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

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm², and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.     

Medial plantar artery island flap for heel reconstruction

Coverage of soft tissue defects of the heel has been a challenge to reconstructive surgeons in the past. The medial plantar artery flap has facilitated heel coverage since its development in the 1980s. This was a prospective study in 2 centers assessing the complications and durability of this flap primarily in patients with sensory impairment. All patients but 1 had chronic plantar ulceration due to sensory loss, and 5 patients also had developed squamous cell carcinoma. Fifty-one flaps were carried out in 48 patients. One flap underwent necrosis, and delayed healing was seen in 4 cases. Total flap survival was 98%. Minor revision of the flap or its pedicle was required in 3 cases. With a mean follow-up of 14 months, there were recurrences of ulceration in 7 feet (14%). The relevant literature is reviewed. The medial plantar artery flap is a reliable flap for heel coverage in both our centers and others. It is durable and long lasting even in insensate.     

Pedicled chimeric gastrocnemius—medial sural artery adipofascial flap for reconstruction of anterolateral defects of the knee

A medial gastrocnemius muscle flap is useful for soft tissue reconstruction of the knee and proximal tibia but insufficient to cover defects involving the lateral aspect of the knee. The purpose of this report is to present the results of the use of a pedicled chimeric gastrocnemius—medial sural artery adipofascial flap for reconstruction of defects of the knee and lateral aspect of the knee. Six patients underwent soft tissue reconstruction of the knee by means of the described procedure. Patients included one female and five males. The mean age of the patients was 48 years. The cause of soft tissue defects was open fractures in three cases and infection in three cases. The mean size of soft tissue defects was 9.3 × 7 cm (range: 6 × 3 to 18 × 14 cm), and the mean size of adipofascial components was 6.8 × 3.8 cm (range: 6 × 3 to 10 × 6 cm). Medial knee defects were covered by the medial gastrocnemius muscle component and lateral knee defects were covered by the medial sural artery adipofascial component. All flaps survived in the six cases. Soft tissue reconstruction and infection control were successful without any additional surgical procedures. A pedicled chimeric gastrocnemius–medial sural artery adipofascial flap may be considered effective for soft tissue reconstruction of the knee as it reduces scars at the donor site and reconstructs the lateral knee defects not covered by the medial gastrocnemius muscle flap. © 2015 Wiley Periodicals, Inc. Microsurgery 37:206–211, 2017.     

足底内侧皮瓣的应用解剖及修复足跟组织缺损的临床应用

目的 报道带神经血管蒂足底内侧皮瓣的解剖特点及修复足跟缺损的应用效果.方法 10具成年人体标本(20侧下肢),解剖观测其足底内侧动脉起源、分支、走行和分布以及该皮瓣的支配神经情况.临床应用带神经血管蒂足底内侧皮瓣修复同侧及对侧足跟皮肤缺损8例,供区植皮.结果 足底内侧动脉深支平均长度(8.9±0.2)cm,3～5条皮支.足底内侧神经的分支5～8支.它包含分布足底皮肤直接皮支3～5支和分布足趾皮肤的趾底固有神经2～4支.8例共用8个皮瓣.皮瓣大小为4 cm×3 cm～5 cm×6 cm,6例带蒂转移修复,2例游离移植.8个皮瓣完全成活,所有病例获随访1个月～1年,皮瓣功能、外形良好.结论 足底内侧皮瓣解剖变异少,血供可靠,不牺牲主要血管,转移后能恢复较好的感觉,是修复足跟皮肤缺损的理想皮瓣     

Various applications of the medial plantar flap to cover the defects of the plantar foot,posterior heel,and ankle

The medial plantar fasciocutaneous flap provides structurally similar tissue to plantar foot, posterior heel, and ankle defects with its thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue, and plantar fascia. During the past 4 years, 24 patients (20 men, 4 women) with skin and soft-tissue defects over the plantar foot, posterior heel, or ankle were treated. They ranged in age from 20 to 42 years (mean, 24 y). The medial plantar flap was transposed to the defects in four different ways: proximally pedicled sensorial island flaps (N = 18), reverse-flow island flaps (N = 2), free flaps (N = 2), and cross-foot flaps (N = 2). Flap size varied from a width of 2 to 5.5 cm and a length of 5 to 7.5 cm. The follow-up period ranged from 2 to 18 months (mean, 9 mo). Partial flap loss was observed in one free flap and one reverse-flow island flap. Partial skin graft lost in the donor site required regrafting in one patient. Durable, sensate coverage of the defects was achieved in all patients.     

Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet. © 2014 Wiley Periodicals, Inc. Microsurgery 34:629–632, 2014.     

显微外科修复足跟部软组织缺损的临床观察

目的：探讨足跟部皮肤软组织缺损修复方法及其临床效果.方法：自1998年6月至2009年6月,收治42例足跟部皮肤及软组织缺损患者,其中男23例,女19例;年龄18～65岁,平均37岁.皮肤缺损范围3 cm×2 cm～18 cm×16 cm.伤后至手术时间8h～10年.足底内侧皮辫13例,腓肠神经小隐静脉营养血管蒂皮瓣18例,隐神经大隐静脉营养血管蒂皮瓣11例.观察术后皮瓣外观、血运、质地、弹性及皮肤两点辨别觉评价术后疗效.结果：术后皮瓣全部成活,其中2例皮瓣远端部分表皮坏死,经换药切痂后用中厚皮片植皮愈合.3例术前有严重深部感染术后残留窦道,经5～12个月换药后窦道痊愈.所有患者获得随访,时间8个月～6年.术后皮瓣外形满意,患肢正常步态行走,皮瓣耐磨,无溃疡发生,有痛觉,两点辨别觉为4～12 mm.结论：足跟部软组织缺损小于8 cm×6 cm选用足底内侧皮瓣修复,手术简单,疗效显著.足跟部缺损面积大于8 cm×6 cm选用皮神经营养血管皮瓣,该类皮瓣具有血供可靠、不牺牲主要动脉、存活率高等优点.     

Anatomic study of a new axial skin flap based on the cutaneous branch of the medial plantar artery

A new axial skin flap based on the middle cutaneous branch of the medial plantar artery was evaluated in 33 fresh cadaver legs. The vascular pedicle of the skin flap is based on the middle cutaneous artery, its venae comitantes, and segments of the great saphenous vein, if necessary. The middle cutaneous artery is the largest cutaneous branch, arising from the medial plantar artery 2.5 cm distal to its origin. The diameter of its origin is 1.2 mm, and its pedicle is 2 cm long. The midline of the flap runs from the first web space to the heel tip. The upper and lower borders of the flap are 3 to 4 cm on either side of this line. The upper border is medial to the extensor hallucis tendon, and the lower border is medial to the abductor hallucis. Distally, the border begins 2 cm proximal to the metatarsalphalangeal joint; proximally, the border is at the middle of the medial malleolus. The flap diameter can be up to 8 × 12 cm. The middle cutaneous branch of the medial plantar artery was found in all cadaver specimens, except for one with a common trunk. The new flap design leaves the major blood supply to the foot and the plantar aponeurosis intact. It is easy to harvest and may be used either as an island flap or free flap. © 1995 Wiley-Liss, Inc.     

Plantar heel reconstruction with a sensate plantar medial artery musculocutaneous pedicled island flap after wide excision of melanoma

Reconstruction of soft tissue defects in the plantar heel pad presents a surgical challenge that requires replacing the lost tissue with another tissue having similarly unique physical characteristics. This case report describes a reconstruction of the plantar heel pad after wide excision of a heel melanoma, using a sensate plantar medial artery musculocutaneous pedicled island flap.     

腓动脉穿支供养的远端蒂腓肠神经营养血管皮瓣的临床应用

目的：总结腓动脉穿支供养的远端蒂腓肠神经营养血管皮瓣修复足踝部软组织缺损的临床效果。方法：自2004年2月至2007年12月对27例各种原因造成的小腿远端及足踝部软组织缺损采用腓动脉穿支供养的远端蒂腓肠神经营养血管皮瓣进行修复。其中男21例,女6例;年龄7个月-64岁,平均31．5岁。缺损部位：外踝部7例,内踝部5例,足背部8例,足跟及足底7例。皮肤软组织缺损面积2．5cm×3．5cm-10cm×24cm,切取皮瓣面积3cm×4cm～12cm×26．5cm。结果：7例术后3—7d皮瓣轻度肿胀,7d后肿胀逐渐消退,所有皮瓣全部成活。术后随访3-12个月,平均5个月,皮瓣不臃肿,外形良好,供区功能无障碍。结论：应用腓动脉穿支供养的远端蒂腓肠神经营养血管皮瓣,具有血供丰富,血管解剖恒定,皮瓣近端可达胭窝区,逆转距离长,修复范围大,操作简单,皮瓣较薄的优点,是修复小腿远段及足踝部软组织缺损的较好方法。     

足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部软组织缺损

目的探讨足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部皮肤软组织缺损的临床效果。方法回顾性分析2015年10月至2020年12月榆林市第二医院烧伤整形手足外科收治的足跟部皮肤软组织缺损患者的临床资料。患者经急诊清创或扩创后,应用足底内侧岛状皮瓣修复足跟部创面,腹股沟游离皮瓣修复足底内侧供区创面,腹股沟供区直接缝合。术后观察皮瓣血运及存活、皮瓣供区愈合情况,并对足跟外形与功能恢复情况进行随访。结果共纳入8例患者,男7例,女1例,年龄20~71岁,平均32.2岁。其中5例为足跟外伤,1例足跟鳞状细胞癌,1例足跟冻伤,1例足跟溃疡。足跟部创面面积4 cm×3 cm~7 cm×6 cm。手术过程顺利,足跟岛状皮瓣及腹股沟皮瓣切取范围较足跟创面扩大0.5~1.0 cm。8例患者术后皮瓣血运良好,创面均一期愈合。术后随访3~12个月,所有患者足跟弹性佳,外形无臃肿,耐磨、耐压,感觉及行走功能满意;足底内侧供区无凹陷,无瘢痕增生及挛缩,无局部皮肤溃疡;腹股沟供区仅见线性瘢痕。结论足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部缺损,足部外观及功能恢复良好,效果满意。     

Soft-tissue reconstruction for recalcitrant diabetic foot wounds

Thirty-three consecutive patients with plantar soft-tissue defects were managed by a single surgeon (EDN) with reconstruction by a medial plantar artery (MPA)-based flap. Foot defects resulted from a combination of abnormal weightbearing distribution and neuropathy secondary to diabetes mellitus in all patients. A retrospective study of diabetic patients from 1984 to 1997 with foot defects reconstructed with a MPA-based flap were reviewed. Thirty-three patients (age 55 +/- 9) with an average tissue deficit of 13 +/- 9 cm2 had MPA reconstruction of the heel (n = 8), midfoot (n = 23), and forefoot (n = 2). The mean follow-up was 19 months (range, 3 months-5 years). There were four minor complications, including marginal flap necrosis or localized infection, although all healed uneventfully. There were six major complications resulting in loss of the flap and proximal amputation. Out of seven patients, there were 12 rerotations of the previously rotated flap. Various techniques for reconstruction of plantar foot defects have been described in the literature. Utilizing glabrous skin for reconstruction of these defects is appealing for its unique shear and pressure-resisting properties. Surgical management of diabetic foot defects with the medial plantar artery flap is an effective means of soft tissue reconstruction.     

阔筋膜瓣移植修复手背软组织缺损

目的:采用吻合血管的阔筋膜瓣移植修复手背软组织缺损,观察其临床应用效果。方法:修复12例(男8例,女4例)手背软组织缺损;右手7例,左手5例;年龄16~46岁(平均30岁)。缺损范围4 cm×6 cm~8 cm×15 cm,切取阔筋膜瓣范围5.0 cm×7.5 cm~8 cm×16 cm。行Ⅰ期中厚网状游离植皮,供区直接缝合,阔筋膜瓣的血管蒂与受区的血管行端端吻合。结果:1例术后发生远端尖部小片植皮坏死,经更换敷料逐渐自行愈合。11例术后经过顺利,全部成活,取得了满意的临床效果。结论:该筋膜瓣以旋股外侧动脉降支为血供,血运丰富,血管解剖恒定,血管蒂长以及切取容易,而且较薄,适宜修复手背软组织缺损。     

Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases

Background

Soft tissue defects over the mid- and distal third tibia, heel, dorsum and plantar aspect of the foot and over the medial, lateral and posterior aspect of the ankle are a common scenario in clinical orthopaedic practice. In this article, we describe the utility of the reverse sural fasciocutaneous flap with a cutaneous pedicle in 109 clinical cases with distal lower limb soft tissue defects.

Materials and methods

A total of 109 patients were operated on for moderate (5–15 cm) and large (more than 15 cm) soft tissue defects at various sites along the lower limb including foot, heel and sole with the reverse sural fasciocutaneous flap. The defects were secondary to trauma (61 cases), diabetic ulcers (12 cases), post-traumatic scar contracture (8 cases), venous ulcer (4 cases), wound dehiscence (10 cases), leprotic non-healing ulcer (1 case), post-infective wound (1 case), radiation-induced ulcer following radiotherapy for synovial cell sarcoma (1 case), post-fibromatosis excision (1 case), post-dermatofibrosarcoma excision (1 case), post-heel melanoma excision (1 case) and actinomycosis foot (1 case). Patients were assessed for flap uptake and healing of defects.

Results

Among the 102 cases analysed, 81 were male and 21 female with an average age of 32.7 years. The average size of the flaps was 148.10 ± 59.54 cm². The flap healed uneventfully in 89.21 % of patients. Edge necrosis occurred in 9 cases. Donor site regrafting was required in 7 patients.

Conclusion

The reverse sural fasciocutaneous flap with a cutaneous pedicle is a quick, versatile, easy and safe soft tissue defect coverage technique to cover most of the soft tissue defects of the lower limb in common orthopaedic practice and does not require any microvascular repair, though it may be cosmetically unappealing in a few cases.

Level of evidence

IV (Case series)     

Combined medialis pedis and medial plantar fasciocutaneous flaps for coverage of soft tissue defects of multiple adjacent fingers

Soft tissue defects of adjacent multiple fingers covered by a single large flap require secondary separation of the flap into each finger. Such covering obstructs independent motion of injured fingers until the single large flap is separated. This report describes the technique of combined medialis pedis and medial plantar fasciocutaneous flaps for reconstructing soft tissue defects of multiple adjacent fingers. Three male patients (age range, 18–33 years) underwent soft tissue reconstructions of multiple adjacent fingers with combined flaps. Injuries involved three adjacent palmar fingers, two adjacent palmar fingers, and two adjacent dorsal fingers. Average sizes of the combined flaps were 4.2 × 4.0 cm for the medialis pedis flap and 3.0 × 1.8 cm for the medial plantar fasciocutaneous flap. All flaps survived without vascular complications, and donor sites healed uneventfully. All patients experienced excellent recovery of range of motion for the reconstructed fingers. In conclusion, combined flaps may offer an alternative for coverage of soft tissue defects that involve multiple adjacent fingers. © 2014 Wiley Periodicals, Inc. Microsurgery 34:454–458, 2014.     

Anatomical Study of the Medialis Pedis Flap and its clinical applications in Asian Singaporean Patients

PurposeThe purpose of this study was to revisit the medial plantar artery's anatomy and study its distribution for raising the medialis pedis flap. Several investigators have reported their clinical experience with the use of this flap for reconstruction of soft tissue defects of the hand. However, many have reported difficulty raising the flap due to variations in its arterial anatomy and the confusion that exists with respect to the nomenclature in our literature.MethodsThis study was divided into 2 parts: an anatomic study and clinical application. In the anatomic study, 12 cadaveric feet specimens from 6 patients were injected with latex and barium-gelatin injections and the medial branch of the deep division of the medial plantar artery distribution was studied. We then described the use of a medialis pedis flap in four clinical cases to cover defects of the digits.ResultsThe anatomic study revealed that the average pedicle length of the deep division of the medial plantar artery was 1.94cm. In the four illustrative clinical cases where the flap was used, the average flap size was 4.5 × 3.75cm. Donor sites were either closed primarily or with skin grafts. The vessels used for this flap were the medial branch of the deep division of the medial plantar artery and venae commitantes, or subcutaneous veins which provided the superficial drainage. All flaps were successful without any significant complications. The study is novel in that it describes the anatomic variability of length of the medial branch of the deep division of the medial plantar artery that exits in nature.ConclusionsThis paper describes the medial branch of the deep division of the medial plantar artery and the anatomic variations that exist in the raising of the medialis pedis flap. We have shown how a medialis pedis flap is an ideal option for reconstructing soft tissue defects of the hand because of its texture, bulkiness and pliability in the context of like for like reconstruction.     

Reconstruction of distal forefoot burn defect with retrograde medial plantar flap

Burn reconstruction of forefoot remains as a difficult challenge, because the local flap alternatives are limited. We evaluated the efficiency of distally based medial plantar fasciocutaneous island flap in the coverage of forefoot defects resulting from release of toe contracture and burn debridement. Four patients with toe contractures and two patients with third degree burn in forefoot were treated between June 2004 and February 2006. The mean follow-up period was 10.4 months. The flaps were elevated as with a fasciocutaneous base on the distal medial plantar artery. The dimensions of the flaps ranged from 4cmx3cm to 5cmx4cm. The skin over the pedicle was included as a part of flap in three cases. Concomitant vein of the pedicle was anastomosed with the first plantar digital vein in four cases. In the early postoperative period, one flap used to cover third degree burn due to high-voltage electric injury was lost completely. We concluded that this flap was an appropriate alternative reconstructive option for the forefoot defect. Including skin and subcutaneous tissue over the pedicle to flap protects the pedicle against kinking and compression. Venous supercharging of the flap improves venous drainage.     

足底内侧皮瓣在足跟部恶性黑色素瘤的应用

目的探讨足跟部恶性黑色素瘤的手术切除和修复重建的方法。方法5例老年足跟部恶性黑色素瘤患者，手术行局部扩大切除，切缘距病损2cm，深度达跟骨骨膜，足跟部软组织缺损Ф5～9cm，根据缺损大小，用带足底内侧血管神经束的皮瓣移位修复，皮瓣面积8cm×6cm-10cm×8cm。结果5例皮瓣全部成活。随访2年6个月～5年，患者均健在，肿瘤未见局部复发，皮瓣感觉功能良好，患足功能与对侧相比无明显差异。结论足跟部恶性黑色素瘤应行局部扩大切除术，切除范围应距肿瘤边缘不小于2cm为宜，在切缘阴性的基础上进行修复重建，应用足底内侧皮瓣移位修复，临床疗效满意。     

跖内侧皮瓣联合肋骨移植修复多手指末节骨与软组织缺损

目的 总结跖内侧皮瓣联合肋骨移植修复多手指末节掌侧骨与软组织缺损的临床应用结果. 方法 2004年2月至2006年7月,应用吻合血管的跖内侧皮瓣联合肋骨移植修复5例(男4例,女1例)手指末节掌侧骨与软组织缺损,年龄19～43岁(平均31岁).其中,双指损伤3例,3指损伤2例.皮瓣血管蒂与受区的血管行端端吻合,供区创面行中厚网状游离植皮修复. 结果 1例术后供区发生表浅感染,经更换敷料逐渐自行愈合.皮瓣全部成活,随访10～28个月(平均19个月),供区与受区外形较好,手指感觉恢复.两点分辨觉5～14 mm(平均8 mm).结论 跖内侧皮瓣以跖内侧动脉为血供,血运丰富、血管解剖恒定、血管蒂长以及切取容易,联合肋骨移植很适宜修复多手指末节掌侧骨与软组织缺损.     

拇指背动脉岛状皮瓣的临床应用及血供障碍处理

目的：介绍拇指背动脉岛状皮瓣修复拇指软组织缺损的临床经验,并探讨血供障碍的原因及处理方法。方法：自2005年7月至2008年12月,外科治疗21例21指拇指软组织缺损,男16例,女5例;年龄16～55岁,平均39岁。应用拇指背桡侧动脉岛状皮瓣修复拇指远节桡侧软组织缺损（4例）,拇指背尺侧动脉岛状皮瓣修复拇指尺侧、指腹及甲床缺损（17例）,皮瓣旋转点指间关节近侧0.5cm,皮瓣面积2cm×1.5cm～4cm×2.5cm。结果：术中术后6例发生血供障碍,经对应处理皮瓣无坏死。随访3个月～2年,皮瓣质地优良,色素沉着轻度,外形满意,拇指掌指关节及指间关节活动范围正常。修复指腹者感觉不同程度恢复,两点辨别觉：4～10mm。结论：拇指背动脉岛状皮瓣修复拇指软组织缺损方法简单,效果满意。蒂部长度、宽窄及受压均能影响皮瓣的血供,蒂部处理是治疗成功的关键。