Muscle versus Fasciocutaneous Free Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis

Abstract

Background Management of soft tissue injuries of the heel is challenging and the composition of free tissue transfer that provides optimal aesthetic and functional outcomes in heel reconstruction is not clear. While fasciocutaneous flaps may result in shear planes that cause instability with mobilization, insensate muscle flaps may not be able to withstand the pressures of weight bearing and thus ulcerate.

Methods A systematic literature search was performed using Medline and PubMed databases. Primary outcome measures were time to mobilize, ulceration, revision or debulking surgery, and the requirement for specialized footwear. Analysis of pooled outcomes was undertaken using fixed-effects meta-analysis, calculating the incidence rate ratio for included articles.

Results Overall 576 articles were identified; out of which 11 articles met the final inclusion criteria, detailing 168 free tissue transfers in 163 patients. The study size ranged from 4 to 72 cases. There was a trend toward higher rates of ulceration (17 vs. 26%), requirement for revision (23 vs. 31%), and the requirement for specialized footwear (35 vs. 56%) in muscle flaps, but these differences were not statistically significant.

Conclusion The current review provided a summary of reported outcomes of free heel reconstruction in the literature till date. With the current evidence largely limited to small cohort studies (level IV evidence), there were no significant differences found between reconstructive options. These findings serve as a call to action for more reconstructive surgeons to collaborate on multi-institutional prospective studies with robust outcomes assessment. As such, an ideal flap for reconstruction of the weight-bearing heel has not yet been made clear.

Keywords

weight-bearing heel - reconstruction - fasciocutaneous - musculocutaneous

• References

• 1 McCabe WP, Kelly Jr AP, Behan FC. Reconstruction of the plantar pad after degloving injuries of the foot. Surg Gynecol Obstet 1973; 137 (6) 971-974
• 2 Jeng SF, Wei FC. Classification and reconstructive options in foot plantar skin avulsion injuries. Plast Reconstr Surg 1997; 99 (6) 1695-1703 , discussion 1704–1705
• 3 Cichowitz A, Pan W-R, Ashton M. The heel: anatomy, blood supply, and the pathophysiology of pressure ulcers. Ann Plast Surg 2009; 62 (4) 423-429
• 4 Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg 1986; 13 (4) 663-680
• 5 Oh SJ, Moon M, Cha J, Koh SH, Chung CH. Weight-bearing plantar reconstruction using versatile medial plantar sensate flap. J Plast Reconstr Aesthet Surg 2011; 64 (2) 248-254
• 6 Iorio ML, Shuck J, Attinger CE. Wound healing in the upper and lower extremities: a systematic review on the use of acellular dermal matrices. Plast Reconstr Surg 2012; 130 (5) (Suppl. 02) 232S-241S
• 7 Sinha AKA, Wood MBM, Irons GBG. Free tissue transfer for reconstruction of the weight-bearing portion of the foot. Clin Orthop Relat Res 1989; (242) 269-271
• 8 Sönmez A, Bayramiçli M, Sönmez B, Numanoğlu A. Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps. Plast Reconstr Surg 2003; 111 (7) 2230-2236
• 9 May Jr JW, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985; 75 (5) 627-641
• 10 Chang KN, DeArmond SJ, Buncke Jr HJ. Sensory reinnervation in microsurgical reconstruction of the heel. Plast Reconstr Surg 1986; 78 (5) 652-664
• 11 Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw 2010; 36 (3) 1-48
• 12 El-Shazly M, Yassin O, Kamal A, Makboul M, Gherardini G. Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study. J Foot Ankle Surg 2008; 47 (2) 145-152
• 13 Langstein HN, Chang DW, Miller MJ , et al. Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer. Plast Reconstr Surg 2002; 109 (1) 152-159
• 14 Noever G, Brüser P, Köhler L. Reconstruction of heel and sole defects by free flaps. Plast Reconstr Surg 1986; 78 (3) 345-352
• 15 Oztürk S, Bayram Y, Möhür H, Deveci M, Sengezer M. Evaluation of late functional results of patients treated with free muscle flaps for heel defects caused by land-mine explosions. Plast Reconstr Surg 2005; 116 (7) 1926-1936
• 16 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (3) 285-292
• 17 Heymans O, Verhelle N, Lahaye T. Covering small defects on the weight bearing surfaces of the foot: the free temporal fasciocutaneous flap. Br J Plast Surg 2005; 58: 460-465
• 18 Harris PG, Letrosne E, Caouette-Laberge L, Egerszegi EP. Long-term follow-up of coverage of weight bearing surface of the foot with free muscular flap in a pediatric population. Microsurgery 1994; 15 (6) 424-429
• 19 Yücel A, Senyuva C, Aydin Y, Cinar C, Güzel Z. Soft-tissue reconstruction of sole and heel defects with free tissue transfers. Ann Plast Surg 2000; 44 (3) 259-268 , discussion 268–269
• 20 Potparić Z, Rajacić N. Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps. Br J Plast Surg 1997; 50 (3) 176-181
• 21 Ducic I, Hung V, Dellon AL. Innervated free flaps for foot reconstruction: a review. J Reconstr Microsurg 2006; 22 (6) 433-442
• 22 Rautio J, Asko-Seljavaara S, Laasonen L, Härmä M. Suitability of the scapular flap for reconstructions of the foot. Plast Reconstr Surg 1990; 85 (6) 922-928
• 23 Lord M, Reynolds DPD, Hughes JRJ. Foot pressure measurement: a review of clinical findings. J Biomed Eng 1986; 8 (4) 283-294
• 24 Santanelli FF, Tenna SS, Pace AA, Scuderi NN. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002; 109: 2314-2314
• 25 Duncan MJ, Zuker RM, Manktelow RT. Resurfacing weight bearing areas of the heel. The role of the dorsalis pedis innervated free tissue transfer. J Reconstr Microsurg 1985; 1: 201-208