Soft tissue loss of the heel is difficult to treat as it may cause significant morbidity particularly recurrent ulceration and subsequent chronic osteomyelitis. Reconstruction of such defect with local flap can provide good result. We report our experience in treating four patients with heel defect using the in-step island flap. The flap, which is based on the medial plantar neurovascular pedicle, provides a sensate durable tissue required for weight-bearing and normal gait.
Provision of sensation to the weightbearing surface of the heel is very vital in the sensate foot. Hence, resurfacing the weightbearing surface of the heel requires provision of stable skin cover and sensation. We have many options to fulfill the above requirements. Skin of the instep area can be raised as an island fasciocutaneous flap based on medial plantar vessels, with the branch of medial plantar nerve supplying the instep skin to provide the sensation. Medial plantar artery (instep) flap provides similar tissue with sensation and reaches the posteriormost part of the weightbearing surface of the heel with ease. We present in this article the relevant surgical anatomy, technique, and the clinical experience of 12 patients.
The diagnosis of malignant melanoma (MM) in children is difficult due to its uncommon occurrence as well histological similarities to Spitz nevus. A case of MM of the foot in an 11-year-old boy is reported illustrating the histological overlap between Spitz nevus and MM. In our patient, both the primary foot lesion and the regional inguinal metastases were amelanotic, further increasing the diagnostic difficulty. The literature on MM in children is limited and the documentation of such unusual cases is necessary to improve the knowledge on this disease.
Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm2, and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.