Case 1
Clinical Presentation
A 36-year-old White male developed a wound dehiscence following an open reduction and internal fixation of his calcaneus fracture by the orthopedic foot and ankle service ( Fig. 50.1 ). He had sustained a right foot calcaneus fracture from a fall. He underwent soft tissue debridement by the orthopedic foot and ankle service, which left a complex heel wound with the exposed fracture site ( Fig. 50.2 ). The plastic surgery service was asked by the primary service to provide soft tissue coverage to this complex posterior heel wound of the right foot.
Operative Plan and Special Considerations
For a complex heel wound, a medial plantar artery flap, a type B fasciocutaneous flap, can be selected as a valid reconstructive option. The flap receives a blood supply from the medial plantar artery, which is a continuation of the posterior tibial artery after bifurcation. The size of the flap’s skin paddle can be up to 12 × 6 cm from the instep of the foot, which is in the non-weight-bearing area. The pedicle of the flap is under the fascia and the extent of the flap’s arc of rotation depends on the level of bifurcation in the medial ankle ( Fig. 50.3 ). The flap can be rotated posteriorly to cover a heel soft tissue defect. The donor site of the flap can be closed with a skin graft because it is in the non-weight-bearing area. A preoperative angiogram should be obtained to determine the blood supply to the foot and the level of bifurcation from the posterior tibial artery in the ankle.
Operative Procedures
Under general anesthesia, with the patient in the supine position, the right heel wound was debrided by the plastic surgery service. All unhealthy-looking skin or tissue was debrided and the wound was then irrigated with Pulsavac. After the definitive debridement, the heel wound, measuring 6 × 3.5 cm, looked fresh and clean ( Fig. 50.4 ).
The medial plantar artery was mapped with a handheld Doppler and a 6 × 3.5 cm skin paddle of the flap was designed ( Fig. 50.5 ). Under tourniquet control, the skin paddle was incised down to the fascia. The fascia around the skin paddle was incised and the pedicle was identified between the abductor and flexor digitorum brevis muscles. At the distal edge of the flap, the pedicle artery was divided with hemoclips and a subfascial dissection was performed. The medial plantar artery was included within the fasciocutaneous component of the flap and visualized all the time during the flap dissection. Additional pedicle dissection was performed through the extended proximal incision toward the heel wound ( Fig. 50.6 ).
After the pedicle dissection had been completed and the tourniquet released, the flap appeared well perfused. It was rotated posteriorly to cover the heel wound ( Fig. 50.7 ). The flap was then inset into the wound and approximated to the adjacent skin edges with several interrupted 3-0 nylon sutures in half-buried horizontal mattress fashion. A drain was placed under the flap before the final closure of the skin paddle. The medial ankle incision was closed with interrupted 3-0 nylon sutures and skin staples.
The flap donor site in the mid-plantar foot was closed with a split-thickness skin graft. It was harvested from the right lateral thigh with a dermatome. The skin graft was meshed to 1:1.5 ratio and then placed on the flap donor site and secured with multiple skin staples ( Fig. 50.8 ). A bolster dressing was used to immobilize the skin graft.
Follow-Up Results
The patient did well postoperatively without any issues related to the medial plantar artery flap for soft tissue coverage of a posterior heel wound. He was discharged from hospital on postoperative day 5. The right heel wound healed without problems ( Fig. 50.9 ) and the flap donor site skin graft took well. He was followed by the plastic surgery service for routine postoperative care and the orthopedic foot and ankle service for orthopedic care.
