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

  • Technical Note
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European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Purpose

The instep medial plantar flap is a well-known flap based on the medial plantar artery of the foot and usually used for coverage of soft tissue defects of the heel area. It has seldom been reported for coverage of anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures. The primary purpose of this study is to evaluate the feasibility and viability of this flap as well as its reliability saving the internal fixation devices and efficiency protecting bone healing; the secondary purpose is to assess the condition of the flap and its cosmetic appearance, as well as occurrence of complications related to its harvesting.

Material and methods

This is a retrospective review of medical records of patients operated from December 2015 to December 2020 with application of an instep flap for coverage of the anterior ankle area with exposure of the bone and metallic hardware secondary to open reduction and internal fixation of distal tibial fractures. All patients were reviewed for the purpose of this study; they were assessed for the viability and functional and sensory condition of the flap, signs of local infection, as well as for residual pain and sensory impairment of the toes; subjective cosmetic appearance of the flap was also judged.

Results

There were four patients with 32 years mean age and 35 months mean follow-up. The mean flap size was 7.75 cm × 5.75 cm. At final follow-up, all fractures were completely consolidated, and all flaps were living, stable, and sensitive. No distal sensation disturbance was noticed, and none of the patients had pain or annoyance caused by the flap or presented signs of infection. Only one patient expressed mild aesthetic complain.

Conclusion

The fascio-cutaneous instep medial plantar flap is a reliable solution to cover the anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures, especially for defects measuring up to 9 cm × 6 cm. This flap is technically valid and reproducible; it offers good quality of soft tissue coverage with satisfactory cosmetic appearance and minimal morbidity.

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References

  1. Baker GL, Newton ED, Franklin JD (1990) Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot. Plast Reconstr Surg 85:47–60. https://doi.org/10.1097/00006534-199001000-00009

    Article  CAS  PubMed  Google Scholar 

  2. Baumeister S, Germann G (2001) Soft tissue coverage of the extremely traumatized foot and ankle. Foot Ankle Clin N Am 6:867–903. https://doi.org/10.1016/s1083-7515(02)00006-2

    Article  CAS  Google Scholar 

  3. Korompilias A, Gkiatas I, Korompilia M, Kosmas D, Kostas-Agnantis I (2019) Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction. Eur J Orthop Surg Traumatol 29:367–372. https://doi.org/10.1007/s00590-018-2330-8

    Article  PubMed  Google Scholar 

  4. Sahu RK, Kala PC, Midya M (2020) Two-staged reverse sural flap: a versatile flap with consistent results in the soft tissue reconstruction of distal leg and heel defects-an institutional experience. Eur J Orthop Surg Traumatol 30:337–341. https://doi.org/10.1007/s00590-019-02544-x

    Article  PubMed  Google Scholar 

  5. Acikel C, Celikoz B, Yuksel F, Ergun O (2003) Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg 50:498–503. https://doi.org/10.1097/01.SAP.0000044141.35292.A7

    Article  PubMed  Google Scholar 

  6. Cang ZQ, Ni XD, Xu Y, Wang M, Wang Q, Yuan SM (2020) Reconstruction of the distal lower leg and foot sole with medial plantar flap: a retrospective study in one center. J Plast Surg Hand Surg 54:40–46. https://doi.org/10.1080/2000656X.2019.1673169

    Article  PubMed  Google Scholar 

  7. Oberlin C, Saffar P (1984) Le lambeau en îlot plantaire interne. Étude anatomique et applications chirurgicales. Rev Chir Orthop 70:151–154

    CAS  PubMed  Google Scholar 

  8. Oberlin C, Bastian D, Gréant P (1994) Le lambeau plantaire médial. In: Oberlin C, Bastian D, Gréant P (eds) Les lambeaux pédiculés de couverture des membres. Expansion Scientifique Française, Paris, pp 117–121

    Google Scholar 

  9. Masquelet AC (2010) Lambeau cutané plantaire médial. In: Masquelet AC (ed) Chirurgie réparatice en orthopédie-traumatologie. Tome1: Les lambeaux. Sauramps Medical, Montpellier, pp 242–246

    Google Scholar 

  10. De Macedo JLS, Rosa SC, De Neto AVRF, Da Silva AA, De Amorim ACS, Barbosa IM (2017) The medial plantar flap: a case series. Rev Bras Cir Plást 32:256–261. https://doi.org/10.5935/2177-1235.2017RBCP0041

    Article  Google Scholar 

  11. Opoku-Agyeman JL, Allen A, Humenansky K (2020) The use of local medial plantar artery flap for heel reconstruction: a systematic review. Cureus 12(8):e9880. https://doi.org/10.7759/cureus.9880

    Article  PubMed  PubMed Central  Google Scholar 

  12. Harrison DH, Morgan BDG (1981) The instep island flap to resurface plantar defects. Br J Plast Surg 34:315–318. https://doi.org/10.1016/0007-1226(81)90019-9

    Article  CAS  PubMed  Google Scholar 

  13. Attinger CE, Evans KK, Bulan E, Blume P, Cooper P (2006) Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 117(7 Suppl):261S-293S. https://doi.org/10.1097/01.prs.0000222582.84385.54

    Article  CAS  PubMed  Google Scholar 

  14. Shanahan RE, Gingrass RP (1979) Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg 64:295–298. https://doi.org/10.1097/00006534-197909000-00001

    Article  CAS  PubMed  Google Scholar 

  15. Dc W, Gabbay J, Levi B, Boyd JB, Granzow JW (2011) Quality of innervation in sensate medial plantar flaps for heel reconstruction. Plast Reconstr Surg 127:723–730. https://doi.org/10.1097/PRS.0b013e3181fed76d

    Article  CAS  Google Scholar 

  16. Liu L, Zhou Y, Cao X, Cao X, Cai J (2014) Heel reconstruction with free instep flap: a case report. J Med Case Reports 8:319. https://doi.org/10.1186/1752-1947-8-319

    Article  Google Scholar 

  17. Lohasammakul S, Turbpaiboon C, Chaiyasate K, Tatsanavivat P, Chompoopong S, Roham A, Ratanalekha R, Aojanepong C (2018) Anatomy of medial plantar superficial branch artery perforators: facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction. Microsurgery 38:536–543. https://doi.org/10.1002/micr.30321

    Article  PubMed  Google Scholar 

  18. Jitprapaikulsarn S, Patamamongkonchai C, Gromprasit A, Thremthakanpon W (2021) Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft. Eur J Orthop Surg Traumatol 31:365–373. https://doi.org/10.1007/s00590-020-02786-0

    Article  PubMed  Google Scholar 

  19. Jitprapaikulsarn S, Benjawongsathien K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W (2021) Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects. Eur J Orthop Surg Traumatol 31:413–420. https://doi.org/10.1007/s00590-020-02772-6

    Article  PubMed  Google Scholar 

  20. Amarante J, Martins A, Reins J (1988) A distally based medial plantar flap. Ann Plast Surg 20:468–470. https://doi.org/10.1097/00000637-198805000-00012

    Article  CAS  PubMed  Google Scholar 

  21. Morrison WA, Crabb DM, O’Brien BM, Jenkins A (1983) The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 72:56–65. https://doi.org/10.1097/00006534-198307000-00013

    Article  CAS  PubMed  Google Scholar 

  22. Scaglioni MF, Rittirsch D, Giovanoli P (2018) Reconstruction of the heel, middle foot sole, and plantar forefoot with the medial plantar artery perforator flap: clinical experience with 28 cases. Plast Reconstr Surg 141:200–208. https://doi.org/10.1097/PRS.0000000000003975

    Article  CAS  PubMed  Google Scholar 

  23. Amarante J, Schoofs M, Costa H, Reis J, Gongaza R (1986) International dermatosurgery: use of medial plantar-based skin flaps for correction of foot defects. J Dermatol Surg Oncol 12:693–695. https://doi.org/10.1111/j.1524-4725.1986.tb01973.x

    Article  CAS  PubMed  Google Scholar 

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Funding

The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of the current study.

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Authors and Affiliations

  1. Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25., Ghoubeiry, Beirut, Lebanon

    Ali Hassan Chamseddine, Abbas A. Dib & Hassan M. Wardani

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  1. Ali Hassan Chamseddine
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  2. Abbas A. Dib
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  3. Hassan M. Wardani
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Correspondence to Ali Hassan Chamseddine.

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The authors declare that the current study was approved by the Ethical Committee of their institution.

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Chamseddine, A.H., Dib, A.A. & Wardani, H.M. The instep flap for anterior ankle coverage with bone and hardware exposure. Eur J Orthop Surg Traumatol 32, 775–781 (2022). https://doi.org/10.1007/s00590-021-03055-4

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  • DOI: https://doi.org/10.1007/s00590-021-03055-4

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