Orthoplastic Approach for Management of the Severely Traumatized Foot and Ankle

The foot and ankle region is often a difficult to reconstruct, because of the complex bony anatomy and thin soft-tissue envelope. The orthopedic surgeon traditionally is responsible for the bony fixation that will allow functional rehabilitation with normal biomechanics, whereas the plastic surgeon has to deal with problems of resurfacing the foot and ankle in a way that does not hamper wearing shoes and walking. The authors presented their concept of management of the severely traumatized foot and ankle.

From January 2000 to July 2003, 22 patients underwent an orthoplastic approach for complex foot trauma. There were 16 male and 6 female patients, with a mean age of 36.2 (8 to 72) years. The injuries were due to trauma (16×) or burns (6×). The authors were especially interested in the practicability of Godina's golden window (fix and flap within 72 hr after injury), and in the long-term outcome of the orthoplastic approach. Because there is no validated DASH for the lower extremity, they used the SF 36 questionaire as an outcome score.

The following free flaps wereused: latissimus dorsi (5×), gracilis (4×), serratus anterior (3×), latissimus dorsi/serratus (2×), radial forearm flap (4×), parascapular flap (2×), ALT (2×). There was no flap loss. The average time between trauma and flap coverage was 16 (4 to 27) days. The average SF 36 score was only 52, with two major complaint – pain and aesthetic appearance.

The orthoplastic approach is inherently a team approach, and state-of-the-art for structural restoration. The management of the severely damaged foot and ankle is best suited for a facility where varied surgical resources and personnel are readily available, and a team approach to these injuries has been developed. Although this is common practice in the authors'institution, they never reached Godina's golden window in clinical reality. To get there, it might be helpful to install a clinical pathway for complex foot injuries. The results of the SF 36 score were fair to middling. To improve the results, it is important to encourage continuous foot care, because these reconstructions remain fragile, and ulcers are the rule and not the exception. It is also necessary to address posttraumatic pain during follow-up. The authors currently employ fasciocutaneous flaps whenever possible, because the outcome is superior to musculocutaneus flaps.