Arterial reconstruction to the foot vessels: is it worth the trouble?

Between 1974 and 1988, 32 patients with severe rest pain and ischemic ulcerations of lower extremities underwent 34 arterial reconstructions to the foot vessels, using, in the majority of cases, the in-situ vein technique. There were 10 early graft failures, resulting in the loss of five extremities. The indication for surgery, presence of diabetes and type of bypass were not predictive of early thrombosis. Five-year primary and secondary patency rates were 52.8% and 62.6%, with a foot salvage rate of 74%. Although a number of these long bypass grafts fail early because of the severity of tibial disease, this procedure appears to be durable in a selected group of patients.     

Advanced techniques in foot and ankle reconstruction

Complex deformities of the foot and ankle remain a difficult problem for even the most experienced surgeon. Many techniques are available to provide correction and no single one is appropriate for all cases. Identical deformities often can be treated with different techniques with equally successful outcomes. Each deformity is unique and the surgeon should be capable of using multiple techniques to provide the most appropriate treatment for the patient and the deformity. Simple deformities often can be handled with simple techniques but more complex problems often require more complex solutions. The techniques discussed here have worked well at the authors' institution but are undergoing constant reevaluation and occasional modification. It is important that the surgeon and the patient understand that with these techniques it is usually possible to provide a functional outcome but never possible to provide a normal foot or ankle. If appropriate goals are set, correction of these challenging deformities can be satisfying to surgeon and patient.     

Fusion in posttraumatic foot and ankle reconstruction

Despite appropriate acute treatment, many foot and ankle injuries result in posttraumatic arthritis. Arthrodesis remains the mainstay of treatment of end-stage arthritis of the foot and ankle. An understanding of the biomechanics of the foot and ankle, particularly which joints are most responsible for optimal function of the foot, can help guide reconstructive efforts. A careful history and physical examination, appropriate radiographs, and, when necessary, differential selective anesthetic blocks help limit fusion to only those joints that are causing pain. Compression fixation, when possible, remains the treatment of choice. When bone defects are present, however, neutralization fixation may be necessary to prevent a secondary deformity that could result from impaction into a bone defect.     

Validation of the foot and ankle outcome score for ankle ligament reconstruction

We studied the validity and reliability of the Foot and Ankle Outcome Score (FAOS) when used to evaluate the outcome of 213 patients (mean age 40 years, 85 females) who underwent anatomical reconstruction of the lateral ankle ligaments with an average postoperative follow-up of 12 years (range, three to 24 years). The FAOS is a 42-item questionnaire assessing patient-relevant outcomes in five separate subscales (Pain, Other Symptoms, Activities of Daily Living, Sport and Recreation Function, Foot- and Ankle-Related Quality of Life). The FAOS met set criteria of validity and reliability. The FAOS appears to be useful for the evaluation of patient-relevant outcomes related to ankle reconstruction.     

Surgical reconstruction of acquired spastic foot and ankle deformity

With the aging population and improved methods of emergency transport, the number of surviving stroke and brain injury patients continues to increase. Aggressive rehabilitation of appropriate candidates is justified. In the period of spontaneous recovery, efforts are made to prevent fixed contractures using passive mobilization, splinting, nerve blocks, and electrical stimulation. If deformity persists and the patient is no longer recovering, operative management can help alleviate the functional and hygiene problems associated with these limb deformities.     

Use of external fixation in the reconstruction of the Charcot foot and ankle

External fixation allows the progressive foot and ankle surgeon to approach Charcot foot and ankle deformities in a new way. Surgeons can now correct Charcot pathology with percutaneous techniques using a new generation of external fixation frames. These fixators allow the surgeon to adjust or manipulate the Charcot foot after surgery and the patient early weightbearing. External fixation provides the foot and ankle surgeon the opportunity to reconstruct and stabilize this destructive disease.     

Experience with the distally based sural neurofasciocutaneous flap supplied by the terminal perforator of peroneal vessels for ankle and foot reconstruction

The distally based sural fasciocutaneous flap has been proved an excellent option for coverage of the soft tissue defects of the lower third of the leg, ankle, and foot. In this article, we reported on a series of foot and ankle reconstructions with a distally based sural neurofasciocutaneous flap supplied by the terminal perforating branch of the peroneal artery. The vascular pedicle of the flap includes the terminal perforator branch of the peroneal artery and concomitant veins. The pivot point is approximately 5 cm above the tip of lateral malleolus. Fifteen patients with soft tissue defects of the foot and/or ankle underwent the procedures of reconstruction. The flaps were designed with the size measuring 8 x 9 cm to 13 x 31 cm. Thirteen flaps survived completely and 2 with partial or margin necrosis. Our experience has demonstrated that this sural flap with a thin perforator pedicle can be easily rotated, used for coverage of a large tissue defect including the forefoot area, and provide a good texture match and contour for the recipient area.     

The use of local muscle flaps in foot and ankle reconstruction

Pedicled muscle flaps always should be considered as a reconstructive option when evaluating possible options to filling a defect around the foot and ankle. To gain confidence in using this option, multiple anatomic dissections with special attention to the vascular anatomy are necessary. These dissections also should give the surgeon a feel for the reach of the various flaps and their applicability in various circumstances. For optimal results, the interoperative dissections should be performed with loupes and the Doppler. This allows the surgeon to identify and protect the dominant pedicle. When insetting the flap, special attention is directed to avoid placing excessive torsion or tension on the pedicle so that the blood flow is not compromised. The flow, both arterial and venous, should be assessed after insetting the muscle with a Doppler. Pedicled muscle flaps offer a rapid and easy solution to difficult soft tissue problems around the foot and ankle. The operation can be performed with a regional block in under two hours. The postoperative stay is short, and the donor defect is minimal. Pedicled muscle flaps offer a great alternative to microsurgical free flaps, especially in the sick patient. They should be considered more often when looking at how to fill small defects with exposed bone or osteomyelitis around the foot and ankle.     

Distally based perforator sural flaps for foot and ankle reconstruction

Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. These flaps are supplied by a perforating artery issued from the deep peroneal artery or the posterior tibial artery, and the chain-linked adipofascial neurovascular axis around the sural/saphenous nerve. It is a versatile and reliable technique for soft-tissue reconstruction of the heel and ankle region with 180-degrees rotation. In this paper, we present its developing history, vascular basis, surgical techniques including flap design and elevation, flap variations in pedicle and component, surgical indications, and illustrative case reports with different perforating vessels as pivot points for foot and ankle coverage.     

Arterial and venous reconstruction for free tissue transfer in diabetic ischemic foot ulcers.

OBJECTIVE: To review our experience with temporary arteriovenous (AV) fistula followed by free tissue transfer in the treatment of diabetic foot ulcers associated with peripheral arterial occlusion. PATIENTS AND METHOD: From July 1997 to July 2002, 15 lower extremities were operated in 14 patients. An AV loop with its apex below the medial malleolus was created between popliteal artery and saphenous system. Three weeks later, the loop was divided to provide an artery and a vein end. Foot defect was covered with latissimus dorsi muscle flap followed by split thickness skin grafting. RESULTS: Fistulas were patent in 12 extremities. Free tissue transfer was performed in 13 extremities. Two free flaps failed. After patent temporary arteriovenous fistula, free tissue transfer was successful in 11 of 12 extremities. One patient was amputated below knee due to ongoing infection despite successful free tissue transfer. Early mortality rate was 7%. Limb salvage was achieved in 11 of 13 extremities that staged operation was performed. Overall extremity loss was four of 15 lower extremities in 14 patients. Overall mortality was 21% for mean 20 follow-up period. CONCLUSION: Temporary AV fistula and free flap may provide stable wound coverage and high rate of limb salvage in treatment of diabetic foot ulcers with large tissue loss.     

Charcot foot and ankle reconstruction: current thinking and surgical approaches

The surgical repair of unstable diabetic neuropathic osteoarthropathy of the midfoot or the hindfoot and ankle remains a challenge with little guidance available in the medical literature. The authors present their proposed surgical intervention techniques regarding the use of external fixation with or without combined internal fixation. A step-by-step guide through the authors' preferred technique for these difficult limb salvage cases is presented in detail.     

Arterial lesions of the foot vessels in diabetic and non-diabetic patients undergoing lower limb revascularisation

This study was undertaken to compare the atherosclerotic involvement of the foot arteries in diabetic and non-diabetic patients with leg ischaemia. Ninety-four non-diabetic and 57 diabetic patients were investigated with intraoperative postreconstruction serial angiography during femoro-popliteal and femoro-distal bypass surgery. The foot vessels were evaluated with regard to the anterior and posterior foot arches which were classified as intact, deficient or occluded. Integrity of the pedal circulation was defined as patency of both the anterior and posterior foot arches. Severe involvement of the foot arches was rarely seen in limbs with 3- or 2-lower leg vessel run-off to the foot. The posterior foot arch was more often spared than the anterior foot arch, especially in the non-diabetic group (P less than 0.001). The integrity of the pedal circulation was similar in diabetic and non-diabetic patients (intact in about 20%). Patients with claudication showed a significantly lower occlusion rate of leg and foot arteries than patients with rest pain or gangrene. The results of this study showed that the foot vessels were similarly affected in diabetics and non-diabetics undergoing lower limb revascularization. The same aggressive diagnostic and therapeutic approach should be applied for limb salvage in both groups.     

Stress fractures of the foot and ankle.

Stress fractures of the foot and ankle are common injuries that require a high index of suspicion to make the appropriate diagnosis. If required, advanced imaging modalities should be used to establish the diagnosis. When developing a treatment plan for the runner, the sports medicine physician must keep the athlete informed as to the nature of the injury and the necessity of the treatment. A fitness plan must be developed with the runner to ensure that strength, flexibility, and cardiovascular conditioning are maintained during this period. Ideally the physician should develop this plan with the runner and not dictate the type of activity that is used to obtain these goals.     

Synovial sarcoma of the foot and ankle.

Synovial sarcoma of the foot and ankle frequently is misdiagnosed, which leads to delays in treatment. The clinical records of 14 patients with synovial sarcoma of the foot and ankle were reviewed. Common findings at presentation were an enlarging mass with a variable incidence of pain, tenderness, and edema. The patients tended to be younger than patients with other soft tissue sarcomas (30 years) and had a median duration of symptoms of 14 months. Of the 14 patients, 12 underwent an attempted curative surgical procedure. Ten patients had partial foot amputations or below knee amputations, whereas two had an attempted limb salvage by wide resection. Of the 14 patients, one experienced regionally recurrent disease and eight had pulmonary metastasis developed. All patients who had metastasis develop died of their disease. Tumor size was not observed to be a prognostic variable in this group of patients. Patients with biphasic histologic features had a better outcome than did those with a monophasic subtype. Patients with a prolonged duration of symptoms before diagnosis had a better outcome, presumably because these tumors biologically were less aggressive. Wide resection can be considered in a select group of patients.