|Year : 2014 | Volume
| Issue : 5 | Page : 603-607
Reconstruction of soft tissue defects around the ankle and foot
Bharat Bhushan Dogra, Siddhartha Priyadarshi, Ketak Nagare, Raveesh Sunkara, Ashwani Kandari, Karamvir Singh Rana
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharahstra, India
|Date of Web Publication||10-Sep-2014|
Bharat Bhushan Dogra
Prof of Surgery, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Soft tissue defects over ankle and foot region are encountered quite frequently following road traffic trauma and surgery. Management of such cases is a challenging task for any reconstructive surgeon because of paucity of skin and relative poor vascular status of skin in this region. Hence, invariably such cases require microsurgical free flap coverage, expertise for which may not be available at all the centers, such procedures require long operating hours and suitable recipient vessel may not be available in crush injuries. Materials and Methods: Thirty consecutive patients having soft tissue defects around ankle and foot region who underwent various reconstructive procedures in a medical college hospital during last 2 years form the basis of this study. This study was carried out to enlist various etiological factors and reconstructive surgical procedures employed to manage such cases without microsurgery. Results: The age of these patients ranged from 9 to 72 years. Twenty-five patients were males while 05 were females, with a mean age of 25 years. Road traffic accidents happened to be the primary cause of such defects in as many as 15 patients, cycle spoke trauma in 02 patients, implant exposure following orthopedic surgery in 6 patients, diabetic angiopathy in 4 patients and chronic osteomyelitis in 3 patients. The site of the defect was lower fourth of tibia in 16 patients, dorsum of foot in 2 patients, sole in 5 patients, medial aspect of ankle in 02 cases, lateral aspect in 02 cases and retro calcaneal region in 03 cases. In 10 cases distally based superficial sural artery flap was used to reconstruct the defect. In step rotation flap was used to provide sensory flap cover in the weight bearing heel in 04 cases. Inferiorly based fasciocutanenous flaps in 09 cases and muscle flaps were used in 07 cases. Conclusion: Distally based sural artery based flaps are very handy to provide skin cover around ankle and malleolar regions. Muscle flap can be used when the defect is small but deep to obliterate the cavity and it can be covered with skin graft.
Keywords: Distally-based sural artery flap, muscle flap, soft tissue defects ankle and foot
|How to cite this article:|
Dogra BB, Priyadarshi S, Nagare K, Sunkara R, Kandari A, Rana KS. Reconstruction of soft tissue defects around the ankle and foot. Med J DY Patil Univ 2014;7:603-7
|How to cite this URL:|
Dogra BB, Priyadarshi S, Nagare K, Sunkara R, Kandari A, Rana KS. Reconstruction of soft tissue defects around the ankle and foot. Med J DY Patil Univ [serial online] 2014 [cited 2020 Apr 2];7:603-7. Available from: http://www.mjdrdypu.org/text.asp?2014/7/5/603/140426
| Introduction|| |
Soft tissue defects occur very frequently around the ankle and foot region as a result of road traffic trauma, chronic osteomyelitis or following implant exposure after orthopedic surgery. On the one hand, such defects are problematic because of the limited mobility and availability of the overlying skin and on the other hand, there is relatively poor vascularity of the skin of lower leg area. Various reconstructive options available are local, distant and free flaps. The flap chosen should be easy to execute, with minimal discomfort to the patient and should provide durable coverage of the defect. The fasciocutaneous flap described by Ponten is very useful in the repair of such defects. It is easy to design and construct large flaps that are safe because of the good circulation.  Similarly, the medial plantar artery flap has facilitated heel coverage since its development in the 1980s.  This flap is an ideal option for the weight bearing heel but its involvement in trauma frequently precludes its use. Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s.  Intrinsic muscles from the foot like abductor hallucis and abductor digiti minimi muscle flaps may be an option but these flaps have inadequate tissue and a limited arc of rotation, thereby limiting their use. Free tissue transfer may be a good option in most circumstances but the need for microsurgical expertise and operating microscope remain its disadvantages. The distally based superficial sural artery flap, first described as a distally based neuroskin flap by Masquelet et al., is a skin island flap supplied by the vascular axis of the sural nerve.  This flap is another option for coverage of lower 1/3 of leg, ankle and foot defects in the lower limbs.
This report is based on our study of different type of flaps used for soft tissue coverage for defects in lower leg especially around ankle and foot.
| Materials and Methods|| |
A total of 30 consecutive cases of soft tissue defect involving ankle and foot form the basis of present study carried out in a medical college hospital during June 2011 to May 2013. Preoperatively the age and sex of each patient, etiological factor, size and site of the defect, exposure of bone or tendons, presence of chronic osteomyelitis, and any other co-morbid conditions were noted. All patients with exposed bones or fractures were radiographed to look for bony status in terms of fracture healing, implant exposure or presence of chronic osteomylitis. Pus swab culture was carried out to find out the nature of invading micro-organisms and their culture sensitivity.
Distally based sural artery flaps were raised from middle third of leg over calf region in all but one case, where heel defect extended up to mid sole. Requirement in this case was a longer pedicle and a larger flap, hence flap extended to upper third of calf. All the flaps were islanded and in none of the cases we used cuff of muscle.
Muscle flaps used were only intrinsic muscles available locally as a pedicle flap.
Twenty-five patients were males while five cases were females. Their age ranged from 9 to 72 years, with a mean age of 25.6 years.
Road traffic accident was the cause of soft tissue defect in 15 patients (50%) , implant exposure in 6 patients (20%), diabetic ulcers in 4 patients (13.33%), chronic osteomyelitis in 3 patients (10%) and cycle spoke trauma in 2 patients (6.67%) [Table 1].
The site of the defect was lower forth of Tibia in 16 patients (53.33%), dorsum of foot in 2(6.67%) , sole of foot in 5 patients (16.67%), medial aspect of Ankle in 2 patients (6.67%), lateral aspect of Ankle in 2 patients (6.67%) and retro-calcaneal region in 3 patients (10%) [Table 2].
We used distally based superficial sural artery flap in 10 cases (retro-calcaneal defets-3, medial aspect of ankle-2 cases, lateral aspect of ankle-2 cases, heel-01 case and lower 4th of tibia-02 cases). Heel defect extended up to mid sole and required a large flap with a longer pedicle. Donor area after raising the flap was skin grafted in all cases and it healed without any problem. One of the cases had a large deep defect on medial aspect of ankle and talus was exposed [Figure 1]. Cavity required some sort of filler, which was provided by transposing flexor digitorum brevis muscle and cover was provided by distally based sural artery flap with excellent results [Figure 2].
|Figure 1: Large deep soft tissue defect medial aspect of ankle with exposed talus|
Click here to view
|Figure 2: Flexor digitorum brevis muscle and distally based sural artery fl ap used to cover the defect|
Click here to view
Intrinsic foot muscles were used in seven cases (23.33%) [Table 3]. Extensor digitorum brevis was used in a case of soft tissue defect anterior aspect of ankle, following Blair arthrodesis by an Ortho surgeon for avascular necrosis of talus [Figure 3]. Deep defect was obliterated by transposing extensor digitorum brevis muscle and distally based fasciocutaneous flap for cover [Figure 4]. Abductor digiti minimi muscle flap was used in two cases of cycle spoke trauma having a relatively smaller skin defect but with exposed bone on lateral aspect of heel [Figure 5]. We used Abductor digiti minimi muscle to cover the bone and muscle was covered by split skin graft [Figure 6].
|Figure 3: Bone deep soft tissue defect 5 x 3 cm x 2 cm over anterior ankle following modifi ed blair arthrodesis by an ortho surgeon|
Click here to view
|Figure 4: Extensor digitorum brevis muscle and distally based fasciocutenous flap used for reconstruction|
Click here to view
|Figure 5: Cycle spoke injury lateral aspect of foot with exposed calcaneum|
Click here to view
In step rotation flaps were found to be very handy in managing heel defects since it provided thick glabrous sensory skin cover in the weight bearing heel and was used in four (33.33%) cases. One patient had trophic ulcer heel and chronic osteomyelitis of calcaneum [Figure 7]. He was managed by excision of all unhealthy tissue followed by instep rotation flap [Figure 8].
Fascio-cutanenous flaps described by Ponten were used in 9 (30%) cases (distally based-7, proximally based-2). We had an 82-year-old lady with implant exposure over medial malleolus after ortho surgery elsewhere [Figure 9]. She was managed with distally based Fascio cutaneous flap with satisfactory results [Figure 10].
In our study we noted complete flap survival in 27 cases (90%), marginal flap necrosis in 2 cases of distally based sural artery flaps and there was complete loss of distally based sural artery flap in 01 case of large heel defect extending up to mid sole.
| Discussion|| |
Reconstruction of the soft tissue defects over lower leg and foot continues to be one of the most challenging tasks for any reconstructive surgeon, because of the frequent involvement of tendon, and bone, which is caused by the thinness and poor circulation of the skin covering them. In our study, the defect was over lower fourth of Tibia in 16 patients (53.33%), ankle region in 07 cases (20.33%) and heel in 5 patients (16.67%). Bhandari et al. in a similar study of 30 cases found ankle involvement in 33.3% cases and involvement of heel in 16.6% cases.  The site of the defect was distal third of the tibia in 11 (58%) patients, heel in 5 (26%) cases in a study carried out by Samo Saeed. 
The distally based sural artery fasciocutaneous flap has been used effectively by various authors to resurface these defects and in many instances, it has obviated the need for free tissue transfer. Akhtar et al. used this flap in 84 patients and defects in this study comprised 52 distal tibia; 20 tendo-Achillis and posterior heel defects; seven-malleolar region; three-anterior ankle and two-foot amputation stumps.  In present series, although small, we managed 10 out of 30 cases by distally based superficial sural artery flap (retro-calcaneal defects-3, medial side of ankle-2, lateral malleolar defects-2, heel-1and lower 4th of tibia-2 cases).
Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. 
A meta-analysis of 50 articles that reported the use of 720 distally based sural flaps, suggested 82% success rate of the flap. Complete flap necrosis was reported in 3.3%, and partial or marginal flap necrosis in 11%.  Akhtar in his study of 84 patients observed flap survival in 78.5%, partial necrosis in 16.5% and complete necrosis in 9.5%.  In another study done by Samira Ajmal et al., complete flap survival was noted in 80% of the patients, partial flap loss in 8%, marginal necrosis in 8% and complete loss in 4%. 
| Conclusion|| |
The distally-based sural artery fasciocutaneous flap is a reliable flap to repair defects involving lower third of leg, heel, malleoli and hind foot.  The advantages of this flap are that dissection is fast and easy, it is not necessary to sacrifice important arterial pedicle and it can be used in traumatized limbs without further damage to main arteries, and a wide Arc of rotation is possible.  Muscle flap can be used when the defect is smaller and within reach of the local muscle flap. Muscle flaps act as fillers to obliterate the cavity. Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base.  Muscle only flaps are preferred over musculocutaneous flaps in order to avoid contour disturbances. The muscles are covered normally with split thickness skin grafts. Microsurgical free flaps provide good contour, color and texture but require microsurgery facilities to execute. Moreover, they do not fill cavities as efficiently as muscles.
| References|| |
|1.||Pontén B. The fasciocutaneous flap: Its use in soft tissue defects of the lower leg. Br J Plast Surg 1981;34:215-20. |
|2.||Schwarz RJ, Negrini JF. Medial plantar artery island flap for heel reconstruction. Ann Plast Surg 2006;57:658-61. |
|3.||Attinger CE, Ducic I, Cooper P, Zelen CM. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg 2002;110:1047-54. |
|4.||Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93:1012-20. |
|5.||Bhandari PS, Bath AS, Sadhotra LP, Manmohan S, Mukherjee MK. Management of soft tissue defects of the ankle and foot. Medical Journal Armed Forces India. 2005;61:252-5. |
|6.||Saeed S, Zulfiqar S, Zamir S. Use of distally based sural artery flap to manage the soft tissue defects of lower tibia and ankle. J Basic Appl Sci 2012;8:625-8. |
|7.||Akhtar S, Hameed A. Versatility of the sural fasiocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006;59:839-45. |
|8.||Follmar KE, Baccarani A, Steffen P, Baumeister L, Levin S, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007;119:138-48. |
|9.||Ajmal S, Khan MA, Khan RA, Shadman M, Yousof K, Iqbal T. Distally based sural fasciocutaneous flap for soft tissue reconstruction of the distal leg, ankle and foot defects. J Ayub Med Coll Abbottabad 2009;21:19-23. |
|10.||Fraccalvieri M, Boqetti P, Verna G, Carlucci S, Favi R, Bruschi S. Distally based fasiocutaneous sural flap for foot reconstruction: A retrospective review of 10 years experience. Foot Ankle Int 2008;29:191-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]