Functional Outcome of Weight Bearing Heel following its Reconstruction by Distally Based Sural Flaps

Introduction: Tissue defects of the heel require resurfacing by flaps that could bear a great proportion of body weight and assist in pain free locomotion with minimum morbidity. The distally based sural flaps, also known as reverse sural flaps, have found widespread applications including reconstruction of the weight bearing heel. The durability of the reverse sural flap and its ease of resurfacing peculiar contour of the heel have encouraged its use. The evaluation of the functional aspect of this flap with regards to the pain, ulceration and ambulation is vital to establish and authenticate its use in heel reconstruction. American Orthopaedic Foot and Ankle Society (AOFAS) clinical ratings scale is one of the assessment schemes for its evaluation. Aim: To evaluate the usefulness and versatility of reverse sural flap in reconstruction of heel as well as assessment of functional outcome of foot using AOFAS scoring system. Materials and Methods: In this prospective study, carried out in the Department of Plastic Surgery at a tertiary care centre in Eastern Uttar Pradesh, India, 15 patients with soft tissue defects of the weight bearing heel were found who fulfilled the inclusion criteria. Reconstruction was carried out using reverse sural flap and its surgical planning as operative details were discussed. AOFAS scale was used to measure functional outcome of the reconstructed heel. Results: Average age was 38.33±13.48 years and they presented earlier than 72 days. The dimensions of the reverse sural flap were 147.46±20.87 cm2 to resurface heel defects of 57.75±17.08 cm2. The largest defect was 13 cm long and 7 cm wide. Three flaps demonstrated distal necrosis as the length: width ratio was more than the well described safe limit of 3:1. They were 19- 22 cm long while the width was narrowed to 5-7 cm at the base resulting in unfavourable dimensions and consequent necrosis. Other complications were persistent discharge and ulceration. AOFAS rating had a maximum score of 60, the average score being 50.2±7.39 (31-58). Conclusion: The AOFAS clinical rating is a reliable and valid quantitative tool which is used for evaluating functional outcome in patients with reconstruction of weight bearing heel. Reconstruction of such challenging defects by the distally based sural flap proves its versatility and relialibity. At the same time, the surgical technique of flap harvest is safe, of shorter duration and provides alternative to microsurgical reconstruction.

Heel Reconstruction With Bipedicled Flap: A Salvage Procedure

Reconstruction of the heel region poses great challenge to plastic surgeons not only due to calcaneal bone lying just deep to the subdermal fat pad but also due to easily exposed Achilles tendon. In order to achieve permanent closure of the heel defect, exposed bone or tendon—or both—should be covered with durable, preferably sensate, well-vascularized, thin skin flaps. Even though fasciocutaneous free flaps remain the gold standard in the reconstruction of heel defects with exposed bone or tendon, a significant number of these patients are older individuals with multiple comorbidities such as diabetes mellitus, hypertension, atherosclerosis, and peripheral vascular disease. In this study, with a clinic series consisting of 6 patients (1 female, 5 males), we present a new technique of reconstruction with a bipedicled flap as a safe, reliable, and efficient reconstructive modality in the treatment of heel defects in cases where free flaps and other more sophisticated reconstructive options are either not feasible or have failed. Achieving complete reconstruction of defects in all 6 patients, this technique proves to be successful as a salvage procedure in reconstruction of heel defects.

Acellular Dermal Matrix and Heel Reconstruction: A New Prospective

Background Heel reconstruction represents a challenge for all plastic surgeons due to the anatomical and functional features of this weight-bearing area. In the last decade a combined use of acellular dermal matrices and skin grafts has been proposed as a reliable and less invasive alternative for complex wound management; nevertheless only a few cases have been reported in the literature. Methods We describe the long-term outcome of 2 cases of severe degloving trauma of the plantar region with massive soft tissue defects of the foot, that underwent surgical reconstruction with artificial dermis and skin grafts. At the fifth year of follow-up, both patients underwent a clinical and a computerized gait analysis to study their functional outcomes and the kinematics of their gait. Results Both patients recovered functional ambulation and returned to their own work and vocational activities, showing a symmetric gait and parameters of upright posture fully comparable to normality. Conclusions Despite the initial concerns about the use of acellular dermal matrices and skin grafts for this kind of injury, they seem to be a simple and safe alternative for weight-bearing reconstruction of the degloved foot. The authors believe that the current study yields useful information and reassurance about their long-term reliability.