Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases

Free Fibular Osteocutaneous Flap Combined With Simultaneous Tendon Reconstruction for Midfoot Restoration After Myoepithelial Carcinoma Resection

ABSTRACT

Myoepithelial carcinomas of soft tissue are rare, and most are malignant. The optimal treatment is surgical excision. The arches of the foot are a composite structure responsible for weight bearing and pressure distribution, so it is a vast challenge in reconstruction. We report a case of reconstruction of the midfoot with a free fibular bone flap and tendon graft. We review the literature to compare various options in foot reconstructions and sort out the outcomes of different bone flaps. The free fibula osteocutaneous flap is the superior choice for midfoot reconstruction owing to its sufficient length, strength, flexible skin paddles, easy-to-withstand osteotomy, and simultaneous tendon graft harvesting.

Microvascular Muscle vs. Fascio-Cutaneous Free Flaps for Reconstruction of Plantar Load-Bearing Foot Defects-An International Survey

Background: The reconstruction of plantar load-bearing foot defects faces many plastic surgeons with a major challenge. The optimal patient- and defect-oriented reconstructive strategy must be selected. Methods: To analyze the current trends and recommendations in reconstruction of plantar load-bearing foot defects, we conducted an international survey among plastic surgeons querying them about their recommendations and experiences. Results: The survey revealed that the most common strategies for reconstruction of the foot sole are locoregional and microvascular free flaps, emphasizing the relevance of plastic surgery. Among microvascular free flaps, muscle and fascio-cutaneous free flaps are by far the most frequently used. The target qualities of the reconstructed tissue to be considered are manifold, with adherence being the most frequently mentioned. We observed a noteworthy correlation between the utilization of muscle flaps and a preference for adherence. In addition, we identified a substantial correlation between the usage of fascio-cutaneous free flaps and further target qualities, such as good skin quality and sensitivity. Conclusions: Our findings provide insights into the clinical reality and highlight important aspects that must be considered in reconstruction of the weight-bearing areas of the foot providing support in the selection of the appropriate therapy.

Flaps for lower limb diabetic wound reconstruction: A systematic review and meta-analysis

BACKGROUND

The treatment of chronic diabetic wounds includes wound dressing, debridement, flap surgery, and amputation. For suitable patients with nonhealing wounds, locoregional flaps or free flaps may be used. This paper aims to review the outcomes of flap surgery and identify the risk factors for flap loss.

METHODS

MEDLINE, Embase, and Cochrane Library were searched. Articles reporting flap loss outcomes for flap surgery in lower limb chronic diabetic wounds were included. Case reports and case series with fewer than five patients were excluded. A subset of articles was used for revascularization subgroup analysis and another subset for meta-analysis of risk factors for flap loss.

RESULTS

In the free flap group, the total flap failure rate was 7.14% and partial flap failure rate was 7.54%. The rate of major complications requiring operative takeback was 19.0%. Early mortality was 2.76%. In the locoregional flap group, the total flap failure rate was 3.24% and partial flap failure rate was 5.36%. The rate of major complications requiring operative takeback was 13.3%. There was no early mortality. The rate of free flap loss was 18.2% with revascularization, significantly higher than 6.66% without revascularization.

CONCLUSIONS

Our findings concur with previously published studies on flap loss and complications in diabetic lower limb wounds. There is an increased risk of flap loss in patients who require free flap and revascularization compared to patients who only require free flap. This could be because of the fragile and fibrotic vessels found in diabetics with comorbid atherosclerosis.

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.

Heel reconstruction with ALT free flap in a 4-year-old patient after a severe lawnmower injury. A case report

Lawnmowers represent a danger in pediatric population. Frequently, traumas involve limbs. Among the different reconstructive techniques, a free flap is often needed. We discuss the first case of heel reconstruction with an anterolateral thigh flap in a 4-years-old patient after a lawnmower's trauma.

Reconstruction and Outcome of Foot Defects Following Oncological Resection-Experience from a Cancer Centre in North-East India

Solid tumours around the foot are rare and include soft tissue sarcomas, skin and bone malignancies. Extended soft tissue defects due to oncological resection result in the loss of shock-absorbing and friction resistant tissue, which leads to altered walking patterns and pain. Replacement of plantar tissue requires soft tissue resistant to weight, pressure and shear stress. The other important desired goal of foot reconstruction is short wound healing time in order to allow adjuvant therapy at stipulated time. This is a retrospective study from March 2016 to October 2019. A total of twenty-one (n = 21) patients were operated for foot malignancies during this period in our institute and the resulting defects were reconstructed using various methods. Different reconstructive surgeries were performed depending on tumour size, location and general health status of patients. The length of hospitalization and the presence of local postoperative complications were assessed. Functional outcomes were measured in terms of MSTS score. Average age of the series is 53.1 years. Sixty-six percent of the patients (n = 14) presented with tumour at the weight bearing areas and 33% patients (n = 7) at the non-weight bearing areas of the foot. Fifty-seven percent of patients (n = 12) presented with malignant melanoma of foot, squamous cell carcinoma was seen in 33% (n = 7) patients and 4% patients (n = 1 each) presented as osteosarcoma and malignant peripheral nerve sheath tumour respectively. The mean MSTS score in patients with weight bearing areas (location) is statistically significant (p = 0.031). There is a significant correlation between the surgical complications and follow up MSTS score (p = 0.046) which signifies that flap related complications result in lower MSTS score. The mean MSTS score was 22.71/30. Complications were observed in three cases which included partial flap necrosis, graft loss and foot stiffness. Simple skin grafts to local flaps maybe a viable option in a limited resource setting based on the location of defect. Free tissue transfer is the ideal choice in case of weight bearing areas to achieve acceptable outcomes.

Microsurgical Reconstruction of Foot Defects: A Case Series with Long-Term Follow-Up

(1) Background: Microsurgical reconstruction of foot defects with free flaps is rare as it is a challenging task for a surgeon. For extensive defects, advanced surgical procedures, such as free flap transfer with microsurgical anastomosis, may be the last chance to avoid major amputation. The aim of the study was to examine the opportunities and risks posed by free flap reconstruction of foot defects and to illustrate in which situations reconstruction is useful on the basis of case characteristics. (2) Methods: In this study, we retrospectively analyzed data of cases with free flap reconstruction of the foot from 2007 to 2022. Therefore, demographic data, comorbidities, information about the defect situation, data on the operational procedure, and complications were evaluated. (3) Results: A total of 27 cases with free flap coverage of foot defects could be included. In 24 of these cases (89%), defect coverage was successful. In 18 patients, some form of complication occurred in the postoperative stage. The most frequently used flap was the latissimus dorsi flap, with 13 procedures. (4) Conclusions: Foot reconstruction using free flaps is a proven procedure for the treatment of larger foot defects and can offer a predominantly good functional outcome. The lengthy process and possible complications should be thoroughly discussed in advance so as to provide criteria, suitably adjusted to the individual prerequisites of the patients, for deciding whether limb salvage using advanced surgical procedures should be attempted.

Comparison of distally based sural artery and supramalleolar flap for coverage of dorsum of foot and ankle defects; a cross-sectional study of 53 patients

Background

Soft tissue defects over the foot and ankle region are most challenging in reconstructive surgery. Sural artery and supramalleolar flaps have been commonly used for the reconstruction of non-weight-bearing surfaces of the foot. This article aimed to evaluate the long-term outcome comparisons between a sural artery and Supramalleolar flap in the reconstruction of extensive defects of foot and ankle only.

Methods

Between 1996 and 2020, a retrospective analysis of 53 fasciocutaneous flaps (27 sural and 26 Supramalleolar) used for reconstruction of soft tissue defects of foot and ankle were reviewed in this study. The parameters included were demographics data, causes, site and size of the defect, flap size, hospital stay, complications, and outcomes in a pre-structured proforma. The clinical outcome was assessed by a Self-Designed Tool based on flap survival, coverage of defect, weight-bearing status, functional activities of daily living, and cosmetic appearance. Data were analyzed through SPSS version 25.

Results

Among 53 flaps, the major cause of the defect was Trauma (60.4%). The maximum flap size harvested was 25*10 for sural and 20*8 cm for supramalleolar. Complications were seen in 8 (15%) cases in both flaps. Flap tip necrosis and venous congestion were seen in 4 cases. 2 each in Supramalleolar whereas 1 partial necrosis, 1 venous congestion, and 2 infections were seen in the sural artery flap. The flap survival rate in both flaps was 96.2%. Based on the self-designed Tool, flaps were graded Excellent in 43, Good in 8, and Fair in 2 cases. There was no case of Poor in both flaps.

Conclusion

Compared with the sural artery flap, the lateral supramalleolar flap demonstrated higher rates of functional outcomes although flap tip necrosis was higher in Supramalleolar.

•

The comparative long-term clinical and functional outcomes of Sural and Supramalleolar flap is based on defect coverage, cosmetic appearance of surgical limb and activity of daily living.

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Compared with the sural artery flap, the lateral Supramalleolar flap is more reliable and exhibit higher rates of functional outcomes.

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Outcomes of Supramalleolar Flap was better than Sural artery flap as it was much more vascular and robust.

Reconstruction of Foot and Ankle Defects Using Free Lateral Arm Flap: A Retrospective Review of Its Versatile Application

Background

Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects.

Methods

Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps.

Results

Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups.

Conclusions

Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions.

Long Term Outcomes of Split-Thickness Skin Grafting to the Plantar Foot

The most common consequence of neuropathy is a diabetic foot ulcer, which usually occurs on the plantar surface of the foot. Split-thickness skin grafting (STSG) has been shown in numerous studies to be an effective treatment for rapid coverage of diabetic ulcers. The purpose of this study is to retrospectively examine the outcomes of STSG to the plantar foot and determine the durability of this treatment compared to non-plantar surface STSG. This is a retrospective, single-center, institutional review board approved, case-control study of all patients who received STSG to their lower extremity for chronic ulcers from November 2013 to February 2017. Patients with ulcers on the plantar surface were considered cases, and non-plantar surface ulcers were considered controls. There were 182 patients who received STSG to the lower extremity, 52 to the plantar surface foot and 130 to non-plantar surface locations. Healing at 30 days was not significantly different between plantar and nonplantar ulcers (19% versus 28%, p = .199) but did become significant at 60, 90, and 365 days (21% versus 45%, p = .003; 33% versus 49%, p = .043; 38% versus 64%, p = .002, respectively). However, time to full healing was not significantly different between plantar and nonplantar groups (18.2 ± 19.5 versus 17.4 ± 21.6 weeks, mean ± standard deviation, p = .84). Recurrence was low for both groups (17% versus 10%, respectively), and there was no significant difference between groups (p = .17). Patients with plantar surface ulcers can achieve a durable coverage/closure of their wounds with STSG. When combined with appropriate patient selection and postoperative offloading, acceptable recurrence rates can be achieved.

Treatment of traumatic losses of substance in the foot

Treatment of traumatic loss of bone and tissue substance in the foot necessitates special consideration of the anatomy and physiology of the segment. The causes of foot trauma are multiple and in many cases violent, leading to progressive tissue deterioration that may require multi-phased debridement. The therapeutic objective is to reconstruct a functional foot permitting painless pushing off, walking and footwear use by restoring a stable bone framework, with resistant covering satisfactorily adjusted to the different zones of the foot. While coverage of the back of the foot must be fine, coverage of the plantar zones will be padded. The reconstructive surgeon shall be particularly attentive to plantar sensitivity. To take up the surgical challenge, it is of paramount importance to fully master a wide-ranging therapeutic arsenal ranging from conventional grafts to composite free flaps in view of proposing the solution most suited to the type, size and location of the loss of substance, all the while striving to generate as few sequelae as possible at the donor site. In order for reconstruction to be successful, multidisciplinary collaboration between plastic surgeons, orthopedists and physician is highly recommended.

Free flaps for lower limb soft tissue reconstruction in children: Systematic review

BACKGROUND

Since the first reports on microsurgery in children, there has been an evolution in the reconstruction of soft tissue defects as evidenced by a shift to free flaps as the first-line treatment.

METHODS

The primary objective of this systematic review was to compare the complication rate of free perforator/fasciocutaneous flaps with free muscular/myocutaneous flaps in pediatric lower limb soft tissue reconstructions. The secondary objective was to evaluate the frequency and severity of complications for both reconstructive options. A search was performed in the databases PubMed, Web of Science, Embase, Scopus, and Cochrane Library depending on predefined inclusion criteria.

RESULTS

The evolution to perforator flaps from muscular and myocutaneous flaps is reflected in this systematic review as demonstrated by the anterolateral thigh (ALT) flap, which is the most common reconstructive option with a very low complication rate (11.3%) and flap loss. The latissimus dorsi (LD) flap was the second most frequently reported reconstruction with a complication rate comparable with that of the thoracodorsal artery perforator (TDAP) flap (32% vs. 39%, respectively), but the former suffers few failures. The radial forearm (RFA) fasciocutaneous flap can be considered a good alternative for ALT and TDAP flaps with a very low complication rate (16%) and no flap loss.

CONCLUSIONS

The ALT flap is considered the best reconstructive method for pediatric lower limb soft tissue defects. More adequate prospective studies specifically concerning free flap reconstructions for lower limb defects in children are necessary in the future to provide guidelines for treatment and optimize outcomes in the long term.

Ten Tips to Simplify the Spaghetti Wrist

Hand surgeons refer to deep lacerations of the volar distal forearm as “spaghetti wrists.” Given that multiple tendons, vessels, and nerves often require repair, this injury may be intimidating. We review management of spaghetti wrists and summarize with 10 simplifying tips.

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.

Muscular Versus Non-Muscular Free Flaps for Soft Tissue Coverage of Chronic Tibial Osteomyelitis

BACKGROUND

Eradication of chronic tibial osteomyelitis necessitates aggressive debridement is often followed by soft tissue reconstruction. Muscular flaps are said to be more effective than non-muscular flaps for infection treatment, while fasciocutaneous and perforator flaps are considered to be less invasive and offering a better aesthetic result.

METHODS

In this study, we reviewed 24 consecutive cases of chronic tibial osteomyelitis treated according to a specific protocol in a tertiary hospital. Soft tissue coverage was done with either muscular or non-muscular free flaps. Infection recurrence and complications were compared between different flap types. Additionally, we assessed the long-term functional and aesthetic results and patient’s satisfaction.

RESULTS

Muscular flap was used in 13 patients (13 latissimus dorsi and 1 serratus anterior) and 11 patients underwent fasciocutaneous/perforator flaps [1 anterolateral thigh flap, 4 lateral arm flaps, 5 thoracodorsal artery perforator (TAP) flaps and 1 radial forearm flap]. Infection was resolved for 84.6% of patients in the muscular flaps group and 90.9% in the non-muscular flaps group. None of the patients with muscular flaps were satisfied with the aesthetic appearance of their reconstructed leg when compared to 83.3% of patients with non-muscular flaps. Also, a slight regain of touch sensitivity was acknowledged in the non-muscular flap group compared to the muscular.

CONCLUSION

In this study of adult chronic tibial osteomyelitis cases, we demonstrated that fasciocutaneous and perforator free flaps offer a comparable efficacy to the muscle flaps for infection treatment, with a significantly higher patient satisfaction and aesthetic result.

Immediate emergency free anterolateral thigh flap after car-tyre friction injury: A case report with eight years follow-up

The car-tyre friction injury has differences from other injuries. The components of injury which are burn, crushing, shearing, and degloving occur. Many treatment options can be performed for coverage of wound which are Vacuum Assisted Closure system (V.A.C), skin grafting, free flaps, local flaps and cross leg flap.

Microsurgical free muscle flaps for reconstruction of post-traumatic complex tissue defects of foot

BACKGROUND

Crush injuries of the foot often result in complex tissue loss with exposed bones and tendons. These three-dimensional defects ideally require flexible well-perfused flaps to fill the space, afford resistance to infections, and to provide supple, durable weight- and pressure-bearing surfaces. Free muscle flaps with split thickness skin graft cover have been found to have several advantages in covering three-dimensional defects with exposed tendons and bones.

METHODS

All patients with post-traumatic composite tissue defects of the foot exposing bones and tendons, who presented to a tertiary care center during a 40-month period, were reconstructed with free muscle flaps as the first option. Gracilis muscle flap was used for eight patients and latissimus dorsi muscle for two patients. Decision regarding the choice of muscle was based on the size of the defect. The patients were followed up for 1 year and observed for return to activity, ability to wear footwear, requirement of secondary procedures, and any other complications.

RESULTS

Ten patients presented with composite post-traumatic tissue defects in the foot. All were male, with age ranging from 25 to 76 years. The defects ranged from 25 cm(2) to 225 cm(2). Free muscle transfer was successful in nine patients. Even though four required secondary flap contouring, all patients had normal weight-bearing ambulation and returned to their normal activities at 1-year follow-up.

CONCLUSION

Free muscle flaps merit consideration as primary reconstructive option for post-traumatic composite tissue defects of foot.

Thoracodorsal artery perforator flap: Indeed a versatile flap

Introduction:

The thoracodorsal artery perforator (TDAP) flap has emerged as one of the ideal perforator flaps. We, hereby, describe its versatility in indications (free/pedicled), methods of harvest (patient position and paddle orientation) and perforator consistency.

Materials and Methods:

We have performed a total of six TDAP flaps-five free and one pedicled, over a period of 1-year from March 2014 to February 2015 at a single centre. Our indications have been: Reconstruction of oral cavity, breast and upper and lower extremities.

Results:

We had neither any failures nor any re-explorations. The average perforator length is about 6 cm and the pedicle length can be extended to 12-14 cm by including the thoracodorsal artery. There is inconsistency in perforator position; however, the presence of a perforator is certain. It can be harvested in lateral, prone or supine position, thus, does not require any position change allowing a two-team approach to reconstruction. The paddle can be oriented vertically or horizontally, both healing with scars in inconspicuous locations. Apart from providing a good colour match for extremities, this flap can be thinned primarily.

Conclusion:

The versatility of TDAP has several advantages that make it a workhorse flap for most reconstructions requiring soft tissue cover. Further, the ease of harvest makes it a good perforator flap for beginners. Its use in chimerism with the underlying latissimus dorsi muscle provides reconstruction for coverage and volume replacement.

Traumatic Forefoot Reconstructions With Free Perforator Flaps

The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used.

The use of fabricated chimeric flap for reconstruction of extensive foot defects

Repair of extensive foot defects requires both adequate tissues for wound coverage and special tissues for functional reconstruction. To maximize its function reconstruction, fabricated chimeric flaps consisting of multiple separate flaps were designed to reconstruct such defects. Five patients suffered extensive foot defects with sizes ranging from 23 × 12 cm to 38 × 14 cm(2) in multiple regions including heel, forefoot, dorsum, ankle, anterior leg, and even toes. Causes included crushing injuries, avulsion injuries, and scar excision. Most areas of the defects except heel were first covered by latissimus dorsi muscle flap or anterolateral thigh flap and their pedicles were anastomosed with recipient vessels. Then free medial plantar flaps were transferred for heel reconstruction and their pedicles were further attached to either side branches of the main source vessel or to its distal continuation. All chimeric flaps survived uneventfully and all patients were able to walk in normal footwear during the 1.5- to 4-years follow-up. None of the flaps developed ulcer and flap breakdown. The assessment by Maryland Foot Score showed that four of the five patients gained a "good" recovery and one patient showed moderate improvement of foot functions. Appearances of reconstructed heels were near-normal. The results indicate that fabricated chimeric flap has good design flexibility and may provide an option for functional reconstruction of extensive foot defects. © 2015 Wiley Periodicals, Inc. Microsurgery 36:303-309, 2016.

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.

Neurotized sural flap: An alternative in sensory reconstruction of the foot and ankle defects

INTRODUCTION

The sensory reconstruction of the lower extremity is one of the main goals in lower extremity reconstruction. Reconstructive options endowing sensory recovery are limited. The aim of this report is to evaluate the neurotized sural flap in reconstruction of foot and ankle defects.

PATIENTS AND METHODS

Seven cases that were operated for foot and ankle skin defects with the neurotized sural flap were reported. The largest flap was 10 cm × 14 cm in size. Median age was 38 years. Four defects were on the heel, two were on the ankle, and one was on the dorsum of the foot. The sural nerve was coaptated to a recipient nerve in seven patients.

RESULTS

All flaps survived totally. Follow-up time ranged between 9 and 29 months. All cases had hot-cold perception and two-point discrimination at average 14 ± 1.63 mm at 6th month. Sensory conduction test revealed very low action potentials related to stimulation of the flap.

CONCLUSION

The neurotized sural flap is a versatile modification, for the sensory reconstruction of the moderate size foot and ankle defects.

Long-term sensation in the medial plantar flap: a two-centre study

BACKGROUND

Reconstruction in the foot and ankle region is challenging. This study aimed to quantify objective sensation return when a sensate medial plantar flap is used for like-for-like reconstruction of foot and ankle defects.

METHODS

Two-point discrimination (2PD) was assessed in flap and normal tissue at a minimum of 1 year post-operatively. A paired T-test assessed for significance.

RESULTS

8 patients were included. Mean 2PD in normal tissue and flap was 29 mm (SD: 11.9) and 33 mm (SD: 9.97) respectively with no statistically significant difference between the two (two-tailed p-value: 0.1898). Mean age was 53.2 years (range: 15-84). There was no statistically significant correlation between age and 2PD in flap tissue (r=0.6, p=0.15).

CONCLUSIONS

This is the largest case series of its kind. Our results suggest that sensation in medial plantar flaps can return to near normal and demonstrate the important role the medial plantar flap plays in soft tissue reconstruction in this region.

Plantar reconstruction with free thoracodorsal artery perforator flaps

PURPOSE

The plantar region presents unique challenges for reconstructive surgeons. Reconstruction using a thoracodorsal artery perforator (TDAP) flap yields favourable results in various fields of microsurgical reconstruction, but reports on the reconstruction of plantar defects are sparse. Here, the authors present their experience in the reconstruction of various defects in the plantar region using free TDAP flaps.

METHODS

From January 2005 to July 2011, 40 free TDAP flaps were transferred for reconstructive purposes to restore skin and soft-tissue defects in the plantar region. Hospital and outpatient records were reviewed independently for all patients. A patient questionnaire including five questions was administered to subjectively evaluate reconstructive results.

RESULTS

A total of 24 male and 16 female patients were enrolled in this study. The mean age was 47.8 years and ranged from 7 to 77 years. The most common cause of defect was oncology related (n=21), followed by trauma-related (n=11), diabetes-related (n=6) and other causes. The average flap size was 63.7 cm2 and ranged from 25 to 212 cm2. All flaps survived except for one, resulting in a below-knee amputation. The mean follow-up period was 20.4 months. Four patients underwent secondary revisional procedures, including simple defatting in two patients and excision of redundant skin due to flap instability in two patients. The satisfaction surveys were completed by 34 (85%) patients. Patients reported high levels of satisfaction in terms of pain, limitation of daily activities, donor site satisfaction and overall satisfaction. Most patients were satisfied and reported that they would recommend the procedure to others.

CONCLUSION

An appropriately thinned free TDAP flap with thick skin provided favourable outcomes with high patient satisfaction and is a valuable option for the restoration of skin and soft-tissue defects in the plantar region.

Reconstructive options for defects after melanoma excision in the foot and ankle region

Cutaneous wounds created by excision of primary cutaneous melanoma localized to the foot and ankle can be challenging to reconstruct. A wide range of coverage techniques are available for wound coverage. The techniques we have found useful in this regard include skin grafts and flaps, as well as specialized wound dressings. In this techniques report, we describe the specialized anatomic surface subunits of the foot and ankle and the reconstructive coverage methods we have found useful for each site.

Arthroscopic subtalar arthrodesis after a calcaneus fracture covered with a forearm flap

Surgical treatment of intraarticular calcaneal fractures is often associated with postoperative wound problems. Soft tissue necrosis, bone loss and uncontrollable infection are a challenge for the surgeon and amputation may in some cases be the ultimate solution. A free flap can be very helpful to cover a significant soft tissue defect and help in fighting the infection. However, the free flap complicates the surgical approach if subtalar arthrodesis and bone reconstruction are needed. This study demonstrates the value of an arthroscopic technique to resect the remaining articular cartilage in preparation for subtalar arthrodesis and bone grafting. This approach avoids compromising the soft tissues and minimizes damage to the free flap.

Limb salvage for soft-tissue sarcomas of the foot and ankle

We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes.

Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid.

Limb salvage can achieve good oncological and functional results with additional treatment.

Free anterolateral thigh flap for reconstruction of car tire injuries of children's feet

BACKGROUND

Grade IV and V car tire injuries occurring in children cause extensive soft tissue defects with exposure or loss of tendons and bone on the dorsum of the foot. Free tissue transfer is indicated for reconstruction of these defects because of the limited local tissue available. We describe our management of high-grade car tire foot injuries in children with free anterolateral thigh flap (ALT).

MATERIALS AND METHODS

Five pre-school children with car tire injuries (one grade IV and four grade V) were treated with free ALT flap in the last 4 years. The mean age was 4.8 years. In four patients, immediate flap coverage after initial debridement was performed and delayed reconstruction was used as a secondary procedure in one patient.

RESULTS

One of the flaps was re-explored for hematoma evacuation and salvaged. All of the flaps survived completely and there were no donor site complications. None of the flaps required a debulking procedure and custom shoe wear has not been necessary in any of the patients. Minor gait abnormalities were detected in two of the patients.

CONCLUSION

With minimal donor site morbidity, long vascular pedicle allowing anastomosis outside of the trauma zone, we believe free ALT flap provides the ideal soft tissue reconstruction for high grade car tire injuries of foot in children. ALT flap can be further thinned to adapt to the defect, contracts less than muscle flaps and contains a vascularized fascia which can be used for extensor tendon reconstruction.

Comparison of free muscle and perforator skin flaps for soft tissue reconstruction of the foot and ankle

BACKGROUND

Free tissue transfer is generally required for reconstruction of soft-tissue defects of the foot and ankle region because of the limited local tissue available. This type of reconstruction may interfere with postoperative function and footwear if a bulky flap is used.

MATERIALS AND METHODS

Twenty-nine patients had free tissue transfers to the foot and ankle region during a period of 3 years. Sixteen had reconstruction with free anterolateral thigh perforator flaps (ALT) and 13 had reconstruction with free muscle flaps. The outcomes of both types of reconstructions were compared according to flap scores and complications, operative time, hospitalization, gait and shoewear problems.

RESULTS

The patients in the ALT group were younger compared with those of the free muscle flap group (p = 0.022). The operative time and flap complication rate was significantly higher (p = 0.007 and 0.040, respectively) in the ALT group. ALT was generally used for reconstruction of the dorsal foot, heel and plantar regions. Muscle flaps were preferred in the ankle region, where open fractures of the tibia and fibula were frequently present, and for the patients with increased risk of perioperative morbidity.

CONCLUSION

Free ALT flap consisting of skin and adaptable subcutaneous tissue, both diminishes donor site morbidity and is ideally suited for most soft-tissue reconstruction of the dorsal foot, heel and plantar foot. Free muscle flaps, however, may offer relatively less complicated tissue transfers and are preferred at the ankle region in the presence of open tibia fractures, and in high risk patients to decrease the perioperative morbidity.

Plantar reconstruction using the medial sural artery perforator free flap

Free flaps are usually required rather than local flaps for large plantar defects, due to a lack of locally available tissue. The medial sural artery perforator free flap, recently introduced clinically by several authors, is a noticeable option for soft tissue coverage, but it has still not been widely used for the reconstruction of various large plantar defects. Between 2005 and 2007, medial sural artery perforator free flaps were used to reconstruct soft tissue defects in plantar areas in 11 patients at our institute. Patient ages ranged from 10 to 68 years (mean, 43 years), and follow-up periods ranged from 7 to 22 months (mean, 13 months). Flap sizes ranged from 10 to 14 cm in length and from 5 to 7 cm in width. Flaps survived in all patients. Marginal loss over the distal flap region was noted in 1 patient, and this was treated successfully with a subsequent split-thickness skin graft. In another one case, venous insufficiency developed, but salvage was successful with leech application. Long-term follow-up showed good flap durability with a protective sensation. The medial sural artery perforator flap provides sufficient durability for weight-bearing areas, even though it is a thin cutaneous flap. The authors recommend that this flap be considered as a reliable alternative for the reconstruction of large plantar defects.

[Closure of defects on the dorsum of the foot with free flaps. Functional and aesthetic aspects]

BACKGROUND

Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.

PATIENTS AND METHODS

Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.

RESULTS

On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.

CONCLUSION

Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.

Rehabilitation following surgery for reconstruction of a foot defect

Background

This report illustrates the use of pressure for scar management to aid in foot re-shaping following a surgical intervention to repair an arterio-venous (AV) malformation.

Methods

This report describes the rehabilitation of a 13-year-old girl after surgical reconstruction of a defect in her left foot following the removal of an AV malformation. Early surgical attempts to repair the problem resulted in complications that required the amputation of toes 2, 3, and 4, and the use of a split thickness skin graft to cover the plantar surface of the medial longitudinal arch on the left foot. Following surgery, the patient had an antalgic gait pattern with decreased weight bearing on the left. The graft obliterated the left medial longitudinal arch and the patient would only weight bear on the heel. The patient had decreased metatarsal joint mobility on the affected side and no movement in the remaining toes. Left talocrural joint active range-of-motion (AROM) was within normal limits and gross ankle muscle force production was assessed to have a grade of 3/5.

Results

Treatment included reshaping the left foot using a pressure garment and orthotic, followed by interventions to address range-of-motion and muscle force production deficiencies. All treatment objectives were achieved and all patient goals were achieved.

Conclusions

Pressure was effective in re-shaping the foot to promote normal gait mechanics.

Perforator-Sparing Transposition Flaps for Lower Limb Defects

The local fasciocutaneous flap has the advantage of low donor-site morbidity when used for the coverage of lower limb defects. However, flap reliability remains a major problem with its use. The purpose of this study was to determine the feasibility of preserving perforators to the tip of conventional local fasciocutaneous flaps to improve its vascularity. The technical considerations of raising these flaps were examined in cadaveric specimens. Twenty-one local perforator-sparing transposition flaps were raised in 12 specimens. The leg was divided into knee/proximal-third, middle-third, and lower-third/ankle regions. We raised 7 flaps in each region. Success was defined as ability to transpose flaps to cover defects without tension on the perforators. In the knee/upper-third and middle-third regions of the leg, all wounds were successfully closed. However in the lower-third and ankle region, we were unable to close wounds in 3 of 7 cases. The reasons for this were the inadequate length of the perforator and the presence of tendons in the distal leg that interfered with perforator transposition. We successfully employed this flap in 6 clinical cases. This flap represents a technical advancement over conventional lower limb skin flaps because of its improved vascularity. It can safely be performed in the knee and upper and middle-thirds of the leg and can potentially be a valuable alternative to local muscle flaps for wounds in these areas.

Instep free flap for plantar soft tissue reconstruction: Indications and options

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.

Sole Reconstruction Using Anterolateral Thigh Perforator Free Flaps

BACKGROUND

The goal of sole reconstruction should be functional and aesthetic. These goals can be achieved by providing the sole with a durable and comfortable weight-bearing surface, adequate contour, protective sensation, and solid anchoring to deep tissue to resist shearing. Various flaps such as fasciocutaneous, musculocutaneous, or split skin grafted muscle flaps have been reported for reconstruction of the weight-bearing foot. The perforator flap, however, deserves attention in the debate for the ideal flap because of its anatomical characteristics.

METHODS

Between June of 2002 and February of 2005, 69 patients were treated for soft-tissue defects in the plantar areas with anterolateral thigh perforator free flaps. Sensory nerve coaptation was performed in 17 cases. The follow-up period ranged from 4 to 38 months, with a mean of 14.7 months.

RESULTS

Satisfactory aesthetic and functional results were observed using 4- to 6-mm-thick anterolateral thigh perforator flaps. All flaps survived, with the exception of one case. Partial necrosis and dehiscence of the wound developed in three cases, but secondary healing was achieved and final outcome was not impaired. Partial weight bearing began at 3 weeks, and acceptable gait recovery was noted by 3 months as evaluated by clinical observation and gait analysis. Most patients regained protective sensation by 12 months regardless of nerve coaptation, but earlier sensory recovery was noted in patients who underwent reconstruction with sensate flaps.

CONCLUSION

This article suggests the anterolateral thigh perforator flap to be a reliable option in sole reconstruction, resulting in an acceptable functional and aesthetic outcome.

Lower extremity reconstruction

The current recommendation for surgical treatment of tumors of the lower extremity is a limb-sparing resection. Limb-sparing resection coupled with complex reconstructive techniques and complemented by new chemotherapeutic agents and adjuvant radiation therapy has allowed us to achieve survival rates that are comparable to those of amputation with a better functional outcome. Recent advances in microsurgical techniques and the associated technologies and a better understanding of microvascular anatomy has allowed us to customize flaps to the specific needs of the patients and to achieve a lower donor site morbidity. Increased communication between the specialties of the multidisciplinary treatment team has also improved outcomes. The reconstructive component has become an integral part of the multidisciplinary care for patients with lower extremity tumors. It not only allows them to rapidly resume adjuvant therapies but also enables them to more easily resume their activities of daily living.

Outcome Comparison between Free Muscle and Free Fasciocutaneous Flaps for Reconstruction of Distal Third and Ankle Traumatic Open Tibial Fractures

BACKGROUND

The advantages of free muscle flaps for reconstruction of lower extremity defects have been largely reported to be superior to those of fasciocutaneous flaps.

METHODS

One hundred seventy-four patients received 177 microsurgical free tissue transfers for distal third and ankle open tibial fractures. Patients were divided into two groups. In group I, 96 patients received 98 free muscle flaps (55.4 percent). In group II, 78 patients were treated with 79 free fasciocutaneous flaps (44.6 percent).

RESULTS

Complete flap survival was 92.9 percent and 91.1 percent in groups I and II, respectively. Postoperative infection was 11.2 percent in group I and 12.7 percent in group II. Chronic osteomyelitis developed in 9.3 percent and 12.7 percent in groups I and II, respectively. The rate of primary bone union was 84.5 percent in group I and 81 percent in group II and the rate of overall bone union was 96.9 percent in group I and 98.7 percent in group II. Finally, 92 patients in group I and 77 patients in group II could walk without crutches at 2-year follow-up. There were no statistically significant differences between the two flaps.

CONCLUSIONS

The authors achieved equal functional outcomes in both soft-tissue transfers because of (1) preoperative adequate débridement of wounds and (2) selection of proper free flaps in appropriate defects. Defects with serious tridimensionality needed free muscle flaps because they conform better to such complex defects. However, free fasciocutaneous flaps are reliable and as effective for covering the less three-dimensional distal third and ankle traumatic open tibial fractures as free muscle flaps and can better tolerate the subsequent secondary surgical procedures.