Utilizing a crossover reverse sural artery flap for soft tissue reconstruction of the plantar forefoot after a severe degloving injury

Extensive soft tissue defects involving the weight-bearing areas of the plantar aspect of the foot often require coverage with flaps. The options often include free flaps, free muscle flaps with split-thickness skin grafting, or local flaps. When presented with high-energy-induced soft tissue injuries of the foot, choices become narrow, secondary to the associated zone of injury. Free flaps require a viable recipient vessel suitable for microvascular anastomosis. Split-thickness skin grafts applied to the plantar aspect of the foot are prone to persistent breakdown. Local flaps if available are useful for coverage of plantar soft tissue defects. However, when local flaps of the affected limb are compromised or extension is not sufficient for coverage, crossover leg and foot flaps become invaluable. The reported cases of crossover sural artery flaps are sparse. To the best of the authors' knowledge, the few reported cases of crossover leg and sural artery flaps were described to provide soft tissue coverage over the heel and leg. The authors report a case of a crossover reverse sural artery flap for soft tissue coverage to the plantar aspect of the forefoot after a high-energy-induced degloving injury.     

Salvage of a partially avulsed sole following complex foot trauma by anchor fixation

BackgroundThe prognosis of complex trauma to the foot is often determined by the soft tissue condition. Degloving injuries are rare but especially challenging soft tissue lesions. Larger studies are lacking, but it is a general agreement to preserve in particular the unique plantar skin, if feasible.Material & MethodsIn the present case a 28-year old woman suffered a severe trauma of the foot, being rolled over by a forklift. The shearing forces led to unstable fractures of all toes and non-displaced fractures of the tarsal bones with an open décollement of the dorsum and closed degloving of the medial sole.Results and ConclusionsThe individual concept of debridement of all necrotic tissue including amputation of the first to third toe, wound conditioning through negative pressure wound therapy, split-skin grafting of the dorsum and reattachment of the plantar skin with suture anchors and additional reefing resulted in a plantigrade and pain free foot with a stable soft tissue coverage. The unique tissue of the sole can sometimes be reattached and preserved with simple surgical methods.     

Plantar pressure and sole thickness of the forefoot

BACKGROUND: Based on earlier observations that the forefoot bears the highest plantar pressure at its center, the existence of a functional distal transverse arch in normal feet was denied, and plantar pressure was defined as merely the outcome of loading, surface area, and soft tissue. Although plantar pressure drives the changes in the foot, neither the position nor the behavior of the metatarsals during loading can be derived from plantar pressure alone. In light of this, our goal was to describe the changes in thickness in the sole and the corresponding plantar pressure during loading of the foot. METHODS: We used CT to image the foot of 10 subjects in four postures that were chosen to imitate four phases in the walking cycle. Before imaging we also recorded the plantar pressure with a pressure measuring insole on which the subjects were standing. From the data, the minimal thickness of the sole and the corresponding plantar pressure were derived. RESULTS: With the exception of the sesamoids, the thickness of the sole under the bones of the forefoot increased from lateral to medial. This persisted in all postures. Our pressure readings matched previously reported distributions. CONCLUSIONS: Depending on the point of view concerning the sesamoids, the bony prominences were placed in a geometrical arch; but they did not form a functional arch. The soft tissue underneath the heads kept the metatarsals in place; the soft-tissue thickness reflected the principle of adequate cushioning.     

Application of plantar pressure assessment in footwear and insert design

This clinical perspective describes the application of plantar pressure assessment in footwear and insert design. First, the rationale and evidence for using pressure assessment to assist in the design of footwear for patients with diabetes is described. I discuss 2 important measures obtained from pressure assessment: peak pressure, because it represents the magnitude of potential mechanical stresses that can contribute to skin breakdown, and contact area, because this identifies the treatment areas. Using measures obtained from pressure assessment, guidelines are presented to maximize contact area of the insert to the foot and reduce highest peak pressures on the skin, with the goal of preventing skin breakdown. Second, a rationale and guidelines are presented for the application of plantar pressure assessment in the evaluation and design of footwear for people without impairments (i.e., the general public). Finally, future applications of pressure assessment to improve the design and fit of shoes are discussed. Benefits and limitations of using pressure assessment to assist in footwear design are addressed throughout.     

足内侧远端筋膜蒂皮瓣修复？？及前足背皮肤缺损

目的：探讨足内侧远端筋膜蒂岛状皮瓣修复及前足背皮肤缺损的临床疗效。方法2007年8月-2012年12月,采用足内侧远端筋膜蒂岛状皮瓣修复及前足背皮肤缺损29例,皮肤缺损面积为2.0 cm×3.0 cm～5.0 cm×8.0 cm,供区直接拉拢缝合或行全厚皮片移植修复。结果本组29例皮瓣全部顺利成活,术后随访6～24个月,皮瓣质地柔软,外形及色泽良好,不臃肿,耐磨性好,恢复正常行走功能。供区植皮全部成活,愈合较满意。结论足内侧远端筋膜蒂岛状皮瓣血供可靠、操作简单、质地柔软、耐磨性好,是修复及前足背皮肤缺损的一种较好的手术方法。     

Lipofilling for functional reconstruction of the sole of the foot

BackgroundNew advances in regenerative surgery may increase the potential for rehabilitation in the injured foot.ObjectivesA clinical prospective observational study was carried out to assess the effectiveness of lipofilling to improve the functional recovery of the injured foot.MethodsFour patients with anatomical–functional impairment following repair of post-traumatic soft tissue loss of the foot were involved in the study. All of the patients complained of pain in the repaired plantar weight bearing area, skin instability, recurrent ulcerations and were walking on crutches.A combined plastic surgery and technical orthopaedic assessment identified the plantar areas requiring anatomical changes for load redistribution. Two selective sequential lipofillings with a 12 weeks’ time interval were performed. Manufacturing of custom-made plantar insoles and/or shoes followed each surgical procedure.ResultsAfter the treatment all of the patients progressively recovered both a better plantar load distribution and a local soft tissue stability, referred the remission of chronic pain and discontinued the use of crutches.ConclusionLipofilling proved to be an effective and versatile surgical technique for both reconstructive and regenerative purposes. The interaction between the Plastic Surgery staff and the Orthopaedic Technician outlined a successful multidisciplinary approach model for the rehabilitation of the injured foot.     

Split-thickness plantar skin grafts for coverage in the hand and digits.

The instep of the foot is an excellent donor site for split-thickness skin grafts to cover soft tissue defects of the palm and digits. The technique is described and three illustrative clinical cases are presented. The unique, specialized characteristics of plantar skin are described, emphasizing similarities to palmar skin. The indications for this technique are hyperpigmentation, hair growth, ulceration, hyperkeratosis, marginal scarring, or recurrent breakdown of a preexisting graft, but we have also employed it for primary reconstructions in selected circumstances. The instep graft provides ideal color and texture match and long durability for a palmar graft, with the added advantage of an inconspicuous donor site.     

Foot reconstruction in weight bearing area

Summary Multiple reconstructive procedures have been described for replacing skin loss in weight bearing areas of the foot. The reason for this is that the reconstruction of the plantar surface easily breaks down because of the particular structure of the soft tissues of this area. Furthermore, sensation is usually incomplete. For these reasons, stable, functional reconstruction is uncommon, even when using microvascular sensate skin flaps. In order to assess the best reconstructive management, functional long-term results of 13 patients who suffered from soft tissue defects of the weight-bearing areas of their feet were analyzed using gait analysis. The most reliable results were obtained with the Musgrave Footprint^®. It stores the dynamic footprint on a computerized plate allowing to assess qualitatively and quantitatively pressure against time. This non-invasive method simultaneously analyzes pressure data from both feet. Furthermore, it allows the detection of areas about to break down. This may prevent ulcer formation by prophylactic management.     

Ausbreitung von Ulzerationen im diabetischen Fuß

The abnormally elevated plantar pressures under the bony prominences of the diabetic foot (mainly under the medial metatarsal heads and calcaneus) were associated with intensified internal stresses in the deep soft tissues padding these bones. In this study, we tested changes in mechanical properties of muscular tissue after exposure to the internal stress levels typically developing under the first and second metatarsal heads in the load bearing diabetic foot (40-80 KPa).The gracilis muscles of anesthetized rats were subjected to constant external pressures of 35 and 70 KPa for 2 h, which caused average internal compression stresses of 40 and 80 KPa, respectively, within the living gracilis. The animals were then killed and the tangent elastic moduli of the harvested gracilis were measured in uniaxial tension at strains of 2.5%, 5% and 7.5%. Tangent moduli of gracilis muscles exposed to internal compression of 40-80 KPa in vivo ( n=6) were 1.6-fold stiffer ( p<0.05) than those of controls ( n=6).These abnormally stiff mechanical properties were incorporated into a finite element (FE) model of the plantar tissue under the second ray of the foot, and were shown to increase the magnitude of deep internal stresses and project elevated stresses to larger regions. Hence, the integration of animal model data with FE simulations indicates a mechanism of plantar tissue deterioration in the diabetic foot, where muscles exposed to critical stresses respond with increased stiffness which then further intensifies the deep plantar stresses. This suggests a new positive feedback mechanism for the diffusion of ulcers and the atrophy of intrinsic plantar muscles in the diabetic foot, where the injury spreads from deep muscles to the skin surface by an evolving mechanical stress wave.     

不同类型皮瓣修复足踝部软组织缺损的临床效果

目的探讨不同类型皮瓣修复足踝部软组织缺损的临床效果。方法对30例足踝部软组织缺损患者进行皮瓣修复,其中足底内侧皮瓣修复足跟部软组织缺损7例,股前外侧皮瓣修复足背、足内侧软组织缺损12例,腓肠神经营养血管皮瓣修复足踝部软组织缺损11例。结果患者均获得随访,时间1~5年。29例皮瓣完全成活,仅1例股前外侧皮瓣发生坏死,二次手术给予植皮。13例患者因皮瓣臃肿,二期行皮瓣修整术;2例患者因术后长期从事体力劳动足跟部发生溃疡;其余患者皮瓣质地柔软,踝关节功能恢复满意。供区均未出现并发症。足底内侧皮瓣修复患者皮瓣感觉功能完全恢复,股前外侧皮瓣修复患者感觉均部分恢复,5例吻合神经腓肠神经营养血管皮瓣患者于术后3~5个月感觉功能完全恢复,剩余患者感觉功能部分恢复。结论足底内侧皮瓣、股前外侧皮瓣、腓肠神经营养血管皮瓣各有优缺点,应根据足踝部软组织缺损面积、部位的不同选择合适的皮瓣,以提高皮瓣成活率,重建肢体功能。     

Glabrous skin grafts for plantar defects

The principle of reconstructing like to like has been a long-standing and useful concept for plastic surgeons. One arena in which this concept has not been put to its full use is that of reconstructing soft tissue deficits of the sole of the foot. Most commonly, plantar defects that are to be skin grafted are reconstructed with split- or full-thickness, nonglabrous skin grafts. Nonglabrous skin grafts have significant disadvantages when used for reconstruction of plantar defects. These include painful hyperkeratotic build up at the periphery of the skin grafts, craters, contractures, and tight subgraft fibrosis. Glabrous skin grafting has been applied widely for coverage of smaller defects in the hand and has yielded superior results with improved function and sensation, more normalcy of appearance, and increase durability. The concept of reconstructing plantar defects by this method has probably been impeded by the vague and erroneous, but broadly held, belief that donor-site healing in the foot would be problematic, that is, significant potential for excessive scarring, pain, and functional deficit. The long-standing use of glabrous skin grafts for plantar defects in this unit, however, confirms the desirability, functional advantage, and minimal morbidity of this technique.     

Microvascular free muscle reconstruction of a large plantar defect

Large plantar defects present a difficult problem in reconstructive surgery. Skin grafts are not durable and most distant flaps are too bulky to allow for ambulation in conventional footwear. Free muscle transfer with skin graft may represent a modality to provide a contoured and durable reconstruction for large plantar defects when local tissue is not available. This study presents a case of sole of foot and distal heel reconstruction with a free microvascular latissimus muscle transfer. The transfer was contoured to fit the defect and then covered with a split-thickness skin graft. Three months following surgery, the patient was walking without assistive devices and using conventional footwear. Now, two and one-half years after surgery, he is employed full-time in a job that entails walking, and has never experienced a tissue breakdown.     

Histomorphological and biochemical properties of plantar soft tissue in diabetes

BackgroundDiabetes results in pathophysiological changes, leading to tissue that is unable to withstand and adapt to the same loads, resulting in breakdown. Certain locations are more susceptible to breakdown, yet differences between locations are largely not well understood. The authors performed a histological and biochemical analysis of isolated plantar adipose tissue at six relevant locations.MethodsTissue from six plantar locations (hallux, first, third and fifth metatarsal heads, lateral midfoot and calcaneus) was taken from fresh cadaveric feet of older diabetic and older non-diabetic intact donors. Histomorphological and biochemical analysis of isolated plantar tissue from both diabetic and non-diabetic feet at six relevant locations was performed.ResultsThe main differences found between diabetic and non-diabetic tissue were in the thickness of the septal walls and the elastin content. Diabetic tissue had significantly thicker septal walls and an increased elastin concentration. When comparing the calcaneus to other locations, although there were no differences found in the thickness of the septal walls of diabetic tissue, elastin content was lower in the calcaneous tissue compared to the non-calcaneus sites.ConclusionsModifications in the structural and biochemical properties could translate to changes in the mechanical properties. This information could lead to an understanding of how the structural and biochemical changes result in an increase in susceptibility of tissue to breakdown with load at the different locations of the foot.     

Der simultane distal gestielte Suralislappen

Exposed bradytrophic tissue in regions with high mechanical loading is an indication for defect coverage with (myo-, adipo-) fasciocutaneous flaps. In this case, distally based sural flaps were used for bilateral coverage of defects in weight-bearing areas of feet after fourth-degree frostbite. Residual defects can be covered with a split skin mesh graft. The definitive prosthetic supply of the foot assumes a stabilized plantar soft tissue situation. Among its advantages in comparison to free microvascular flaps, the locally based fasciocutaneous flap can be harvested with less donor site morbidity after elevation and does not require secondary debulking. It has been shown that the reduced stability at the border zone between flap and mesh graft has an adverse effect.     

Comparison of Plantar Pressure Distribution between Different Speed and Incline During Treadmill Jogging

The aim of this study was to examine the effect of changes in speed and incline slope on plantar pressure distribution of the foot during treadmill jogging. Plantar pressure parameters were measured with the Pedar-X system in twenty healthy girls (mean age of 20.7 years, mean height of 1.60m, and a mean weight of 53.35kg). Because variations in walking speed or slope can significantly change the magnitude of plantar pressure, comparisons of plantar pressure distribution between the two independent protocols during treadmill jogging were considered in this study. First, the subjects ran at the same speed of 2 m·s^-1 with different incline slopes of 0%, 5%, 10%, and 15%. Second, they ran on the same slope of 0% with different speeds of 1.5 m·s^-1, 2.0 m·s^-1, and 2.5 m·s^-1. The peak pressure of the eight plantar surface areas, apart from the medial forefoot and the hallux, significantly increased (p < 0.05) with an increase of 33% of peak pressure from 1.5 m·s^-1 to 2.5 m·s^-1 (speed) at heel region. In contrast, the peak pressures at the heel, medial fore-foot, toe and hallux decreased significantly (p < 0. 05) with increasing incline slope. At the heel, peak pressure reduced by 27% from 0% to 15% incline, however, pressure at the lateral midfoot region increased as following. Different speeds and incline slopes during jogging were associated with changes in plantar pressures. By systematic investigation of foot kinematics and plantar pressure during jogging with varying incline slope and speed, the results of this study provided further insight into foot biomechanics during jogging.

Key points

• The study aimed to compare the plantar pressure distribution of the foot between different incline and speed during treadmill jogging by using plantar insole measurement system.
• With the increase of speed, apart from the hallux and medical forefoot, the peak pressure of all regions was raised significantly.
• As the slope increased, there was reduced peak pressure of the heel, medial forefoot, and hallux and toes.

Key words: Jogging, plantar pressure, incline, speed     

The Effect of Landing Surface on the Plantar Kinetics of Chinese Paratroopers Using Half-Squat Landing

The objective of the study was to determine the effect of landing surface on plantar kinetics during a half-squat landing. Twenty male elite paratroopers with formal parachute landing training and over 2 years of parachute jumping experience were recruited. The subjects wore parachuting boots in which pressure sensing insoles were placed. Each subject was instructed to jump off a platform with a height of 60 cm, and land on either a hard or soft surface in a half-squat posture. Outcome measures were maximal plantar pressure, time to maximal plantar pressure (T-MPP), and pressure-time integral (PTI) upon landing on 10 plantar regions. Compared to a soft surface, hard surface produced higher maximal plantar pressure in the 1^st to 4^th metatarsal and mid-foot regions, but lower maximal plantar pressure in the 5^th metatarsal region. Shorter T- MPP was found during hard surface landing in the 1^st and 2^nd metatarsal and medial rear foot. Landing on a hard surface landing resulted in a lower PTI than a soft surface in the 1^stphalangeal region. For Chinese paratroopers, specific foot prosthesis should be designed to protect the1^st to 4^thmetatarsal region for hard surface landing, and the 1^stphalangeal and 5^thmetatarsal region for soft surface landing.

Key Points

• Understanding plantar kinetics during the half-squat landing used by Chinese paratroopers can assist in the design of protective footwear.
• Compared to landing on a soft surface, a hard surface produced higher maximal plantar pressure in the 1^st to 4^th metatarsal and mid-foot regions, but lower maximal plantar pressure in the 5^th metatarsal region.
• A shorter time to maximal plantar pressure was found during a hard surface landing in the 1^st and 2^nd metatarsals and medial rear foot.
• Landing on a hard surface resulted in a lower pressure-time integral than landing on a soft surface in the 1^st phalangeal region.
• For Chinese paratroopers, specific foot prosthesis should be designed to protect the 1^st to 4^th metatarsal region for a hard surface landing, and the 1^st phalangeal and 5^th metatarsal region for a soft surface landing.

Key words: Half-squat landing, plantar kinetics, plantar pressure, surface reaction force, pressure time integral     

Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema

Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.     

Comparison of plantar pressure distribution patterns between foot orthoses provided by the CAD-CAM and foam impression methods

Foot orthotic treatment is one of the major conservative methods used to handle foot problems. Total plantar contact foot orthoses are used to reduce and redistribute peak pressures. For the fabrication of a total plantar contact foot orthosis, the computer-aided design and computer-aided manufacturing (CAD-CAM) method has been applied. In this study, the plantar foot-orthosis interface pressure data during walking were collected by the Novel Pedar-mobile in-shoe plantar pressure measuring system. The data were collected under three conditions: (i) Flat insole, (ii) foot orthosis provided by the CAD-CAM method, and (iii) foot orthosis provided by the foam impression method. The Swiss Comfort CAD-CAM foot orthotics system was used in this study. For conditions (ii) and (iii), foot shapes were collected in partial weight bearing and subtalar neutral conditions. Thirty normal subjects were recruited for this study. The plantar foot surface was divided into eight plantar foot regions and then was investigated. These regions included the heel, the medial and lateral arches, the medial, mid and lateral forefoot, the hallux, and the lateral toes. The results showed that the orthoses provided by both the CAD-CAM and foam impression methods could decrease the peak pressure and the maximum force in the heel region, and increase the peak pressure and the maximum force in the medial arch region. Both orthoses redistributed the peak pressure and the maximum force from the heel to the medial arch region. The peak pressure in the mid forefoot region was different between the orthoses provided by the CAD-CAM and foam impression methods.     

跖内侧皮瓣切取方法的改进及应用

目的研究跖内侧动脉向足内侧区发出皮支的分布情况,改进皮瓣切取方法。方法通过８例成人新鲜足标本的显微解剖,灌注美蓝,测定跖内侧动脉所供应的皮区范围。结果跖内侧动脉向足内侧区恒定发出三个皮支,以第２支较粗并与第１、３支相吻合。临床以该支为蒂设计皮瓣局部转移修复足部创面７例,游离移植修复手指创面６例,范围为３ｃｍ×３ｃｍ～１１ｃｍ×７ｃｍ,术后皮瓣全部成活,效果满意。结论该皮瓣质地优良,面积适中,血供可靠,是修复足部与手指中、小面积皮肤缺损的最佳选择之一。     

正常足与外翻足的足底压力研究

目的　对正常足与外翻足的足底压力进行测量。方法　运用自行研制的足底生物力学测试系统对30 名健康人60 足,45 例外翻患者89 足进行了行走时足底压力的测试。结果　重度外翻组31 足和正常组相比,第一跖骨头下压力明显减低( P< 0.001),第二跖骨头下压力明显增加(P< 0 .05),第三、五跖骨头下压力有增高的趋势。结论　正常人前足第一跖骨头下压力最高,并向外侧递减。重度外翻足前足第一跖骨头下压力明显减低,第二跖骨头下压力明显增高