Soft tissue coverage options for ankle wounds
Section snippets
Guiding principles
Before discussing regional differences in ankle tissue deficiencies, several principles should be stated. First and foremost, when undertaking treatment for ankle wounds, a patient's vascular status must be determined [6]. It is common in this author's practice to see patients who have been treated expectantly for wounds as described in the previous examples, and treatment led only to the discovery of inadequate documentation of vascular inflow and outflow. Assessment of palpable pulses,
Regional difference in anatomy
Soft tissue coverage decisions for the ankle can be regionalized. The ankle can be divided into the area of the Achilles' tendon and the anterior aspect of the tibiotalar joint. The plantar aspect of the hindfoot is a unique structure, especially the heel pad, which contains cushionlike, shock-absorbing chambers of fat that are not replaced easily (Fig. 2). Around the heel-pad anatomy, instep coverage is important to avoid scarring around the posterior tibial nerve and exposure or risk to the
Reconstructive ladder
Once the extent of the wound is identified and categorized, an algorithm known as the reconstructive ladder can be applied [7]. If possible primary closure is performed, such as after correction of hallux valgus deformity. Small sutures are used, often with a dermal layer, and primary wound healing can be expected. In grossly contaminated wounds, such as a grade II ankle fracture, that require a second look in the operating room at 48 to 72 hours and initial débridement, delayed primary closure
Wound problems after surgical intervention
When considering surgical intervention for fractures of the foot and ankle, an important determinant for successful healing is the amount of soft tissue swelling that is present at the time of surgery and that develops after surgery. Ice, elevation, and bulky dressings, allow edema to subside within a few days. If swelling is not sufficiently decreased, problems with wound closure occur.
Operative technique is important in preventing soft tissue complications of open treatment. A traumatic
Open fractures and osteomyelitis
There is good evidence to suggest that early coverage of open fractures is the treatment of choice, provided the wound environment is suitable (see Fig 1) [5]. The type of soft tissue coverage depends on and must be tailored to the underlying reconstructive needs. Rather than commit patients to multiple procedures over a long period with anticipated poor outcomes, consideration should be given to immediate amputation if bone and soft tissue parts are not salvageable. Poor prognosticators
Flap selection for ankle reconstruction
Assuming that a skin graft is inadequate for soft tissue coverage, the reconstructive ladder leads to the use of local flaps. Simple fasciocutaneous flaps on the dorsum of the foot or plantar surface (such as the V–Y advance flap) can be used for small defects. The advantage is that the dissection is confined to local areas. The disadvantage is that fasciocutaneous flaps are reserved for small defects. The difficulty with these flaps is that the dissection is often tedious, particularly in an
Skin flaps (microvascular)
The lateral arm flap can be used for small defects, such as the instep (see Fig. 5). Advantages include remote harvest site, and disadvantages include donor-site morbidity, such as the aesthetic result from resultant flap harvest if a skin graft is needed for closure.
Another cutaneous choice from the upper extremity is the radial forearm flap. Again, the cosmetic problem at the donor site is not insignificant if the deficit cannot be closed primarily. It provides some innervation potential, as
Muscle flaps (microvascular)
Several choices exist for muscle flaps, and tailoring and custom design of all potential donor sites is possible. The gracilis can supply adequate muscle coverage and may be harvested from the same extremity, allowing the procedure to be performed under epidural anesthesia. The rectus abdominus muscle is particularly suitable if the patient requires supine positioning. The serratus is more suitable than the latissimus in that the muscle is thinner and can be tailored to a smaller flap. The
Osteocutaneous flaps (microvascular)
Osteocutaneous flaps may be required for treatment of composite defects, including bone and soft tissue. The lateral arm and radial forearm flaps can be harvested with bone from the humerus or radius. Disadvantages, particularly in the radius, are that this may lead to a stress fracture and that the amount of bone provided is usually of insufficient quality and cancellous content to be structurally beneficial, particularly in cases of large defects of the ankle. Although it is acceptable to
Authors preferred method for reconstruction around the ankle
The armamentarium of the reconstructive surgeon is vast, including local, regional, and distal substitutions. One of the major difficulties of soft tissue foot and ankle reconstruction is that the wound often can be covered and epithelialized but that the actual contour of the ankle that allows shoeing is difficult to normalize. Often flaps need to be transferred and then debulked perhaps one or two times to achieve the optimum contour after transfer. The patient should be informed about this
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Cited by (15)
Posttraumatic Reconstruction of the Foot and Ankle in the Face of Active Infection
2017, Orthopedic Clinics of North AmericaFlap reconstruction for soft-tissue defects with exposed hardware following deep infection after internal fixation of ankle fractures
2014, InjuryCitation Excerpt :Half of the patients had shoe wear limitations, the health-related quality of life of the patients was poorer than that of a general population, and only half of them achieved their pre-injury level of function. Soft-tissue defects around the ankle are demanding to manage [13,26]. Our study showed that 91% of the soft-tissue defects following ankle fracture infection occur over the lateral malleolus, which is not surprising since most ankle infections occur over the lateral malleolus [27].
Perforator-based chimaeric thoracodorsal flap for foot reconstruction
2013, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :The disadvantage of parascapular flaps is that they need to be debulked several times to allow correct shoe fitting.2 The radial forearm is thinner but has an important donor-site morbidity and more and more surgeons prefer the use of perforator flaps.3 The anterolateral thigh flap4 has minimal donor-site morbidity, a long pedicle with large-calibre vessels; multiple tissue components available and chimaeric flap options; flow-through flap design for vascular reconstruction; and vascularised fascia lata for single-stage tendon reconstruction.5
Complex Wounds and Their Management
2010, Surgical Clinics of North AmericaCitation Excerpt :For scar minimization, W- and Z-plasties may be used, decreasing tensions per length of the wound.6 Secondary intention healing can also be allowed depending on the size of the wound, the presence of infection, or the preservation of dermal elements.11 Skin substitutes, with properties of adherence to the wound bed, elasticity, pliability, and flexibility, maintain a barrier to microfloral invasion, help with wound fluid balance, and retain integrity over time.
Ankle and foot osteomyelitis: Treatment protocol and clinical results
2010, InjuryCitation Excerpt :However, the reconstruction of the resulting skeletal and soft tissue defects is often complex. In contrast to the more proximal segments of the leg, the availability of soft tissue for the coverage of full thickness defects with local or regional flaps is limited.3,21 Reconstruction of skeletal defects can be accomplished with bone grafting.50