Pitfalls in Reconstruction of Heel Defects due to Ground Landmine Explosions

Landmines are among the high-energy weapons that explode when a person steps on them and steps off. Ground landmine explosion results in severe complex soft tissue and bone defects, especially in the heel area. Such injuries bring a formidable challenge to both patients and reconstructive surgeons. The authors presented one of the largest series of patients with complex heel defects due to landmine explosion. They discussed their experience, as well as the pitfalls of reconstruction.

Seventy-two of 135 patients who had heel defects treated with muscle flaps in the Department of Plastic and Reconstructive Surgery at GMMA were included in the study. Type of injury, localization of the wounds, tissue defects, and timing of the definitive treatment were examined retrospectively. Treatment modalities according to the severity and localization of the wounds were defined. The authors' preference was for reconstruction of large complex defects with free muscle flaps covered by split-thickness skin grafts. Among these, they used free latissimus dorsi muscle flaps in 42 patients, and rectus abdominis muscle flaps in 30 patients.

Late functional results in the patients were evaluated by clinical observation, a questionnaire, three-dimensional gait analysis, dynamic podography, and dynamic EMGs. The mean follow-up of these patients was 5.6 years, ranging from 1 to 11 years. Values were compared with both the results of the intact foot and with those obtained from 20 healthy volunteer men (control group). Statistical analyses were performed by the Mannn-Whitney U and Wilcoxon (non-parametric) tests.

Chronic and repetitive ulcerations (24 patients, 33%) and chronic discharge through the ulcer (20 patients, 27.8%) were found. Most of the patients declared their satisfaction with having their own feet instead of prostheses. Forty-one patients are working without any difficulty for a mean of 3.4 years (range: 1 to 8 years). The mean time of standing or walking per day was 2.85 hr for the rest of the patients. Dynamic pressure distribution tests revealed significantly higher pressure and load values on the injured feet of the patients than in the control group (p < 0.05). Three-dimensional motion analysis showed restricted range of motion (ROM) at the ankle and hip joints of the injured extremity, and the difference was statistically significant (p < 0.05).

Reconstructive options should always be preferred to amputation procedures in extensive tissue losses of the heel due to mine explosion. Long-term functional results showed that free muscle flaps are promising in reconstruction of such extensive heel defects due to high-energy landmine injuries.