Skip to main content

Advertisement

SpringerLink
Log in

Surgical Technique: Repair of Forefoot Skin and Soft Tissue Defects Using a Lateral Tarsal Flap With a Reverse Dorsalis Pedis Artery Pedicle: A Retrospective Study of 11 Patients

  • Surgical Technique
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Various authors have proposed flaps to reconstruct traumatic forefoot skin and soft tissue defects, especially with exposure of tendon and/or bone although which is best for particular circumstances is unclear.

Description of Technique

The indications for the technique were a forefoot defect area of no more than 8-cm × 8-cm and a well-preserved lateral tarsal (LT) donor site. The injured tendons were repaired using tendon grafts. The free dorsalis pedis flap was outlined by centering it on the cutaneous branch of the LT artery and tailoring it to the size of the wound, allowing 0.5-cm margins in length and width. The flap was rotated around the plantar perforating branch of the dorsalis pedis artery (DPA) to cover the forefoot defect. The lateral dorsalis pedis cutaneous nerve was anastomosed with the recipient plantar nerve stump. The donor site was covered with an inguinal, full-thickness skin graft.

Patients and Methods

Traumatic forefoot skin and soft tissue defects with exposure of the tendon and/or bone involving 11 feet in 11 patients (mean age, 32 years) were covered using a LT flap with a reversed DPA pedicle. Three patients with forefoot defects underwent emergency repair within 8 hours of injury, whereas eight patients required delayed repair. All patients were followed up for at least 6 months (mean, 13 months; range, 6–24 months).

Results

All flaps survived uneventfully, except for two that had superficial marginal necrosis or severe venous insufficiency. All skin grafts covering the donor sites survived and all wounds healed. None of the patients had restricted standing or walking at followups. The two-point discrimination was 4 mm to 10 mm at 6 months postoperative. The mean hallux-metatarsophalangeal-interphalangeal scale score was 93 points (range, 87–98 points).

Conclusions

Our observations suggest the LT flap with a reversed DPA pedicle is a reasonable option for repair of traumatic forefoot skin and soft tissue defects with exposure of tendon and/or bone but a well-preserved LT donor site and is associated with minimal morbidity.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1A–D
Fig. 2A–D
Fig. 3A–D

Similar content being viewed by others

References

  1. Balakrishnan C, Chang YJ, Balakrishnan A, Careaga D. Reversed dorsal metatarsal artery flap for reconstruction of a soft tissue defect of the big toe. Can J Plast Surg. 2009;17:e11–12.

    PubMed  Google Scholar 

  2. Basile A, Stopponi M, Loreti A, Minniti de Simeonibus AU. Heel coverage using a distally based sural artery fasciocutaneous cross-leg flap: report of a small series. J Foot Ankle Surg. 2008;47:112–117.

    Article  PubMed  Google Scholar 

  3. Chen SL, Chou TD, Chen SG, Cheng TY, Chen TM, Wang HJ. The boomerang flap in managing injuries of the dorsum of the distal phalanx. Plast Reconstr Surg. 2000;106:834–839.

    Article  PubMed  CAS  Google Scholar 

  4. 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. 2006;40:106–110.

    Article  PubMed  Google Scholar 

  5. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.

    Article  PubMed  Google Scholar 

  6. Giannini S, Faldini C, Pagkrati S, Miscione MT, Luciani D. One-stage metatarsal lengthening by allograft interposition: a novel approach for congenital brachymetatarsia. Clin Orthop Relat Res. 2010;468:1933–1942.

    Article  PubMed  Google Scholar 

  7. Hills AP, Hennig EM, McDonald M, Bar-Or O. Plantar pressure differences between obese and non-obese adults: a biomechanical analysis. Int J Obes Relat Metab Disord. 2001;25:1674–1679.

    Article  PubMed  CAS  Google Scholar 

  8. Hirsch G, McBride ME, Murray DD, Sanderson DJ, Dukes I, Menard MR. Chopart prosthesis and semirigid foot orthosis in traumatic forefoot amputation: comparative gait analysis. Am J Phys Med Rehabil. 1996;75:283–291.

    Article  PubMed  CAS  Google Scholar 

  9. Huang W, Liu D, Robb GL, Zhang Q. Distally based dorsal pedal neurocutaneous flap for forefoot coverage. Ann Plast Surg. 2011;66:235–240.

    Article  PubMed  CAS  Google Scholar 

  10. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 15:349–353.

    PubMed  CAS  Google Scholar 

  11. Kohli JS, Pande S, Bajaj SP. Large transverse fasciocutaneous leg flap: whole leg flap. Br J Plast Surg. 2000;53:495–498.

    Article  PubMed  CAS  Google Scholar 

  12. 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. 2004;114:1478–1485.

    PubMed  Google Scholar 

  13. Miao W, Liu Z, Xu C. [Repair of forefoot skin and soft tissue defect with reverse lateral tarsal artery flap] [in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2010;24:53–56.

    PubMed  Google Scholar 

  14. Moucharafieh R, Wehbe J, Maalouf G, Atiyeh B. Long-term follow-up on microsurgical free-tissue transfer in foot and ankle reconstruction. Foot Ankle Surg. 2008;14:82–88.

    Article  PubMed  Google Scholar 

  15. Oberlin C, Accioli de Vasconcellos Z, Touam C. Medial plantar flap based distally on the lateral plantar artery to cover a forefoot skin defect. Plast Reconstr Surg. 2000;106:874–877.

    Article  PubMed  CAS  Google Scholar 

  16. Oestern HJ, Tscherne H, Sturm J, Nerlich M. [Classification of the severity of injury] [in German]. Unfallchirurg. 1985;88:465–472.

    PubMed  CAS  Google Scholar 

  17. Oh SJ, Moon M, Cha J, Koh SH, Chung CH. Weight-bearing plantar reconstruction using versatile medial plantar sensate flap. J Plast Reconstr Aesthet Surg. 2011;64:248–254.

    Article  PubMed  Google Scholar 

  18. Takahashi A, Tamura A, Ishikawa O. Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect. J Foot Ankle Surg. 2002;41:247–250.

    Article  PubMed  Google Scholar 

  19. Unglaub F, Wolf MB, Dragu A, Forst J, Horch RE, Kneser U. Reconstruction of a child’s forefoot defect using a distally based pedicled medial plantar flap. Arch Orthop Trauma Surg. 2010;130:155–158.

    Article  PubMed  Google Scholar 

  20. Uygur F, Duman H, Ulkür E, Noyan N, Celiköz B. Reconstruction of distal forefoot burn defect with retrograde medial plantar flap. Burns. 2008;34:262–267.

    Article  PubMed  Google Scholar 

  21. Van Landuyt K, Monstrey S, Tonnard P, Vermassen F. Free flap coverage of a gangrenous forefoot in a patient with Buerger’s disease: a case report. Ann Plast Surg. 1996;36:154–157.

    Article  PubMed  Google Scholar 

  22. Vermassen FE, van Landuyt K. Combined vascular reconstruction and free flap transfer in diabetic arterial disease. Diabetes Metab Res Rev. 2000;16(suppl 1):S33–S36.

    Article  PubMed  Google Scholar 

  23. Wang X, Qiao Q, Burd A, Qi K. Reconstruction of distal foot wounds with reverse first dorsal metatarsal artery flap. Burns. 2005;31:1025–1028.

    Article  PubMed  Google Scholar 

  24. Wu N, Xu Y, Li J. [Anatomical studies and clinical applications of distally-based intermediate dorsal neurocutaneous flap on the foot] [in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2007;21: 363–366.

    PubMed  Google Scholar 

  25. 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. 2010;63:164–169.

    Article  PubMed  Google Scholar 

  26. Yeh JT, Lin CH, Lin YT. Skin grafting as a salvage procedure in diabetic foot reconstruction to avoid major limb amputation. Chang Gung Med J. 2010;33:389–396.

    PubMed  Google Scholar 

Download references

Acknowledgments

We thank Medjaden Biosciences Ltd. for proofreading the English manuscript.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China

    Dehao Fu MD, Shuhua Yang MD & Baojun Xiao MD

  2. Department of Orthopaedics, The Jiangxi Provincial People’s Hospital, Nanchang, China

    Liyi Zhou MD

Authors
  1. Dehao Fu MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Liyi Zhou MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shuhua Yang MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Baojun Xiao MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Shuhua Yang MD.

Additional information

The institution of one or more of the authors (DF) has received, during the study period, funding from National Natural Scientific Foundation of China (#30901522). Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This study was performed at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.

About this article

Cite this article

Fu, D., Zhou, L., Yang, S. et al. Surgical Technique: Repair of Forefoot Skin and Soft Tissue Defects Using a Lateral Tarsal Flap With a Reverse Dorsalis Pedis Artery Pedicle: A Retrospective Study of 11 Patients. Clin Orthop Relat Res 471, 317–323 (2013). https://doi.org/10.1007/s11999-012-2598-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-012-2598-7

Keywords

Search

Navigation