heel reconstruction

1. Heel reconstruction
Dr.Amit Kumar Choudhary
RIMS,IMPHAL

2. Anatomy

3. SOLE OF THE FOOT

4. Skin
 Thick and hairless.
 Firmly bound down to the underlying deep
fascia by numerous fibrous bands.
 Shows a few flexure creases at the sites of
skin movement.
 Sweat glands are present in large numbers.
The sensory nerve supply to the skin of the
sole of the foot
 Medial calcaneal branch of the tibial nerve,
which innervates the medial side of the
heel;
 Medial plantar nerve, which innervate the
medial two thirds of the sole;
 Lateral plantar nerve, which innervate the
lateral third of the sole.

5. PLANTAR APONEUROSIS
Definition:
Thickened band of deep fascia in the sole of the foot.
Attachment:
Posteriorly: Medial tubercle of calcaneus.
Anteriorly: Divides into 5 slips which pass to the 5
toes.
On each side: Attached to the metatarsal bones by
medial and lateral intermuscular septa.
Functions:
Protects the underlying nerves and
vessels.
Maintains the longitudinal arches of
the foot.

6. LAYERS OF THE SOLE

7. 1ST LAYER
• Three Muscles:
1) Abductor hallucis
2) Flexor digitorum
brevis
3) Abductor digiti minimi

8. 2ND LAYER
• Two Tendons:
1) Flexor hallucis longus
2) Flexor digitorum longus
• Two Muscles:
1) Quadratus Plantae (Flexor
digitorum accessorius)
2) 4 Lumbricals muscles

10. 3RD LAYER
• Three Muscles:
1) Flexor hallucis brevis.
2) Adductor hallucis
3) Flexor digiti minimi brevis

11. 4TH LAYER
• Two Tendons:
1) Tibialis posterior
2) Peroneus Longus
• Two Muscles:
1) 3 Planter Interossei
2) 4 Dorsal Interossei

13. MEDIAL PLANTAR NERVE
Origin:
• posterior tibial nerve.
Course:
• Enter the foot midway between
the medial malleolus and the
medial tubercle of the calcaneus,
under cover the flexor
retinaculum.
• Passes forwards deep to the
abductor hallucis muscle.
• Pass between the abductor
hallucis and flexor digitorum
brevis muscle.
• The medial planter vessels run
along its medial side
Termination:
• At the bases of the metatarsal
bones by dividing into 3 planter
digital nerves.

14. Branches:
• Muscular (to four muscles) to:
1) Abductor hallucis.
2) Flexor digitorum brevis.
3) Flexor hallucis brevis
4) First lumbrical muscle
• Cutaneous:
Planter cutaneous branches:
1) To the skin of the medial 2/3 of the
sole of the foot.
2) Planter digital nerves
• Articular branches: To intertarsal
and tarso-metatarsal joints

15. LATERAL PLANTAR NERVE
Origin:
• The smaller of the two terminal branches
of the posterior tibial nerve.
Course:
• Enters the foot midway between the
medial malleolus and the medial tubercle
of the calcaneus under cover the flexor
retinaculum.
• Passes forwards and laterally deep to
abductor hallusis.
• Passes between flexor digitorum brevis &
flexor digitoum accessorius.
The lateral planter vessels rum along its lateral
side.
Termination:
• At the base of the 5th metatarsal bone, by
dividing into a superficial and a deep
branches.

16. Branches:
Muscular :
1) Flexor digitoum accessorius
muscle
2) Abductor digiti minimi
3) Flexor digiti minimi brevis
4) Adductor halucis muscle.
5) Interossei
6) 2nd, 3rd & 4th lumbricals.
Cutaneous:
1) Skin of the lateral 1/3 of the sole
2) Skin on the lateral side of the
planter surface of the little toe
and the adjoining sides of the
4th & 5th toes.
3) The planter digital branches, also,
supply the skin on the dorsum of
the terminal phalanges of the
lateral one and half toes

17. MEDIAL PLANTAR ARTERY
Origin:
• One of the two terminal branches of the
posterior tibial artery.
Course:
• Enter the foot midway between the medial
malleolus and the medial tubercle of the
calcaneus, under cover the flexor
retinaculum.
• Passes forwards deep to the abductor
hallucis muscle.
• Passes between the abductor hallucis and
flexor digitorum brevis.
• It is accompanied by two venae comitantes.
• The medial planter nerve runs along its
lateral side.
Termination:
• By anastmosing with the 1st planter
metatarsal artery.

18. • Branches:
Muscular:
• to the surrounding
muscles.
Digital:
• These are 3 superficial
digital branches these
branches end by
anastmosing with the
first, second and third
planter metatarsal
arteries

19. LATERAL PLANTAR ARTERY
Origin:
• One of the two terminal branches
of the posterior tibial artery.
Course:
• At first between the 1st and 2nd
layers, then curves medially
between the 3rd and 4th layers of
the sole.
• The lateral planter nerve lies
along its medial side.
Termination:
• Turns medially with the deep
branch of the lateral planter nerve
with slight forward convexity to
from the plantar arch between
the 3rd & 4th layers of muscles

20. Branches:
 Muscular: to the surrounding muscles.
 Anastomotic branches:
Anastomosis with branches of arcuate & lateral
tarsal arteries of the dorsalis pedis artery.
 Posterior perforating arteries:
3 branches which ascend through the proximal
ends of the 2nd, 3rd & 4th interosseous spaces to
anastomose with the dorsal metatarsal arteries.
 Planter digital artery: to the lateral side of the
little toe. From the beginning of the arch.
 Three planter metatarsal arteries: Each divides
into two planter digital arteries which supply the
adjacent sides of two toes.
• These planter metatarsal arteries supply the
adjacent sides between the 2nd, 3rd, 4th toes.
Before it division into planter digital arteries, each
planter metatarsal artery sends an anterior
perforating artery to joint the correspondingdorsal
metatarsal artery.

21. Heel reconstruction

22. Reconstruction
• Heel is the important integrated part of the sole of the foot
which is essential for smooth walking.
• Without heel the propelling function of the foot during
walking is severely interrupted.
• Trauma is the leading cause of soft tissue loss of the heel
followed by tumor, infective gangrene and burn.
• Most of the cases of isolated soft tissue injuries result from
degloving type of injury .

23. Heel divided into
 The anterior or weight-bearing heel
 The posterior or non–weight-bearing heel.

24. Anterior heel
Local flaps
 Transposition and Rotation Skin
Flaps of the Sole of the Foot
 Bipedicle Skin Flap to the Heel
 V-Y Advancement Flaps to the
Heel and Ankle
 Medial Plantar Flap
 Lateral Calcaneal Artery Skin
Flap
 Dorsalis Pedis Flap
 Reverse Anterior Tibial Artery
Flap
 Lateral Supramalleolar Flap
 Dorsalis Pedis Flap
• Free flap
• Skin grafting
• distant flaps-Cross-Foot
Skin Flap

25. Posterior heel
Skin grafting
Local flap
 Sural flap
 Transposition and Rotation Skin Flaps
of the Sole of the Foot
 Bipedicle Skin Flap to the Heel
 V-Y Advancement Flaps to the Heel
and Ankle
 Plantar Artery-Skinfascia Flap
 Medial Plantar Flap
 Lateral Calcaneal Artery Skin Flap
 Dorsalis Pedis Flap
 Reverse Anterior Tibial Artery Flap
 Lateral Supramalleolar Flap
 Dorsalis Pedis Flap
• Free flaps
• Distant flaps-Cross-Foot Skin Flap

27. Medial Plantar Flap
INDICATIONS
• The plantar concavity or non-weight-bearing
region of the sole has sufficient surface area
to cover the entire plantar surface of the heel.
• Sensory innervation L4 and L5 nerve roots
•

28. FIG. 1. Anatomy of the medial plantar artery. 1, Medial plantar nerve; 2, medial
plantar artery; 3, abductor hallucis; 4, plantar aponeurosis; 5, flexor digitorum brevis;
6, tendon of the abductor hallucis; 7, divided branches of the medial plantar artery;
8, medial malleolus; 9, skin; 10, subcutaneous tissue; 11, plantar cutaneous
branches of the medial plantar nerve.

29. ANATOMY
• The medial plantar artery is the terminal branches of the posterior tibial artery.
- Arises behind the origin of the abductor hallucis muscle and courses deep to the
plantar fascia between the abductor hallucis and the flexor digitorum brevis
muscles.
- terminates in small digital branches to the medial two or three toes.
- supplies the skin of the medial two thirds of the plantar concavity
The medial plantar nerve arises from the tibial nerve behind the medial malleolus.
- It accompanies the medial plantar artery and terminates in one proper digital
and three common digital nerves. It provides motor branches to the abductor
hallucis, the flexor digitorum brevis, and the medial lumbricals.
• Sensory branches perforate the plantar fasciae and are distributed to the skin of
the medial two thirds of the plantar concavity. The plantar cutaneous fascicles can
be separated from the remainder of the nerve by perineurial dissection. The
greater saphenous vein and the venae comitantes provide venous outflow.

30. OPERATIVE TECHNIQUE
• The presence of a patent medial plantar artery
should be verified using a Doppler device or
arteriography.
• Dissection is begun distally.
• Skin incision is deepened through the plantar
fascia, the digital branches of the artery are
divided.
• The plantar cutaneous nerve branches are
identified and separated from the medial plantar
nerve by perineurial dissection.
• Arterial branches to the flexor digitorum brevis
are divided.
• Finally, as the artery and nerve branches pass
proximally beneath the abductor hallucis, this
muscle must be divided near its insertion in
order to achieve mobility of the flap.
• If further mobility is desired, the proximal
attachments of the plantar fascia and the origin
of the abductor hallucis also may be divided.

31. • Preserve the greater saphenous vein along with its plantar tributaries. It
may be necessary to mobilize the vein by dividing the dorsal tributaries.
• After the flap is transferred, the donor area is resurfaced with a split
thickness skin graft.

32. Sural Flap
• Reconstruction around the ankle and foot.
• Advantages are an extensive mobility and versatility, without sacrificing
important arteries.
• Flap had several nomenclatures:
Neurocutaneous flap,
Distally based superficial sural artery flap,
Reverse sural island flap,
Lesser saphenous sural veno-neuro adipofascial flap.

33. INDICATIONS
- Posterior aspect of the heel and Achilles tendon,
- The anterior and lateral aspects of the ankle,
- The dorsum of the foot, the lateral aspect of the hindfoot,
- The anterior crest of the lower third of the leg .

34. ANATOMY
• The sural artery
- Issues from the popliteal artery .
- Joins the sural nerve coursing between the two heads of the
gastrocnemius and follows the lateral edge of the Achilles tendon.
- Connected with the sural nerve and plays an important role in supplying
the skin of the lower and middle posterior leg.
- Terminates with the lateral supramalleolar branch of the fibular artery and
posterior tibial artery. A pair of comitant veins travel with the sural artery.

35. • The sural nerve
- descends in close association with the lesser saphenous vein, coursing posterior to
the lateral malleolus, to innervate the lateral side of the foot and the fifth toe.
- vascularization is ensured by the sural artery in the proximal third of the leg and by
an arterial fascial plexus issuing from the perforators of the fibular artery.
• Perforators
- Approximately four to eight perforators arise from the fibular artery, pierce the
crural fascia, and give rise to several branches that join adjacent perforators,
forming an interconnecting vascular suprafascial plexus.
- A larger perforator is located approximately 5 cm proximal to the lateral malleolus.
- distal portion of the fibular artery gives off a posterior lateral malleolar branch
and more distally, thelateral calcaneal artery.

36. FLAP DESIGN AND DIMENSIONS
• The flap pedicle includes superficial and deep fascia, sural nerve, lesser
saphenous vein, and sural artery.
• The lesser saphenous vein is generally used to determine the axis of the
pedicle .
• The pivot point of the pedicle is the main perforator, located 5cm proximal
to the lateral malleolus, .
• The two more distal perforators issuing from the posterior lateral malleolar
and lateral calcaneal branches are likely to provide a pivot point for the
pedicle .

37. Flap is designed as follows.
• The skin island is designed on the posterior aspect of the calf at the junction
of the two heads of the gastrocnemius.
• The pivot point of the pedicle and the source supplying the flap is the most
reliable perforator.
• The pedicle is a strip of adipofascial tissue, including subdermal tissue,
lesser saphenous vein, sural nerve, and deep fascia
• The ratio of length to width of the pedicle is approximately 4:1.

38. .1, Sural nerve; 2,lesser saphenous vein; 3, the larger perforator; 4, perforator from the posterior
malleolar branch; 5, perforator from the lateral calcaneal artery.

39. • The pivot point is approximately 5 cm proximal to the lateral malleolus and
posterior to the fibula.
• The axis of the pedicle is oblique and can be located precisely by the
course of the lesser saphenous vein.
• The length of the pedicle is determined by the arc of rotation required.
• A reliable adipofascial pedicle should not exceed the ratio of 4:1 (i.e., if the
pedicle length is 12 cm, the width is about 3 cm).
• The design of the skin island is in continuity with the pedicle.
• The dimensions of the flap can reach 15 cm in length and 12 cm in width.

40. OPERATIVE TECHNIQUE
• A prone position is indicated only when the defect is located at the
posterior aspect of the heel or the lateral aspect of the ankle.
• The flap is outlined approximately at the junction of the two heads of the
gastrocnemius.
• The precise location of the skin paddle depends on the length of pedicle
required.
• The pivot point of the pedicle is about three finger-breadths proximal to the
tip of the lateral malleolus.
• The line of incision is traced over the course of the sural nerve and lesser
saphenous vein.
• In cases of a thick subcutaneous layer, it is advisable to leave a thin layer of
adipose tissue connected with the two skin flaps.

41. Flap design and landmark of the pivot point.

42. • Once the pedicle is isolated, the flap, with fascia included, is raised.
• Small arteries arising from the fibular artery should be ligated and divided
within the adipofascial pedicle.
• The arc of rotation allows easy coverage of the posterior aspect of the heel.
• The skin bridge is incised to bury the pedicle.
• The donor site and the exposed aspect of the pedicle are covered with a
split thickness skin graft

43. CAUSE OF COMPLICATION
• Too much proximal location or the adipofascial pedicle is notlarge enough.
• The lesser saphenous vein and the sural nerve are not included in the
pedicle.
• The twisting of the base of the pedicle at the pivot point is too tight.
• The flap or the connections between the flap and the pedicle are angulated
at the recipient site.
• The flap has been placed at the recipient site before deflating the
tourniquet, which causes difficulties in flap reperfusion.
• The pedicle is passed subcutaneously through retractile tissue, which leads
to high pressure on the pedicle.

44. • The ratio of length to width of the pedicle should not exceed 4:1.
• The pedicle should be long enough to allow loose twisting.
• The use of a tourniquet must be carefully assessed in arteriosclerotic
patients.
• The flap should be placed without angulation. the repair of the totality of
the heel may require an excision of the greater tuberosity of the calcaneus
to avoid flap angulation.
• It is preferable to incise the skin bridge between the pivot point and the
recipient site. The use of a “skin tail” overlying the pedicle seems to
improve venous return but limits rotation of the pedicle .
• The skin-to-skin suture of a bulky flap implies performance of extensive
mobilization of the recipient area and planning the design of the flap
initially larger than the defect.
• use of an external device or a posterior plaster splint, providing a posterior
chamber to avoid excessive pressure.

45. Transposition and Rotation Skin Flaps of the Sole of
the Foot

46. FLAP DESIGN AND DIMENSIONS
• Medially based plantar flap would seem more ideally designed as an axial
flap, the resulting skin graft on the lateral donor area would be on the
weight-bearing part of the foot.
• Therefore, laterally based flaps are preferred. It is usually necessary to
carry out delay procedures on these laterally based flaps because they must
be considered random flaps.

48. • The bulk of the delayed laterally based plantar flap will consist of
epidermis, dermis, and the specialized fibrofatty pad overlying the plantar
fascia.
• The size of these flaps varies but will usually measure 5 × 6 cm or 6 × 8
cm, depending on the size of the anticipated surgical defect

49. OPERATIVE TECHNIQUE
• The corrective operation should consist of ulcer excision, shaving or
removal of the entire metatarsal head, or shortening of the metatarsal shaft .
• Sectioning of the extensor and flexor tendons to the affected.
• The donor site, which will be on a relatively non-weight-bearing surface of
the foot, will be covered by a moderately thick splitthickness skin graft.

50. Bipedicle Skin Flap to the Heel
INDICATIONS
• This bipedicle skin flap has been used to repair ulcers of the non-weight-
bearing areas of the heel caused by pressure from a tight cast,
immobilization in bed, direct trauma, and excision of a tumor or congenital
sinus.

51. The vertical bipedicle flap has the following advantages:
1. It involves a simple one-stage operation.
2. It eliminates skin-graft complications over the defect, such as graft loss,
hyperkeratosis, an unstable graft, and a painful scar.
3. It covers the defect with a thick layer of skin and subcutaneous tissue with
good sensation, helping to prevent recurrence of the ulcer.
4. The donor area is placed well on the side of the foot, where a skin graft will
“take” more easily and remain stable.

52. FLAP DESIGN AND DIMENSIONS
• This bipedicle skin flap to the heel is an advancement flap.
• Its length is twice that of the defect and usually varies from 4 to 6 cm.
• The width of the flap should be at least half the length, that is, about 2 to 3
cm.
• The lateral incision should parallel the vertical long axis of the ulcer .
• Two bipedicle flaps, one on each side of the defect, may be used if the
defect is too large .

53. V-Y Advancement Flaps to the Heel
and Ankle
• The triangular flap is
designed to be 1.5 to 2 times
as long as the diameter of the
defect in the plane of
advancement, and with its
base equal to the
perpendicular diameter of
the defect .
• For flap survival and
mobility, a ratio of 1:2 can
be recommended

54. Lateral Calcaneal Artery Skin Flap
• The lateral calcaneal artery skin flap is an extremely reliable flap for
providing sensate coverage for the posterior heel .
• The extended form of the flap reaches the plantar portion of the heel.
Because it includes a random area, however, it is not as reliable as the
shorter version.

55. ANATOMY
• The lateral calcaneal artery skin flap is an axial-
pattern flap that contains the lateral calcaneal
artery, lesser saphenous vein, and sural nerve .
• The lateral calcaneal artery is terminal branch of the
peroneal artery. Occasionally, it can be present as
the terminal branch of the posterior tibial artery.
• The artery, paralleled by one or two small veins, is
located in the subcutaneous tissue at the level of
the lateral malleolus, within 1 cm lateral to the
gastrocnemius tendon.
• From this point, the artery slowly descends into a
deeper plane to lie immediately over the extensor
retinaculum covering the peroneus longus and
peroneus brevis tendons.
• The artery usually bifurcates at this point, and the
tributaries branch distally toward the plantar
surface of the heel and toward the head of the fifth
metatarsal bone.

56. FLAP DESIGN AND DIMENSIONS
• The proximal 8 cm of the flap, that is, the vertical distance between the
lateral malleolus and the plantar surface of the heel, is completely axial.
• The flap can be extended up to 6 cm more distally by including a random
portion of tissue proximal to the base of the fifth metatarsal.
• The position and course of the calcaneal artery is marked on the skin .
• Course of the lesser saphenous vein is also marked out.
• The length and width of the desired flap are planned in reverse.
• The pedicle of the flap lies immediately above the level of the lateral
malleolus.
• The base of the flap is usually left intact and optimally should be at least 4
cm wide.

57. Plantar Artery-Skinfascia Flap
• Defects on the plantar aspect of the calcaneus can be covered easily with a
proximally based flap
• With greater flap rotation, defects on the posterior surface of the calcaneus,
including the level of insertion of the Achilles tendon, also can be reliably
covered.
• The distally based flap can be used to cover defects over the metatarsal
head region ; however, this flap cannot provide sensory coverage because it
is distally based.

58. FLAP DESIGN AND DIMENSIONS
• The fact that blood may reach the lateral plantar artery either antegrade
from the posterior tibial artery or retrograde from the plantar arch makes
the design of two lateral plantar artery skin-musclefascia arterialized flaps
possible.

59. Proximally based flap. The lateral plantar artery is divided just proximal to the
plantar arch. The branches of the lateral plantar nerve that supply the flap are split
longitudinally from the remainder of that nerve. The flexor digitorum brevis muscle
and plantar fascia are divided proximally from the calcaneus and distally at the level
of the skin incision, which is located just proximal to the metatarsal head weightbearing
region.

60. Distally based flap. The lateral plantar artery is divided just anterior to
the calcaneus. The lateral plantar nerve is left in situ. The flexor digitorum
brevis muscle and plantar fascia are divided as before.

61. THANK YOU