients got superficial rupture at the previous wounds and healed after outpatient dressing change combined with oral antibiotics. The novel technique described is particularly applicable for large heel ulceration in diabetic patients. It offers a better alternative for achieving wound healing with a favourable encouraging outcome.

A modified perforator-based stepladder V-Y advancement flap in the Achilles tendon area for coverage of larger posterior heel defects

BACKGROUND

Posterior heel defect coverage is challenging because of the paucity of suitable flaps. The traditional local stepladder V-Y advancement flap is recommended only for small defects because of the lack of an axial pedicle. This study reports our experience of using the perforator-based stepladder V-Y advancement flaps in a larger posterior heel defect repair.

METHODS

Twenty-two patients with posterior heel defects were treated with modified perforator-based stepladder V-Y advancement flaps in the Achilles tendon area for 11 years. Sixteen males and six females aged 3-74 years underwent surgery. The defect size, perforator characteristics, flap size, flap movement, sural nerve, lesser saphenous vein, deep fascia, flap survival, and outcome quality were analyzed.

RESULTS

The perforators were found to predominate within two 2-cm intervals: 0-2 cm and 4-6 cm proximal to the tip of the lateral malleolus. Twenty-one perforator-based flaps healed uneventfully, and only one developed tip necrosis on the lower edge, which healed by secondary intention. The maximum distance of distal movement was 5.0 cm for the modified flap in contrast to 2.5 cm for the traditional flap. All flaps allowed adequate and durable reconstruction to be achieved, with excellent contouring after 2-28 months of follow-up.

CONCLUSIONS

The perforator-based stepladder V-Y advancement flap resulted in good outcomes for larger posterior heel defects compared with conventional transfer methods. The flap is a reliable, well-vascularized, sensate, and pliable local flap option that uses similar tissue from adjacent skin for defect repair and creates an internal gliding surface for the Achilles tendon.

RB. Outcome Analysis Comparing Muscle and Fasciocutaneous Free Flaps for Heel Reconstruction: Meta-Analysis and Case Series

Background Choosing the components of free flap (fasciocutaneous or muscle) is one of the crucial but controversial decisions in heel reconstruction. This meta-analysis aims to provide an up-to-date comparison of fasciocutaneous flaps (FCFs) and muscle flaps (MFs) for heel reconstruction and to ascertain if one flap has an advantage over the other.

Methods Following the Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed identifying studies on heel reconstruction with FCF and MF. Primary outcomes were survival, time of ambulation, sensation, ulceration, gait, need for specialized footwear, revision procedures, and shear. Meta-analyses and Trial Sequential Analysis (TSA) were performed to estimate the pooled risk ratios (RRs) and standardized mean difference (SMD) with fixed effects and random effects models, respectively.

Results Of 757 publications identified, 20 were reviewed including 255 patients with 263 free flaps. The meta-analysis showed no statistically significant difference between MF and FCF in terms of survival (RR, 1; 95% confidence interval [CI], 0.83, 1.21), gait abnormality (RR, 0.55; 95% CI, 0.19, 1.59), ulcerations (RR, 0.65; 95% CI, 0.27, 1.54), footwear modification (RR, 0.52; 95% CI, 0.26, 1.09), and revision procedures (RR, 1.67; 95% CI, 0.84, 3.32). FCF had superior perception of deep pressure (RR, 1.99; 95% CI, 1.32, 3.00), light touch, and pain (RR, 5.17; 95% CI, 2.02, 13.22) compared with MF. Time to full weight-bearing (SMD, –3.03; 95% CI, –4.25, –1.80) was longer for MF compared with FCF. TSA showed inconclusive results for comparison of the survival of flaps, gait assessment, and rates of ulceration.

Conclusion Patients reconstructed with FCF had superior sensory recovery and early weight bearing on their reconstructed heels, hence faster return to daily activities compared with MFs. In terms of other outcomes such as footwear modification and revision procedure, both flaps had no statistically significant difference. The results were inconclusive regarding the survival of flaps, gait assessment, and rates of ulceration. Future studies are required to investigate the role of shear on the stability of the reconstructed heels.

Dual-Perforator Flap With Wide Pedicle Versus Sural Neurocutaneous Flap With Peroneal Artery Perforator in the Treatment of Soft Tissue Defects of Foot and Ankle

How to deal with large soft tissue defects around the foot and ankle is still controversial. The aim of this study was: (1) to display a new pedicled flap, also named the dual-perforator flap with wide pedicle (DPFWP), and (2) to compare it with the sural neurovascular flap with peroneal artery perforator (SNFPAP) in foot and ankle reconstruction. According to different surgical methods, 82 patients were divided into 2 groups: the DPFWP group (42 cases) and the SNFPAP group (40 cases). All cases underwent a flap surgery after radical debridement. The 2 groups were homogeneous in terms of age, sex, body mass index (BMI), etiology, location, and follow-up duration. Operation indexes were compared, including flap length, flap width, operation time and blood loss. Complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed. The DPFWP group had larger flap length (24.5 ± 4.6 cm vs 16.3 ± 3.8 cm), and flap width (10.5 ± 2.7 cm vs 7.8 ± 1.7 cm) than the SNFPAP group. In postoperative follow-up, DPFWP group showed a lower complication rate and better cosmetic, functional outcomes than SNFPAP group. In conclusion, this study showed that a DPFWP flap brought better results than a SNFPAP flap in terms of complications, cosmetic appearance, and functional outcomes for patients undergoing reconstruction of foot and ankle defects.

Two-team-approached free flap reconstruction for plantar malignant melanoma: An observational (STROBE-compliant) trial

Reconstructive treatments of heel defects usually involve regional flap techniques such as medial plantar flap procedures due to the limited availability of adjacent soft tissues. Although free flaps have advantages in terms of function and aesthetics, they remain challenging due to the longer operation time required than for regional flaps. Thus, we introduce an appropriate 2-team surgical protocol to reconstruct plantar defects after wide excision of malignant melanoma using free flap coverage. From 2015 to 2020, a retrospective study was performed including 21 patients who underwent free flap surgeries to reconstruct defects due to plantar malignant melanoma. Lymphoscintigraphy was performed to localize sentinel lymph nodes, and the procedure was carried out by 2 teams working together, a tumor-ablative team and a reconstructive team. The present study is adhered to the STROBE guidelines for cohort studies. The average operation time was 241.4 minutes and was not significantly different even in cases with inguinal dissection (P value: 0.641). All flaps survived after 2 cases of venous insufficiency and 1 case of hematoma were resolved by immediate revision surgery. The 2-team approach to surgically reconstruct heel defects after wide excision of malignant melanoma using free flap coverage offers favorable results and lower morbidity than regional flap approaches.

Medial Plantar Fasciocutaneous Flap Reconstruction for Load-Bearing Foot Defects in Patients With Acral Melanoma

BACKGROUND

Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma that usually involves the weight-bearing plantar area. Plantar defect reconstruction has traditionally been performed with skin grafts or free flaps. This study examined the efficacy and safety of a medial plantar artery perforator flap (MPAPF) for plantar defect reconstruction after wide excision of an ALM.

METHOD

Twenty-five patients who underwent reconstruction with a MPAPF between 2011 and 2021 were enrolled in this study. The defects were classified into 6 plantar zones. Demographic and clinical data were retrospectively analyzed.

RESULTS

Reconstruction with medial plantar fasciocutaneous island flaps was performed in all cases, except for 4 patients who had lesions in forefoot, which required free medial plantar flaps. Defects in lateral and posterior heel were more likely to present with venous congestion and require longer healing times and revision surgery (P < 0.05). The average follow-up period was 49 months. Four and 5 patients developed local recurrence and distant metastasis, respectively. Four cases of hyperkeratosis and paresthesia were documented, but there were no cases of ulceration or wound dehiscence. None of the cases required secondary debulking procedures.

CONCLUSIONS

The MPAPF is safe and effective for plantar defect reconstruction among patients with ALM. Meticulous dissection and adequate tunneling are needed, particularly for defects in the lateral and posterior heel, to minimize flap congestion and revision operations.

An Innovative Approach to Calcaneal Decubitus Ulcerations Through Calcaneal Decorticalization with Use of Localized Bone Marrow and Negative-Pressure Wound Therapy: A Case Study

Heel decubitus ulcerations are relatively common occurrences that can be limb threatening. There are many options to treat these ulcerations, ranging from conservative wound care to serial debridement with flap reconstruction. However, not all patients are good candidates for major reconstructive surgery. In this case, we present a 46-year-old man who failed 3 months of conservative wound care after sustaining a heel decubitus ulcer because of immobilization from a motor vehicle accident. The ulceration was treated with sharp excision of the wound with calcaneal decorticalization and use of negative-pressure wound therapy to use the localized bone marrow within the wound bed. The patient went on to heal within 3 months of operative intervention and remains healed greater than 1 year postoperatively. This technique provided the ability to use localized bone marrow to assist in wound healing without the operative morbidity of a reconstructive procedure.

Complete avulsion of the heel pad with talar and calcaneal fracture: salvage with multiple K-wire anchorage, internal fixation and free ALT flap

BACKGROUND

Degloving of the sole of the foot is a rare and serious injury because the heel pad cannot be replaced by similar tissue. The management is challenging and only a few cases have been reported with different treatment regimens.

METHODS

Here, we report on a 46-year-old female patient with complex foot trauma consisting of complete avulsion of the heel pad at the hindfoot and a soft tissue defect at the posterior aspect of the heel accompanied by rupture of the anterior tibial tendon and fractures of the talus, calcaneus and midfoot. The sole of the foot was fixed to the calcaneus with multiple temporary Kirschner wires and moist wound dressings. The anterior tibial tendon was sutured. The soft tissue defect at the posterior heel was treated with a free anterolateral thigh flap. The fractures were fixed in staged procedures.

RESULTS

At 2-year follow-up, the patient had a durable soft tissue cover over the heel with full sensation over the sole and a pliable flap over the posterior aspect of the heel. The patient was able to fully bear weight and was pain free during her daily activities in comfortable, custom shoes. All fractures had healed, the talar neck fracture after one revision and bone grafting. The foot was plantigrade and stable with preserved painless but limited range of motion at the ankle, subtalar and mid-tarsal joints.

CONCLUSION

The unique tissue at the sole of the foot can be salvaged even in cases of full degloving at the hindfoot with the simple method of anchorage with multiple temporary K-wires. Traumatic defects of the vulnerable skin at the posterior aspect of the heel requires durable coverage with free flap coverage. With staged treatment of all bone and soft tissue injuries, a favorable result can be obtained even in case of a complex foot trauma.

Quantification and Further Refinement of Lateral Calcaneal Artery Flap for Complicated Heel Defect Reconstruction

Background:

Reconstruction of posterior heel defects requires tissues with adequate blood supply, good elasticity, and sensate; because of the traumatic origin in the young population, it ends up with morbidity. The lateral calcaneal artery is the arterial supply of the lateral calcaneal artery flap. This is one of the viable choices for coverage of hind foot soft-tissue defects. The objective of this study was to determine the outcome of the lateral calcaneal artery flap in terms of function, donor site morbidity, and duration of surgery.

Method:

This was a descriptive case series. Patients with complicated heel defects of small to medium size were included. The follow-up period was 6 months to 1 year of posttreatment. Outcome measures were noted and assessed in all patients in terms of function, donor area morbidity, and total duration of surgery. Significance was determined by assessing the gait, donor site pain, physical appearance at the surgical site, and time needed for surgery.

Results:

Twelve patients [men: eight (62.5%), women: four (37.5%)] were selected for this study, with their mean age being 14.4 ± 7.4 years. Mean defect size was (4.4 ± 0.5) cm. Mean flap size was 3.5–5.5 cm (P < 0.001). There was a near-normal gait in all patients, with a pain score of (0–2) on the visual analogue scale score, physical appearance by Vancouver scar scale score (0–3), and the mean duration of surgery was 45 ± 4.5 minutes.

Conclusion:

The lateral calcaneal artery flap is more effective for reconstruction of posterior heel and tendon Achilles defects in terms of function, donor area morbidity, and duration of surgery.

Reconstruction of Complex Soft Tissue Defects of the Heel With Versatile Double Skin Paddle Anterolateral Thigh Perforator Flaps: An Innovative Way to Restore Heel Shape

Background

Complex heel defects constitute a significant challenge for plastic surgeons.

Objectives

In this study, versatilities of free double skin paddle ALT flaps in the reconstruction of complex soft tissue defects of heels were explored.

Methods

From January 2010 to December 2019, 16 patients (13 male and 3 females) aged 16–74 years underwent double skin paddle ALT flap reconstruction in our department. All the patients had large defects located at the heel, and 5 had a dead space. Underlying structures such as vessels, bones, and tendons were exposed in all cases.

Results

Flap survival rate was 100% after the reconstruction. Eleven double skin paddle ALT flaps and 5 vastus lateralis muscle-chimeric double skin paddle ALT flaps were used. The size of the skin flap ranged from 9.5 × 4.5 cm² to 22 × 10 cm², and the size of a muscle segment ranged from 6 × 3 × 1 cm³ to 10 × 3 × 2 cm³. The mean follow-up was 22.6 months (range: 10–81 months). The wounds healed well, providing reliable soft tissue coverage and good heel contour. All the patients ambulated independently during the follow-up period. Most of them regained protective sensation. The average two-point discrimination was 32.7 mm (range: 27–37 mm).

Conclusion

Double skin paddle ALT flaps are a feasible option for the reconstruction of complex heel defects, with good functional and aesthetic results. Nonetheless, further studies comparing double skin paddle ALT flaps to other flap techniques are needed.

Foot Wounds and the Reconstructive Ladder

Background:

Foot soft tissue coverage represents a challenge to reconstructive surgeons due to a lack of donor sites for this specialized skin. This glabrous tethered thick skin is designed to withstand weight bearing stress and is hard to replace. The limited arch of rotation of foot local flaps contributes to further difficulties. In this study, we share our experience in foot soft tissue loss coverage using techniques tailored to each wound presentation.

Methods:

This case series presents eight patients with wounds of the plantar and dorsal surfaces of the foot, heel, and ankle. Closure techniques were selected and planned based on wound presentation and comorbidity status.

Results:

Patients’ mean age at surgery was 61 years. Etiologies of wounds include trauma, frostbite, diabetic ulceration, malignancy, pressure ulcer with osteomyelitis, and necrotizing infection. Coverage techniques included split and full-thickness skin graft, medial plantar arch pinch graft, cultured epithelial autograft, Hyalomatrix wound device, EpiFix tissue matrix, pedicle flap, and free rectus flap. Complete soft tissue coverage was achieved in each case within reasonable postoperative periods, and ambulation was preserved and/or restored.

Conclusions:

Foot soft tissue reconstruction is challenging and should be planned carefully due to the required specialized skin replacement. Primary closure should be considered first and attempted if possible. Technique escalation in accordance with the reconstructive ladder should be undertaken based on wound etiology, presentation, amount and nature of tissue loss, available resources, and surgeon experience.

Sensory Reconstruction of a Posterior Heel Defect Using a Proximally Based Sensate Medial Plantar Flap with Retrograde Nerve Cleavage Technique

Reconstruction of posterior heel defects is important because it requires thick and durable skin that can withstand pressure and shear from shoe and bed contact. Therefore, the sensate flap could be a better option for the defect. This paper reports on the safety of a medial plantar sensory flap for these defects as well as an objective measurement of the sensation of the medial plantar flap and the plantar surface distal to the donor site. Twelve patients had soft-tissue defects in the posterior heel and underwent reconstructive surgery using a proximally based sensate medial plantar sensory flap. Cases of plantar defects involving not posterior heel were excluded. For wider flap coverage, special neurovascular dissection was required. We evaluated levels of sensation quantitatively using Semmes-Weinstein (SW) monofilaments and a two-point discriminator at the final follow-up. All flaps survived without major complications. Postoperative follow-up was 12 to 64 months (mean 26 months). All 12 flaps healed without postoperative complications. There was no significant difference in minimal two-point discrimination and SW evaluator size between the transferred medial plantar flap area and the contralateral heel area or between the plantar area distal to the donor site and the contralateral side. Patients could walk normally and sleep without protective shoes or brace. A proximally based sensate medial plantar flap is a good option for the reconstruction of posterior heel defects. It can restore the characteristics of the posterior heel for shoe wearing and sleeping.

Repair of Small-Size Wound With Achilles Tendon Exposure With Proximal Pedicled Cutaneous Neurovascular Flap

OBJECTIVE

To investigate the clinical outcomes associated with repairing of small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap in the dorsolateral foot.

METHODS

After thorough debridement, 16 cases with small-sized wounds of Achilles tendon exposure were repaired by proximal pedicled cutaneous neurovascular flap of the dorsolateral foot, and their clinical outcomes were observed.

RESULTS

All the flaps in the 16 cases survived completely, excluding the marginal part necrosis in 1 case, and all the wounds were healed. The 2-point discrimination of the flaps was 14.53 ± 1.55 mm (range, 12-17 mm) in patients without sural nerve injury after 3 to 18 months follow-up. No discomfort was felt in wearing normal shoes by all the 16 patients.

CONCLUSIONS

It is reasonable to repair the small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap of dorsolateral foot due to its effective repair of the wound, relatively uncomplicated surgery, and had satisfactory healing recovery.

Free Medial Plantar Flap Versus Free Dorsal Myocutaneous Flap for the Reconstruction of Traumatic Foot Sole Defects

BACKGROUND

Trauma can cause large defects in the weight-bearing foot sole. The reconstruction of such defects poses a major challenge in providing a flap that is durable, sensate, and stable. The pedicled medial plantar flap has been commonly used for reconstructing heel and plantar forefoot defects; however, the ipsilateral instep region is usually compromised by trauma. The purpose of this article was to report the use of contralateral free medial plantar flaps for the coverage of weight-bearing plantar defects and to compare these with distant free flaps.

METHODS

Between 2005 and 2019, 15 patients (10 men and 5 women) with weight-bearing foot plantar defects were treated with a contralateral medial plantar flap, 11 (7 men and 4 women) with either a latissimus dorsi flap or a scapular flap. The average age was 18.07 ± 10.14 years (range, 4-34 years) and 26.55 ± 13.05 years (range, 13-56 years), respectively. Surgery was performed as a primary or secondary reconstruction after a trauma by the same surgical team.

RESULTS

The mean size of defects was 9.73 ± 3.55 × 6.43 ± 2.8 cm in the contralateral free medial plantar flap group and 17.14 ± 6.84 × 11.41 ± 4.29 cm in the free dorsal flap group. All flaps survived in both groups. In the instep flap group, the appearance was satisfactory, the flap was durable, and tactile sensation was preserved in all patients, and none required a revision procedure. Two patients experienced delayed union of the donor-site grafted skin. In the dorsal flap group, 5 patients complained of a partial necrosis or delayed union at the recipient site, and 9 developed recurrent ulcerations over the weight-\bearing area. Five patients achieved only partial sensation in the flap.

CONCLUSIONS

The contralateral medial plantar flap provides superior appearance, duration, and sensation over distant muscle flaps, without recurrent ulcerations. However, dorsal myocutaneous flaps may be used as a substitute when the defects are beyond the maximum boundaries of the instep area or are combined with bone loss.

Management of Heel Pad Degloving Injury After Severe Foot Crush Injury: A Case Report Study

Crush injuries of the foot and ankle are uncommon and they have a poor prognosis leading to some form of disability. Degloving injuries of the heel and foot after crush injuries are rare and very challenging to manage due to the need for reconstruction of both osseous and soft tissue architecture. We present a salvage strategy for an open injury to the foot with extensive soft tissue detachment from the plantar and dorsal surface. A 30-year-old man was transferred to the Emergency Department from a neighboring hospital with a crush injury to the foot that had resulted in a degloving injury of the heel pad, after a motorcycle accident. The patient had a 20 cm circumferential wound that was extending from dorsal to the plantar surface along with rupture of the extensor digitorum longus (EDL) tendons and transection of the superficial peroneal nerve. There was an extensive detachment of soft tissues from the deep fascia and bones, whereas the posterior tibial artery was intact. In radiographic imaging, a small inferior avulsion fracture of the calcaneus along with fractures of the cuneiform bones was revealed. The initial management involved thorough surgical debridement, removal of necrotic tissues, repair of EDL tendons and fracture stabilization. Negative-pressure wound therapy was also applied for six weeks. Subsequently, a split-thickness skin graft was used to cover the skin defect. Six months after injury, the patient had a normal range of motion, intact sensation over the sole and could ambulate independently. Although the majority of heel pad degloving injuries have a poor prognosis, there are positive prognostic factors as presented in the current case for a satisfying functional final outcome, which include vascular intergrity, fracture stabilization, soft-tissue reconstruction with negative pressure wound therapy, and application of skin grafts.

Heel Pad Reconstruction With Medial Plantar Flap

The heel of the foot is covered by highly specialized thick, glabrous skin containing fibroadipose tissue with numerous fibrous septae traversing the subcutaneous tissue, which acts as a shock-absorbent and prevents shearing of the skin. The loss of heel pad would cause interruption of the propelling function of the foot during walking. Therefore, heel pad reconstruction is an important procedure for wound closure in the acute phase and also functional reconstruction in delayed cases. We report a case of heel pad deformity in a patient who presented to us with left heel pain and inability to fully bear weight, which has caused her walking difficulty, following a road traffic accident. She sustained a degloving injury of the left foot and an open fracture of left calcaneum with ruptured Tendon Achilles in which the wound was initially addressed with failed reverse sural flap and the wound was allowed to heal by secondary intention. Delayed heel reconstruction was carried out with a propeller medial plantar flap and split skin graft. Postoperatively, the patient had improved functional and esthetic outcome.

Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: A case report and literature review

Charcot foot is can result in bone deformities and soft tissue defects. We report a case of alcohol-induced Charcot (AIC) foot with soft tissue defect including the weight-bearing zone of the heel and osteomyelitis, which was successfully reconstructed with free tensor fascia lata true-perforator flap (TFLtp). A 56-year-old male suffered from AIC foot with an 18 × 6 cm defect. Based on the preoperative ultrasound, we identified the overlying upper thigh area offering one of the thickest dermis. A TFLtp flap was raised sparing the TFL muscle based on one perforator without including the main trunk of the transverse/ascending branch of the lateral femoral circumflex vessel. The TFLtp flap was transferred to the heel and anastomosed to the posterior tibial artery in an end-to-side fashion. The patient complained no postoperative discomfort of the donor site and was able to walk on his foot after 5 weeks. This case report highlights that the TFLtp flap may offer thick dermis, faster surgery due to perforator level dissection and a concealed donor site.

Squamous Cell Carcinoma of the Heel Invading the Calcaneus Treated by Radical Excision and Reverse Sural Flap

Cutaneous squamous cell carcinoma (cSCC) is relatively rare in the heel and foot. It is characterized by great loco-regional aggressiveness but low metastatic potential. If left untreated, cSCC can grow to a large diameter. The rarity and unfamiliarity of this condition pose therapeutic difficulties to many surgeons. We hereby submit the case of a 32-year-old male patient presenting with a large 14 x 8 cm scaly, ulcerated, and bloody skin lesion covering the entire left heel and invading the calcaneus. The patient was treated with radical excision of the mass and a reverse sural fasciocutaneous flap to cover the remaining heel defect, with a very positive outcome and no complications. This case is presented due to the rarity of the squamous cell carcinoma of the heel, and its large size (14 x 8 cm) in a relatively young patient, especially when it is invading the calcaneus.

The Vertical Contour Calcanectomy, an Alternative Approach to Surgical Heel Ulcers: A Case Series

Heel ulcers have a significant impact on lower-extremity morbidity and confer high risk of major amputations. Treating these ulcers is difficult because of poor tissue coverage and the bony os calcis, often leading to proximal amputation. This case series shows the vertical contour calcanectomy (VCC) as a surgical alternative in functional limb salvage. Sixteen feet (14 patients) with recalcitrant heel wounds who underwent VCC were identified. The minimum follow-up time for inclusion was 1 year. Body mass index, diabetes, renal disease, peripheral vascular disease, lymphedema/venous insufficiency, smoking status, Charcot, amputation, vascular intervention, wound recurrence, reoperation rate, and ambulatory status were evaluated. The average follow-up time was 27.1 months (range 13.5 to 51.1). At 1 year of follow-up, 56% of heel wounds (9 of 16) treated with the VCC remained closed. An average of 1.44 subsequent surgeries were required per patient. Baseline or improved ambulatory status was achieved in 69% of patients (9 of 14) at 1-year follow up and 100% of patients (8 of 8) at 2-year follow up. The overall rate of major amputation was 19%. The long-term ambulatory status of patients treated with the VCC shows promise. The VCC should be considered as an alternative, reliable, surgical limb salvage tool for heel ulcerations.

Reconstruction of Defects in the Weight-Bearing Plantar Area Using the Innervated Free Medial Plantar (Instep) Flap

BACKGROUND

Defects in the weight-bearing heel or forefoot are commonly derived from chronic wounds, acute trauma, or tumor excision. Reconstruction of such defects pose a significant challenge to provide a flap that is stable, durable, and sensate. Several flaps have been described for reconstruction of plantar defects, but recurrent ulcerations and/or the need of additional procedures are common. This article provides the approach and outcomes of innervated free medial plantar flap for weight-bearing plantar defects reconstruction.

METHODS

Chart review was performed of 17 consecutive patients with defects in the weight-bearing heel and/or forefoot who were treated with innervated free medial plantar flaps between the years 1999 and 2016. Eleven patients were male, and 6 patients were female. The mean age was 29.5 years (range, 4-52 years). One case was combined heel/forefoot defect, 7 were heel defects, and 9 were forefoot defects. Indications were acute trauma, secondary reconstruction after trauma, and tumor excision.

RESULTS

The mean defect size was 8.0 ± 5.4 cm × 5.1 ± 2.1 cm, and mean flap size was 9.7 ± 1.4 cm × 6.4 ± 0.9 cm. One flap suffered from arterial thrombosis, which necessitated reoperation, and was salvaged. For the remaining cases, the postoperative course was uneventful. The mean follow-up time was 59.3 (±51.3.6) months. Two patients received minor flap corrections due to hyperkeratosis and hypertrophic scar, and 2 patients required donor site correction owing to partial loss of skin graft. One patient succumbed within 1 year owing to metastatic disease. All patients that were followed more than 1 year (n = 15) could sense blunt touch of the flap. Ten patients underwent 2-point discrimination test. No patient had recurrence of ulceration.

CONCLUSIONS

The innervated medial plantar flap is an excellent solution for treatment of medium-to-large defects in the weight-bearing heel or forefoot. It provides glabrous skin that is stable, durable, and sensate. The long-term results are good, with no patient afflicted by recurrent ulceration during the follow-up time.

Medial Plantar Artery Perforator Flap: Experience with Soft-tissue Coverage of Heel

Background:

Soft-tissue coverage is a challenge to the ankle and foot reconstructive surgeon due to its unique requirement of simultaneously withstanding body weight and to provide sensory feedback. We share our experience of medial plantar artery perforator (MPAP) flap, which provides a robust sensate coverage to heel defects.

Methods:

Three-year retrospective study, which included soft-tissue injury to heel. All patients underwent MPAP flap for the coverage of the defect. Patients' demographic, mode of injury, defect size, flap size and survival, time to start weight bearing, return of protective sensations, and comparative 2-point discrimination with opposite heel were studied.

Results:

We studied 16 cases with heel soft-tissue injuries. Fifteen had motor vehicle accident, and 1 had chronic diabetic wound. Mean surface area of flap was 4 × 5 cm. Except 1 flap, 15 flaps had complete survival and provided reliable wound coverage with comparable normal sensation as on other foot.

Conclusion:

We suggest that MPAP flap, when available, is a good local tissue for heel wounds coverage.

Functional and Aesthetic Outcomes of Reconstruction of Soft-Tissue Defects of the Heel with Free Flap

Objective

To evaluate functional and aesthetic outcomes of the reconstruction of soft-tissue defects of the heel with microsurgical techniques using a free radial forearm flap and an anterolateral thigh flap.

Patients and methods

The study included 25 patients, 15 males and 10 females, with a mean age of 34.3 ± 10.4 years, with soft-tissue defects of the heel. Of them, 11 patients whose defects were of size between 5 and 10 cm in their largest dimension were treated using a free radial forearm flap, and 14 patients whose defects were of size larger than 10 cm in their largest dimension were treated using a free anterolateral thigh flap.Post-operatively, avoidance of weight-bearing and walking was required for 8 to 10 weeks. At the end of the follow-up, all patients underwent functional, aesthetic and sensation evaluation in addition to assessment of patient satisfaction.

Results

The median follow-up period was 24 months. The causes of the defect were trauma (14 patients), neuropathic ulcer (8 patients) and neoplasia (3 patients). The size of the defect ranged from 5 × 6 cm to 14 × 24 cm. Four patients had calcaneal fracture. By the end of the follow-up period, 21 cases showed complete success, whereas 2 flaps failed, one in each flap type, and the remaining two flaps showed partial loss of the edges (anterolateral thigh flaps). Failure was due to venous congestion (one patient) and ischaemia (one patient). Eighteen patients were satisfied with their aesthetic appearance, functional outcome and flap sensation.

Conclusion

Reconstruction of large heel defects, using radial forearm and anterolateral thigh free flaps, provides acceptable functional and aesthetic outcomes.

Foot and Ankle Reconstruction Using the Distally Based Sural Artery Flap Versus the Medial Plantar Flap: A Comparative Study

Soft tissue defects around the foot and ankle region often present an awkward problem for plastic surgeons. The medial plantar artery flap raised from the non-weightbearing instep of the plantar foot offers a thick, sensorial, durable, and glabrous skin. The reversed sural artery flap offers a reliable option for coverage with the advantages of a wide arc of rotation, adequate dimensions, and a reliable blood supply. The present study compared the outcomes of the medial plantar artery flap and the distally based sural artery flap in foot and ankle reconstruction. The present comparative cross-sectional study included 30 adult patients with soft tissue defects in the foot and around the ankle, who were divided into 2 equal groups. One group underwent reconstruction with the proximally based island medial plantar artery flap (MPAF). The second group underwent reconstruction with the reversed sural artery flap (RSAF). The operative time and complications were carefully recorded. The surgical outcomes in terms of flap survival, durability of coverage, and functional outcome were assessed for all patients. No significant differences were found between the 2 groups in age, sex, etiology, or site of the defect. The defect size was significantly smaller in the MPAF group than in the RSAF group (22 ± 2.7 cm² versus 66.2 ± 7.7 cm²; p < .001). However, the operative time was significantly longer in the MPAF group than in the RSAF group (100 ± 2.9 minutes versus 80.5 ± 3.1 minutes; p < .001). The flap survived in all cases in the MPAF group, but total flap necrosis occurred in 1 patient in the RSAF group. The mean follow-up period was 13.2 months. Weightbearing was significantly earlier in the MPAF group than in the RSAF group (5.8 ± 0.26 weeks versus 6.9 ± 0.19 weeks; p = .003). None of the 30 patients developed recurrent ulceration. The incidence of complications (33.3% versus 80%) was significantly less in the MPAF group than in the RSAF group (p = .01). Significantly greater improvement was found in the functional outcomes in the MPAF group compared with the RSAF group (p = .004). In conclusion, the MPAF and distally based sural artery flap are the 2 flaps available for foot and ankle reconstruction. However, the MPAF offers better functional outcomes with a lower frequency of postoperative complications. Thus, the sensate MPAF is recommended for reconstruction of moderate-size defects of the foot and ankle region.

Reconstruction of Heel Soft Tissue Defects Using Medial Plantar Artery Island Pedicle Flap: Clinical Experience and Outcomes Analysis

We report our clinical experience with 11 cases of heel soft tissue defects treated with a medial plantar artery island pedicle flap. We also evaluated the functional outcomes of reconstruction. We enrolled 11 patients (10 [90.9%] males and 1 [9.1%] female), who received a medial plantar artery island pedicle flap for heel soft tissue defects from August 2010 to July 2014. The cause of the defects included trauma (post-traumatic heel skin necrosis) in 2 (18.2%) patients, infection (calcaneal osteomyelitis with overlying soft tissue infection) in 2 (18.2%) patients, and tumor (stage IA melanoma) in 7 (63.6%) patients. The mean average size of the defect was 3.7 cm × 4.4 cm (range 3.1 cm × 4.0 cm to 4.5  cm × 5.5  cm). The mean follow-up period was 19.6 (range 8 to 35) months, and all flaps survived within that period. The mean static 2-point discrimination was 34.4 (range 29 to 40) mm at the heel and 17.2 mm at the distal sole. The mean visual analog scale score for the aesthetic appearance of the reconstructed heel was 9 (range 8 to 9.5). The average revised Foot Function Index score was 25.8 (range 21 to 37). The medial plantar artery island pedicle flap is a versatile and effective method for reconstructing heel soft tissue defects.

Free Medial Plantar Flap Connection with a Posterior Tibial Artery Flap in Reconstruction of Fore-Mid Foot Skin Defect

BACKGROUND

Although there are many surgical treatments for covering the skin defect of the fore-mid foot, how to reconstruct the weight-bearing region remains a challenge. The weight-bearing region of the sole needs to withstand the pressure and shearing stresses of walking, so the plantar skin is anatomically different from other skins in the areas of texture, thickness, subcutaneous tissue, etc. Medial plantar flaps that are harvested from the instep region are regarded as the first choice for weight-bearing region reconstruction because of their excellent functional and aesthetic long-term result. However, when facing an extensive skin defect on a weight-bearing area such as a fore-mid foot avulsion, the application of this flap is limited because if we put the flap in a weight-bearing area of the forefoot, the set of vessels will be exposed to outside.

METHODS

We suggest 2 connected free flaps (posterior tibial artery flap and medial plantar flap) pedicled with 1 set of vessels. The medial plantar flap was used to cover the skin defect of the weight-bearing area in the forefoot. The dorsal skin defect of the injured foot was covered with a posterior tibial artery flap and supplied the medial plantar flap with the posterior tibial vessel. The midfoot skin defect was repaired by a full-skin grafting.

RESULTS

Long-term follow-up results showed that the shape and function of the injured limbs recovered almost entirely.

CONCLUSION

This method of connected flaps is suitable for repairing large skin defects of the fore-mid foot.

A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix

Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

The medial plantar artery flap: a series of cases over 14 years

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga Khan University and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity.