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Traumatic Forefoot Reconstructions With Free Perforator Flaps
The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Traumatic Forefoot Reconstructions With Free Perforator Flaps Yue-Liang Zhu, MD, Xiao-Qing He, MD, Yi Wang, MD, Qian Lv, BS, Xin-Yv Fan, MD, Yong-Qing Xu, MD Surgeon, Orthopaedic Department, Kunming General Hospital of Chengdu Military Region, Kunming, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: flap forefoot injury plastic and reconstructive surgery tissue loss
The forefoot is critically important for normal walking. The loss of the base of the proximal phalanx of the great toe disrupts the plantar aponeurosis and the windlass mechanism and destabilizes the medial longitudinal arch. This destabilization decreases weightbearing on the first metatarsal head and transfers it to the lesser metatarsal heads (1). If the base of the proximal phalanx of one of the lesser toes is removed, similar instability will occur, but to a much lesser degree, particularly moving laterally across the foot (2). The shortened ray also causes increased stress and callus formation beneath the adjacent metatarsal head, which is subjected to increased weightbearing (3). Any reconstruction of the soft tissue defects of the forefoot, therefore, is worthwhile. Modern flap surgery has made the preservation of the distal forefoot possible. The free perforator flap is more suitable than local flaps for forefoot coverage because the antegrade arterial blood flow and retrograde venous return provide better circulation. Any distally pedicled flap for forefoot coverage will have nonphysiologic blood circulation because the arterial blood flows retrogradely and the venous blood flows from proximally to distally. However, the free perforator flap is generally more difficult and time-consuming to use than classic free transfers. When appropriately chosen and managed, the flap can greatly improve Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Yong-Qing Xu, MD, Orthopaedic Department, Kunming General Hospital of Chengdu Military Region, No. 212, Daguan Road, Kunming, Yunnan Province 650032, China. E-mail address: [email protected] (Y.-Q. Xu).
functional outcomes of the foot results in less donor site morbidity. It is thick enough to allow the reconstructed foot to be accommodated to reasonable footwear without a second debulking. During the past 20 years, we have tried nearly all the flap techniques for foot coverage. In the present study, we report our experience with free perforator flaps in treating patients with partial amputation of the forefoot. Patients and Methods We reviewed our experience of consecutive patients presenting to the Department of Orthopaedic Surgery at Kunming General Hospital from January 2007 to December 2012 with traumatic injuries and soft tissue defects over the forefoot, including metatarsal or phalanx fractures, defects, and dislocations. We did not include patients who had undergone emergency amputation of their foot. Before the definite flap operation, any dead bone or tissue was debrided. If the wound had much effusion liquid or pus, the debridement operation would be repeated until fresh granulation tissue was grown. We used vacuum-assisted closure to help in preparation of the wound. If the patient had a fever or a low hemoglobin level, we would treat those conditions first. To begin the flap surgery, a Doppler probe was routinely used to decide on the optional perforators for the flaps. Each flap was designed to meet the needs of each wound, although all flaps were 1 cm larger than the length and width of the wound. We used 2 surgical teams, 1 team (the first 3 of us [Y.-L.Z., X.Q.H., Y.W.]) to harvest the flaps and perform microsurgical anastomosis and 1 team (Q.L., X.-Y.F., Y.Q.X.) to expose the recipient site and close the donor site. We began by incising only 1 edge of the skin flap so the skin paddle can be altered according to the feeding vessel selected. The dissection proceeded at the subfascial level. At this level, the perforators could be easily located. Blood-free, clean dissection was achieved by separating the tissue with a knife and direct ligation of the vessel branches. Once a clear view of the main perforator had been
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.04.019
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Table Perioperative complications and treatment of forefoot deformities reconstructed with free perforator flaps Complications
Patients (n)
Treatment
Results
Insufficient circulation of flap margins Too bulky; difficulty with shoe wear Vein or artery thrombosis Partial flap necrosis Chronic subflap infections Deformity union of bones Mild varus deformity Equinus deformity Delayed healing of donor site
5 5 3 2 2 2 1 1 1
Continuous massage for 72 hr Second debulking Re-exploration Dress change Daily wound caring None None Ilizarov techniques None
Healed Normal shoe wear 1 saved; 2 lost Secondary healing Healed Normal foot walking Normal gait Deformity corrected Healed
established, we follow the vessel through its intramuscular course. Usually we would leave a cuff of fascia around the vessel. At the point at which the perforator entered the muscle, the muscle fibers were split in both directions using blunt dissection. Every side branch was ligated until a sufficient pedicle length was obtained. We did not use coagulation or clipping. For certain flaps, such as a free anterolateral thigh perforator flap, which had a long pedicle, we would dissect the pedicle in reverse direction (i.e., we started the pedicle dissection where it descended from the source artery). From proximally to distally, we ligated all the side branches until the perforators had entered into the deep fascia. When the pedicle had been dissected and carefully preserved, the other edge of the skin flap was dissected quickly, and the whole flap was taken down. It was then inset into the recipient bed using skin suturing. The flap pedicle was anastomosed to the recipient vessels under a microscope. In some cases, we used a fillet flap to help cover the distal forefoot and decrease the size of the simultaneous free perforator flap. The sensory nerves were not coapted. The dorsal pedal vessels were most often used for microvascular anastomosis. Fractures or dislocations were also reduced and fixed with Kirschner wire fixation during flap transfer. Postoperatively, the patients were monitored in hospital for 3 to 5 days and then transferred to a rehabilitation unit. The dressings were changed with special care during this period, because it is the key time for survival of the transferred flap. Problems with venous perfusion, which usually occurred in the distal flap if they developed, were treated with 72 hours of continuous massage on the flap. This massage was done by the finger pressing and releasing repeatedly on the distal flap and was usually successful. It could also be performed by the patient’s nurse or relatives.
Results We treated 41 patients (mean age, 30 years; range, 13 to 56 years; 33 males and 8 females). Of the 41 defects, 22 (53.7%) were in the dorsal forefoot, 4 (9.8%) in the plantar forefoot, and 12 (29.3%) in the distal forefoot; 3 (7.3%) were mega-size defects that included the midfoot or hindfoot. The injuries had been caused by traffic accidents in 11 (25.6%), crushing forces in 19 (46.3%), mechanical accidents in 8 (19.5%), and an electrical accident in 1 (2.4%). Only 4 patients (9.8%) had intact bones and joints of the foot. All other patients had metatarsal or phalanx fractures, defects, dislocations, or amputations. The size of the soft tissue defects ranged from 3 2 cm to 28 6 cm. We used 32 free anterolateral thigh perforator flaps (78.0%), 2 free fibular flaps (4.9%), 5 free lateral arm perforator flaps (12.2%), 1 free medial arm perforator flap (2.4%), and 1 free thoracodorsal artery perforator flap (2.4%). After discharge, the patients were followed up on an outpatient basis. The follow-up period started from the day the patient was discharged. It lasted 18 months. In the present series, the follow-up period was 26.7 9.3 (range 18 to 45) months. Partial weightbearing was begun at 3 weeks, and gait recovery was usually acceptable by 3 months. Full weightbearing began after full union of the flap and fractures.
Fig. 1. (A) The right foot of a 19-year-old female became partially necrotic 1 week after primary debridement. (B) After the second debridement and 2 weeks of daily wound nursing, the wound was clean. (C) When harvesting a free anterolateral thigh perforator flap, one half of the subcutaneous fat was left in situ (1-stage debulking). The flap thickness was already considerably decreased. (D) After 3 months, the flap had healed well but was too bulky. The patient had trouble wearing shoes, especially when the ankle was dorsiflexed. (E) The flap was thinned a second time, and the dorsal contours of the feet were now the same. She had no more trouble wearing shoes. (F) The plantar aspect of the foot showed a satisfactory flap form.
Y.-L. Zhu et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Of the 41 flaps, 3 required repeat exploration: 1 was saved, but 2 were lost. On recognition of anastomotic failure or venous congestion, intravenous urokinase (40 mg) was given. If no signs of resolution were seen within 1 hour, the patients were returned to the operating room for re-exploration. For artery thrombus, we cut the anastomosis ends, removed the thrombus, and re-anastomosed the arteries. For vein thrombus, we cut the anastomosis of the anastomosed ends, milking the flap or vessels gently to push the thrombus out, and reanastomosed the vein ends. If we found the original recipient vessels were no longer suitable for reanastomosis, a healthy neighboring vessel was used. The flap was repositioned for convenience of the reanastomosis. The remaining 38 flaps survived completely, although other complications developed (Table). Most patients regained protective sensation within 4 to 7 months postoperatively, although the flap nerve had not been coapted. Case Reports Patient 1
3
necrosis developed 1 week after debridement. After the second debridement, we waited 9 days until the wound was clean to transfer the flap. A free anterolateral thigh perforator flap was harvested with 1-stage debulking. We had hoped 1 debulking procedure would be sufficient; however, 3 months later, the flap still seemed to be too large. The patient reported trouble wearing shoes. A second debulking procedure provided satisfactory results. This case illustrates the strict requirements of flap thickness for the dorsal forefoot (Fig. 1). Patient 2 A 29-year-old male had minor soft tissue defects of the forefoot. Local flaps could hardly reach the sites with intact circulation. We chose the medial arm perforator flap for only 1 reason: it is thin and would not require secondary debulking. The aesthetic result was satisfactory. The only disadvantage of this flap, or the lateral arm perforator flap, is its limited size. Medial arm perforator flaps are suitable for small to midsize defects of the distal foot (Fig. 2). Patient 3
The right foot of a 19-year-old female had been crushed by a machine. During primary debridement, the skin was sutured and open metatarsal fractures were fixed using Kirschner wires. Partial
A 19-year-old male had had his left great toe crushed under a machine. The distal phalanx of the toe had become necrotic. We tried
Fig. 2. The left foot of a 29-year-old male after being crushed by falling stones. (A) The defect was minor and could be covered by a flap from the upper arm. (B) The design of the medial arm perforator flap was based on the Doppler mark. (C) Two perforators could be seen during the harvest, and only the larger one was chosen as the flap pedicle. (D) The flap had been taken down. The perforator calibers were very small but could match the dorsal pedal vessels. (E) Two months after flap transfer, the appearance of the foot was satisfactory, and a second debulking procedure was not needed.
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Fig. 3. (A) Dorsal and (B) plantar views of the crushed great toe of a 19-year-old male. (C) We used a triangle design (20 cm 4 cm) to cover the defect so the donor site could be directly closed. (D) The flap was taken down. (E,F) The color and contour of the flap matched the surrounding skin at 6 months after surgery. (G) Preoperative and (H) postoperative radiographs of the great toe showing bony healing. (I) The shoe size of both feet was the same.
to preserve the proximal phalanx to save as much function of the first ray as possible. The lateral arm perforator flap was designed and transferred. The flap healed uneventfully, and the comminuted fractures of the proximal phalanx head healed simultaneously under this flap. Both feet could wear the same size shoe. The lateral arm perforator flap is also excellent for covering the forefoot because secondary thinning is not necessary (Fig. 3).
Patient 4 The right foot of a 57-year-old male had been crushed under a machine. The initial treatment was managed by a local hospital. Seven days later, the skin of the dorsal and distal foot was black, and he was transferred to our center. During debridement, the remaining toes were amputated. We designed a long, narrow,
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5
Fig. 4. (A) The crushed right foot of a 57year-old male had skin defects after debridement and toe amputation. (B) The design of a long and narrow anterolateral thigh perforator flap (30 cm 4 cm). (C) The value of this flap is that the donor site could be directly sutured without the need for skin grafts, and the flap was long enough to cover the most distal forefoot, avoiding shoe friction. (D) The inset flap was wound over the dorsal foot and metatarsal heads. (E) At 5 months after surgery, the metatarsal heads were well protected by the flap.
anterolateral thigh perforator flap to cover the skin defect. With such a design, the donor site could be directly closed, and the distal foot avoided pressure from the shoe tips, which can lead to pain and sores. The other parts of the defects were corrected with skin grafts. The patient was pleased with the result, because the maximal length of the foot was preserved, and he had rather a normal gait (Fig. 4). Discussion The movement of the center of pressure along the bottom of the foot in a normal person follows a consistent pattern. The center of pressure moves distally rapidly after the heel strike. Pressure then dwells beneath the metatarsal head for 30% to 55% of the cycle, after which it moves rapidly out toward the great toe. When the great toe is lost, the pressure tends to dwell more laterally in the metatarsal area and then passes out toward the third toe (1). The great toe, just as is the thumb among the fingers, is the most important among the toes.
During running and changing direction and during acceleration and deceleration, the toes play an active role in push-off (2). Push-off from the metatarsals cannot be achieved without the forefoot. We tried to save as much of the functioning foot as possible. The 2 qualifications of that principle are that the salvaged foot must achieve complete healing with a stable soft tissue envelope and that the foot must be sufficiently plantigrade to be functional. Skin grafts are only suitable for foot wounds without tendon or bone exposures, and they cannot be used at the weightbearing sites or on the distal foot, which bears repeated friction from the shoe tip. The distally based sural neurocutaneous flap, superficial peroneal neuroadipofascial turnover flap, and lateral supramalleolar island flap are common pedicled flaps for foot reconstruction (4–6). They are effective for the hind- and midfoot. Partial necrosis along the distal margin of the flap is common, however. This complication occurs more often when they are used to resurface the forefoot, given their relatively high pivot points and long transfer distance. The blood supply of these reverse flaps is not reliable enough to support distal
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transfers. The crossover reverse sural artery flap is not an optimal choice because the prolonged postoperative immobilization of both legs is a great inconvenience to patients (7). Limited reports have been published on the use of local flaps for forefoot coverage, such as the dorsal metatarsal V-Y advancement flap, reversed island flaps, reverse first dorsal metatarsal artery flap, distally based islanded dorsal flap, dorsal pedal neurocutaneous flap, retrograde-flow medial plantar island flap, reverse flow digital artery pedicle flap, and digital fillet flap (8–18). These flaps have the disadvantages of limited size and the requirement of a donor site, which is always impossible in traumatic foot injuries. Free muscle flaps with skin grafts or musculocutaneous flaps are too bulky for the distal foot. After much testing of these flaps, we chose the free perforator flap as the flap of choice to provide coverage of the distal forefoot. Weinzweig and Davies (19) reported stable and aesthetically acceptable results with the radial forearm flap for foot reconstruction, suggesting that this flap is an almost ideal foot flap. In addition, we also favor the free lateral arm perforator flap and medial arm perforator flap. We prefer free perforator flaps from the arm for midsize or small defects and the use of a free anterolateral thigh perforator flap only for large defects. If 2 perforator vessels are harvested, the anterolateral thigh perforator flap would be large enough to cover the whole foot. The donor site morbidity of this flap can be minimal. When the width is no more than 7 cm in adults, the donor site can be directly and safely closed. Certain complications, such as chronic infection under a flap, have not been commonly reported. Two cases of chronic infection in our series healed secondarily. Avoiding such complications is difficult; however, we believe 2 precautions will be helpful. The first is to thoroughly debride the devitalized bone and soft tissue. The second is to be patient before deciding which flap to use. Initially, in some wounds, the border between the dead and living tissue will not be obvious. We waited and observed until the borders were more clearly defined. Usually 2 weeks will be long enough for such an observation period. In conclusion, we believe that forefoot preservation with a free perforator flap will provide better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used. Reconstructing the soft tissues of the forefoot is an important, if often unappreciated, part of foot and ankle surgery.
References 1. Mann RA, Haskell A. Biomechanics of the foot and ankle. In: Surgery of the Foot and Ankle, ed 8., pp. 2–42, edited by MJ Coughlin, RA Mann, CL Saltzman, Mosby, Philadelphia, 2007. 2. Dubbeldam R, Buurke JH, Simons C, Groothuis-Oudshoorn CG, Baan H, Nene AV, Hermens HJ. The effects of walking speed on forefoot, hindfoot and ankle joint motion. Clin Biomech (Bristol, Avon) 25:796–801, 2010. 3. Jacob HA. Forces acting in the forefoot during normal gaitdan estimate. Clin Biomech (Bristol, Avon) 16:783–792, 2001. 4. Bharathwaj VS, Quaba AA. The distally based islanded dorsal foot flap. Br J Plast Surg 50:284–287, 1997. 5. Chang SM, Hou CL, Liu DX. Distally based superficial peroneal neuroadipofascial turnover flap for dorsal foot reconstruction. Ann Plast Surg 45:101–102, 2000. 6. Demiri E, Foroglou P, Dionyssiou D, Antoniou A, Kakas P, Pavlidis L, Lazaridis L. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast Reconstr Surg Hand Surg 40:106–110, 2006. 7. Zgonis T, Cromack DT, Stapleton JJ. Utilizing a crossover reverse sural artery flap for soft tissue reconstruction of the plantar forefoot after a severe degloving injury. Int J Low Extrem Wounds 6:114–119, 2007. 8. Onishi K, Maruyama Y, Yang YL. Longitudinally designed dorsal metatarsal VY advancement flap for middle dorsal foot reconstruction. Br J Plast Surg 50:561– 563, 1997. 9. Pallua N, Di Benedetto G, Berger A. Forefoot reconstruction by reversed island flaps in diabetic patients. Plast Reconstr Surg 106:823–827, 2000. 10. Wang X, Qiao Q, Burd A, Qi K. Reconstruction of distal foot wounds with reverse first dorsal metatarsal artery flap. Burns 31:1025–1028, 2005. 11. Lee YH, Rah SK, Choi SJ, Chung MS, Baek GH. Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle. Plast Reconstr Surg 114:1478–1485, 2004. 12. Xu YQ, Zhu YL, Wu NX, Li J, Yang J, He XQ. Distal foot coverage with reverse dorsal pedal neurocutaneous flaps. J Plast Reconstr Aesthet Surg 63:164–169, 2010. 13. Huang W, Liu D, Robb GL, Zhang Q. Distally based dorsal pedal neurocutaneous flap for forefoot coverage. Ann Plast Surg 66:235–240, 2011. 14. Uygur F, Duman H, Ulkur E, Noyan N, Celikoz B. Reconstruction of distal forefoot burn defect with retrograde medial plantar flap. Burns 34:262–267, 2008. 15. Coruh A. Distally based perforator medial plantar flap: a new flap for reconstruction of plantar forefoot defects. Ann Plast Surg 53:404–408, 2004. 16. Tsai J, Liao HT, Ulusal BG, Chen CT, Lin CH. Modified retrograde-flow medial plantar island flap for reconstruction of distal dorsal forefoot defectsdtwo case reports. Microsurgery 30:146–150, 2010. 17. Ramanujam CL, Zgonis T. Reverse flow digital artery pedicle flap for closure of diabetic forefoot ulceration. Diabet Foot Ankle, 2010 Jun 1. 18. Yarmel D, Dormans JP, Pawel BR, Chang B. Recurrent pedal hobnail (Dabska-retiform) hemangioendothelioma with forefoot reconstructive surgery using a digital fillet flap. J Foot Ankle Surg 47:487–493, 2008. 19. Weinzweig N, Davies BW. Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases. Plast Reconstr Surg 102:1999–2005, 1998.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Traumatic Forefoot Reconstructions With Free Perforator Flaps Yue-Liang Zhu, MD, Xiao-Qing He, MD, Yi Wang, MD, Qian Lv, BS, Xin-Yv Fan, MD, Yong-Qing Xu, MD Surgeon, Orthopaedic Department, Kunming General Hospital of Chengdu Military Region, Kunming, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: flap forefoot injury plastic and reconstructive surgery tissue loss
The forefoot is critically important for normal walking. The loss of the base of the proximal phalanx of the great toe disrupts the plantar aponeurosis and the windlass mechanism and destabilizes the medial longitudinal arch. This destabilization decreases weightbearing on the first metatarsal head and transfers it to the lesser metatarsal heads (1). If the base of the proximal phalanx of one of the lesser toes is removed, similar instability will occur, but to a much lesser degree, particularly moving laterally across the foot (2). The shortened ray also causes increased stress and callus formation beneath the adjacent metatarsal head, which is subjected to increased weightbearing (3). Any reconstruction of the soft tissue defects of the forefoot, therefore, is worthwhile. Modern flap surgery has made the preservation of the distal forefoot possible. The free perforator flap is more suitable than local flaps for forefoot coverage because the antegrade arterial blood flow and retrograde venous return provide better circulation. Any distally pedicled flap for forefoot coverage will have nonphysiologic blood circulation because the arterial blood flows retrogradely and the venous blood flows from proximally to distally. However, the free perforator flap is generally more difficult and time-consuming to use than classic free transfers. When appropriately chosen and managed, the flap can greatly improve Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Yong-Qing Xu, MD, Orthopaedic Department, Kunming General Hospital of Chengdu Military Region, No. 212, Daguan Road, Kunming, Yunnan Province 650032, China. E-mail address: [email protected] (Y.-Q. Xu).
functional outcomes of the foot results in less donor site morbidity. It is thick enough to allow the reconstructed foot to be accommodated to reasonable footwear without a second debulking. During the past 20 years, we have tried nearly all the flap techniques for foot coverage. In the present study, we report our experience with free perforator flaps in treating patients with partial amputation of the forefoot. Patients and Methods We reviewed our experience of consecutive patients presenting to the Department of Orthopaedic Surgery at Kunming General Hospital from January 2007 to December 2012 with traumatic injuries and soft tissue defects over the forefoot, including metatarsal or phalanx fractures, defects, and dislocations. We did not include patients who had undergone emergency amputation of their foot. Before the definite flap operation, any dead bone or tissue was debrided. If the wound had much effusion liquid or pus, the debridement operation would be repeated until fresh granulation tissue was grown. We used vacuum-assisted closure to help in preparation of the wound. If the patient had a fever or a low hemoglobin level, we would treat those conditions first. To begin the flap surgery, a Doppler probe was routinely used to decide on the optional perforators for the flaps. Each flap was designed to meet the needs of each wound, although all flaps were 1 cm larger than the length and width of the wound. We used 2 surgical teams, 1 team (the first 3 of us [Y.-L.Z., X.Q.H., Y.W.]) to harvest the flaps and perform microsurgical anastomosis and 1 team (Q.L., X.-Y.F., Y.Q.X.) to expose the recipient site and close the donor site. We began by incising only 1 edge of the skin flap so the skin paddle can be altered according to the feeding vessel selected. The dissection proceeded at the subfascial level. At this level, the perforators could be easily located. Blood-free, clean dissection was achieved by separating the tissue with a knife and direct ligation of the vessel branches. Once a clear view of the main perforator had been
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.04.019
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Table Perioperative complications and treatment of forefoot deformities reconstructed with free perforator flaps Complications
Patients (n)
Treatment
Results
Insufficient circulation of flap margins Too bulky; difficulty with shoe wear Vein or artery thrombosis Partial flap necrosis Chronic subflap infections Deformity union of bones Mild varus deformity Equinus deformity Delayed healing of donor site
5 5 3 2 2 2 1 1 1
Continuous massage for 72 hr Second debulking Re-exploration Dress change Daily wound caring None None Ilizarov techniques None
Healed Normal shoe wear 1 saved; 2 lost Secondary healing Healed Normal foot walking Normal gait Deformity corrected Healed
established, we follow the vessel through its intramuscular course. Usually we would leave a cuff of fascia around the vessel. At the point at which the perforator entered the muscle, the muscle fibers were split in both directions using blunt dissection. Every side branch was ligated until a sufficient pedicle length was obtained. We did not use coagulation or clipping. For certain flaps, such as a free anterolateral thigh perforator flap, which had a long pedicle, we would dissect the pedicle in reverse direction (i.e., we started the pedicle dissection where it descended from the source artery). From proximally to distally, we ligated all the side branches until the perforators had entered into the deep fascia. When the pedicle had been dissected and carefully preserved, the other edge of the skin flap was dissected quickly, and the whole flap was taken down. It was then inset into the recipient bed using skin suturing. The flap pedicle was anastomosed to the recipient vessels under a microscope. In some cases, we used a fillet flap to help cover the distal forefoot and decrease the size of the simultaneous free perforator flap. The sensory nerves were not coapted. The dorsal pedal vessels were most often used for microvascular anastomosis. Fractures or dislocations were also reduced and fixed with Kirschner wire fixation during flap transfer. Postoperatively, the patients were monitored in hospital for 3 to 5 days and then transferred to a rehabilitation unit. The dressings were changed with special care during this period, because it is the key time for survival of the transferred flap. Problems with venous perfusion, which usually occurred in the distal flap if they developed, were treated with 72 hours of continuous massage on the flap. This massage was done by the finger pressing and releasing repeatedly on the distal flap and was usually successful. It could also be performed by the patient’s nurse or relatives.
Results We treated 41 patients (mean age, 30 years; range, 13 to 56 years; 33 males and 8 females). Of the 41 defects, 22 (53.7%) were in the dorsal forefoot, 4 (9.8%) in the plantar forefoot, and 12 (29.3%) in the distal forefoot; 3 (7.3%) were mega-size defects that included the midfoot or hindfoot. The injuries had been caused by traffic accidents in 11 (25.6%), crushing forces in 19 (46.3%), mechanical accidents in 8 (19.5%), and an electrical accident in 1 (2.4%). Only 4 patients (9.8%) had intact bones and joints of the foot. All other patients had metatarsal or phalanx fractures, defects, dislocations, or amputations. The size of the soft tissue defects ranged from 3 2 cm to 28 6 cm. We used 32 free anterolateral thigh perforator flaps (78.0%), 2 free fibular flaps (4.9%), 5 free lateral arm perforator flaps (12.2%), 1 free medial arm perforator flap (2.4%), and 1 free thoracodorsal artery perforator flap (2.4%). After discharge, the patients were followed up on an outpatient basis. The follow-up period started from the day the patient was discharged. It lasted 18 months. In the present series, the follow-up period was 26.7 9.3 (range 18 to 45) months. Partial weightbearing was begun at 3 weeks, and gait recovery was usually acceptable by 3 months. Full weightbearing began after full union of the flap and fractures.
Fig. 1. (A) The right foot of a 19-year-old female became partially necrotic 1 week after primary debridement. (B) After the second debridement and 2 weeks of daily wound nursing, the wound was clean. (C) When harvesting a free anterolateral thigh perforator flap, one half of the subcutaneous fat was left in situ (1-stage debulking). The flap thickness was already considerably decreased. (D) After 3 months, the flap had healed well but was too bulky. The patient had trouble wearing shoes, especially when the ankle was dorsiflexed. (E) The flap was thinned a second time, and the dorsal contours of the feet were now the same. She had no more trouble wearing shoes. (F) The plantar aspect of the foot showed a satisfactory flap form.
Y.-L. Zhu et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Of the 41 flaps, 3 required repeat exploration: 1 was saved, but 2 were lost. On recognition of anastomotic failure or venous congestion, intravenous urokinase (40 mg) was given. If no signs of resolution were seen within 1 hour, the patients were returned to the operating room for re-exploration. For artery thrombus, we cut the anastomosis ends, removed the thrombus, and re-anastomosed the arteries. For vein thrombus, we cut the anastomosis of the anastomosed ends, milking the flap or vessels gently to push the thrombus out, and reanastomosed the vein ends. If we found the original recipient vessels were no longer suitable for reanastomosis, a healthy neighboring vessel was used. The flap was repositioned for convenience of the reanastomosis. The remaining 38 flaps survived completely, although other complications developed (Table). Most patients regained protective sensation within 4 to 7 months postoperatively, although the flap nerve had not been coapted. Case Reports Patient 1
3
necrosis developed 1 week after debridement. After the second debridement, we waited 9 days until the wound was clean to transfer the flap. A free anterolateral thigh perforator flap was harvested with 1-stage debulking. We had hoped 1 debulking procedure would be sufficient; however, 3 months later, the flap still seemed to be too large. The patient reported trouble wearing shoes. A second debulking procedure provided satisfactory results. This case illustrates the strict requirements of flap thickness for the dorsal forefoot (Fig. 1). Patient 2 A 29-year-old male had minor soft tissue defects of the forefoot. Local flaps could hardly reach the sites with intact circulation. We chose the medial arm perforator flap for only 1 reason: it is thin and would not require secondary debulking. The aesthetic result was satisfactory. The only disadvantage of this flap, or the lateral arm perforator flap, is its limited size. Medial arm perforator flaps are suitable for small to midsize defects of the distal foot (Fig. 2). Patient 3
The right foot of a 19-year-old female had been crushed by a machine. During primary debridement, the skin was sutured and open metatarsal fractures were fixed using Kirschner wires. Partial
A 19-year-old male had had his left great toe crushed under a machine. The distal phalanx of the toe had become necrotic. We tried
Fig. 2. The left foot of a 29-year-old male after being crushed by falling stones. (A) The defect was minor and could be covered by a flap from the upper arm. (B) The design of the medial arm perforator flap was based on the Doppler mark. (C) Two perforators could be seen during the harvest, and only the larger one was chosen as the flap pedicle. (D) The flap had been taken down. The perforator calibers were very small but could match the dorsal pedal vessels. (E) Two months after flap transfer, the appearance of the foot was satisfactory, and a second debulking procedure was not needed.
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Fig. 3. (A) Dorsal and (B) plantar views of the crushed great toe of a 19-year-old male. (C) We used a triangle design (20 cm 4 cm) to cover the defect so the donor site could be directly closed. (D) The flap was taken down. (E,F) The color and contour of the flap matched the surrounding skin at 6 months after surgery. (G) Preoperative and (H) postoperative radiographs of the great toe showing bony healing. (I) The shoe size of both feet was the same.
to preserve the proximal phalanx to save as much function of the first ray as possible. The lateral arm perforator flap was designed and transferred. The flap healed uneventfully, and the comminuted fractures of the proximal phalanx head healed simultaneously under this flap. Both feet could wear the same size shoe. The lateral arm perforator flap is also excellent for covering the forefoot because secondary thinning is not necessary (Fig. 3).
Patient 4 The right foot of a 57-year-old male had been crushed under a machine. The initial treatment was managed by a local hospital. Seven days later, the skin of the dorsal and distal foot was black, and he was transferred to our center. During debridement, the remaining toes were amputated. We designed a long, narrow,
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Fig. 4. (A) The crushed right foot of a 57year-old male had skin defects after debridement and toe amputation. (B) The design of a long and narrow anterolateral thigh perforator flap (30 cm 4 cm). (C) The value of this flap is that the donor site could be directly sutured without the need for skin grafts, and the flap was long enough to cover the most distal forefoot, avoiding shoe friction. (D) The inset flap was wound over the dorsal foot and metatarsal heads. (E) At 5 months after surgery, the metatarsal heads were well protected by the flap.
anterolateral thigh perforator flap to cover the skin defect. With such a design, the donor site could be directly closed, and the distal foot avoided pressure from the shoe tips, which can lead to pain and sores. The other parts of the defects were corrected with skin grafts. The patient was pleased with the result, because the maximal length of the foot was preserved, and he had rather a normal gait (Fig. 4). Discussion The movement of the center of pressure along the bottom of the foot in a normal person follows a consistent pattern. The center of pressure moves distally rapidly after the heel strike. Pressure then dwells beneath the metatarsal head for 30% to 55% of the cycle, after which it moves rapidly out toward the great toe. When the great toe is lost, the pressure tends to dwell more laterally in the metatarsal area and then passes out toward the third toe (1). The great toe, just as is the thumb among the fingers, is the most important among the toes.
During running and changing direction and during acceleration and deceleration, the toes play an active role in push-off (2). Push-off from the metatarsals cannot be achieved without the forefoot. We tried to save as much of the functioning foot as possible. The 2 qualifications of that principle are that the salvaged foot must achieve complete healing with a stable soft tissue envelope and that the foot must be sufficiently plantigrade to be functional. Skin grafts are only suitable for foot wounds without tendon or bone exposures, and they cannot be used at the weightbearing sites or on the distal foot, which bears repeated friction from the shoe tip. The distally based sural neurocutaneous flap, superficial peroneal neuroadipofascial turnover flap, and lateral supramalleolar island flap are common pedicled flaps for foot reconstruction (4–6). They are effective for the hind- and midfoot. Partial necrosis along the distal margin of the flap is common, however. This complication occurs more often when they are used to resurface the forefoot, given their relatively high pivot points and long transfer distance. The blood supply of these reverse flaps is not reliable enough to support distal
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transfers. The crossover reverse sural artery flap is not an optimal choice because the prolonged postoperative immobilization of both legs is a great inconvenience to patients (7). Limited reports have been published on the use of local flaps for forefoot coverage, such as the dorsal metatarsal V-Y advancement flap, reversed island flaps, reverse first dorsal metatarsal artery flap, distally based islanded dorsal flap, dorsal pedal neurocutaneous flap, retrograde-flow medial plantar island flap, reverse flow digital artery pedicle flap, and digital fillet flap (8–18). These flaps have the disadvantages of limited size and the requirement of a donor site, which is always impossible in traumatic foot injuries. Free muscle flaps with skin grafts or musculocutaneous flaps are too bulky for the distal foot. After much testing of these flaps, we chose the free perforator flap as the flap of choice to provide coverage of the distal forefoot. Weinzweig and Davies (19) reported stable and aesthetically acceptable results with the radial forearm flap for foot reconstruction, suggesting that this flap is an almost ideal foot flap. In addition, we also favor the free lateral arm perforator flap and medial arm perforator flap. We prefer free perforator flaps from the arm for midsize or small defects and the use of a free anterolateral thigh perforator flap only for large defects. If 2 perforator vessels are harvested, the anterolateral thigh perforator flap would be large enough to cover the whole foot. The donor site morbidity of this flap can be minimal. When the width is no more than 7 cm in adults, the donor site can be directly and safely closed. Certain complications, such as chronic infection under a flap, have not been commonly reported. Two cases of chronic infection in our series healed secondarily. Avoiding such complications is difficult; however, we believe 2 precautions will be helpful. The first is to thoroughly debride the devitalized bone and soft tissue. The second is to be patient before deciding which flap to use. Initially, in some wounds, the border between the dead and living tissue will not be obvious. We waited and observed until the borders were more clearly defined. Usually 2 weeks will be long enough for such an observation period. In conclusion, we believe that forefoot preservation with a free perforator flap will provide better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used. Reconstructing the soft tissues of the forefoot is an important, if often unappreciated, part of foot and ankle surgery.
References 1. Mann RA, Haskell A. Biomechanics of the foot and ankle. In: Surgery of the Foot and Ankle, ed 8., pp. 2–42, edited by MJ Coughlin, RA Mann, CL Saltzman, Mosby, Philadelphia, 2007. 2. Dubbeldam R, Buurke JH, Simons C, Groothuis-Oudshoorn CG, Baan H, Nene AV, Hermens HJ. The effects of walking speed on forefoot, hindfoot and ankle joint motion. Clin Biomech (Bristol, Avon) 25:796–801, 2010. 3. Jacob HA. Forces acting in the forefoot during normal gaitdan estimate. Clin Biomech (Bristol, Avon) 16:783–792, 2001. 4. Bharathwaj VS, Quaba AA. The distally based islanded dorsal foot flap. Br J Plast Surg 50:284–287, 1997. 5. Chang SM, Hou CL, Liu DX. Distally based superficial peroneal neuroadipofascial turnover flap for dorsal foot reconstruction. Ann Plast Surg 45:101–102, 2000. 6. Demiri E, Foroglou P, Dionyssiou D, Antoniou A, Kakas P, Pavlidis L, Lazaridis L. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast Reconstr Surg Hand Surg 40:106–110, 2006. 7. Zgonis T, Cromack DT, Stapleton JJ. Utilizing a crossover reverse sural artery flap for soft tissue reconstruction of the plantar forefoot after a severe degloving injury. Int J Low Extrem Wounds 6:114–119, 2007. 8. Onishi K, Maruyama Y, Yang YL. Longitudinally designed dorsal metatarsal VY advancement flap for middle dorsal foot reconstruction. Br J Plast Surg 50:561– 563, 1997. 9. Pallua N, Di Benedetto G, Berger A. Forefoot reconstruction by reversed island flaps in diabetic patients. Plast Reconstr Surg 106:823–827, 2000. 10. Wang X, Qiao Q, Burd A, Qi K. Reconstruction of distal foot wounds with reverse first dorsal metatarsal artery flap. Burns 31:1025–1028, 2005. 11. Lee YH, Rah SK, Choi SJ, Chung MS, Baek GH. Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle. Plast Reconstr Surg 114:1478–1485, 2004. 12. Xu YQ, Zhu YL, Wu NX, Li J, Yang J, He XQ. Distal foot coverage with reverse dorsal pedal neurocutaneous flaps. J Plast Reconstr Aesthet Surg 63:164–169, 2010. 13. Huang W, Liu D, Robb GL, Zhang Q. Distally based dorsal pedal neurocutaneous flap for forefoot coverage. Ann Plast Surg 66:235–240, 2011. 14. Uygur F, Duman H, Ulkur E, Noyan N, Celikoz B. Reconstruction of distal forefoot burn defect with retrograde medial plantar flap. Burns 34:262–267, 2008. 15. Coruh A. Distally based perforator medial plantar flap: a new flap for reconstruction of plantar forefoot defects. Ann Plast Surg 53:404–408, 2004. 16. Tsai J, Liao HT, Ulusal BG, Chen CT, Lin CH. Modified retrograde-flow medial plantar island flap for reconstruction of distal dorsal forefoot defectsdtwo case reports. Microsurgery 30:146–150, 2010. 17. Ramanujam CL, Zgonis T. Reverse flow digital artery pedicle flap for closure of diabetic forefoot ulceration. Diabet Foot Ankle, 2010 Jun 1. 18. Yarmel D, Dormans JP, Pawel BR, Chang B. Recurrent pedal hobnail (Dabska-retiform) hemangioendothelioma with forefoot reconstructive surgery using a digital fillet flap. J Foot Ankle Surg 47:487–493, 2008. 19. Weinzweig N, Davies BW. Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases. Plast Reconstr Surg 102:1999–2005, 1998.