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J Reconstr Microsurg 2016; 32(05): 402-410
DOI: 10.1055/s-0036-1579536
Original Article: WSRM 2015 Scientific Paper
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Microsurgical Reconstruction of Plantar Ulcers of the Insensate Foot

Dinesh Kadam
1   Department of Plastic and Reconstructive Surgery, A.J. Institute of Medical Sciences and A.J. Hospital & Research Centre, Mangalore, Karnataka, India
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Publikationsverlauf

13. Oktober 2015

09. Januar 2016

Publikationsdatum:
24. Februar 2016 (online)

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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.

TECHNICAL NOTE: All the patients were operated by the author under epidural/regional anesthesia except in spinal injury. The ulcers were adequately debrided until the healthy tissue margin and bone. Recipient vessels were either posterior tibial or dorsalis pedis, chosen on the basis of the proximity to the pedicle of the flap. Patency of the artery was confirmed by palpation and adequate flow on arteriotomy. Based on the defect size, location, and availability of recipient vessel, we chose the free flaps that include ALT flap, radial artery forearm flap, and gracilis muscle with skin graft. The ALT flap harvested from the contralateral thigh was able to provide good coverage for wounds located in the heel. The radial forearm flap was used for the defects in the region of the metatarsal heads and forefoot. The gracilis flap was used in large defects of the sole involving multiple weight-bearing areas particularly with bony cavities that were osteomyelitic. A suprafascial dissection was used for the radial forearm flap harvest and the fascia was excised in the case of the ALT flap. The defects in most of the cases were conical in cross section with a wider base. This necessitated a de-epithelialization of the flap margins to maximize the contact with the native skin and withstand the shearing stresses. An end-to-side anastomosis was performed whenever posterior tibial vessel was used, thus preserving the continuity of the artery. Donor sites were closed primarily for the gracilis and anterolateral flap and with a skin graft for the radial forearm flap. Postoperatively the patients were monitored closely for flap vascularity, Limb elevation was given for 2 weeks postoperatively. A protective splint was used for a period of 4 weeks, following which they were made ambulant. Elastic compression bandage was advised for 6 months following splint removal. Ambulation without assistance was allowed following 6 weeks.

Keywords

trophic ulcer - sole reconstruction - diabetic foot free flap