Abstract
Background Plantar, neuropathic, or trophic ulcers are often found in patients with decreased
sensation in the foot. These ulcers can be complicated by infection, deformity, and
increased patient morbidity. Excision results in wider defects and local tissues are
often insufficient for reconstruction
Methods Total 26 free flaps were used in 25 patients to reconstruct plantar ulcers between
years 2007 and 2013. The etiology included diabetic neuropathy (n = 13), leprosy (n = 3), spinal/peripheral nerve injury (n = 7), spina bifida (n = 1), and peripheral neuropathy (n = 1). The duration of the ulcer ranged from 1 to 18 years. Fifteen patients had associated
systemic comorbidities and six had previous attempts. Free flaps used in reconstruction
were the anterolateral thigh flap (n = 18), radial artery forearm flap (n = 4), and the gracilis muscle flap (n = 4). Recipient vessels were the posterior tibial artery (end to side) in 19 and
the dorsalis pedis artery in 7.
Results The average age at presentation was 44.6 years with mean duration of ulcer of 5.8
years predominantly located over weight-bearing areas. Mean size of ulcer was 59.45
cm2 and mean follow-up period was 48 months. All flaps survived except a partial loss.
Average time to resume ambulation was 6 weeks. Three patients had recurrence with
mean follow-up of 48 months. Secondary flap reduction and bony resection was done
in four.
Conclusion Microvascular reconstruction of the sole has advantages of vascularity, adequate
tissue, and leaving rest of the foot undisturbed for offloading. Three significant
local conditions influencing selection and transfer of the flap include (1) distally
located forefoot ulcers, (2) extensive subcutaneous fibrosis secondary to frequent
inflammation, and (3) Charcot arthropathy. In our series, the anterolateral thigh
flap is our first choice for reconstruction of these defects.
Keywords trophic ulcer - sole reconstruction - diabetic foot free flap
