Comparison of instep and non-instep flap in the reconstruction of the weight-bearing portion of the forefoot and heel.

BACKGROUND: Instep flaps are commonly used for the reconstruction of weight-bearing areas of the foot. However, in cases of large defects or damage to the instep area, non-instep flaps such as reverse sural flaps (RSF) or free anterolateral thigh flaps (ALTF) can be employed. Previous studies have primarily focused on heel reconstruction when comparing different flaps, without considering the forefoot. This study aims to verify the clinical outcomes of these flaps and determine the appropriate donor site for weight-bearing areas of the foot including forefoot reconstruction. METHODS: In a retrospective study, 39 patients who had undergone flap reconstruction of weight-bearing area defects in the foot with a follow-up period of ≥1 year were included. The patients were categorized into two groups: Group A (n = 19) using instep flaps, and Group B (n = 20) using non-instep flap including RSFs and ALTFs. Surgical outcomes were assessed based on the success of the flap, the presence of partial necrosis, the number of additional surgeries, and complications related to the donor site. Clinical evaluation included visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score, and the occurrence of ulcers. RESULTS: All flaps were successful, while partial necrosis occurred in one case in Group B. There were three reclosures after flap border debridement in both groups and one donor site debridement in Group A. The VAS scores during weight-bearing were 2.0 ± 1.1 and 2.2 ± 1.5 for Groups A and B, respectively (p = .716). The AOFAS scores were 52.8 ± 6.8 and 50.2 ± 12.7 for Groups A and B, respectively (p = .435). The occurrence of ulcers was 0.4 ± 0.9 times for Group A and 0.3 ± 0.7 times for Group B, with no significant difference between the two groups (p = .453). CONCLUSION: There was no difference in clinical outcomes between the types of flaps after reconstruction of the forefoot and hindfoot. Therefore, it is recommended to choose the appropriate flap based on factors such as the size of the defect, its location, and vascular status rather than the type of flap.

Application of Human Acellular Dermal Matrix with Skin Graft for Lacunar Soft-Tissue Defect of Lateral Heel after Calcaneal Fracture.

OBJECTIVE: To investigate the clinical effect of human acellular dermal matrix (HADM) combined with split-thickness skin graft in repairing lacunar soft tissue defects of the lateral heel after calcaneal fracture. METHODS: From June 2018 to October 2020, providers repaired 11 cases of lacunar soft tissue defects at the lateral part of the heel using HADM combined with split-thickness skin graft. After thorough debridement, the HADM was trimmed and filled into the lacunar defect area. Once the wound was covered, a split-thickness skin graft and negative-pressure wound therapy were applied. Providers evaluated the appearance, scar, ductility of the skin graft site, appearance of the donor site, healing time, and any reoperation at follow-up. RESULTS: Of the 11 cases, 8 patients achieved successful wound healing by primary intention. Three patients showed partial necrosis in the edge of the skin graft, but the wound healed after standard wound care. Evaluation at 6 and 12 months after surgery showed that all patients had wound healing and mild local scarring; there was no obvious pigmentation or scar formation in the donor skin area. The average healing time was 37.5 days (range, 24-43 days). CONCLUSIONS: The HADM combined with split-thickness skin graft is a simple and effective reconstruction method for lacunar soft tissue defect of the lateral heel after calcaneal fracture. In this small sample, the combination demonstrated few infections, minor scar formation, few donor site complications, and relatively short hospital stays.

Functional Reconstruction of Hindfoot With Total Calcaneus and Talus Loss by Ilizarov Technique: A Case Report.

Total calcaneus and talus loss in the hindfoot is an unusual but severe condition encountered in clinical settings. This condition affects lower-extremity function and poses a significant challenge to limb salvage. We present a case of a 43-year-old man with total calcaneus and talus loss in the right foot treated by Ilizarov technique. A staged treatment protocol was planned to reconstruct and optimize the heel for weightbearing and walking. During the 15-month postoperative follow-up, the patient reported no significant discomfort in the targeted foot and regained satisfactory function, including shoe wearing, walking, driving, and climbing stairs. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 71, which was an improvement from a preoperative score of 40. This case is the first reported on the functional reconstruction by Ilizarov technique of hindfoot with total calcaneus and talus loss. This treatment protocol provides an effective approach to reconstructing the hindfoot with massive bone loss, although the long-term outcome remains unknown.

Distally Based Posterior Tibial Artery Perforator Flaps for Reconstruction of the Defects in Achilles Region.

BACKGROUND: Patients with Achilles region defects remain a challenge for clinicians. The purpose of this article is to evaluate the surgical procedure to reconstruct the defects in Achilles region using distally based posterior tibial artery perforator flaps. METHODS: Between May 2015 and May 2017, 10 patients (aged from 35 to 68 years. 4 females and 6 males) with soft-tissue defects (sizes from 3 × 2 cm to 8 × 4 cm) in Achilles region received surgical therapy of posterior tibial artery perforator flap transplantation in the Affiliated Hospital of Xuzhou Medical University. RESULTS: The length of hospital stay ranged from 10 to 15 days (mean, 12 days). Local small superficial necrosis (5% of the area) was observed in only 1 case; however, it healed well after dressing was changed. All the others survived and healed well. At follow-up ranging from 12 to 24 months, all patients were satisfied with the aesthetic and functional aspects. CONCLUSIONS: Using the posterior tibial artery perforator flaps to cover the Achilles region defects is a promising, feasible, first-line, safe option and should be extensively applied in clinical therapy.

Compressed Fixation Combined with Vacuum-Assisted Closure for Treating Acute Injury of the Heel Fat Pad.

BACKGROUND Treating acute injury of the heel fat pad is different from treating common soft tissue damage. Due to the paucity of literature on the topic, we described our initial experience treating acute injury of the heel fat pad to determine the ideal treatment method. MATERIAL AND METHODS A total of 53 patients with acute injury of the heel fat pad admitted to our hospital were selected for the study and were randomly divided into 2 groups: the compressed fixation combined with vacuum-assisted closure group and the only reimplanted and sewn group. Twenty-seven of the heel fat pads were compressed and fixed using a flat, hard piece of plastic and hollow screws; then, they were covered with a vacuum-assisted closure device. The other 27 were only sewn without tension. The clinical results were evaluated according to the American Orthopedic Foot and Ankle Society hindfoot score and the British Medical Research Council function evaluation criteria RESULTS In the compressed fixation combined with vacuum-assisted closure group, flaps of 12 feet with retrograde avulsion injury survived successfully. Partial flap necrosis occurred in 8 feet. Seven feet underwent repair using the neurocutaneous vascular resupinated island flap. Results were excellent or good for 74% of patients according to the AOFS. However, in the only reimplanted and sewn group, results were excellent or good for 44% of patients according to the AOFS. CONCLUSIONS Compressed fixation with vacuum-assisted closure is effective for treating acute injury of the heel fat pad, with high success rates and good utility.

The lateral calcaneal artery as an alternative recipient vessel option for heel and lateral foot reconstruction.

BACKGROUND: Clinical outcomes of consecutive use of the lateral calcaneal artery (LCA) as a recipient vessel for microsurgical reconstruction have not been reported. This study aimed to evaluate the feasibility and safety of the LCA as a recipient vessel for microsurgical foot reconstruction based on anatomical study of CT angiography and clinical results of using this vessel as the recipient. METHODS: Anatomic study was performed using CT angiography of 61 lower extremities (31 patients). The emerging point, course, and diameter of the LCA were evaluated using 3-D reconstructed images. The LCA was used as the recipient artery in 17 consecutive patients with a mean age of 59 years (range: 23-77 years). Thoracodorsal artery perforator flap was used in most cases (16 of 17), and clinical outcomes were evaluated. RESULTS: The LCA emerged 31.1 ± 9.8 mm proximal and 14.7 ± 5.0 mm posterior to the tip of the fibula and traversed 13.9 ± 2.7 mm posterior to the posterior margin of the lateral malleolus. The accompanying vein was used for venous outflow in five patients and the small saphenous vein was used in the remaining cases. Emergent re-operation was performed in one case due to venous thrombosis, and salvage was successful. All flaps except for one with partial flap necrosis completely survived. During a mean follow-up of 13 months, all but one of the patients were able to wear shoes and walk. CONCLUSIONS: The LCA may be safely used as a recipient vessel for microsurgical heel and lateral foot reconstruction. LEVEL OF EVIDENCE: IV.

Patterns and associations of structural and functional cutaneous responses during loading at heel and sacral skin in aged females: A reanalysis of clinical study data.

AIM OF THE STUDY: The aim of this study was to explore possible interrelationships and cutaneous response patterns at the heel and sacral skin due to prolonged loading. MATERIALS AND METHODS: Skin stiffness, elasticity, roughness and transepidermal water loss, stratum corneum hydration, erythema, and temperature of n = 20 aged females (mean age 69.9 years) were measured before and after 90 and 150 min loading in supine position. Delta values were calculated and correlated using Spearman's rho. Strengths and directions of associations and similar patterns were subsequently identified for the heel and sacrum areas. RESULTS: At the sacral area decreased stiffness (Uf) was associated with increased TEWL and there was a positive relationship between mean roughness (Rz) and erythema. At the heel there was a positive association between TEWL and decreasing stiffness (Uf). CONCLUSIONS: Our results indicate a dynamic interaction between skin changes during loading and different physiological response patterns for sacral and heel skin. There seems to be close association between transepidermal water loss and stiffness changes during loading.

Do Prophylactic Foam Dressings Reduce Heel Pressure Injuries?

PURPOSE: The purpose of this evidence-based report card is to examine the evidence and provide recommendations related to the effectiveness of prophylactic foam dressings in reducing heel pressure injuries. QUESTION: Do prophylactic foam dressings applied to the heel reduce heel pressure injuries for patients in the acute care setting? SEARCH STRATEGY: A search of the literature was performed by a trained university librarian that resulted in 56 articles that examined pressure injury, prevention, and prophylactic dressings. A systematic approach was used to review titles, abstracts, and text, yielding 13 studies that met inclusion criteria. Strength of the evidence was rated based on the methodology from Essential Evidence Plus: Levels of Evidence and Oxford Center for Evidence-Based Medicine. FINDINGS: Thirteen studies were identified that met inclusion criteria; 1 was a randomized controlled trial, 2 were systematic reviews, 3 quasi-experimental cohort studies, 1 quality improvement study, 1 case series, 1 scoping review, 1 consensus panel, and 3 bench studies. All of the studies identified suggest that the use of prophylactic foam dressings reduces the development of pressure injuries on the heel when used in conjunction with a pressure injury prevention program. The strength of the evidence for the identified studies was level 1 (4 level A, 4 level B, and 5 level C). CONCLUSION/RECOMMENDATION: The use of prophylactic multilayer foam dressings applied to the heels, in conjunction with an evidence-based pressure injury prevention program, is recommended for prevention of pressure injuries on the heel (SORT level 1).

Microsurgical Replantation of the Posterior Heel Skin and Subcutaneous Tissue.

A 45-year-old male presented with amputation of posterior heel soft tissue after an accident involving broken glass panes. The defect measured 4 × 6.5 cm, and the composite amputated tissue consisted of skin and subcutaneous layers. Intraoperative exploration of the amputated tissue revealed 2 perforator arteries (diameter ≤0.4 mm) in the central portion of the subcutaneous tissue and 4 superficial veins (diameter ≈0.6 mm) in the wound margin. These vessels were anastomosed end-to-end to the corresponding vessels from the wound bed using 11-0 nylon sutures. The replanted tissue survived completely. The patient retained excellent aesthetic and functional outcomes at the 13-month follow-up visit. The present case serves to demonstrate the feasibility of microsurgical replantation for the posterior heel. Although such isolated amputations are far less common than digital amputations, our experience suggests that microsurgical replantation is indicated beyond the current spectrum of clinical repertoire.

Case Report: Late Reconstruction of the Land Mine-Injured Heel With an Osteomyocutaneous Composite Fibular Flap.

The heel comprises the epidermis, minimal subcutaneous tissue, a dense septum, and the calcaneus. Injury to any of these structures can impair the ability to walk. The soft tissue or calcaneal bone can be injured by trauma. Injuries incurred in war are usually high-energy traumas caused by weapons such as rifles, rockets, and land mines. Such injuries can be life threatening and involve the loss of tissue, including skin, soft tissue, bone, and neurovascular tissue. Two main treatment protocols are used for such injuries with large tissue defects: amputation and reconstruction. We describe a reconstruction with an osteomyocutaneous fibular flap for a heel injury. At the 2-year follow-up point, the patient had 30% loss of ankle range of motion. The visual analog scale score had dramatically decreased from 8 to 1, and the patient was satisfied with the result. In conclusion, patients with significant problems such as infection, pain, and anatomic deterioration of the calcaneus can be successfully treated using an osteomyocutaneous fibular flap in a single surgery.

The Effect of Swaddling on Pain, Vital Signs, and Crying Duration during Heel Lance in Newborns.

To determine the effect of swaddling on pain, vital signs, and crying duration during heel lance in the newborn. This was a randomized controlled study of 74 (control: 37, experiment: 37) newborns born between December 2013 and February 2014 at the Ministry of Health Bagcilar Training and Research Hospital. An information form, observation form, and Neonatal Infant Pain Scale were used as data collection tools. Data from the pain scores, peak heart rates, oxygen saturation, total crying time, and duration of the procedure were collected using a video camera. Newborns in the control group underwent routine heel lance, whereas newborns in the experimental group underwent routine heel lance while being swaddled by the researcher. The newborns' pain scores, peak heart rates, oxygen saturation values, and crying durations were evaluated using video recordings made before, during, and 1, 2, and 3 minutes after the procedure. Pain was assessed by a nurse and the researcher. No statistically significant difference was found in the characteristics of the two groups (p > .05). The mean pain scores of swaddled newborns during and after the procedure were lower than the nonswaddled newborns (p < .05). In addition, crying duration of swaddled newborns was found to be shorter than the nonswaddled newborns (p < .05). The average preprocedure peak heart rates of swaddled newborns were higher (p < .05); however, the difference was not significant during and after the procedure (p > .05). Although there was no significant difference in oxygen saturation values before and during the procedure (p > .05), oxygen saturation values of swaddled newborns were higher afterward (p < .05). For this study sample, swaddling was an effective nonpharmacologic method to help reduce pain and crying in an effort to soothe newborns. Although pharmacologic pain management is the gold standard, swaddling can be recommended as a complementary therapy for newborns during painful procedures. Swaddling is a quick and simple nonpharmacologic method that can be used by nurses to help reduce heel stick pain in newborns.

Reducing the Incidence of Cast-related Skin Complications in Children Treated With Cast Immobilization.

BACKGROUND: Cast immobilization remains the mainstay of pediatric orthopaedic care, yet little is known about the incidence of cast-related skin complications in children treated with cast immobilization. The purposes of this quality improvement project were to: (1) establish a baseline rate of cast-related skin complications in children treated with cast immobilization, (2) identify trends in children who experienced cast-related skin complications, (3) design an intervention aimed at decreasing the rate of cast-related skin complications, and (4) determine the effectiveness of the intervention. METHODS: A prospective interrupted time-series design was used to determine the incidence of cast-related skin complications overtime and compare the rates of skin complications before and after an intervention designed to decrease the incidence of cast-related heel complications. All consecutive patients who were treated with cast immobilization from September 2012 to September 2014 were included. A cast-related skin complications data collection tool was used to capture all cast-related skin complications. A high rate of heel events was noted in our preliminary analysis and an intervention was designed to decrease the rate of cast-related skin complications, including the addition of padding during casting and respective provider education. RESULTS: The estimated cast-related skin events rate for all patients was 8.9 per 1000 casts applied. The rate for the total preintervention sample was 13.6 per 1000 casts which decreased to 6.6 in the postintervention sample. When examining the heel-only group, the rate was 17.1 per 1000 lower extremity casts applied in the preintervention group and 6.8 in the postintervention group. CONCLUSIONS: Incorporating padding to the heel of lower extremity cast was an effective intervention in decreasing the incidence of cast-related skin complications in patients treated with cast immobilization. LEVEL OF EVIDENCE: Level II.

A pilot study comparing custom contoured and planar support surfaces for pressure ulcer risk over the heels for night time postural management using interface pressure mapping and discomfort scores.

PURPOSE: Custom contouring techniques are effective for reducing pressure ulcer risk in wheelchair seating. These techniques may assist the management of pressure ulcer risk during sleep for night time postural management. OBJECTIVES: To investigate the effectiveness of custom contoured night time postural management components against planar support surfaces for pressure ulcer risk measures over the heels. METHOD: Supine posture was captured from five healthy participants using vacuum consolidation and 3-dimensional laser scanning. Custom contoured abduction wedges were carved from polyurethane and chipped foams. Pressure mapping and the visual analog scale were used to evaluate the effectiveness of the contoured foams in reducing pressure and discomfort under the posterior heel against standard planar support surfaces. RESULTS: Custom contoured shapes significantly reduced interface pressures (p < 0.05) and discomfort scores (p < 0.05) when compared to planar support surfaces. Polyurethane foam was the most effective material but it did not differ significantly from chipped foam. Linear regression revealed a significant relationship between the Peak Pressure Index and discomfort scores (r = 0.997, p = 0.003). CONCLUSIONS: The findings of this pilot study suggested that custom contoured shapes were more effective than planar surfaces at reducing pressure ulcer risk surrogate measures over the posterior heels with polyurethane foam being the most effective material investigated. It is recommended that Evazote foam should not be used as a support surface material for night time postural management.

Prevention of Heel Pressure Injuries and Plantar Flexion Contractures With Use of a Heel Protector in High-Risk Neurotrauma, Medical, and Surgical Intensive Care Units: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare the use of a heel protector to standard of care (pillows) in the prevention of hospital-acquired pressure injuries (HAPI) of the heels and prevention of plantar flexion contractures. DESIGN: Randomized controlled trial. SUBJECTS AND SETTING: The study took place on a surgical intensive care unit, medical intensive care unit, and neurotrauma intensive care unit. Inclusion criteria were a minimum of 5 days of sedation related to care for a critical illness, immobility for 6 to 8 hours before study initiation, a Braden Scale for Pressure Sore Risk score 18 or less, and a mobility subscale score 2 or less. Patients were included if they had preexisting heel pressure injury or plantar flexion contracture. The sample comprised 54 subjects; 37 were randomly allocated to the intervention group and 17 to the control group. Their average age-mean (standard deviation)-was 40.7 (14.96) years in the control group and 44.6 (17.15) years in the intervention group. METHODS: Data were collected from patients' electronic medical records. We recorded subject demographics, presence of diabetes mellitus or peripheral vascular disease, Glasgow Coma Scale scores (every shift), Braden Scale for Pressure Sore Risk scores (every shift), heel skin assessments (every shift), goniometric measurements (every other day), and adverse events (every shift). Assessments and measurements were continued until the patient was discharged from the study. RESULTS: None of the patients in the intervention group developed HAPI of the heels, as compared to 7 in the control group (0% vs 41%, P < .001). Patients in the intervention group had a significantly greater decrease in goniometric scores (mean decrease = 1.4 ± 2.25) compared to the control group by day 3 (mean decrease = 0.1 ± 0.52 P = .004) and the last study day (mean decrease = 2.0 ± 3.02 for the intervention group vs 0.07 ± 0.96 for the control group; P < .001). CONCLUSIONS: Study findings indicate that a heel protector that ensures off-loading and maintains the foot in a neutral position is more effective for prevention of HAPI of the heel and contractures as compared to standard care using pillows to position the heel and redistribute pressure.

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.

Heel ulcers do heal in patients with diabetes.

A heel ulcer is considered to be a serious complication in patients with diabetes, and there is limited information regarding outcome. In most of the literature, a poor prognosis is described. The aim of this study was to investigate a large cohort of ulcers located in the heel in patients with diabetes. Seven hundred and sixty-eight patients [median age 73 (17-98)], presenting with a heel ulcer at a multidisciplinary diabetes foot clinic, fulfilled the inclusion criteria and were followed-up until final outcome. Fifty-eight per cent of the patients healed primarily; 7% healed after major debridement; 9% healed after amputation and 25% died unhealed. Median healing time was 17 weeks. Ulcer progression was seen in 19% of patients. Thirty-one percent of patients had severe peripheral vascular disease. A creatinine level below 91 µmol/l was related to a higher probability for healing without major debridement or amputation, whereas vascular surgery, nephropathy and oedema were related to a lower probability for healing without major debridement or amputation. Two thirds of heel ulcers do heal in patients with diabetes despite patients being elderly and with extensive comorbidity. The extent of peripheral vascular disease, nephropathy, oedema and decreased renal function are important factors influencing outcome.

Apex Pro-care mattress: How can this advanced mattress assist in prevention of pressure injuries?

Avalon Nursing Home is fully aware of the potential for pressure ulcers in immobile residents and were keen to undertake an evaluation to ensure their residents have the most appropriate care possible. They selected Apex Pro-care to evaluate as there were concerns for residents heels in those with any arterial insufficiency. The Apex Pro-care mattress has a heel section where one or more of the bottom five cells can be deflated under the patient's heel to create a void, which will enable the heel to "float" so that there is no pressure in contact with the heel area. The mattress would reduce the cost of nursing care as repositioning times can be optimised according to need. The three residents who agreed to evaluate the mattress found it to be extremely comfortable and they remained free of any pressure injury.

Heel reconstruction with parallel fibular osteoseptocutaneous flap.

Reconstruction of heel defects can be challenging and requires careful consideration in restoring both the functional and aesthetic deficit. This study assessed the use of parallel fibular osteoseptocutaneous flap to repair composite heel defects. Follow-up of the 4 patients included in this study ranged from 24 months to 3 years after their operation. The flap survival rate was 100% in all patients, with good coverage of the heel defects. Postoperative complication was one -superficial wound infection. Union of the graft with the host bone was achieved in all patients at an average of 6 months (range : 5-10 m/onths). The parallel fibular osteoseptocutaneous flap is thus a reliable means of reconstruction of composite bone and soft-tissue -defect in the heel region.