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.

Coverage of defects over Posterior aspect of Ankle Joint and Heel with Lateral Calcaneal Artery Flap- Experience in Mymensingh Medical College Hospital.

Lateral calcaneal artery flap is randomly used by many Plastic Surgeons for covering any defect on the posterior aspect of heel. A prospective observational study was conducted in the Department of Burn and Plastic Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2020 to June 2022, to see the outcome of the flap for coverage of defects over the posterior aspect of ankle joint and heel. A total number of 09 patients, selected by purposive sampling, were included in the study. The age of the patients ranged from 06 years to 70 years. The cause of the defects were post traumatic in 07 cases, electric burn in 01 case and pressure sore in 01 case. The defect sizes varied from 3×2 to 6×3cm. and flap size ranged from 4×2.5 to 7×4.5cm. The follow-up period ranged from 3 to 6 months. All the flaps survived completely without any complications; except in two cases. In one case, there was marginal epidermal necrolysis that healed secondarily without the need of any further surgical intervention. In the other case, there was gangrene of about 0.5 cm area at the flap tip, which was debrided and the resulting wound healed secondarily. The average operating time was 63 minutes. The results were satisfactory on the context of adequate coverage, and flap and donor site morbidity. So, the lateral calcaneal artery flap can be a good and safe option for the coverage of posterior ankle and heel defects.

Ankle Muscle Strength and Gait Function After Dorsal Closing Wedge Calcaneal Osteotomy for Haglund Exostosis-Related Heel Pain.

BACKGROUND: Haglund exostosis-related heel pain may be surgically treated with dorsal closing wedge calcaneal osteotomy (DCWCO). Recent reports on this technique show good clinical and self-reported outcomes. However, uncertainty about functional consequences related to ankle muscle strength and gait function due to a shortened Achilles tendon lever arm exists. METHODS: Fifteen patients (15 feet) with Haglund exostosis-related heel pain were surgically treated with DCWCO and evaluated before and 1 year after surgery. Isometric plantar flexion and dorsiflexion strength was quantified for both the involved and the uninvolved limb. Gait analysis was performed at a self-selected walking speed using a 3D motion capture system including force plates. Self-reported outcomes (Foot Function Index and Global Treatment Outcome) were also assessed. RESULTS: Before surgery, as well as after surgery, plantar flexion strength of the involved limb was significantly lower compared to the uninvolved limb while dorsiflexion strength did not differ between limbs at both time points. Step length and time, ankle flexion angles, power generation, and propulsive impulses during gait did not differ between limbs both before and after surgery. Propulsive impulse and step length of the involved limb increased from pre- to postsurgery with an effect size of 1.04 and 0.48, respectively, revealing a general improvement in gait dynamics. Total Foot Function Index improved by 48% after surgery, and 80% of patients rated their surgery as "helped" or "helped a lot" (Global Treatment Outcome). CONCLUSION: In this relatively small cohort, we found that patients treated for Haglund exostosis-related heel pain with DCWCO surgery had minor interlimb differences in gait kinematics and kinetics and generally improved gait dynamics and self-reported function at 1-year follow-up. LEVEL OF EVIDENCE: Level II, observational prospective cohort study.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study / Configuración y localización óptima de los tornillos posteriores en las fracturas de calcáneo Sanders 2B: estudio biomecánico

Background: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. Methods: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm). Results: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations...(AU)

Introducción: Las fracturas de calcáneo suelen ser lesiones intraarticulares de alta energía asociadas con hundimiento articular. Además, se añade con frecuencia el estallido de la pared lateral, la superposición de la pared medial, la conminución y la pérdida de hueso bajo la carilla articular. La deformidad secundaria, como el varo del retropié, altera la biomecánica del pie. Nuestra comunidad utiliza cada vez más abordajes mínimamente invasivos con reducción indirecta de la tuberosidad del calcáneo para mantener la reducción mediante tornillos posteriores. Hay estudios que proponen diferentes configuraciones de tornillos, tras experimentación biomecánica, pero aún no es bien conocido qué configuración controla mejor la deformidad en varo. Este estudio tiene como objetivo determinar la configuración óptima del tornillo para controlar la deformidad en varo en las fracturas de calcáneo Sanders 2B. Método: Se prepararon modelos en Sawbone para replicar la fractura de Sanders tipo 2B, con pérdida de hueso central y con conminución. Se eliminó una cuña medial de 0,5cm de la tuberosidad calcánea para crear inestabilidad en varo. Tras estabilizar el ángulo de Gissane con un tornillo aislado parcialmente roscado de 4mm y una placa moldeada, se utilizaron tornillos de compresión multiuso Charlotte (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) sin cabeza, canulados y parcialmente roscados de 7mm insertados sobre una AK bajo escopia. El desplazamiento del plano sagital del fragmento de tuberosidad fracturado en comparación con el cuerpo al aplicar una fuerza de 5N, 10N y 20N se midió en milímetros (mm). Resultados: Dos tornillos insertados (un tornillo medial en el sustenaculum tali de inferior a superior y un tornillo lateral en el eje largo del astrágalo) proporciona el menor desplazamiento (0,88±0,390 a 5N y 1,7±1,251 a 20N) y resulta la construcción más estable (p<0,05) en comparación con otras configuraciones...(AU)

[Artículo traducido] Configuración y localización óptima de los tornillos posteriores en las fracturas de calcáneo Sanders 2B: estudio biomecánico / Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study

Background: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. Methods: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm). Results: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations...(AU)

Introducción: Las fracturas de calcáneo suelen ser lesiones intraarticulares de alta energía asociadas con hundimiento articular. Además, se añade con frecuencia el estallido de la pared lateral, la superposición de la pared medial, la conminución y la pérdida de hueso bajo la carilla articular. La deformidad secundaria, como el varo del retropié, altera la biomecánica del pie. Nuestra comunidad utiliza cada vez más abordajes mínimamente invasivos con reducción indirecta de la tuberosidad del calcáneo para mantener la reducción mediante tornillos posteriores. Hay estudios que proponen diferentes configuraciones de tornillos, tras experimentación biomecánica, pero aún no es bien conocido qué configuración controla mejor la deformidad en varo. Este estudio tiene como objetivo determinar la configuración óptima del tornillo para controlar la deformidad en varo en las fracturas de calcáneo Sanders 2B. Método: Se prepararon modelos en Sawbone para replicar la fractura de Sanders tipo 2B, con pérdida de hueso central y con conminución. Se eliminó una cuña medial de 0,5cm de la tuberosidad calcánea para crear inestabilidad en varo. Tras estabilizar el ángulo de Gissane con un tornillo aislado parcialmente roscado de 4mm y una placa moldeada, se utilizaron tornillos de compresión multiuso Charlotte (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) sin cabeza, canulados y parcialmente roscados de 7mm insertados sobre una AK bajo escopia. El desplazamiento del plano sagital del fragmento de tuberosidad fracturado en comparación con el cuerpo al aplicar una fuerza de 5N, 10N y 20N se midió en milímetros (mm). Resultados: Dos tornillos insertados (un tornillo medial en el sustenaculum tali de inferior a superior y un tornillo lateral en el eje largo del astrágalo) proporciona el menor desplazamiento (0,88±0,390 a 5N y 1,7±1,251 a 20N) y resulta la construcción más estable (p<0,05) en comparación con otras configuraciones...(AU)

Colgajo sural reverso neurotizado en el tratamiento de úlcera postraumática del talón / Neurotization in reverse sural flap in treatment of postraumatic heel ulcer

En la reconstrucción de la región plantar se debe de cumplir el objetivo de proporcionar una sensibilidad protectora para las zonas de presión del talón y de las epífisis dístales del primer y del quinto metatarsianos. La reconstrucción dependerá del defecto y de las estructuras a restituir, pudiendo emplear colgajos locales, a distancia o microquirúrgicos. El colgajo sural reverso es muy eficaz para cubrir la zona del talón, con vascularización constante, fácil diseño, disección y poca morbilidad del sitio donante. Inicialmente fue considerado neurocutáneo, debido a la inclusión del nervio sural en su pedículo; sin embargo, éste no consta con las características de un colgajo sensitivo. Presentamos el caso de una mujer de 23 años de edad con ulceración crónica del talón izquierdo secundaria a traumatismo y tratada con colgajo sural reverso con exteriorización de pedículo para realizar retardos intermitentes; a los 22 días se realizó sección del pedículo y coaptación de la porción proximal del nervio sural al nervio peroneo medio, obteniendo una cubierta cutánea definitiva, sin recurrencia de la ulceración, con adecuada sensibilidad protectora y con discriminación táctil de dos puntos a los 6 meses (AU)

The main goal in the plantar area reconstruction is to restore the protective sensation in the zones of pressure of the heel and distal epiphysis of the first and fifth metatarsals. The reconstruction is in dependence of the defect and of the structures to be replaced that can be treated with local, distant or microvascular free flaps. The reverse sural flap is very efficient for the heel coverage, with constant vascularity, easy tailoring, dissection, and low morbidity of the donor site. Initially the flap was term neurofasciocutaneos due to sural nerve inclusion in the pedicle; never the less, it does not fulfill the characteristics of a sensitive flap. We present the case of a 23 year old female patient with chronic ulceration of the left heel due to trauma, treated with a reverse sural flap, not burying its pedicle, with intermittent delays, and release 22 days later, performing the coaptation of the proximal stump of the sural nerve to the medial peroneal nerve. Definitive cutaneous cover was achieved without recurrence of ulceration and appropriate protective sensibility, with a two-point discrimination in 6 months (AU)

Liberacion endoscopica de la fascia plantar / Arthroscopic facial plantar release

Objetivo: Presentar nuestra experiencia con el tratamiento endoscopico de la fascitis plantar refractaria a tratamiento medico ortopedico. Metodo: Once pacientes con diagnostico de fascitis plantar tratados en forma incruenta por un periodo de 6 meses sin respuesta fueron intervenidos quirurgicamente entre abril de 2003 y agosto de 2006 con tecnica endoscopica. Diez de ellos fueron analizados en forma retrospectiva y los resultados evaluados con el Clinical Rating System para tobillo y retropie de AOFAS, el sistema otorga un maximo de 100 puntos, y los resultados son categorizados como muy bueno, bueno, regular y malo. El tiempo minimo de seguimiento fue 14 meses y el maximo 41 meses, con una media de 32,6 meses. Resultados: 8 fueron categorizados como muy buenos, 1 como bueno y 1 como regular. No se registraron complicaciones infecciosas ni hematomas. Dos pacientes refirieron sintomas neurologicos en el postoperatorio. Un caso con parestesias en la region plantar externa, el cuadro se resolvio espontaneamente a los 6 meses. El otro paciente refirio una zona de hipoestesia alrededor del portal medial, que a la fecha del ultimo control no se ha resuelto. Conclusiones: La liberacion endoscopica de la fascia plantar es una alternativa util para el tratamiento de los casos refractarios a tratamiento medico y segura en la medida que se respeten los detalles de tecnica quirurgica descriptos.

Alargamiento percutaneo del tendón de Aquiles en el pie esquino espastico: experiencia en los últimos 5 años del Hospital Ortopedico Infantil / Lengthening percutaneous elongation of the Aquiles tendon in spastic foot corner: experience over the past 5 years of the Hospital Ortopedico Infantil

El alargamiento subcutáneo del tendón de Aquiles en el tratamiento de la deformidad en equino del tobillo fue realizado por Delpech en 1.816 y modificado por numerosos autores a lo largo de la historia, sin embargo su utiliación fue descartada durante mucho tiempo hasta Hoke en 1947 la realizó en forma percutánea con exelentes resultados. Nosostros en el HOI la practicamso de manera rutinaria en los pacientes con PCI obteniendo resultados satisfactorios. En el presente trabajo revisamos en forma prospectiva los resultados obtenidos en 64 pacientes a quienes se les realizó la técnica quirúrgica.

Cobertura plantar distal mediante colgajo cutáneo de perforantes. Caso clínico / Coverage of distal plantar area with a medial plantar perforator cutaneous flap. Case report

En las últimas dos décadas, el desarrollo de las técnicas microquirúrgicas ha hecho que cada vez existan más posibilidades de cobertura en zonas anatómicas difíciles, como la región plantar distal. La aplicación de esta técnicas ha dado lugar al empleo de colgajos libres, tanto musculares como fasciocutáneos, para defectos en esta zona. La llegada de los colgajos basados en perforantes ha hecho que el abanico de posibilidades sea aún mayor, tanto en forma de colgajos libres como pediculados. Sin embargo, hoy en día se sigue admitiendo que la mejor cobertura plantar es la de la propia zona anatómica. Presentamos el caso de un paciente que sufrió una lesión compleja traumática plantar, con fractura luxación de la primera articulación metatarsofalángica y avulsión de partes blandas del primer radio, con exposición de la articulación, la falange proximal y el sistema músculotendinoso. Tras el desbridamiento seriado se llevó a cabo la reparación de todas las estructuras y la cobertura de la pérdida cutánea con un colgajo plantar cutáneo basado en una perforante de la arteria plantar medial, localizada mediante Eco-Doppler. La baja morbilidad de la técnica utilizada, el menor tiempo operatorio, así como el resultado funcional y estético, hacen que este tipo de colgajos se deban considerar entre las técnicas de reconstrucción para cobertura plantar (AU)

In the last two decades development of microsurgical techniques has provided a wider range of possibilities within the coverage of difficult anatomical regions such as the distal plantar area. Development of perforator flaps furthermore permits the application of new techniques in this area, however, the authors always advise that the best coverage of the plantar area is the actual itself. We report the case of a distal plantar injury with a fracture- luxation of the first metatarsophalangeal joint and avulsion of soft tissue of the first radix with exposure of the joint, proximal phalangeal and muscle-tendinosus system. A cutaneous plantar flap based on a perforator of the medial plantar artery located with directional Doppler probe was used to cover soft tissue loss. The low morbidity of this technique, its low operative time and the excellent functional and aesthetic results have allowed these type of flaps to become a prefered choice in the coverage of partial defects of the distal plantar area (AU)

El rolgajo de Mc Farlane revisitado: una aplicación adelantada del concepto fasciocutáneo para cobertura del sector distal del Tendón de Aquiles / Mc Farlane's flap revisited: An early application of the fasciocutaneous conception for distal Achilles Tendon coverage

Hace 40 años, Mc Farlane publicó un colgajo de cara posterior de pierna para reparar úlceras e hiperqueratosis de cara posterior del talón, por "transposición descendente". Describió claramente el plano de disección subaponeurótica y los pedículos nutricios alojados en tabiques intermusculares, constituyendo así un claro ejemplo precursor de colgajo fasciocutáneo con pedículos septocutáneos. Sin embargo, desde entonces, casi no ha sido citado en la literatura científica. Se presenta una serie de 6 pacientes en que se empleó este colgajo para reconstruir diversos tipos de defectos en dicha región. Se analizan sus bases a la luz de los nuevos conceptos sobre la circulación tegumentaria, y se destaca su sencillez de diseño y ejecución, así como su efectividad para aportar la cobertura cutánea de calidad (AU)

Tratamento das perdas cutaneas do calcanhar com retalho da arteria calcanea lateral / Treatment of cutaneous losses of the heel with lateral calcaneus artery flap

O retalho da arteria calcanea lateral tem padrao axial e em seu pediculo esta incluido o nervo sural e a veia safena parva. E utilizado para cobertura cutanea de defeitos da regiao do tornozelo; e de simples execucao e seguro. A area doadora do retalho e fechada com enxerto de pele de espessura parcial. No presente trabalho, relatamos experiencia com oito pacientes que foram submetidos a reconstrucao da regiao calcanea com retalho da arteria calcanea lateral. E, sete casos o retalho foi utilizado em ilha, com diametro de ate 4 cm. No presente, o retalho foi realizado em sua forma original, como descrito por Grabb e Argenta. A etiologia da perda de substancia foi o trauma em cinco casos e ulceras de pressao em tres pacientes paraplegicos. Os resultados mostraram que o retalho foi adequado para promover a cobertura de lesoes da regiao calcanea, pois e resistente a marcha normal e nao foram observadas ulceracoes.

Talalgias crónicas / Chronic plantar hindfoot pain

Se presenta una serie de 30 casos con talalgia crónica uni o bilateral con edad promedio de 45 años, que fueron tratados conservadoramente mediante infiltración de corticoides, antiinflamatorios, férulas, cambio de calzado por otro más blando y cómodo y rehabilitación durante 3 a 6 meses, en quienes fracasó dicho tratamiento, por lo que se sometieron a cirugía de fasciotomía plantar, con excelente resultado en el 90 por ciento de los casos y bueno en el 10 por ciento