Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions

Sakarya, Ahmet Hamdi; Tsai, Kun-Tong; Hsu, Chung-Chen; Chen, Shih‐Heng; Nicholas, K; Anggelia, Madonna Rica; Lin, Chih‐Hung

doi:10.1016/j.bjps.2021.11.095

Cited by 4 publications

(3 citation statements)

References 26 publications

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“…In the literature, a variety of free flaps, including free muscle flaps with skin grafts and fasciocutaneous flaps, were reported to be effective (Fox et al, 2015; Hollenbeck et al, 2010; Zhu et al, 2013). However, limitations reported included the relatively higher flap failure rate, ulceration incidence, and the need for secondary procedures are very common (Demirtas et al, 2010; Öztürk et al, 2005; Sakarya et al, 2021).…”

Section: Discussionmentioning

confidence: 99%

“…This could be minimized with thin skin flaps. Thin flaps are supposed to be more adhesive to the damaged sole wound bed and hence more analogous to the indigenous glabrous plantar skin (Fox et al, 2015; Sakarya et al, 2021). Firm adhesion of the flap on the sole can lower the risk of ulcers, most probably through minimizing the shear.…”

Section: Discussionmentioning

confidence: 99%

“…In terms of functional recovery and limb salvage, a free muscle flap with a skin graft can be an excellent tool in sole reconstruction. However, the drawbacks include the donor site functional morbidity, higher wound breakdown complications when compared with the fasciocutaneous flap, delayed full weight‐bearing ambulation, and the poor cosmetic outcome (Fox et al, 2015; Sakarya et al, 2021). Fasciocutaneous free flap was recently reported to have similar functional outcomes comparable to muscle flaps, with better cosmetic results and preferable as an orthoplastic approach in challenging cases with repeated orthopedic interventions (Cho et al, 2018).…”

Section: Discussionmentioning

confidence: 99%

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The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases

et al. 2022

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Background The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot. Patients and Methods This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm2. Results The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow‐up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12–18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes. Conclusion The SCIP flap can be an optimal durable skin flap for weight‐bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases

et al. 2022

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Free Flap Limb Salvage and Ulcer Recurrence in Chronic Limb-threatening Ischemia

Matsuda,

Seo,

Suzuki

et al. 2024

The International Journal of Lower Extremity Wounds

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Free flap transfer is a well-established treatment for foot reconstruction in patients with chronic limb-threatening ischemia (CLTI) and can achieve prolonged amputation-free survival. However, reports on ulcer recurrence after free flap transfer are scarce, with most focusing on trauma patients. Therefore, we retrospectively reviewed patients with CLTI who underwent free flap reconstruction at our institution over a 17-year period. Patient characteristics, ulcer recurrence rates, activity level, and variables associated with ulcer recurrence were investigated in patients who met the following criteria: successful reconstructive surgery, complete wound healing, and at least 1 year of follow-up. Free flap foot reconstruction was performed in 42 patients (92.9% male, 7.1% female; mean age 57.1 years, range 37-81 years). Among them, 39 patients (92.9%) had diabetes mellitus, 15 (35.7%) had critical limb ischemia, and 15 (35.7%) had end-stage renal disease/hemodialysis. Mean postoperative follow-up was 60.5 (range 12.0-208.0) months. The 5-year primary ulcer recurrence-free survival rate was 48.7%. High activity level and selection of the posterior tibial artery as the recipient artery were significantly associated with ulcer recurrence [hazard ratio, 3.59 and 9.81; P = .046 and P < .001, respectively]. Activity levels were not significantly different before and 1 year after surgery. In conclusion, survival analysis revealed that ulcer recurrence is most likely to occur within the first 2 years after surgery. Although recurrence occurred in approximately half of the patients, most patients maintained activity levels comparable to their preoperative levels.

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Single-stage orthoplastic treatment of complex calcaneal osteomyelitis with large soft-tissue defects

Down,

Ferguson,

Loizou

et al. 2024

Bone Joint J

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AimsCalcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects.MethodsA retrospective review was performed of all patients who underwent combined single-stage orthoplastic treatment of calcaneal osteomyelitis (01/2008 to 12/2022). Primary outcome measures were osteomyelitis recurrence and below-knee amputation (BKA). Secondary outcome measures included flap failure, operating time, complications, and length of stay.ResultsA total of 30 patients (14 female, 16 male; mean age 53.7 years (95% CI 48.0 to 59.5)) underwent combined orthoplastic surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (IQR 11.75 to 49.25). Of these, 19 received a local flap and 11 received a free flap. The most common causes were fracture-related infection (n = 12; 40%) and ulceration (n = 10; 33%); 21 patients (70%) had already undergone at least one operation elsewhere. Osteomyelitis was eradicated in 23 patients (77%). There were seven patients who developed recurrent osteomyelitis (23%), all in the local flap group. One patient required a BKA. Univariate analysis revealed that local flap reconstruction (OR 13.5 (95% CI 0.7 to 269.7); p = 0.029) and peripheral vascular disease (OR 16.5 (95% CI 1.35 to 203.1); p = 0.008) were associated with increased risk of recurrence. Free flap reconstruction took significantly longer intraoperatively than local flaps (mean 481 minutes (408 to 554) vs mean 168 minutes (119 to 216); p < 0.001), but without significant differences in length of stay or frequency of outpatient appointments.ConclusionIn our study involving 30 patients, single-stage orthoplastic management was associated with 77% (n = 23) eradication of infection and only one amputation in this complex and comorbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. While good outcomes can be achieved, this treatment requires high levels of inpatient and outpatient care.Cite this article: Bone Joint J 2024;106-B(12):1443–1450.

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Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions

Cited by 4 publications

References 26 publications

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases

Free Flap Limb Salvage and Ulcer Recurrence in Chronic Limb-threatening Ischemia

Single-stage orthoplastic treatment of complex calcaneal osteomyelitis with large soft-tissue defects

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