Dr Mujtuba Pervez Khan

1. Foot and ankle reconstruction
Dr Mujtuba Pervez Khan
Plastic & Reconstructive Surgery
DUHS/CHK

2. Introduction
 Mostly Traumatic
 90% reconstruction can be achieved by simple
techniques. 10% by complex flaps

3. History
 Etiology
 Duration
 Previous treatment
 Comorbid conditions
 Current medications
 Allergies
 Nutritional Status
 Current level of Activity (if the limb is not used in any way, indication for amputation)

4. Comorbid conditions
Diabetes
Peripheral neuropathy is a major cause of diabetic foot wounds
Elevated intra-neural concentration of sorbitol -> nerve damage -> nerve swells within
tight spaces -> double crush syndrome
Unregulated glucose levels -> Increase advanced glycosylated end products ->
microvascular injury
Decreased insulin levels -> decreased maintenance or repair of nerve
Decreased ability of leukocytes, macrophages and lymphocytes to destroy bacteria
Ability of antibiotic to coat the bacteria is decreased
More prone to infections

5. Comorbid conditions
Neuropathy
Loss of sensation -> delay in detection of skin breaks
Charcot deformityCharcot deformity (neuroarthropathy), joint collapse due to insensitivity to pain
Absence of pain perception -> soft tissue injury -> ligament injury -> joint capsule injury ->
articular cartilage erosion -> joint instability
Accompanied by loss of Achilles tendon flexibility -> loss of dorsiflexion -> stress on the
foot -> loss of medial longitudinal arch
Can lead to ulceration, infection, gangrene and limb loss
Often misdiagnosed as sprain or cellulitis

7. Comorbid conditions
Ischemia
Risk factors: Hypercholestrolemia, hypertension, tobacco use
Buerger disease, vasculitis, thromboembolic disease
Connective tissue disorders
E.g: SLE, RA, scleroderma, Raynauds disease
Steroid and immunosuppressive therapy

8. Examination
 Wound size
 Wound depth
 Vascular supply
 Sensory examination
 Motor examination
 Bone (stable, collapsed, disjointed)
 Achilles Tendon (if 10-15 degree dorsiflexion can not be performed, tendon is tight and
placing stress on plantar arch during gait)
 Donor site

9. Investigation
 Doppler studies
 X-ray, O.M findings 3 weeks after clinical manifestation
 MRI, early detection of O.M
 Bone scan, to see proximal spread of O.M

10. Anatomy

16. Reconstructive options
 Reconstructive ladder
 Simple coverage is
recommended, 15% defects
need flap coverage
 Secondary intention, primary
closure, skin graft, local flap,
pedicle flap, perforator based
flaps, free flap
 NPWT
 Flaps only have to be large
enough to cover the exposed
tendons, bones or joint, rest can
be skin grafted

17. Reconstructive options
 Achilles tendon lengthening
 Unable to dorsiflex foot when knee is
flexed or extended -> both
gastrocnemius and soleus tendons are
tight -> Tendon release
 Dorsiflexion when knee is flexed ->
only gastrocnemius tendon is tight ->
gastrocnemius recession / tongue and
groove incision
 Cast for 6 weeks

18. Algorithm
Achilles region
Local flaps
Free flap
Composite ALTF with vascularized fascia lata
Plantar forefoot
Local flaps
Fillet flap
Neurovascular island flap
Free Flap (Rectus abdominis,
Gracilis, Serratus anterior muscle)
Plantar mid-foot
Local flaps
Flexor digiti minimi brevis
(FDMB) flap
Flexor halluces brevis (FHB)
flap
Abductor halluces flap
Abductor digiti minimi flap
Neurovascular island flaps
Free flaps
(RFFF,parascapular, ALTF)
Contralateral sensate free
instep flap
Plantar hind-foot/ Medial +Plantar hind-foot/ Medial +
Lateral ankleLateral ankle
Abductor halluces flap
Flexor digitorum brevis
flap
Abductor digiti minimi flap
Medial plantar artery flap
Sural flap
Free flap
Anterior ankle/Dorsal Foot
EDB muscle flap
Lateral supramalleolar
artery flap
Free flaps (Lateral arm flap,
RFFF, Parascapular flap, ALTF)

19. Anterior Ankle and Dorsal Foot
 Lateral supramalleolar artery flap
 EDB muscle flap
 Free flaps
Lateral arm flap
RFFF
Parascapular flap
ALTF

20. Anterior Ankle and Dorsal Foot
Lateral Supramalleolar artery flap (LSM)
 cutaneous branch from the
perforating branch of the
peroneal artery
 Perforator 5cm above the
lateral malleolus
 Proximally, the incision
should not exceed the
middle third of the leg
Ref: Hamdi MF, Khlifi A. Lateral supramalleolar flap
for coverage of ankle and foot defects in
children. The Journal of Foot and Ankle Surgery.
2012 Jan 1;51(1):106-9.

22. Anterior Ankle and Dorsal Foot
Extensor digiti brevis flap
 Type 2 muscle
 Dominant: lateral tarsal
artery (branch of dorsalis
pedis)
 Minor: lateral minor tarsal
branches
 Thin and broad
 4x6 cm size
 For smaller defects
 Can be distally based

25. Anterior Ankle and Dorsal Foot
Free flaps
 Thin, pliable tissue
 Proper shoe fitting
 High aesthetic demand
ALTF
 Reliable pedicle
 Minimal donor site morbidity
 Bulky, requires debulking
RFFF
Thin, pliable
Harvested with nerve and tendon
Long pedicle
Donor site scar
Allens test
Lateral arm flap
Long pedicle
Sensate flap
Parascapular flap
Large defects
Insensate flap
Debulking

26. Plantar forefoot
 Preserve prox portion of prox phalynx
 Local flaps (V-Y, rotation,
transposition)
 Fillet flap
 Neurovascular island flap

27. Plantar forefoot
Free Flap
Rectus abdominis
Thin, broad
Easy to harvest
Excellent pedicle
Minimal donor site morbidity
Gracilis muscle
Good choice of flap
Shorter pedicle 7cm, than RA flap
Serratus anterior
Adequate coverage
Long pedicle 18cm

28. Plantar mid-foot
 Low functional and aesthetic importance
 Local flaps (V-Y 1.5cm, double opposing V-Y 3cm,
rotation flap)
 Muscle flaps (Flexor digiti minimi brevis (FDMB)
flap, Flexor halluces brevis (FHB) flap, Abductor
halluces flap, Abductor digiti minimi flap)
 Neurovascular island flaps
 Free flaps (RFFF,parascapular, ALTF)
 Contralateral sensate free instep flap

30. Plantar hindfoot & Medial and Lateral
ankle
 Medial plantar artery flap
 Abductor halluces brevis flap
 Flexor digitorum brevis flap
 Abductor digiti minimi flap
 Sural flap
 Free flap

31. Plantar hind-foot & Medial and Lateral ankle
Medial Plantar artery flap
 Dominant: Medial plantar
artery (branch of post tibial
artery)
 Minor: perforating vessels from
the abductor hallucis brevis and
flexor digitorum brevis

33. Plantar hind-foot & Medial and Lateral ankle
Abductor halluces flap
 Type 2 muscle
 For medial heel and ankle defects
 Dominant: prox. branch of medial
plantar artery
 Minor: muscle perforators arising
from the medial plantar artery
 Line btw medial calcaneum and
base of great toe
 3-10cm skin island can be raised

35. Plantar hind-foot & Medial and Lateral ankle
Abductor digiti minimi flap
 Type 2 muscle
 Workhorse flap for lateral heel and
ankle
 Dominant: Proximal branch of the
lateral plantar artery
 Minor: muscular branches of the
lateral plantar artery
 Pedicle enters 3-4cm inferior to
the malleolus
 3-8cm of skin island

37. Plantar hind-foot & Medial and Lateral ankle
Flexor digitorum brevis flap
 Dominant: Proximal branch of the
medial plantar artery
 Dominant: Proximal branch of the
lateral plantar artery
 Minor: muscular branches of both

39. Plantar hind-foot & Medial and Lateral ankle
Sural flap

40. Achilles region
 Local flaps (lateral calcaneal flap,
reverse sural flap)
 Composite ALTF with vascularized
fascia lata

41. Post op care
 No weight bearing for 4 weeks
 Foot elevation (1 day for local flaps, 3-5 days
for skin grafts, 2 weeks for free flap)
 Ex fix or ilizarov for stabilization
 Gradual rehab to gain strength and mobility

42. Thank you