Heel Soft Tissue Research Articles

Lateral Calcaneal Artery Perforator/Propeller Flap in the Reconstruction of Posterior Heel Soft Tissue Defects

Abstract Introduction Posterior heel soft tissue defects with/without tendoachilles injury are difficult to reconstruct because of bony prominence, limited expendable local soft tissues, and significant donor site morbidity. In this study, we evaluate the lateral calcaneal artery (LCA) perforator/propeller flap for posterior heel soft tissue defect reconstruction. Materials and Methods A preliminary cadaveric study was done on 22 specimens to study the course of the LCA and its perforators. The knowledge gleaned from the cadaveric study was applied in our clinical study. The clinical study was conducted from January 2018 to May 2023 in 13 patients (10 males and 3 females) with posterior heel defects. The primary movement of the perforator flaps were either V-Y advancement (n = 10) or propeller (n = 3). Results All the flaps settled well except for superficial epidermolysis in one patient (7.69%) which healed conservatively. The average follow-up period was 14.53 months. Postoperatively, all patients had normal gait and normal range of movements. The LCA with the maximum number of perforators in the retrofibular/retromalleolar segment and the islanded flaps based on these perforators provided the excellent coverage for tendoachilles insertion defects and posterior heel defects facilitating excellent shoeability in all cases. Conclusion The study concludes that the LCA perforator/propeller flap may be a reliable cover for the posterior heel defects with good color, texture, thickness, and contour match rendering a shoeable stable foot.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience.

BACKGROUNDSensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area. METHODSIn this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel.RESULTSOut of 40 patients’ medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group.CONCLUSIONLocoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience

Using the posterior tibial artery and peroneal artery perforator flaps to repair heel wounds: 18 cases report

Objective To investigate the clinical efficacy of using the posterior tibial artery and peroneal artery perforator flaps to repair the heel wounds. Methods From January, 2011 to May, 2018, heel soft tissue defect caused by trauma in 18 cases were treated by posterior tibial artery and peroneal artery perforator flaps respectively. The posterior tibial artery perforator flap was used in 11 cases, and the peroneal artery perforator flap was used in 7 cases. The area of flaps ranged from 5.0 cm×3.0 cm to 11.0 cm×9.0 cm. The length of the vascular pedicle was from 10.0 cm to 16.0 cm. After operation, the patients were followed-up regularly. The time of wound healing, appearance and texture of the flap, and function of ankle joint were observed. Results After the operation, 13 flaps survived uneventfully. The wound achieved primary healing. Partial necrosis occurred in the distal of posterior tibial artery perforator flap in 2 cases, and repaired by skin graft 1 or 2 months later. Marginal necrosis occurred in posterior tibial artery perforator flap in 2 cases and in peroneal artery perforator flap in 1 case. And scar healing occurred in these 3 cases finally. All the 18 patients were followed-up for 3 to 60 months, with an average of 10 months. Fracture healing time was from 3-6 months, with an average of 4 months. Flap was soft with satisfied appearance in 16 cases. Obvious scar formation occurred in 2 cases. There was no obvious scar contracture in donor sites. There was no obvious limitation of the flexion and extension function of the ankle joint in 18 cases. According to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, there was excellent in 16 cases, and good in 2 cases. Conclusion As for the characteristics of the heel wound, it is a simple and practical method to use leg perforator flap to repair. The flap is based on a long vascular pedicle. And the clinical effect is satisfied. Key words: Posterior tibial artery; Peroneal artery; Perforator flap; Heel; Repair

Repair of soft tissue defect around posterior calcaneal region combined with Achilles tendon defect by the thin-layer free anterolateral thigh flap with iliotibial band

Objective To investigate the clinical effect of thin-layer free anterolateral thigh flap with iliotibial tract for reconstruction of heel soft tissue and Achilles tendon defect. Methods From January, 2017 to December, 2017, 11 cases of heel soft tissue and Achilles tendon defect were repaired by thin-layer free anterolateral thigh flap with iliotibial tract. There were 5 cases with tibia/fibula fracture, 3 cases with ankle fracture and 1 case with calcaneal fracture. The area of soft tissue defect was 6.5 cm×10.0 cm-8.0 cm×13.0 cm, and the length of Achilles tendon defect was 5.5-11.5 cm. All wounds were treated with debridement and negative pressure sealing drainage technique at first stage. After 6 days, the soft tissue defect around posterior calcaneal region combined with Achilles tendon defect were repaired by the thin-layer free anterolateral thigh flap with iliotibial tract. Reasonable rehabilitation training was established after operation. Results The flaps survived in 11 cases and the donor region healed in one stage. The patients were followed-up for 8 to 20(mean, 15.74) months by outpatient review, calling or WeChat. Slightly bloated in appearance in 2 cases, and were thinned by orthopedic operation 1 year later. The other flaps were well shaped and moderately thick. At the last follow-up, the flaps were soft in texture and elastic. The sensory recovery of the flap was good, and the two-point discriminant perception in the posterior region of the heel was 3.0-5.0(mean, 4.11) mm. Thompson’s sign was negative, double or one-foot heel lift test was negative, and there was no recurrence of Achilles tendon rupture or skin ulceration in the heel region. The range of motion(ROM) of affected side was (23.11±1.17)°of extension and (43.67±1.06)° of flexion, and the ROM of normal side was (23.79±1.03)°of extension and (44.03±0.94)°of flexion. There was no statistical difference between them(P>0.05). Postoperative follow-up was conducted according to the Thermann’s function evaluation system, the evaluated result was excellent in 8 cases, good in 2 cases, and receivability in 1 case. Conclusion It is a reliable and effective method to repair heel soft tissue and Achilles tendon defect by thin-layer free anterolateral thigh flap with iliotibial tract. And this method can better restore foot ankle shape and function. Key words: Anterolateral thigh flap; Iliotibial band; Heel; Achilles tendon defect; Microsurgical operation

Reconstruction of heel soft tissue defects using sensate medial plantar flap

Introduction. Reconstruction of heel soft tissue defects represents a true challenge for any surgeon due to the particularities of this anatomical region. The tissue used to reconstruct the heel area must be resistant, innervated, and adapted to take over the body weight. Innervated medial plantar fasciocutaneous flap is one of the best solutions to cover defects at the heel level.

Restoration of Distal Third Leg and Heel Soft Tissue Defects Using Local Muscle Flaps

Restoration of Distal Third Leg and Heel Soft Tissue Defects Using Local Muscle Flaps

Medialis pedis flap for reconstruction of weight bearing heel.

Among the various flaps available for the reconstruction of the heel, a medial plantar flap has been widely accepted as the most ideal. This flap, however, involves the medial plantar nerve and its cutaneous branches, which may lead to postoperative hyperesthesia and dual sensation. The purpose of this report was to report the outcomes of the use of the medialis pedis flap for the coverage of weight bearing heel soft tissue defect. A total of 8 patients who had undergone reconstruction of the weight bearing heel with the medialis pedis flap were enrolled for this study. There were 6 male and 2 female patients and the mean age was 46 years. The causes of the defects included pressure sore, crushing injury and malignant melanoma. The mean size of the defects was 3 × 4 cm. Five cases were reconstructed with island flaps and 3 were covered with free flaps. The mean size of the flaps was 3×5 cm. All flaps survived. One case developed arterial insufficiency and was treated with a vein graft. Ambulation in normal shoes was possible in all the patients. Seven cases did not report pain, but 1 case complained of mild pain. No case reported complications including pain at the donor site, ulcerations, sensory loss, hyperesthesia, or sensory disturbance. The mean follow-up period was 14.4 months. The medialis pedis flap may be considered a useful flap for the reconstruction of soft tissue defects smaller than 5 cm in the weight bearing heel.

Reconstruction of Heel Soft Tissue Defects Using Medial Plantar Artery Island Pedicle Flap: Clinical Experience and Outcomes Analysis

We report our clinical experience with 11 cases of heel soft tissue defects treated with a medial plantar artery island pedicle flap. We also evaluated the functional outcomes of reconstruction. We enrolled 11 patients (10 [90.9%] males and 1 [9.1%] female), who received a medial plantar artery island pedicle flap for heel soft tissue defects from August 2010 to July 2014. The cause of the defects included trauma (post-traumatic heel skin necrosis) in 2 (18.2%) patients, infection (calcaneal osteomyelitis with overlying soft tissue infection) in 2 (18.2%) patients, and tumor (stage IA melanoma) in 7 (63.6%) patients. The mean average size of the defect was 3.7 cm × 4.4 cm (range 3.1 cm × 4.0 cm to 4.5 cm × 5.5 cm). The mean follow-up period was 19.6 (range 8 to 35) months, and all flaps survived within that period. The mean static 2-point discrimination was 34.4 (range 29 to 40) mm at the heel and 17.2 mm at the distal sole. The mean visual analog scale score for the aesthetic appearance of the reconstructed heel was 9 (range 8 to 9.5). The average revised Foot Function Index score was 25.8 (range 21 to 37). The medial plantar artery island pedicle flap is a versatile and effective method for reconstructing heel soft tissue defects.

Medial plantar island flap for soft tissue reconstruction of the heel after excision of melanoma

Objective To study the efficacy of medial plantar island flap for repairing soft tissue defect of the heel after excision of melanoma. Methods Five patients (including 3 males and 2 females) with malignant melanoma were treated. All lesions were located in the heel and were proved by pathological examination. Local extensive resection was performed in all cases. The surgical margin used for excision of melanoma was 2 cm, and the depth used was deep into periosteum of the calcaneus. Plantar medial artery island skin flaps were applied in the reparation according to the size of heel soft tissue defect and anatomic study. The postoperative follow-up was 8 to 14 months. Results The surgical reparation was successful in all 5 cases. The plantar medial artery was very suitable to cover the surgical wound surface and to recover the function and sense. Before 3 months the sense of flaps remained on the donor area and later went to the heel gradually. All patients remained alive and no tumor recurrence was observed. All the patients were walking normally and had protective sensation in the new heel pad comparable to the opposite normal heel. Two patients with more than 10 years follow-up were reported. Conclusions Plantar medial island flap can be used to repair the wound after malignant melanoma resection in the heel, which is an effective method. Key words: Malignant melanoma; Heel; Island flap; Medial plantar artery

Repairing of limb extremity wounds with free descending genicular artery perforator flap without saphenous vein

Objective To explore the surgical technique and the efficacy of free descending genicular artery perforator flap without saphenous vein for tissue defect. Methods 18 cases of extremity tissue defect were involved in this study from August 2010 to April 2014, including 16 males and 2 females with an average age of 32.4 years (8 plantar or heel soft tissue defect, 10 back of hand or palm soft tissue defect). 2 old injury cases that had soft tissue defect after scar release were treated by free flaps and the other 16 were open injury with infection, among which 5 cases were combined with fractures or bone defect. Sizes of the skin and soft tissue defect were 2.0 cm×8.0 cm to 9.0 cm×12.0 cm. All wounds were treated by free descending genicular artery perforator flap from the contralateral limb. Medial femoral cutaneous nerve was kept in flaps as far as possible. The projection points of descending genicular artery perforator and saphenous vein were detected by Doppler, then the flaps were cut with reverse approach, and saphenous vein and saphenous nerve were preserved. Results All 18 flaps were survived and all cases were followed up for 3 to 30 months (average, 10.3 months). The flap sizes varied from 2.5 cm×9.0 cm-9.5 cm×13.0 cm. 2 cases with bone defect were healed 3 months later without infection, and the other 3 cases with fractures were healed 2-3 months after operation. The two point's discrimination distance was 7.0-12.0 mm on the flap. The disabilities of the arm, shoulder, and hand questionnaire score averaged 51, and the mean Japanese Orthopaedic Association's foot rating scale was 70.5. Most patients were satisfied with appearance of the recipient and donor sites, among which 5 cases had skin-graft on the donor sites, and the other 12 cases had small scars on the donor sites. Poor healing was detected in 1 case on the thigh which was healed 3 weeks later. There was no paresthesia and rash on the donor sites. The mean distance between projection points of descending genicular artery perforator and saphenous vein was 3.7 cm. Conclusion Free descending genicular artery perforator flap without saphenous vein is an optimal therapy for the extremity tissue defect, which has the advantage of covert donor site, less invasion, less variation of perforator, and could recover the skin sense of recipient site. Key words: Surgical flaps; Wounds and injuries; Extremities

Repair of high energy injury-induced soft tissue wound of the heel

Objective To investigate the methods and effects of different flaps for repair of high energy injury-induced soft tissue wound of the heel. Methods From January 2002 to June 2012, the patients including 12 males and 9 females aged 18-57 years (mean, 32 years) underwent heel soft tissue defect reconstruction. Causes of injury were traffic injury in 11 case and mechanical injury in 10 cases. Dimension of soft tissue defect ranged from 5 cm×3 cm to 8 cm×6 cm. Soft-tissue defect was repaired with sural neurovascular flaps at the posterolateral heel in 9 cases (Group A), with posterior tibial artery flaps at the posterolateral heel in 5 cases (Group B), and with medial plantar flaps at the loading area of heel in 7 cases (Group C). Sensory recovery and two point discrimination motion of the ankle joint were observed and compared among groups 12 month after operation. Heel pain was observed during weight bearing and joint activity was evaluated using the visual analogue scale (VAS). Results All the flaps survived, except for one with epidermal necrosis over the distal part, which healed after partial changing medication. Duration of follow-up was 12-24 months. There were no differences in the appearance, texture and contour between the flaps and recipient sites. Flaps showed no ulcer in the weight-bearing area and recovered their protective sense. Patients could walk normally after surgery. At postoperative 1 year, sensory recovery rate of the flaps in Groups A, B and C was 0, 20% and 100% respectively (P 0.05). While heel pain existed in weight-bearing exercise.Difference in VAS was significant among the three groups (P 0.05). Conclusion Medial plantar flaps are suitable for tissue defect of 5-8 cm in length but sural neurovascular flaps and posterior tibial artery flaps should be considered for over 8 cm defect in order to elevate survival rate of the flaps and reconstruct limb function. Key words: Foot injuries; Soft tissue injuries; Surgical flaps

Large heel soft tissue defects managed successfully with reverse medial crural fasciocutaneous flap: A 7-year single-center experience with 21 consecutive cases

The medial crural fasciocutaneous flap is a reliable cutaneous flap that can be used for soft tissue reconstruction in the extremities. The purpose of this article is to evaluate the application and clinical significance of this surgical technique in the reconstruction of heel soft tissue defects. Twenty-one cases of heel soft tissue defect between March 2005 and March 2012 were included in this study. Wound sizes varied from 5.0×5.5 to 7.5×10.0cm. All cases were managed with a reverse medial crural fasciocutaneous flap. Patient demographics and case information were analyzed and are reported. The sizes of the reverse medial crural fasciocutaneous flap varied from 6.5×10.0 to 9.0×15.0cm; the average size was 7.7×13.8cm. Out of the 21 consecutive cases, 20 flaps survived intact and one flap underwent partial necrosis. Follow-up observations were conducted for 6-36 months. The cosmetic results were satisfactory, without apparent bulkiness; the weight-bearing outcomes were satisfactory. The donor site can be closed primarily or by skin graft. Reverse medial crural fasciocutaneous flap transfer is appropriate for the reconstruction of heel soft tissue defects. The method is safe and can cover large heel defects.

Rekonstruktion der Ferse eines 2-jährigen Jungen nach Rasenmäherverletzung

Lawn mower injuries in children usually involve the lower extremities and can lead to serious amputation injuries. Treatment should look not only at the acute reconstruction, but also on maintaining the ability to grow. We report the case of a two-year-old boy with amputation of the heel. The boy was run over by a lawn mower. He suffered a complete loss of heel soft tissue, 30 % of the os calcis and the Achilles tendon. The one-stage reconstruction was performed by transplantation of an iliac crest graft, fascia lata to reconstruct the Achilles tendon and a microvascular latissimus dorsi flap. After one year, the functional and cosmetic result is excellent, the bone graft is healed completely and shows growth trends. The successful treatment of such a severe amputation injury requires the interdisciplinary cooperation between paediatric traumatologists, plastic surgeons, physical therapists and orthopaedic shoemaker. The result justifies the great effort.

Treatment of intraarticular calcaneal fractures using poking reduction combined with Ilizarov method

Objective To introduce the treatment of intraarticular calcaneal fractures with poor soft tissue using poking reduction combined with Ilizarov methods. Methods From September 2007 to September 2009,11 patients with the intraarticular calcaneal fractures were treated with poking reduction combined with Ilizarov methods,including 10 males and 1 female at average age of 33.6 years(range,21-50 years).Four patients had the left calcaneal fractures and seven with the right ones.According to Sander classification,there were seven patients with type II fractures,three with type III fractures and one with type IV fracture.The various extents of heel soft tissue injury were emerged in all the patients.Before operation,B(o)hler angle was 0°-12°(average 8°)and Gissane angle 70°-95°(average 80°).According to AO classification of close soft tissue injury,there were three patients with type IC2,six with type IC3,one with type IC5 and one with open soft tissue injury.The collapse of the articular surface was recovered by Steinmann pin which passed through the lateral calcaneal tubercle.The medial and lateral fracture fragments were corrected by using the tensed olive wires.The heighat and width were maintained by using the Ilizarov external fixation. Results The mean duration of follow-up was 13.3 months (range,6-20 months).All fractures were healed after mean duration for 8.1 weeks(range,7-10weeks).The postoperative B(o)hler angle was 20°-45°(average 33°)and Gissane angle 100°-118°(average 107°).According to Maryland Foot Score system,the result of postoperative function was excellent in seven patients,good in three and fair in one,with excellence rate of 91%. Conclusions For the intraarticular calcaneal fractures,the poking reduction combined with Ilizarov method is able to recover and maintain the normal calcaneal height and width and reduce postoperative wound infections and many other complications.specially for Sanders II or III with severe soft tissue injury in the open or closed calcaneal fractures.Master of surgical indications and operating poims can attain satisfactory clinical efficacy. Key words: Foot injures; Calcaneal; Poking reduction

The study of heel soft tissue defect reconstruction with flap

Objective To report the results of heel soft tissue defect reconstruction with locoregional reverse pedicle flaps or free flaps.Methods Operations were carried out in two phases.The first operation was debridement.In the second operation,in order to make a choice between locoregional reverse pedicle flaps and free flaps,the consideration included an effective assessment which Was composed by the size the location and the complexity of injuries of the defect heel. Results The flaps were survived and followed up from 8 to 35 months(mean 22 months).8 cases were graded excellent and 12 good as assessed with Criterion of heel reconstruction which was made by authors. Conclusion The key of the reconstruction of soft tissue defects is to make a good choice to the flaps in terms of the characteristic of the anatomy of defect area and donor site.It is one of important factors to reconstruct sensory function for the heel reconstruction. Key words: Heel; Reconstruction; Flap; Microsurgery

Applied anatomy of the medial plantar skin flaps with repairing heel defects and its clinical application

Objective To explore an anatomical basis for the medial plantar skin flaps and its clinical value of repairing heel defects. Methods The origin,branches,course and distribution of the medial plantar artery and the nerve of flaps were studied in 10 adult cadavers(20 legs).8 cases of homonymy and opposite side heel soft tissue defects with medial plantar skin flaps,aged 10-42 years.Free skin transplantation on the donors. Results The length of media plantar artery deep branch was (8.9±0.2)cm,gives off 3-5 cutaneous branches.Medial plantar nerve have 5-8 branches.it inchdes 3～5cutaneous branches distribute plantar skin and 2-4 plantar digital nerves distribute toes skin.The area of flaps was 4.0 cm×3.0 cm-6.0 cm×5.0 cm in the 8 flaps. 6 pedicle skin flaps were transfenrred to repair homonymy side heel soft tissue defects.2 opposite side heel soft tissue defects were repaired by 2 free flaps.All the flaps were survived. All patients were followed up one months to one year,the function and appearance of the flaps were good.Conclusion The flaps have less anatomic variation or sacrificing major vessels but have reliable blood supply and can restore good sensation after operation.They are ideal flaps for repairing heel soft tissue defects. Key words: Surgical flap; Medial plantar artery; Medial plantar skin flaps; Heel; Microsurgery

X-ray diffraction patterns and anatomical properties of claw tissues of beef and dairy cattle

SUMMARYMedial claws from the right hind feet were obtained post mortem from four 19–20-month-old beef heifers and from four 28-month-old first-calving dairy heifers 3–4 days postpartum. X-ray diffraction (XRD) studies were undertaken on samples of soft and hard (cornified) integumental tissues of dorsal wall, sole and heel (bulb) for varying sites and planes of exposure. The measurements were interpreted as defining diffraction patterns and intermolecular spacings of cytoskeletal and extracellular fibrous structural proteins. The orientation of these proteins was examined in relation to physical characteristics and function including bearing of body weight by these tissues.Physical measurements taken included impression hardness which showed typically greater values for wall than sole and variable differences between horn of dairy and beef origin and husbandry systems. Claws from dairy heifers had significantly smaller values for toe (dorsal wall) angle, claw height and heel height and thickness of solear horn and heel soft tissue. Although few were studied, the results reflected typical husbandry origins and indicated the susceptibility to the lesion formation well recognized in postpartum dairy cattle.Typical XRD patterns for horn samples showed defined arcs of reflectance on the equatorial axis consistent with findings for the presence of α-helices in fibrils reported to occur in other hard-keratin-containing integumental tissues. However, reflectance on the meridional axis also reported for these other tissues was not detected. A similar defined pattern was obtained for less than 0·10 of samples of internal soft pre-cornified epidermal and attached dermal tissue although the values for intermolecular ‘d’ spacing for these were consistent with those reported for type I collagen. Diffuse reflection patterns were thus evident for the majority of samples of soft tissue epidermis and dermis and also for adipose tissue of the digital cushion.The formation of defined arcs of reflectance allowed the determination of fibril alignment in wall and solear horn. For the orientated samples of dorsal wall horn tissue, the outer layer showed a longitudinal angle of orientation essentially maintained proximal to distal. This pattern was maintained throughout the depth of horn at the proximal site. In contrast, layers in mid-wall and towards the distal edge showed a greater circumferential (horizontal) orientation in sections collected anterior to posterior towards the inner corial, including laminar, tissues. The orientation of fibrils in inner wall horn appears to relate to the direction of load-bearing forces in connecting horn to the distal phalanx. Horizontal alignment of fibrils was observed in the sole. In presenting the long axis of cells to the ground surface this orientation may facilitate erosive forces and contribute to the thinning of cornified sole horn under adverse underfoot conditions.