Plantar Flap Research Articles

Clinical Uses of NPWT with Irrigation of Normal Saline in Diabetic Foot Ulcer: Outcome Assessed by DEPA Score.

Introduction:Diabetic foot ulcer (DFU) is a common complication of uncontrolled diabetes. Negative pressure wound therapy (NPWT) with irrigation of normal saline is one of the methods for wound care and dressing techniques in DFU. Wound assessment is another aspect of DFU management for deciding whether the wound is prepared or not for coverage. The present study uses DEPA score as a wound assessment tool in DFU.Materials and Methods:This case series include 11 patients with DFU who were treated using NPWT with simultaneous irrigation of normal saline.Results:All 11 patients were male and age more than 60. Most patients have duration of diabetes for less than 10 years. Staphylococcus aureus (n = 5, 45.4%) was most common bacterial flora. Most patients in series presented with DEPA score more than 7 and after application of NPWT instillation therapy significant improvement seen with score in most of the patient with DEPA score below 6. Mean time for NPWT (irrigation) application was 15 days. Mean time of wound preparation was 18.7 days. Final surgical procedures executed in all patients, split skin grafting performed in 7 patients. 4 patients had wound coverage by reverse sural flap (2), medial plantar flap (1) and local flap coverage (1).Conclusion:NPWT with normal saline irrigation is an effective method of wound preparation in DFU. DEPA score is an important tool for assessment of wound preparation which gives exact information for timing of wound coverage once diabetic foot wound is prepared.

A Case of Extensive Heel Degloving Injury Reconstructed with Pedicled Medial Plantar Flap and Posterior Tibial Artery Perforator Flap

A Case of Extensive Heel Degloving Injury Reconstructed with Pedicled Medial Plantar Flap and Posterior Tibial Artery Perforator Flap

Sensory Reconstruction of a Posterior Heel Defect Using a Proximally Based Sensate Medial Plantar Flap with Retrograde Nerve Cleavage Technique.

Reconstruction of posterior heel defects is important because it requires thick and durable skin that can withstand pressure and shear from shoe and bed contact. Therefore, the sensate flap could be a better option for the defect. This paper reports on the safety of a medial plantar sensory flap for these defects as well as an objective measurement of the sensation of the medial plantar flap and the plantar surface distal to the donor site. Twelve patients had soft-tissue defects in the posterior heel and underwent reconstructive surgery using a proximally based sensate medial plantar sensory flap. Cases of plantar defects involving not posterior heel were excluded. For wider flap coverage, special neurovascular dissection was required. We evaluated levels of sensation quantitatively using Semmes-Weinstein (SW) monofilaments and a two-point discriminator at the final follow-up. All flaps survived without major complications. Postoperative follow-up was 12 to 64 months (mean 26 months). All 12 flaps healed without postoperative complications. There was no significant difference in minimal two-point discrimination and SW evaluator size between the transferred medial plantar flap area and the contralateral heel area or between the plantar area distal to the donor site and the contralateral side. Patients could walk normally and sleep without protective shoes or brace. A proximally based sensate medial plantar flap is a good option for the reconstruction of posterior heel defects. It can restore the characteristics of the posterior heel for shoe wearing and sleeping.

Increasing the Reach of the Submental Artery Island Flap Using the Y-V Pedicle Lengthening Technique: Video and Technical Considerations.

This article and instructional video detail a step-by-step approach to performing the Y-V venous pedicle lengthening technique, which can be used to increase the reach of the submental artery island flap by up to 5 cm, permitting reconstruction of soft-tissue defects of the middle and upper thirds of the face. This technique can also be used to maximize advancement of many common flaps around the body, including the medial plantar and lateral arm flaps.

Free Flap Reconstruction of Extremity Defects in Pediatric Patients

Abstract Background Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients. Methods From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). Results A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100). Conclusion The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.

The instep flap for anterior ankle coverage with bone and hardware exposure.

The instep medial plantar flap is a well-known flap based on the medial plantar artery of the foot and usually used for coverage of soft tissue defects of the heel area. It has seldom been reported for coverage of anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures. The primary purpose of this study is to evaluate the feasibility and viability of this flap as well as its reliability saving the internal fixation devices and efficiency protecting bone healing; the secondary purpose is to assess the condition of the flap and its cosmetic appearance, as well as occurrence of complications related to its harvesting. This is a retrospective review of medical records of patients operated from December 2015 to December 2020 with application of an instep flap for coverage of the anterior ankle area with exposure of the bone and metallic hardware secondary to open reduction and internal fixation of distal tibial fractures. All patients were reviewed for the purpose of this study; they were assessed for the viability and functional and sensory condition of the flap, signs of local infection, as well as for residual pain and sensory impairment of the toes; subjective cosmetic appearance of the flap was also judged. There were four patients with 32years mean age and 35months mean follow-up. The mean flap size was 7.75cm × 5.75cm. At final follow-up, all fractures were completely consolidated, and all flaps were living, stable, and sensitive. No distal sensation disturbance was noticed, and none of the patients had pain or annoyance caused by the flap or presented signs of infection. Only one patient expressed mild aesthetic complain. The fascio-cutaneous instep medial plantar flap is a reliable solution to cover the anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures, especially for defects measuring up to 9cm × 6cm. This flap is technically valid and reproducible; it offers good quality of soft tissue coverage with satisfactory cosmetic appearance and minimal morbidity.

Efficacy and safety of free medial plantar flap in repair of the high-voltage electrical burns in hands.

The purpose of this work was to validate the efficacy and safety of free medial plantar flap in repair of hand wounds resulted from high-voltage electrical burn. 22 patients with high-voltage electrical burn wounds were retrieved between July 2016 and July 2018 in the Affiliated Zhengzhou Central Hospital of Zhengzhou University. All the wounds were the entrance of high-voltage electrical current. After thorough debridement, the blood vessels, nerves, tendons, joints were exposed to defects with different degrees. The soft tissue defects were repaired with the free medial plantar flap repair in 12 patients and medium-thickness skin graft in 10 patients. Postoperative management was similar between the two groups. All the operations were completed within 6h. In the free medial plantar flap group, the mean follow-up period was (11.3 ± 2.4) months, ranging from 9 to 15months, and all flaps survived; there were no vessel crises. Flaps of 10 patients healed without any complications, and local necrosis occurred in two cases, with healing after debridement. The two-point discrimination (TPD) was 7.0-11.0mm, and the mean DASH score was 45.6 ± 7.4. In the medium-thickness skin graft group, the mean follow-up period was (10.9 ± 1.8) months. All flaps survived, and local contracture occurred in 3 cases. The TPD was 8.0-11.0mm, and the mean DASH score was 60.7 ± 9.3. The free medial plantar flap is an ideal option for repairing the hand soft defects resulted from the high-voltage electrical burn.

Anterior tibial artery injury is not the contraindication of medial plantar flap: digital subtraction angiography evidence and clinical application

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF.

Treatment of volar defects of the finger using dorsal digital\u2013metacarpal flap versus free medial plantar artery flap: a comparative study

BackgroundThe treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital–metacarpal flap (DDMF) in finger reconstruction.MethodsThis retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment.ResultsAfter more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005).ConclusionMPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.

Reconstructive surgery of complex calcaneal defects using the medial plantar flap posttreatment of acral melanoma

Reconstructive surgery of complex calcaneal defects using the medial plantar flap posttreatment of acral melanoma

A Novel Approach to Limb Salvage: Healing Transmetatarsal Amputations without a Viable Plantar Flap

The lack of a viable plantar flap in patients undergoing transmetatarsal amputation has been considered an indication for below-knee amputation (BKA). In an effort to reduce limb loss in this patient population, we sought to review our experience with transmetatarsal amputation salvage in patients with an open, guillotine transmetatarsal amputation. We hypothesized that performing a transmetatarsal amputation without a viable flap would extend time of independent ambulation and improve limb salvage. This is a retrospective review of 27 consecutive patients who did not have a viable plantar flap and who underwent an open, guillotine transmetatarsal amputation. Patients presented with a nonviable plantar flap due to either extensive tissue loss on initial presentation, or secondary transmetatarsal amputation (TMA) flap necrosis. Patients initially underwent an open, guillotine TMA for control of infection and debridement of nonviable tissue. To achieve best results, during procedure, the metatarsals were resected to be as flush with soft tissue as possible. Once infection was resolved and all nonviable tissue debrided, negative pressure wound therapy (NPWT) was applied to the open wound. NPWT was continued until a base of granulation tissue covered the previously exposed bone. Wound closure was obtained by either the application of a split-thickness skin graft (STSG) or through continued NPWT allowing the wound to heal by secondary intention. Between January 2016 and December 2018, there were 27 open TMAs performed in 27 patients. Two patients did not granulate sufficiently and underwent BKA. Fourteen patients underwent STSG for closure, whereas 11 patients continued with NPWT. In the STSG group, 12 (86%) of the patients are healed, with a median time to complete healing of 75days (range 28-330days); the remaining 2 are ambulatory and undergoing continued wound care. In the 11 patients who did not receive STSG, 7 (64%) are healed with a median time to heal of 165days. Of the remaining 4 patients in this group, 3 are ambulatory and still undergoing wound care, one was lost to follow-up. Overall, 19 patients (70%) have completely healed with a median time to heal of 82days. Limb salvage in patients with a nonviable plantar flap for TMA is possible and should be a considered procedure. This technique has the potential to improve functional outcomes and limb salvage in patients who might otherwise undergo BKA.

Application of Digital Subtraction Angiography in Reconstruction of Plantar Forefoot With Reverse Medial Plantar Flap.

The reverse medial plantar flap (RMPF) raised from the nonweight-bearing region of the plantar foot represents a viable option for the soft tissue defect in planter forefoot. The anatomical basis of RMPF is the complex anastomotic branches between medial plantar artery (MPA) and deep plantar arch. Those anastomotic branches have high variation rate and may be damaged by trauma such as electric injury. Therefore, it is very important to know whether those anastomotic branches are present and intact before harvesting RMPF. Five patients with soft tissue defect in planter forefoot were enrolled into the study. The digital subtraction angiography (DSA) was performed to evaluate the plantar hemodynamics in the ipsilateral foot. The RMPF was harvested only after the anastomotic connections between MPA and deep plantar arch was confirmed. Anastomosis between superficial branch of MPA and deep plantar arch was observed in all DSA examinations. All 5 patients received the repair of soft tissue defect in plantar forefoot with RMPF. All flaps survived completely. The DSA can effectively evaluate the blood supply basis of RMPF and provide imaging evidence for the design and harvest of the flap. The main anatomical basis of RMPF is the anastomotic connections between superficial branch of MPA and deep plantar arch.

Free Medial Plantar Flap Versus Free Dorsal Myocutaneous Flap for the Reconstruction of Traumatic Foot Sole Defects.

Trauma can cause large defects in the weight-bearing foot sole. The reconstruction of such defects poses a major challenge in providing a flap that is durable, sensate, and stable. The pedicled medial plantar flap has been commonly used for reconstructing heel and plantar forefoot defects; however, the ipsilateral instep region is usually compromised by trauma. The purpose of this article was to report the use of contralateral free medial plantar flaps for the coverage of weight-bearing plantar defects and to compare these with distant free flaps. Between 2005 and 2019, 15 patients (10 men and 5 women) with weight-bearing foot plantar defects were treated with a contralateral medial plantar flap, 11 (7 men and 4 women) with either a latissimus dorsi flap or a scapular flap. The average age was 18.07 ± 10.14 years (range, 4-34 years) and 26.55 ± 13.05 years (range, 13-56 years), respectively. Surgery was performed as a primary or secondary reconstruction after a trauma by the same surgical team. The mean size of defects was 9.73 ± 3.55 × 6.43 ± 2.8 cm in the contralateral free medial plantar flap group and 17.14 ± 6.84 × 11.41 ± 4.29 cm in the free dorsal flap group. All flaps survived in both groups. In the instep flap group, the appearance was satisfactory, the flap was durable, and tactile sensation was preserved in all patients, and none required a revision procedure. Two patients experienced delayed union of the donor-site grafted skin. In the dorsal flap group, 5 patients complained of a partial necrosis or delayed union at the recipient site, and 9 developed recurrent ulcerations over the weight-\bearing area. Five patients achieved only partial sensation in the flap. The contralateral medial plantar flap provides superior appearance, duration, and sensation over distant muscle flaps, without recurrent ulcerations. However, dorsal myocutaneous flaps may be used as a substitute when the defects are beyond the maximum boundaries of the instep area or are combined with bone loss.

A Novel Approach to Limb Salvage: Healing Transmetatarsal Amputations Without A Viable Plantar Flap

The lack of viable plantar flap in patients undergoing trans-metatarsal amputation (TMA) has been considered an indication for below knee amputation (BKA). In an effort to reduce limb loss in this patient population, we sought to review our experience with limb salvage in patients with an open, guillotine TMA.

Reconstruction of the distal lower leg and foot sole with medial plantar flap: a retrospective study in one center

Soft tissue reconstruction of the distal lower leg and foot sole is a challenge for surgeons. In this article, we describe our experience and outcomes with distal lower leg and foot sole reconstruction using the medial plantar flap. From January 2007 to December 2017, 29 consecutive patients from our department underwent reconstruction of soft tissue defects over the distal lower leg, heel and plantar forefoot using medial plantar flaps. Of the 29 patients, the defects were located in the distal lower leg (n = 8 [27.6%]), heel (n = 14 [48.3%]) and plantar forefoot (n = 7 [24.1%]). The mean follow-up period was 18.6 months, 28 (96.6%) survived completely. Lateral partial necrosis occurred in one flap. No patient had recurrence of ulcer and two (6.9%) patients died within 1 year post-reconstruction owing to metastatic malignant melanoma. At last follow-up, all survived patients could walk for more than 1 h in normal shoes. All donor sites were covered with a split-thickness skin graft, no early nor late complications were encountered, and no patients complained about the donor site scar. The medial plantar flap may be considered as an effective method for the repair of small to medium soft tissue defects in the distal lower leg, heel and plantar forefoot.

Successful Balanced Gait after Reconstruction of the Weight-bearing Mid Plantar Region Using a Free Contralateral Medial Plantar Flap

Summary:Although soft tissue sarcoma, especially in the sole of the foot, is a rare disease, weight-bearing region reconstruction considering postoperative gait is needed. For functionally satisfactory sole reconstruction, it is important to cover the weight-bearing region with a nonbulky but durable skin paddle that can withstand a significant amount of shear pressure. We herein present a case in which a free contralateral medial plantar flap was used for reconstruction of the weight-bearing mid plantar region for a 41-year-old man who suffered from mid-foot sarcoma. Gait analysis was performed 6 months after the operation with the lower limb loading gauge sheet, and the result indicated that postoperative balanced gait was obtained. The free medial plantar flap transfer after sole sarcoma resection has several advantages. First, the characteristic of this flap with solid anchoring to deep tissue to resist shearing makes it possible to lower the chances of postoperative ulceration. Second, the medial plantar flap has optimal thickness and good color and texture match for sole reconstruction. Third, a sensate flap can be achieved if the medial plantar nerve is included. Although further clinical investigations such as long-term follow-up will be required to confirm its efficacy, this method would be one option for treating sole sarcoma.

Medial Plantar Flap for Hand Reconstruction: A Systematic Literature Review and Its Application for Post-Sarcoma Excision.

The reconstruction of soft tissue defects on the volar aspect of the hand represents a special challenge for the hand surgeon. Even though local and regional options have been described, in some cases because of their complexity, a free flap is preferred. The medial plantar free flap offers a unique reconstructive alternative by providing glabrous skin resurfacing for the palm and digits. The aim of this article is to present a systematic literature review on the use of the medial plantar free flap for hand surgery and a case report in which this flap was used for reconstructing a thenar eminence defect after sarcoma excision. Twenty-five relevant articles were found, and their findings are included in our study. The fasciocutaneous medial plantar flap and its musculocutaneous, flow-through, venous, perforator, and chimeric variants offer a wide range of reconstructive options for complex hand injuries.

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.

Medial Plantar Venous Flap: Classic Donor Site Modification for Hand Defects.

Destruction of digits from trauma results in a much more significant influence on patients' mental state and quality of life than do injuries to other parts. The purpose of this study was to describe a novel modification of medial plantar venous flap for soft tissue defects in the hands and digits. Nine patients received medial plantar venous flap to resurface soft tissue defects in the hands or digits between January 2015 and February 2017. This flap can be used either in a free-island pattern or in a flow-through pattern through the medial branch of the great saphenous vein. All patient data including preoperative statues and follow-up examinations (flap survival rates, complication rates, total active motion, static 2-point discrimination, and Semme-Weinstein test score) were analyzed. We included 6 men and 3 women, with a mean age of 34.2 years. The medial plantar venous flaps were used for vascularization in 5 patients because of segmental defects of bilateral digit arteries. Eight flaps survived uneventfully in this study. One flap partially failed (20% of the flap area) because of venous congestion. The functional outcomes and sensory restoration were satisfied for all 9 flaps. Compared with the traditional medial plantar flap, the medial plantar venous flap involves a simpler surgical procedure and allows for revascularization of distal areas using the flow-through technique. Furthermore, the medial plantar area presents a sensitive, glabrous skin with proper bulkiness and allows for movement of the underlying structure.

Repair of cicatricial contracture deformity of palm with modified free medial plantar flap with preserved abductor hallucis

To investigate the effectiveness of modified free medial plantar flap with preserved abductor hallucis for repairing cicatricial contracture deformity of palm. Between January 2012 and July 2017, a modified free medial plantar flap with preserved abductor hallucis was used to repair 9 cases of cicatricial contracture deformity at the palm. There were 7 males and 2 females with a median age of 23 years old (range, 15-40 years). The duration of cicatricial contracture was 4-23 years (mean, 9 years). In addition, 3 cases had combined stiffness of finger joints, 2 cases of tendon exposure, and 2 cases with exposed tendon and nerve. The range of flap was 4.5 cm×4.0 cm to 8.0 cm×6.0 cm. The vessel pedicle of the flap was 7-8 cm in length, with an average length of 7.5 cm. Grafting and repairing were performed with full-thickness skin graft from the ilioinguinal region in the donor site. All flaps and skin grafts survived after operation, and all wounds healed at first intention. All 9 patients were followed up 5-22 months (mean, 10 months). The flap exhibited smooth appearance and soft texture, which was similar to that of the normal skin around. The recovery time of dermal sensation was 5-12 months (mean, 9 months). At last follow-up, the flap recovered to level S 4 in 5 cases, level S 3 in 3 cases, and level S 3 in 2 cases. The two-point discrimination was 6.0-10.0 mm (mean, 8.5 mm). According to the assessment of the upper limb function issued by the Hand Surgery Society of Chinese Medical Association, the hand function was excellent in 5 cases, good in 2 cases, and fair in 2 cases. Additionally, the abduction and flexion activities of the great toe of the donor foot were not affected, and the skin grafting area was slightly colored. The modified free medial plantar flap for repairing cicatricial contracture deformity of palm has such advantages as no impact on abductor hallucis, small damage of the donor area, improved survival rate of skin grafting, and the unaffected function of the donor foot.