Volume 10, Issue 3 (7-2021)                   WJPS 2021, 10(3): 63-72 | Back to browse issues page


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Krishna D, Chaturvedi G, Khan M M, Cheruvu V P R, Laitonjam M, Minz R. Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience. WJPS. 2021; 10 (3) :63-72
URL: http://wjps.ir/article-1-852-en.html
Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
Abstract:   (289 Views)
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.
Full-Text [PDF 1329 kb]   (118 Downloads)    
Type of Study: Original Article | Subject: Special
Received: 2021/10/14 | Accepted: 2021/07/6 | Published: 2021/10/23

References
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2. Sommerlad BC, McGrouther DA. Resurfacing the sole: long-term follow-up and comparison of techniques. Br J Plast Surg 1978;31(2):107-116.
3. Jeng SF, Wei FC. Classification and reconstructive options in foot plantar skin avulsion injuries. Plast Reconstr Surg 1997;99(6):1695-1705.
4. Struckmann V, Hirche C, Struckmann F, et al. Free and pedicled flaps for reconstruction of the weightbearing sole of the foot: a comparative analysis of functional results. J Foot Ankle Surg. 2014;53(6):727-734.
5. Steinau HU, Feller AM, Hörl HW, Kunisch M, Klein B, Biemer E. Post-traumatic soft tissue defects of the heel. Chirurg 1989;60(4):287-294.
6. Kalam M, Faruquee S, Rahman S, Uddin H. Reconstruction of heel: options and strategies. Bangladesh J Plast Surg 2010;1(1):14-18.
7. Benito-Ruiz J, Yoon T, Guisantes-Pintos E, Monner J, Serra-Renom JM. Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps. Ann Plast Surg 2004;52(4):380-384.
8. Suri M P, Patel A G, Vora H J, Raibagkar S C, Mehta D R, Vyas U H. Post-traumatic posterior heel soft tissue defect reconstruction. Indian J Plast Surg 2005;38(2):138-143.
9. Puri V, Venkateshwaran N, Khare N. Trophic ulcers-Practical management guidelines. Indian J Plast Surg. 2012;45(2):340-351.
10. Khai Luen K, Wan Sulaiman WA. Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases. J Foot Ankle Surg 2017;56(5):1114-1120.
11. Oh SJ, Moon M, Cha J, Koh SH, Chung CH. Weight-bearing plantar reconstruction using versatile medial plantar sensate flap. J Plast Reconstr Aesthet Surg 2011;64(2):248-254.
12. Harrison DH, Morgan BD. The instep island flap to resurface plantar defects. Br J Plast Surg 1981;34(3):315-318.
13. Gu JX, Huan AS, Zhang NC, et al. Reconstruction of Heel Soft Tissue Defects Using Medial Plantar Artery Island Pedicle Flap: Clinical Experience and Outcomes Analysis. J Foot Ankle Surg 2017;56(2):226-229.
14. Ayyappan T, Chadha A. Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions. Plast Reconstr Surg 2002;109(7):2307-2313.
15. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349-353.
16. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg 2007;46(2):65-74.
17. Santanelli F, Tenna S, Pace A, Scuderi N. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002;109(7):2314-2324.
18. Reiffel RS, McCarthy JG. Coverage of heel and sole defects: a new subfascial arterialized flap. Plast Reconstr Surg 1980;66(2):250-260.
19. Shaw WW, Hidalgo DA. Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg 1986;78(5):637-649.
20. Roblin P, Healy CM. Heel reconstruction with a medial plantar V-Y flap. Plast Reconstr Surg 2007;119(3):927-932.
21. de Rezende MR, Saito M, Paulos RG, et al. Reduction of Morbidity With a Reverse-Flow Sural Flap: A Two-Stage Technique. J Foot Ankle Surg 2018;57(4):821-825.
22. Holmes J, Rayner CR. Lateral calcaneal artery island flaps. Br J Plast Surg 1984;37(3):402-405.
23. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115-1121.
24. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002;109:583-591.
25. Sugg KB, Schaub TA, Concannon MJ, Cederna PS, Brown DL. The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction. Plast Reconstr Surg Glob Open 2015;3(9):e519.
26. Kneser U, Bach AD, Polykandriotis E, Kopp J, Horch RE. Delayed reverse sural flap for staged reconstruction of the foot and lower leg. Plast Reconstr Surg 2005;116(7):1910-1917.
27. Lee HI, Ha SH, Yu SO, Park MJ, Chae SH, Lee GJ. Reverse sural artery island flap with skin extension along with the pedicle. J Foot Ankle Surg 2016;55:470-475.
28. Kececi Y, Sir E. Increasing versatility of the distally based sural flap. J Foot Ankle Surg 2012;51(5):583-587.
29. Herlin C, Bekara F, Bertheuil N, et al. Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps. J Reconstr Microsurg 2017;33(5):343-351.
30. Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap. Microsurgery 2005;25(1):36-43.
31. Erdmann D, Gottlieb N, Humphrey JS, Le TC, Bruno W, Levin LS. Sural flap delay procedure: a preliminary report. Ann Plast Surg 2005;54(5):562-565.
32. Mueller JE, Ilchmann T, Lowatscheff T. The musculocutaneous sural artery flap for soft-tissue coverage after calcaneal fracture. Arch Orthop Trauma Surg 2001;121(6):350-352.
33. ShenY, Hu X, Wen C, Ning F, Yu D, Qin F. Treatment of post traumatic chronic calcaneal osteomyelitis and soft tissue defect by using combined muscle and skin flaps of calf. Chines Journal of Reparative and Reconstructive Surgery 2013, 27 (9): 1061-1064.
34. Kuran I, Turgut G, Bas L, Ozkan T, Bayri O, Gulgonen A. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg 2000;105(2):574-580.
35. Schwarz RJ, Negrini JF. Medial plantar artery island flap for heel reconstruction. Ann Plast Surg 2006;57(6):658-661.
36. Tosun Z, Ozkan A, Karaçor Z, Savaci N. Delaying the reverse sural flap provides predictable results for complicated wounds in diabetic foot. Ann Plast Surg 2005;55(2):169-173.
37. Yücel A, Senyuva C, Aydin Y, Cinar C, Güzel Z. Soft-tissue reconstruction of sole and heel defects with free tissue transfers. Ann Plast Surg 2000;44(3):259-269.
38. Sommerlad BC, McGrouther DA. Resurfacing the sole: long-term follow-up and comparison of techniques. Br J Plast Surg 1978;31(2):107-116.
39. Jeng SF, Wei FC. Classification and reconstructive options in foot plantar skin avulsion injuries. Plast Reconstr Surg 1997;99(6):1695-1705.
40. Struckmann V, Hirche C, Struckmann F, et al. Free and pedicled flaps for reconstruction of the weightbearing sole of the foot: a comparative analysis of functional results. J Foot Ankle Surg. 2014;53(6):727-734.
41. Steinau HU, Feller AM, Hörl HW, Kunisch M, Klein B, Biemer E. Post-traumatic soft tissue defects of the heel. Chirurg 1989;60(4):287-294.
42. Kalam M, Faruquee S, Rahman S, Uddin H. Reconstruction of heel: options and strategies. Bangladesh J Plast Surg 2010;1(1):14-18.
43. Benito-Ruiz J, Yoon T, Guisantes-Pintos E, Monner J, Serra-Renom JM. Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps. Ann Plast Surg 2004;52(4):380-384.
44. Suri M P, Patel A G, Vora H J, Raibagkar S C, Mehta D R, Vyas U H. Post-traumatic posterior heel soft tissue defect reconstruction. Indian J Plast Surg 2005;38(2):138-143.
45. Puri V, Venkateshwaran N, Khare N. Trophic ulcers-Practical management guidelines. Indian J Plast Surg. 2012;45(2):340-351.
46. Khai Luen K, Wan Sulaiman WA. Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases. J Foot Ankle Surg 2017;56(5):1114-1120.
47. Oh SJ, Moon M, Cha J, Koh SH, Chung CH. Weight-bearing plantar reconstruction using versatile medial plantar sensate flap. J Plast Reconstr Aesthet Surg 2011;64(2):248-254.
48. Harrison DH, Morgan BD. The instep island flap to resurface plantar defects. Br J Plast Surg 1981;34(3):315-318.
49. Gu JX, Huan AS, Zhang NC, et al. Reconstruction of Heel Soft Tissue Defects Using Medial Plantar Artery Island Pedicle Flap: Clinical Experience and Outcomes Analysis. J Foot Ankle Surg 2017;56(2):226-229.
50. Ayyappan T, Chadha A. Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions. Plast Reconstr Surg 2002;109(7):2307-2313.
51. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349-353.
52. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg 2007;46(2):65-74.
53. Santanelli F, Tenna S, Pace A, Scuderi N. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002;109(7):2314-2324.
54. Reiffel RS, McCarthy JG. Coverage of heel and sole defects: a new subfascial arterialized flap. Plast Reconstr Surg 1980;66(2):250-260.
55. Shaw WW, Hidalgo DA. Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg 1986;78(5):637-649.
56. Roblin P, Healy CM. Heel reconstruction with a medial plantar V-Y flap. Plast Reconstr Surg 2007;119(3):927-932.
57. de Rezende MR, Saito M, Paulos RG, et al. Reduction of Morbidity With a Reverse-Flow Sural Flap: A Two-Stage Technique. J Foot Ankle Surg 2018;57(4):821-825.
58. Holmes J, Rayner CR. Lateral calcaneal artery island flaps. Br J Plast Surg 1984;37(3):402-405.
59. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115-1121.
60. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002;109:583-591.
61. Sugg KB, Schaub TA, Concannon MJ, Cederna PS, Brown DL. The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction. Plast Reconstr Surg Glob Open 2015;3(9):e519.
62. Kneser U, Bach AD, Polykandriotis E, Kopp J, Horch RE. Delayed reverse sural flap for staged reconstruction of the foot and lower leg. Plast Reconstr Surg 2005;116(7):1910-1917.
63. Lee HI, Ha SH, Yu SO, Park MJ, Chae SH, Lee GJ. Reverse sural artery island flap with skin extension along with the pedicle. J Foot Ankle Surg 2016;55:470-475.
64. Kececi Y, Sir E. Increasing versatility of the distally based sural flap. J Foot Ankle Surg 2012;51(5):583-587.
65. Herlin C, Bekara F, Bertheuil N, et al. Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps. J Reconstr Microsurg 2017;33(5):343-351.
66. Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap. Microsurgery 2005;25(1):36-43.
67. Erdmann D, Gottlieb N, Humphrey JS, Le TC, Bruno W, Levin LS. Sural flap delay procedure: a preliminary report. Ann Plast Surg 2005;54(5):562-565.
68. Mueller JE, Ilchmann T, Lowatscheff T. The musculocutaneous sural artery flap for soft-tissue coverage after calcaneal fracture. Arch Orthop Trauma Surg 2001;121(6):350-352.
69. ShenY, Hu X, Wen C, Ning F, Yu D, Qin F. Treatment of post traumatic chronic calcaneal osteomyelitis and soft tissue defect by using combined muscle and skin flaps of calf. Chines Journal of Reparative and Reconstructive Surgery 2013, 27 (9): 1061-1064.
70. Kuran I, Turgut G, Bas L, Ozkan T, Bayri O, Gulgonen A. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg 2000;105(2):574-580.
71. Schwarz RJ, Negrini JF. Medial plantar artery island flap for heel reconstruction. Ann Plast Surg 2006;57(6):658-661.
72. Tosun Z, Ozkan A, Karaçor Z, Savaci N. Delaying the reverse sural flap provides predictable results for complicated wounds in diabetic foot. Ann Plast Surg 2005;55(2):169-173.

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