Entire calcaneus reconstruction with pedicled composite fibular growth plate flap in a pediatric patient

Abstract

Traumatic calcanectomy is a complicated rare condition that results in chronic pain and loss of limb function as the calcaneus is crucial for bearing weight. For an adult, possible treatment options are limited to below knee amputation, bone grafts, and 3D prosthesis; however, for the pediatric population, therapeutic data are scarce. In this case report, the authors describe a technique that provides the possibility for hindfoot reconstruction while maintaining growth potential without traumatizing other anatomic regions. A 5‐year‐old patient presented in the emergency department after he accidentally slipped under a lawnmower, which resulted in full calcaneal amputation with large bone and plantar soft tissue defects from the medial to lateral malleoli. Four days later, reconstructive surgery was performed using a composite vascularized pedicle growth plate flap. The flap was based on the retrograde anterior tibial artery and consisted of the peroneus longus muscle and fasciocutaneous perforator flap to maintain soft tissue coverage. The calcaneus was reconstructed by a double barrel fibular transplant localizing the growth plate in the distal part of the neocalcaneus. Full consolidation of the fibular barrels was achieved and the growth plate was still open at the 8‐year follow‐up. The fibular transplant has acquired a similar shape to a calcaneus with symmetric flattening and opposite side angulation. The patient's lower extremity functional score was 78/80 points. Reconstruction of an amputated calcaneal bone is rare and complicated, especially for pediatric patients. Authors demonstrate treatment with a complex vascularized flap for sustained growth and good functional outcome in the long term.

Heel reconstruction with ALT free flap in a 4-year-old patient after a severe lawnmower injury. A case report

“…Since the trauma resulted in calcaneal sub-amputation involving heel plantar skin and subcutaneous tissue without any damage on the underlying bone, a composite flap which also provided the bone component was not required in this circumstance [ 16 ].…”

“…As a matter of fact, microsurgical procedures in pediatric patients have developed more slowly than in adults [ 16 ]. Surgeons were initially sceptic to use free flaps in children because the minute vessel diameters, perceived vessel spasticity, and limited tissue availability.…”

Double vascularized fibula growth plate transfer for the reconstruction of long segmental tibia in pediatric patients: Report of three cases

“…Vascularized fibular growth plate flap elevation techniques can be found in the literature described by Innocenti (Innocenti et al, 2005; Innocenti et al, 2007). Ozols et al demonstrated a pedicled growth plate flap for the reconstruction of the calcaneus for a pediatric patient 5 years of age that had positive growth (Ozols et al, 2021). Several articles depict the usage of ipsilateral pedicled fibula flaps for tibial bone reconstructions (Chacha et al, 1981; Coleman & Coleman, 1994; Ozols et al, 2016).…”

“…Vascularized fibular growth plate flap elevation techniques can be found in the literature described by Innocenti (Innocenti et al, 2005;Innocenti et al, 2007). Ozols et al demonstrated a pedicled growth plate flap for the reconstruction of the calcaneus for a pediatric patient 5 years of age that had positive growth (Ozols et al, 2021).…”

Invited Commentary from the authors of: Han Y, et al. Free Medial Plantar Flap Versus Free Dorsal Myocutaneous Flap for the Reconstruction of Traumatic Foot Sole Defects

“…Therefore, we consider that free osteomyocutaneous fibular flap will be another choice in this situation. The fibular could be harvested in folded style, which provided sufficient hard autologous material in the reconstruction of calcaneus 4 …”