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Foot Reconstruction Treatment & Management

Updated: Jun 12, 2017
Author: Fabio Santanelli di Pompeo, MD, PhD; Chief Editor: Jorge I de la Torre, MD, FACS  more...

TREATMENT

Surgical Therapy

The following table summarizes the most common surgical options according to dimensions,
extension, and localization of the defect. [15, 16, 17]

Table 3. Surgical Options for Foot Reconstruction (Open Table in a new window)

Dimension Extension Localization Type of Flap

Weightbearing
< 3 cm2 Soft tissue Local flap
areas

Nonweightbearing
< 3 cm2 Soft tissue Skin grafts
areas

Free flap (free fasciocutaneous,

Weightbearing
>3 cm2 Soft tissue
areas
musculocutaneous flaps, muscle free flap
plus skin graft)

Soft tissue
Weightbearing
>3 cm2 and bone Free osteocutaneous flap
areas
loss

Local Flaps

Sole
See the list below:

Medial plantar flap (instep flap [3] )

Sensitive cutaneous flap harvested from nonweightbearing (NWB) area of the sole

Medial plantar flap, instep flap (O'Brien and Shanahan, 1979).

View Media Gallery

Maximum dimensions - 10 X 7 cm
Pedicle - Medial plantar artery either proximal or distally based
Arc of rotation - Defect of calcaneum, medial malleolar area, distal weightbearing (WB)
areas on the heads of metatarsus
Transposition, rotation, and V-Y skin flaps [2]
Sensitive fasciocutaneous or cutaneous flaps to cover WB areas
Defects less than 3 cm2, with random vascularization
Flexor brevis digitorum
Muscular flap localized under the plantar aponeurosis, indicated to cover small bone
exposure (A sensitive myocutaneous flap also can be harvested.)
Pedicle - Lateral plantar artery
Arc of rotation - Defect of calcaneum and of medial malleolar area
Abductor brevis hallucis
Muscular flap along the medial border of the foot
Pedicle - Branches from the medial plantar artery
Arc of rotation - Medial area of the calcaneum
Abductor brevis minimi dita
Muscular flap along the lateral border of the foot, larger than the abductor brevis hallucis
Pedicle - Branches from the lateral plantar artery
Arc of rotation - Lateral area of the calcaneum
Flexor brevis hallucis
Muscular flap that can be harvested alone or with the abductor brevis hallucis from the
medial forefoot margin
Pedicle - Medial plantar artery and first web space artery
Arc of rotation - Dorsum of the foot, distal forefoot sole on the medial side
Island flaps from the toes
Sensitive fasciocutaneous flaps from the plantar side of the toes
 Difficult dissection
Pedicle - Digitalis artery
Arc of rotation - Distal WB areas on the heads of metatarsus

A study by Struckmann et al indicated that both free and pedicled flaps are equally suitable for the
reconstruction of plantar tissue defects. The study, in which 12 free flaps and nine pedicled flaps were
used, found that the two flap types yielded essentially the same functional results. [18]

Dorsum

See the list below:

Dorsalis pedis flap [5]

Sensitive fasciocutaneous flap or a myocutaneous flap (including the extensor brevis
digitorum muscle) that can be harvested from the dorsum of the foot

Dorsalis pedis flap, described by McCraw and Furlow (1975).

View Media Gallery

Pedicle - Dorsalis pedis artery, which is the terminal branch of the anterior tibialis artery
Arc of rotation - Medial or lateral dorsal area, malleolar areas
First web space (Gilbert and Morrison, 1975)
Fasciocutaneous sensitive flap harvested from the first web space
Very small dimensions
Pedicle - First web space artery, which is the terminal branch of the dorsalis pedis artery
Arc of rotation - Distal dorsum

Medial side

See the list below:

Medialis pedis flap [6]

 Fasciocutaneous flap harvested on the anterior medial axis of the foot

Medialis pedis flap described by Masquelet (1990).

View Media Gallery

Pedicle - Myocutaneous perforator branches from the medial plantar artery
Arc of rotation - Medial malleolar area, Achilles tendon

Lateral side

See the list below:

Lateral calcaneal flap [4]

Cutaneous sensitive flap below the lateral malleolar area along the lateral side of the foot

Lateral calcaneal artery skin flap, described by Grabb and Argenta (1981).

View Media Gallery

Pedicle - Lateral calcaneal artery, which is the terminal branch of the peroneal artery;
reinnervation is provided by branches from the sural nerve
Arc of rotation - Achilles tendon and lateral malleolar area

Lower one third of the leg

See the list below:

Sural flap [19]

Sensitive fasciocutaneous flap harvested from the posterior area of the leg

Sural flap; perforator flap from peroneal artery; described by Donski and Fogdestam, 1983.

View Media Gallery

Pedicle - Sural artery, branch of the peroneal artery
Arc of rotation - Achilles tendon and lateral malleolar area
Perforator flap from posterior tibialis artery
Fasciocutaneous flap along the axis between soleus and flexor longus digitorum muscles

Perforator flap from the peroneal artery.

 View Media Gallery
Pedicle - Septocutaneous branches from the posterior tibialis artery
Arc of rotation - Medial malleolar area, calcaneum, proximal area of the dorsum
Reverse dermis or fascia flap of the lower leg [20]
Dermal or fascia flap harvested from the posterior area of the leg to be skin grafted
Pedicle - Random
Arc of rotation - Calcaneum, Achilles tendon

Free Flaps for the Foot

Perforator

See the list below:

Thoracodorsal artery perforator flap (TDAP) [21]

Reliable skin flap, thick skin flap more similar to the skin of the foot
Advantages - No donor-site morbidity, long vascular pedicle (>18 cm)
Disadvantages - Small diameter of the vessels
Pedicle - Perforator of the thoracodorsal artery
Anterolateral thigh perforator flap [22]
Reliable skin flap
Advantages - No donor-site morbidity, large pliable skin flap and sufficient bulk
Disadvantages - Small diameter of the vessels
Pedicle - Perforator from the descending branch of the lateral femoral circumflex artery
Anterolateral leg perforator flaps [23]
Advantages - Consistent reliable blood supply and good texture
Disadvantages - Small dimensions if direct closure of the donor area is required, small
diameter of the vessls, donor-site morbidity, thin skin
Pedicle - Superficial peroneal perforators, inferior superficial peroneal artery perforators

Cutaneous

See the list below:

Groin flap (Daniel and Taylor, 1973)

First flap that was used to reconstruct a defect of the calcaneum
Iliac crest region as a donor area allows large flap harvest (30 X 15 cm) with direct closure
Disadvantages - Difficult dissection in overweight patients and small diameter vessels
Pedicle - Superficial iliac circumflex artery
Scapular [9]
Can be harvested from the infraspinosa fossa of the scapula
Advantages - Easy dissection, long pedicle, large diameter of vessels, direct closure of
donor area, possibility of composite flaps combining other muscle flaps
Disadvantages - Thickness of the flap and difficult reinnervation
Pedicle - Circumflex artery of the scapula
Parascapular [24]
Harvested in the same area as the scapular flap
 Shares similar advantages and disadvantages
Pedicle - Descendant branch of the circumflex artery of the scapula

Fasciocutaneous

See the list below:

Radial (Chang, 1978)

Most versatile and used free flap for foot reconstruction that now often is harvested as a
pure cutaneous flap
Advantages - Easy dissection, long pedicle with large diameter vessels, reinnervation
through cutaneous antibrachial nerves, and possibility to combine bone
Disadvantages - Mainly due to donor area morbidity that must be closed with a graft
Pedicle - Radial artery
Lateral arm [11]
Thin and small flap that can be harvested from the anterior-lateral area of the lower one
third of the arm
Advantages - Easy dissection and reinnervation
Disadvantages - Small dimensions if direct closure of the donor area is required and small
diameter of the vessels
Pedicle - Septocutaneous branches from the brachialis profunda artery
Dorsalis pedis [8]
Previously described as a local flap; also can be harvested as a free flap, but its small
dimensions and its pedicle, which is one of the main arteries of the foot, make it a second
choice flap
Pedicle - Dorsalis pedis artery

Muscular

See the list below:

Latissimus dorsi [7]

Can be harvested as a pure muscle flap or as a myocutaneous flap; together with the radial
flap, often is used for the foot
Advantages - Large dimension, easy dissection, long pedicle, and large diameter of the
vessels
Main disadvantages - Thickness of the flap, which decreases in at least 6 months time,
and sacrifice of major muscle
Pedicle - Thoracodorsal artery
Gracilis (Tamai, 1971)
Muscular or myocutaneous flap (only a small skin paddle) that can be harvested from the
medial side of the thigh
Easy dissection, vessel diameter of approximately 2 mm, and length of approximately 6 cm
Donor area can be closed directly without functional defect; rarely used for the foot
Pedicle - Medial circumflex of femoris artery
Anterior serratus
Muscular flap that is harvested in the lateral side of the truncus
Advantages - No sacrifices of significant muscle such as latissimus dorsi, possibility to
combine with other flaps, direct closure of the donor area, and long pedicle
Main disadvantage - Difficult dissection
Pedicle - Branch from thoracodorsal artery
Osteocutaneous

See the list below:

Iliac crest [13]

Already described as a cutaneous flap; also can be harvested with the bone; includes a
double pedicle and a difficult dissection
Usually suggested for calcaneum loss or whenever a large amount of bone is required
Donor area always closed directly but usually painful in the postoperative period
Pedicle - For the bone, profundus iliac circumflex artery; for the skin paddle, superficial iliac
circumflex artery
Fibula [12]
Long and hard bone of the leg that can be harvested for almost all of its length, except for
the last 5 cm, without functional impairment
More suitable for metatarsal bone loss
Dissection not easy for the septocutaneous branches that support the skin paddle
Soleus muscle also can be included in the flap
Pedicle - Peroneal artery

Preoperative Details

Evaluation of foot injuries mainly must consider the following:

Amount of tissue loss (dimension and extension of the defect)

Localization (WB or NWB areas)
Neurovascular damage

Consider etiology of the defect, age of the patient, concomitant diseases, concomitant leg fracture,
and working activity.

A meticulous planning of the defect to be reconstructed can be accomplished with a pattern.

In free flaps, the choice of the recipient vessels depends on the vascular condition of the foot and leg.

Intraoperative Details

See the list below:

In patients with limited defects, position the patient supine or prone according to the location of
the defect.
For major surgical treatment, position the patient according to both the location of the defect
and the type of reconstruction to allow simultaneous flap harvest and preparation of the
recipient area.
Extend the debridement of the defect to vital tissues.
 Check the actual size of the loss after the debridement.
With free flaps, verify the condition of the recipient vessels under magnification.
The harvest of the flap can be performed under tourniquet with osteocutaneous flaps such as
the fibula.
Raise the flap and transfer it to fill the gap.
Use drains whenever necessary.
Close the donor area according to the surgeon's preference.

Postoperative Details

See the list below:

Position the patient, possibly on an air or water mattress, with both legs slightly elevated.
Monitor the viability of the flap in the early postoperative period according to the reconstructive
procedure.
For free flaps, monitor every 2 hours in the first 2 days and 4 times per day until 2 weeks
postoperatively with the aid of a Doppler probe to check the patency of the microanastomosis
and to survey the skin or muscle island.

Follow-up

See the list below:

Observe contour and stability of the reconstruction after 2 weeks and 1, 3, 6, and 12 months
postoperatively.
In patients with defects of the sole, load and walking ability generally are recovered in 1 month.
In patients who underwent primary bone reconstruction, load and walking ability are delayed
until bone union is achieved, as evaluated with serial radiographs or bone scans.
Custom-made shoes can be recommended for 3-6 months.

Complications

See the list below:

Complications may be divided into general and specific, and specific complications can be
related to the recipient or to the donor area.
Generic complications are those related to each surgical procedure (eg, reaction to anesthetics,
hematoma, seroma, infection).
Specific complications include partial loss of the flap (eg, de-epithelialization of the flap,
occasional minor breakdowns of the flap, malunion).
In free flap transfers, complications may be divided into 2 groups: complications of the donor
 area and complications of the recipient area.
Donor area complications include hematoma, seroma, skin graft loss, and wound dehiscence.
Recipient area complications include partial or total loss of the flap.
Early complications mainly are related to vascular problems such as venous or arterious
thrombosis and may require a re-exploration of the anastomosis.
Late complications are infections and pressure sores due to early recovery under the 100% load.
(Click here to complete a Medscape CE activity about pressure ulcers.)

Outcome and Prognosis

A retrospective study by Cho et al indicated that diabetes, chronic ulceration, an elevated platelet
count, and an abnormal angiogram increase the risk of reconstruction failure in patients undergoing
foot and ankle free tissue transfer. The study involved 231 free flap procedures (in 225 patients) for
foot and ankle reconstruction, with the investigators identifying chronic ulceration and an elevated
preoperative platelet count as independent risk factors for postoperative foot ischemia (ie, ischemia-
related tissue necrosis not occurring at the reconstruction site), and diabetes and an abnormal
preoperative angiogram as predictors of flap failure. [25]

A study by Sato et al suggested that the use of free flaps in the reconstruction of extensive tissue
defects from diabetic foot ulcers may increase patients’ chances of achieving independent
ambulation. The investigators found that of 23 patients who underwent free flap reconstruction for
diabetic foot ulcers (using free rectus abdominis, latissimus dorsi, or anterolateral thigh flaps), 16
experienced successful surgery, with 12 of these individuals attaining independent ambulation. [26]

Other considerations

The treatment of foot ulcers is often difficult, with a relatively high incidence of recurrence, especially
in older patients with vascular or dysmetabolic diseases.

Always consider the general condition of the patient in advance to plan the most correct treatment of
the local defect. The prognosis is strictly dependent on the age of the patient and the etiology of the
defect.

From a surgical point of view, flaps usually give a better result than grafts, with a low rate of
breakdowns or recurrence. However, grafts can be remarkably durable on weightbearing (WB) areas
and may be the first choice in certain situations.

Even if grafts are advisable in some patients, local flaps provide the most similar tissue and must be
the first choice when the defect is not less than 3 cm wide.

The advent of microsurgery and the use of free flaps have changed the approach for the treatment of
large defects.

Fasciocutaneous flaps for pure soft tissue loss are versatile and usually offer a suitable paddle of
tissue to reconstruct either WB or nonweightbearing (NWB) areas. Surgical recovery is fast, and the
patient can wear normal shoes early on.

Muscular or myocutaneous flaps must be necessary in large avulsions with bone infection. Surgical
recovery with these flaps can be slightly longer, especially because of their thickness, which prohibits
the use of normal shoes.

Myocutaneous flaps, particularly bulky in the beginning, usually reduce their thickness in 6 months
because of the process of atrophy of the denervated muscle.

Finally, osteocutaneous flaps truly represent the option to avoid amputation, restoring not only the
loss of tissue but especially the function of the foot in the gait.

The future of this field will be influenced by new technologies and cellular cultures, with the possibility
of reproducing any type of tissue in the laboratory.