Rev. bras. ortop. vol.52 número6

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Reconstruction

of

soft-tissue

lesions

of

the

foot

with

the

use

of

the

medial

plantar

flap

夽

Jefferson

Lessa

Soares

de

Macedo

,

Simone

Corrêa

Rosa

,

Altino

Vieira

de

Rezende

Filho

Neto

_,

_Adilson

_Alves

_da

_Silva

_,

Alex

Corcino

Silva

de

Amorim

a_{HospitalRegionaldaAsaNorte,Brasília,DF,Brazil}

b_{EscolaSuperiordeCiênciasdaSaúde,CursodeMedicina,Brasília,DF,Brazil}

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t

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o

Articlehistory:

Received15August2016 Accepted4October2016 Availableonline19October2017

Keywords:

Heel

Reconstruction Woundsandinjuries Footinjuries

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b

s

t

r

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c

t

Objective:Tostudyuseofthemedialplantarflapforreconstructionoftheheelandfoot.

Method:Theauthorssharetheirclinicalexperiencewiththeuseofthemedialplantarartery

flapforcoverageoftissuedefectsaroundthefootandheelaftertrauma.Twelvecasesof medialplantararteryflapperformedfromJanuary2001toDecember2013wereincluded.

Results:Ofthe12patients,tenweremaleandtwowerefemale.Theindicationswere

trau-maticlossoftheheelpadintencasesandthedorsalfootintwocases.Alltheflapshealed uneventfullywithoutmajorcomplications,exceptonecasewithpartialflaploss.Thedonor sitewascoveredwithasplit-thicknessskingraft.Theflapshadslightlyinferiorprotective sensationcomparedwiththenormalside.

Conclusion: Fromtheseresults,theauthorssuggestthatthemedialplantararteryflapisa

goodadditiontotheexistingarmamentariumforcoverageofthefootandheel.Itisversatile flapthatcancoverdefectsontheheel,overtheAchillestendonandplantarsurface,aswell asthedorsalfoot.Itprovidestissuetotheplantarskinwithasimilartextureandintact protectivesensation.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Reconstruc¸ão

de

lesões

de

partes

moles

de

pé

com

o

uso

de

retalho

plantar

medial

Palavras-chave:

Calcanhar Reconstruc¸ão Ferimentoselesões Traumatismosdopé

r

e

s

u

m

o

Objetivo:Estudarcasosderetalhoplantarmedialnareconstruc¸ãodocalcanharedopé.

Método:Osautoresapresentamsuaexperiênciacomousodoretalhobaseadonaartéria

plantarmedialparacoberturadedefeitosteciduaisnopé,especialmentedocalcanhar.Doze retalhosdaartériaplantarmedial,feitosentrejaneirode2001edezembrode2013,foram incluídos.

夽

StudyconductedatHospitalRegionaldaAsaNorte,Brasília,DF,Brazil.

∗ _{Correspondingauthor.}

E-mail:jlsmacedo@yahoo.com.br(J.L.Macedo).

http://dx.doi.org/10.1016/j.rboe.2017.10.009

Resultados:Dos12pacientes,dezeramhomenseduasmulheres.Asindicac¸õesforamperda traumáticadocoximdocalcanharemdezpacientesedorsodopéemdoiscasos.Todos osretalhoscicatrizaramsemmaiorescomplicac¸ões,excetoumcasocomperdaparcial. Aáreadoadorafoicobertacomenxertodepeleparcial.Osretalhosapresentaramuma sensibilidadeprotetoralevementeinferioraoladonormal.

Conclusão: Deacordocomosresultados,oretalhoplantarmedialéumaboaopc¸ãopara

coberturadopé,especialmentedaregiãodocalcanhar.Aversatilidadedoretalhopermite a coberturadedefeitosnocalcanhar,sobreotendãodeAquileseapoioplantar,assim comoodorsodopé.Esseretalhoconferepararegiãoplantarumapeledetexturasimilare sensibilidadeprotetoraintacta.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Thereconstruction ofthedistalthird ofthe legremains a challengeforreconstructivesurgeons.Anatomical character-istics,suchasthescarcityofsofttissuesandthinskin,leadto greatdifficultiesinthetreatmentofsofttissuelesionsatthis location.

Theuseoffasciocutaneousflapsinthereconstructionof lesionsofthelowerthirdofthelowerlimb,especiallyofthe foot,iswellindicatedduetothesimilaritieswiththetissues oftheregion. Amongtheseflaps, the medialislandflap is noteworthy.1,2

ThemedialplantarflapwasinitiallydescribedbyHarrison andMorgan.3_{Itisbasedonthemedialplantararteryand}

con-sistsofafasciocutaneousflapthatusesskinfromtheplantar archofthefoot,anidealtissuetocoverdefectsoftheheeland otherregionsofthefoot,duetothestructuralsimilarity.The innervationofthisflapispreserved,givingitsensation,which isaprotectivefactor.4

Thisstudyaimedatpresentingaseriesofcasesinwhich themedialplantarflap wasusedforthe treatmentoffoot injuries,especiallyoftheheel,from2001to2013.

Methods

Thisisaretrospectivestudyofallpatientsadmittedto hos-pitalduringthestudyperiodwhounderwentreconstruction ofthelowerlimbsduetolossofcutaneouscoveragewiththe useofthemedialplantarflap.Thefollowingvariableswere assessed:gender,age,traumaetiology,presenceandlocation ofthefracture,characteristics ofthelossofsubstance,and presenceofboneexposure.

Theinclusioncriteriawerepatientstreatedwithlowerlimb traumain thestudy periodwho underwent reconstruction withamedialplantarflap.Dopplerassessmentofthearterial systemofthefootwasperformedinallpatients.Thedorsal arteryofthefootandtheposteriortibialarterywerepatentin allpatients.

The exclusion criteria were hemodynamically unstable patients,tibialnervelesions,orlesionsintheplantardonor area.

The defect was only measured after preparationof the receptorsite,andthentransferredtothedonorsite.Theflap mustbeslightlylargerthanthereceivingarea.

ThestudywasapprovedbytheResearchEthicsCommittee undertheCAAE(CertificateofPresentationforEthical Consid-eration)number:47391715.6.0000.5553,RecommendationNo.: 1.167.841.

Surgicaltechnique

Thesurgicaltechniquewasasfollows:thelowerlimbisplaced in the supine position, with the hip flexedand externally rotated,kneeflexed,andfootinmaximumsupination.The area ofskin tobe transferred from the plantar cavus was markedoff,accordingtothesizeofthelesiontobecovered, limited bythemargins ofthe footarea that doesnotbear weight.Themidlineoftheplantarsurfaceofthefootandthe prominenceofthenavicularbonedeterminethelateraland medialbordersofthe cutaneousterritory,thatis,10–12cm longand4–6cmwide.Theoriginofthemedialplantarartery (superficialbranch)isidentifiedattheseptumbetweenthe abductorhallucismuscleandtheflexordigitorumbrevis mus-cle and emits several branches through the intermuscular septumtothemedialplantarskin.Thisarterycontinuesalong themedialborderofthefoot,anastomosedwiththefirst plan-tarmetatarsalartery.Themedialplantararteryisgenerally smallerthanthedominantlateralplantarartery.5–7

Themedialplantararteryisattacheddistallytotheflap, andtheproximalstumpissuturedtotheflap.Subfascial dis-sectionoftheflapisthenperformed;theflapiselevatedin adistal-to-proximaldirection.Theabductorhallucismuscle issectionedtoachieveagreaterlengthoftheneurovascular pedicle.Theflapisrotatedcarefullyinordertoavoidbending thepedicle.Thefasciclesofthecutaneousnerveare main-tainedintheflap,andaninterfasciculardissectionismade proximally.Subsequently,apartialskingraftisperformedin thedonorarea,atthesamesurgicaltime.

Results

wereadmittedonanoutpatientbasis,afterclinical/surgical controloftheirwoundsbyother specialties,suchas ortho-pedicsandgeneralsurgery.Themeanageofthepatientsat thetimeofinitialcarewas32years(range:2–53),witha pre-dominanceofthe20–29agegroup.Amalepredominancewas observed,representing83.3%ofthesample.Regardingthe eti-ologyoftrauma,motorcycleaccidents(50%)werenoteworthy, followedbyrun-overinjuries(33.3%),andmotorvehicle acci-dent(16.7%).Regardingthelocationofthelesions,themost frequentwerelossofsofttissueintheplantarsupportregion oftheanteriorheel(58.3%),theposteriorheelovertheAchilles tendon(25%),andthedorsumofthefoot(16.7%)(Figs.1–3). Regardingthepresenceoffracture,83.3%ofthepatientsdid notpresent fractures,while 16.7% presenteda metatarsus fracture.Boneexposurewasobservedin58.3%ofthepatients; theother41.7%presentedsofttissuelosswithoutboneor ten-donexposure.Regardingsurgicaltreatment,in83.3%ofthe casesamedialplantarislandflapwasused.

Inall cases, partialskin graftingwas performedon the donorarea,atthesametime.Surgicalcomplicationsobserved werepartiallossoftheskingraftinonecase(8.3%)and par-tiallossoftheflapinonecase(8.3%).Inthelattercase,the patientlaterunderwentareverseflowsuralfasciocutaneous flap,withoutcomplications.Intheothercases,theuseofthe medialplantarflapwasenoughtocoverthelesion,allowing goodestheticandfunctionalresults.Cutaneoussensationwas preservedinallflaps.Nocasesofdysesthesiaweredetected.

Discussion

Thefirstoptionforthereconstructionofthefootandcalcaneal plantarregionshouldbetheuseoffasciocutaneousflaps;the medialplantarflapisinaprominentpositionforprovidinga resistantskincoveringthatappearsclosetonormal,asitisa regionalflap.5_{Therefore,itallowsareconstructionofsimilar}

tissuewithsimilartissue,thatis,itbringstothe reconstruc-tionregionaglobularskinwithafattycushionandfibrous septafixedtotheskinthatareresistanttosheartraumaand weight-bearing.5,6

Themedialplantarflapisrelativelyeasytoperform,with greatversatility,based onawell-defined vascularanatomy pattern.7 _{Thisflaphasevenbeenusedinpatientswith}

dia-betesmellitus.8

Fromapracticalstandpoint,inthereconstructionofthe softtissueoftheheel,itisimportantthattheheelisdivided into weight-bearing regions (anterior or plantar) and non-weight-bearingregions(posterior, onthe Achillestendon).9

Theskinoftheheelandplantararchhavethesame charac-teristics;therefore,thisisthemainreasonforthepreferential useofmedialplantarflapinlesionsoftheanteriorheel.The factthatthisflapisinnervatedbythe cutaneousbranchof themedialplantarnerveisrelevantasitprovidessensitivity, animportantrequirementforpatientambulation.Theflapis createdalittlelargerthanorthesamesizeasthedefect,as thereisnosignificantprimarycontractionoftheflapdueto itsspecificfibroadiposetissuecharacteristics.

Themedialplantarflaphasalsobeenindicatedforpatients withdiabeticneuropathywhopresentchroniculcersinareas

ofsensoryloss,withalowrateofulcerrecurrenceinthelong term.Sincediabeticpatientsmayhavevascularproblems,this flapmayonlybeindicatedforthosewithgoodvascularflow totheflapregion.8

Locoregional fasciocutaneous flapsare an alternative to freeflapsforlowerlimbreconstruction,especiallyintheheel region.Freeflapswouldbeindicatedformorecomplexcases, whennoneofthelocoregionalflapsareavailable.9

Freeflapsaregood optionsforrebuildinglargelossesof softtissueontheheelandlowerthirdoftheleg.Microsurgery mayrequirelongersurgicaltimethanlocoregionalflaps,and aspecializedteamisneeded.10

Incalcanealreconstructions,thereversesuralflapisalso agoodoption.11,12_{Thisflapwassuccessfullyusedinonecase}

ofpartiallossofthemedialplantarflapinthereconstruction oftheheel.Thedisadvantageofthereversesuralflapislossof sensationinthelateralmalleolus,thelateralsideofthefoot, andonthefifthtoe,duetoligatureofthesuralnerve.

Inthepresentstudy,distalbasedreverseflowmedial plan-tararteryflapswerenotmade.Thistypeofflapisindicated forthereconstructionofdistaldefectsintheplantarregion ofthemetatarsalheads.Theseflapsarebasedonretrograde bloodflowfromthedistalmedialplantararterytothedorsal arteryofthefootthroughthefirstdorsalmetatarsal commu-nicatingbranches.Thedisadvantageofthisflapisitssensory loss.13

Freeflapsbased onthe medialplantararteryare alsoa goodoptionforreconstructionofdistaldefectsofthe plan-tarregion,andtheycanbeflapinnervated.14,15_Moreover,the

medialplantarflapcanbemadecrosslegged,withthedonor regionoftheflapbeingthecontralateralfoot.16

Onedisadvantageoftheflapbasedonthemedialplantar arteryisthelossofafootartery.However,themain irriga-tionplantararchofthefootisthedeepone,whichisformed mainlybythelateralplantarartery,allowingtheformationof ananastomoticnetworkbetweenthetwomainarteriesofthe foot(dorsalarteryofthefootandlateralplantarartery).

Thedeepplantararchalsoformsfourplantarmetatarsal arteriesandsomeperforatingarteries.Thecontributionofthe medialplantararterytothedeepplantararchissmallandis limitedtothelateralbranchofitsdeepbranch.17

Another disadvantage of the medial plantar flap is its limitationinsizeandoncoverageofdeepandextensive cav-itydefects.Therefore,largermuscleorfasciocutaneousflaps shouldbeusedtocoversuchdefects.

The options for reconstruction in complex lesions are numerous;thechoiceofanadequatesurgicalplanningbased onthepatient’sage,gender,andoccupation, aswellasthe sizeandlocationoftissueloss,isparamount.Furthermore, thepresenceoftraumaandassociatedinjuriesmustalways beconsidered,especiallyintraumacausedbytheimpactof highenergy.Theconcernwiththedonorareaandthequality oftheresultsintherecipientareahasbeenincreasing.

Fig.1–(A)53-Year-oldpatient,victimofamotorcycleaccident,withlossofsubstanceintheAchillestendontopography.(B)

Flapdonorarea.(C)MedialplantarflapcoveringtheAchillestendonthreemonthspostoperatively.

Fig.2–(A)5-Year-oldchild,victimofarun-overinjury,withlossofsubstanceinthedorsumofthefootwithcompound

metatarsalfracturesassociatedwithtoeamputation.(B)Dissectedmedialplantarislandflap,withitsneurovascular

pedicle.(C)Flappositionedintherecipientarea,onthedorsumofthefoot.(D)Donorareaofthemedialplantarflapwith

Fig.3–(A)26-Year-oldpatient,victimofamotorcycleaccidentwithlossofcalcanealsubstance.(B)Thedonorareaofthe

skingraftflap,fivemonthspostoperatively.(C)Advancingflapofthemedialplantarregionandtheposteriorregionofthe

heelcoveringthelossofsubstanceintheheel.

Conclusion

Themedialplantarflaphasbeenshowntobeagood treat-mentoptionforinjuriesoftheheelanddorsumofthefoot, withahighsuccessrateandeasyreproducibility.Themain advantagesoftheflaparethepresenceofsensationit pro-videsandthefactthatitbringsspecializedplantartissueto thereconstructed recipientarea,withlowmorbidityinthe donorarea.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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