Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Principles of Defect Reconstruction After Wide Resection of Primary Malignant Bone Tumors of the Calcaneus: A Contemporary Review

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Comparison of instep and non-instep flap in the reconstruction of the weight-bearing portion of the forefoot and heel

BACKGROUND

Instep flaps are commonly used for the reconstruction of weight-bearing areas of the foot. However, in cases of large defects or damage to the instep area, non-instep flaps such as reverse sural flaps (RSF) or free anterolateral thigh flaps (ALTF) can be employed. Previous studies have primarily focused on heel reconstruction when comparing different flaps, without considering the forefoot. This study aims to verify the clinical outcomes of these flaps and determine the appropriate donor site for weight-bearing areas of the foot including forefoot reconstruction.

METHODS

In a retrospective study, 39 patients who had undergone flap reconstruction of weight-bearing area defects in the foot with a follow-up period of ≥1 year were included. The patients were categorized into two groups: Group A (n = 19) using instep flaps, and Group B (n = 20) using non-instep flap including RSFs and ALTFs. Surgical outcomes were assessed based on the success of the flap, the presence of partial necrosis, the number of additional surgeries, and complications related to the donor site. Clinical evaluation included visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score, and the occurrence of ulcers.

RESULTS

All flaps were successful, while partial necrosis occurred in one case in Group B. There were three reclosures after flap border debridement in both groups and one donor site debridement in Group A. The VAS scores during weight-bearing were 2.0 ± 1.1 and 2.2 ± 1.5 for Groups A and B, respectively (p = .716). The AOFAS scores were 52.8 ± 6.8 and 50.2 ± 12.7 for Groups A and B, respectively (p = .435). The occurrence of ulcers was 0.4 ± 0.9 times for Group A and 0.3 ± 0.7 times for Group B, with no significant difference between the two groups (p = .453).

CONCLUSION

There was no difference in clinical outcomes between the types of flaps after reconstruction of the forefoot and hindfoot. Therefore, it is recommended to choose the appropriate flap based on factors such as the size of the defect, its location, and vascular status rather than the type of flap.

The Role of Medial Plantar Artery Flap in Heel Pad Reconstruction: A Report of Two Cases

The heel and sole possess unique anatomical characteristics that serve a weight-bearing and shock-absorbing function. The heel is particularly vital, as any defects in this area can lead to gait instability. Reconstructing a heel defect presents challenges, as the donor flap must be durable enough to withstand high force loads while also providing protective sensation. Recently, the medial plantar artery flap has been successfully employed for the reconstruction of defective heel pads. This flap offers glabrous skin capable of weight transmission and intact protective sensation. In this report, we present two cases of heel pad loss secondary to chronic diabetic complications and trauma, respectively, which were treated with medial plantar artery flap reconstruction. Both cases were successfully treated, and they showed a good functional outcome.

Reconstruction of Foot and Ankle Defects: A Prospective Analysis of Functional and Aesthetic Outcomes

INTRODUCTION

Reconstruction of foot and ankle defects requires selecting an appropriate durable and aesthetically appealing option. From the different options, the procedure's choice depends on the defect's size, location, and donor area's availability. Patients' main goal is to have an acceptable biomechanical outcome.

MATERIALS AND METHODS

In this prospective study, we have included patients who had undergone reconstruction of the ankle and foot defects between January 2019 and June 2021. Patient demographics, location and size of the defect, different procedures, complications, sensory recovery, ankle hindfoot score, and satisfaction score were recorded.

RESULTS

50 patients with foot and ankle defects were enrolled in this study. All flaps survived except one free anterolateral thigh flap. Five locoregional flaps developed minor complications, and all skin grafts healed well. The Ankle Hindfoot Score outcome has no significant relation with the anatomical location of the defects and the reconstructive procedure. All patients reconstructed using random local flap and with free flap were satisfied with the aesthetic outcome.

CONCLUSIONS

Because of limited soft tissue, local flap availability is restricted to small defects. Satisfaction rates are high in local and free flaps and are best suited for reconstructing the weight-bearing part of the foot. Bulky flaps should be avoided over the dorsum and ankle region.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

Racial and Geographic Disparities in Reconstructive Procedures Following Melanoma Resection

INTRODUCTION

Melanoma occurs most commonly in non-Hispanic White patients; however, Black and Hispanic patients experience greater morbidity and mortality. This study assesses how race and socioeconomic factors influence rates of reconstructive procedures and hospital-based outcomes in melanoma patients.

METHODS

Data were extracted from the National Inpatient Sample database from the years 2010-2015. Patients with melanoma who underwent a reconstructive procedure were identified. Univariate and multivariate logistic regression analysis was used to identify the relationship between dependent variables and various patient/hospital components for patients undergoing reconstructive procedures.

RESULTS

Black and Hispanic patients had a greater length of stay (LOS) than non-Hispanic White patients (OR: 2.252, p = 0.0307, and OR: 2.592, p = 0.0014), and Hispanic patients were less likely to receive more complex reconstructive procedures (OR: 0.449, p = 0.0487). Patients living in rural areas were less likely to receive complex reconstructive procedures than those in both urban teaching and non-teaching hospitals (OR: 3.313, p = 0.0135, and OR: 3.505, p = 0.0074). Pedicled or rotational flaps were less likely to be performed at medium- or large-sized hospitals (OR: 0.610, p = 0.0296, and OR: 0.496, p = 0.0002).

CONCLUSION

Race and socioeconomic factors are important predictors of access to complex reconstructive procedures and hospital-based outcomes following extirpation in melanoma patients.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience

BACKGROUND

Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area.

METHODS

In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel.

RESULTS

Out of 40 patients’ medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group.

CONCLUSION

Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

The Treatment Experience of Different Types of Flaps for Repairing Soft Tissue Defects of the Heel

Objective

To summarize the clinical application effects of three different types of flaps for repairing soft tissue defects of the heel, and to discuss the importance of tissue repair and heel reconstruction.

Methods

A total of 46 cases with skin tissue defects of the heel with deep tissue exposure were treated. The reasons for the defect were trauma (n = 26), burns and electric shocks (n = 12), chronic ulcers (n = 2), postoperative infection of the calcaneus and Achilles tendon (n = 5), and tumor resection (n = 1). The scope of wound defect was 2.0×2.5 to approximately 15.0×20.0 cm. The flaps used were medial plantar island flaps (n = 9), distal pedicled sural neurovascular island flaps (n = 23), and free anterolateral thigh (perforator) flaps (n = 14). The flap cutting range was 3.0×3.5 to approximately 16.0×22.0 cm.

Results

After surgery, all 46 flaps survived. In two cases, patients experienced partial epidermal necrosis at the distal end of the flap that healed after local dressing exchange, and after this treatment, the complete skin grafts survived. Follow-up was conducted in 40 cases, with an average follow-up duration of 8.2 months (3-44 months) and the two-point discrimination of 5-14 mm. The average American Orthopaedic Foot and Ankle Society scale was 89.2 points with good flap color and texture, satisfactory appearance, and normal gait.

Conclusion

The repair method should be selected according to the"5-zone method": The plantar medial island flap is suitable for small area (<5 cm) of medial, posterior and plantar defects. The distal pedicled sural neurovascular flap is suitable for lateral, posterior, and medium-range (6-10 cm) joint area defects. The free anterolateral thigh perforator flap is suitable for large-scale (>10 cm) joint area defects.

A study of the pattern of sensory return in various flaps in different body areas

Insensate flaps are used in several reconstructions. A search of the literature showed that most studies are limited to particular flaps in specific body areas. There is a lack of uniform scientific data on the pattern of sensory recovery in various body parts for different kinds of flaps. We conducted a prospective observational study for over one year to study the pattern of sensory return in 74 flaps and studied the disparity in the return of sensation of touch, pain, warmth and cold. After that, we analyzed the relationship between sensory return in flaps and the region of the body (head and neck/upper limb/lower limb), type of flap (cutaneous/fasciocutaneous/musculocutaneous), age of patient and type of wound bed (surgically created defect/raw area such as post trauma, post debridement). Touch sensations were assessed by Semmes-Weinstein (SW) monofilament of 5.01 number, pain was assessed using a sterile 26 G needle, cold sensation was assessed using water at 4 °C and warm sensation was assessed using water at 44 °C. The sensations were evaluated at one-fourth and one-half of distance from the periphery to the center, at eight equidistant points along the circumference and at the center of the flap. Sensations were observed to return in the periphery of the flap earlier and in the center later. Touch sensation was recovered the earliest (three months onwards), followed by sensations of pain, warmth and cold (around the sixth month). Flaps performed in the head and neck showed the best recovery of sensation. Best recovery of sensation was observed in cutaneous flaps. Flaps performed on surgically created defects showed better recovery of sensation compared with flaps performed to cover raw areas; however, the differences were statistically nonsignificant. Children showed better recovery of sensations; however, this was not statistically significant. Sensory nerve coaptation is recommended in flaps folded on themselves and in fasciocutaneous flaps of the lower limb.

"Like For Like" Reconstruction of Heel Pad with Medial Plantar Artery Flap-Functional and Aesthetic Outcomes in A Series of 19 Cases

Heel pad loss can cause serious problems in weight-bearing and locomotion. The medial plantar artery (MPA) flap is a suitable “like for like” replacement. Nineteen patients whose heels were reconstructed with MPA flap between July 2015 and February 2020 were studied. All patients were assessed based on flap survival, functionality, and patient satisfaction. Loss of heel pad was due to diabetic ulcer (11), trauma (6), tumor (1), and unstable scar (1). The largest flap measured 9 × 7 cm. Sixteen flaps were done as fasciocutaneous flaps and three in combination with abductor hallucis muscle (AbdH). All the flaps survived. The average functional scores at 6, 12, 18, and 24 months were 86.86, 89.62, 89.38 and 97.33 based on AOSAS-AH score. Average patients' satisfaction was 8.7/10. To conclude, the MPA system is a versatile vascular axis providing “like for like” tissue for heel pad reconstruction which is reliable and durable.

Partial Calcaneus Reconstruction using 'Opportunistic Grafts': A Case Report

Although replantation of an amputated extremity has been successfully performed, occasionally the surgeon is forced to amputate in the case of an unsalvageable open fracture. These appendages can theoretically act as an autologous 'bone and tissue bank' for patients if they have reconstructable contralateral injuries. We present a case of an athlete who sustained a Gustilo and Anderson IIIC injury on 1 leg resulting in a below knee amputation. Her other lower leg had a traumatic amputation of the heel pad, partial amputation of the calcaneus, and complete Achilles tendon loss. Tissues from this amputated appendage were utilised to restore the anatomy of the contralateral extremity. The distal tibia and the tibialis anterior from the amputated limb were used to reconstruct the missing posterior tuberosity of the calcaneus and the Achilles tendon respectively. The soft tissue deficiency of the heel pad was restored with an anterolateral thigh free flap. At 2-year follow-up, the patient is pain free and back to playing soccer. This case highlights the opportunistic use of amputated parts to reconstruct a calcaneus and Achilles tendon. A multidisciplinary approach with plastic surgeons is required. The main advantage of this 'Spare Part Surgery' philosophy is to provide autologous graft of a similar geometry and to avoid harvesting tissues from an additional donor site.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.