Abstract Between 1986 and 1995, 48 microvascularflaps (14 fasciocutaneous, 13 muscle, and 21 musculocu-taneous) were performed on 47 patients with foot de-fects. The study group consisted of 19 patients who suc-cessfully underwent weightbearing surface reconstruc-tion with free musculocutaneous flaps or muscle flapswith a skin graft. The groups were identified on the basisof the free flap used. Group 1: Latissimus dorsi musculo-cutaneous flaps (11 patients); group 2: Skin grafted mus-cle flaps (8 patients: latissimus dorsi - 6, gracilis - 1, rec-tus abdominis - 1). The follow-up period was 1–11 years(average: 8.3 years). Follow-up included documentationof foot pain, presence of ulceration, sensory recovery,the ability to wear normal shoes, and the need for a sec-ond operation. In group 1, debulking operations werenecessary (8 patients, 72.7%). Debulking was not re-quired in group 2. Ulceration occurred in four (36.4%)group 1 patients and in one (12.5%) group 2 patient. Allpatients had good deep pressure sensation. All the group2 patients could wear normal shoes. Four (36.4%) of thegroup 1 patients had to wear special orthopedic shoes.The gait analysis consisted of two parts: footprint analy-sis with the Harris mat technique and plantogram of Pa-rotec system by Kraemer. Foot analysis with the Harrismat showed that the pressure on the muscle flap is lessthan the pressure on the musculocutaneous flap. Gait

analysis by the Parotec system showed that in patientswith musculocutaneous flaps, static load distribution onthe reconstructed bare foot is nearly normal, but dynamicload distribution is pathological. In patients with muscleflaps, both static and dynamic load distribution wereclose to normal.

Key words Foot reconstruction · Musculocutaneousflaps · Muscle flaps with skin grafts · Gait study

Introduction

Treatment of soft tissue defects of the foot has alwaysbeen a problem. For reconstruction of small and interme-diate size defects of the weightbearing area, the firstchoice is a local plantar flap with the same structuralcharacteristics and sensation as plantar skin. For largedefects of the weightbearing area, the first choice is freemyocutaneous or free muscle flaps with a split-thicknessskin graft.

The purpose of this study is to retrospectively analyze19 patients with reconstruction of the weightbearing areaof the foot by free musculocutaneous flaps or free skingrafted muscle flaps.

Material and methods

Between 1986 and 1995, 48 microvascular flaps (14 fasciocutane-ous, 13 muscle and 21 musculocutaneous) were performed in 47 patients presenting with foot defects. The study group consist-ed of 19 patients who successfully underwent weightbearing sur-face reconstruction with free musculocutaneous flaps or skingrafted muscle flaps.

In a group of patients with chronic disease, most of them hav-ing undergone 1–11 previous foot surgeries, the average time fromprevious unsuccessful treatment was 4.3 years. The microvascularflap transfer on those patients was frequently the second and finaltreatment. The most common reasons for the free flap transferwere a posttraumatic soft tissue defect (7), calcaneal osteomyelitiswith dead space in the bone and heel ulcers (10), diabetic ulcers(1), and ulcerated carcinoma (1). The wound bacterial contamina-tion rate was 73.7% (14 patients); nine patients had Staphylococ-

Presented at the 8th Annual Meeting of the European Associationof Plastic Surgeons, Amsterdam, The Netherlands, May 15–17,1997

S. Vikšraitis (✉) · T. Norkus · T. Astrauskas · V. Kaikaris R. Rimdeika · S. AverkinaTvirtoves al. 61–8, 3009 Kaunas, Lithuaniae-mail: Saulius.Viksraitis@takas.ltFax: +370-7-77-82-94

S. Vikšraitis · T. Norkus · T. Astrauskas · V. Kaikaris R. Rimdeika · S. AverkinaDepartment of Plastic Surgery and Burns, Kaunas Medical University Hospital, Kaunas, Lithuania

Eur J Plast Surg (2000) 23:111–116 © Springer-Verlag 2000

E U R A P S PA P E R

S. Vikšraitis · T. Norkus · T. Astrauskas · V. KaikarisR. Rimdeika · S. Averkina

Free musculocutaneous and muscle flaps for foot reconstruction:a clinical and gait analysis study1

Received: 19 May 1997 / Accepted: 8 November 1999

1 The Parotec Systemis a trademark of ParomedMedizintechnikGmbH, 83115 Markt Neubeuern, Germany

cus aureus, five patients Pseudomonas aeruginosa, three patientsProteus mirabilis, and two patients Proteus vulgaris. In four casesthere was mixed bacterial contamination. The defect size rangedfrom 12 cm2 to 45 cm2, with the average size being 26.3 cm2. Theshape of the foot soft tissue defect varied – circular 4–5 cm in di-ameter or elliptical 9 cm long and 5 cm wide. This measurementrepresented only the surface area of the defect but not the three-dimensional depth, which was often very significant.

In making the choice of free flap, the following should be con-sidered: Development of defect, previous method of reconstruc-tion, the size of the defect, significant bacterial contamination, re-cipient vessel problems (e.g., division close to the defect), areas ofscarring and chronic inflammation. Initially, the latissimus dorsimusculocutaneous free flap was used; it has a long vascular pedi-cle, large muscle mass, and a great amount of elastic skin. Laterthe split-thickness skin grafted muscle flap was found to be betterfor weightbearing surface reconstruction.

The groups were identified on the basis of the free flap used:

Group 1: Patients with latissimus dorsi musculocutaneous flap (11patients)

Group 2: Patients with skin grafted muscle flaps (eight patients:latissimus dorsi, six; gracilis, one; rectus abdominis, one)

Eleven were male and eight were female. Their ages ranged from18 to 61 years with an average of 44 years. The follow-up periodwas 1–11 years (average: 8.3 years). At follow-up, foot pain, thepresence of ulceration, sensitivity recovery, the possibility ofwearing normal shoes, and the need for a second operation weredocumented.

The gait analysis consisted of two parts:

1. Footprint analysis with the Harris mat technique. In this proce-dure, the patient stepped on a mat the undersurface of whichwas coated with ink, and the pressure from the foot in a normalambulation cycle made a permanent print on a paper beneaththe mat. This analysis showed the patient’s weightbearing di-rectly on the flap while walking barefoot.

2. Plantogram of Parotec system by Kraemer [27].The Parotecsystem offers a highly innovative electronic means for assess-ing static and dynamic load distribution in a shoe with loadreadings being collected under the foot based on actual time[27]1.. This system has been on the market since March 1993and has been constantly updated to match technological ad-vances. The new system software introduced in May 1994,based on Windows, has updated the program to improve the

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Fig. 1 Twenty-four points in the foot registered by the Parotecsystem

a b

Fig. 2a,b Case 2: a (Left)Plantar view of right footshowing a healed myocutane-ous flap on medial part of plan-tar (print has been reversed foreasier comparison with matprints).b (Right) Harris matprints of both feet. Line de-notes plantar area of the footcovered with latissimus dorsimusculocutaneous flap. TheHarris mat confirmed that thepatient was directly weight-bearing on the flap while walk-ing barefoot

handling of test data and to provide extended data evaluationoptions. The system consists of two parts: One is a special solehaving 24 points indicating sensitivity, and another is a control-ler fastened to the patient’s belt, which registers load distribu-tion at different points (Fig. 1). During the investigations, thepatient’s weight and the size of his foot are taken into consider-ation. Newton to square centimeter (N/cm2) is a unit of mea-surement used to measure pressure in this system. The control-ler is connected to the test sole by two thin cables. The informa-tion stored in the recorder is then analyzed on the computer.Sensibility was investigated with Semmes-Weinsten scores.

Results

Flap survival rate was 90.5%. Of the 21 muscle and mus-culocutaneous flaps performed, 19 flaps survived andtwo failed. The failures were due to thrombosis. In 9 muscle and 12 musculocutaneous transfers, there werefive microvascular thrombosis : one arterial and four ve-nous. Three venous thrombosis were successfully reop-erated. Four (19%) flaps became infected and two(9.5%) had partial flap necrosis. In spite of this, the re-construction could be salvaged.

Flap debulking procedures were done in five (45.5%)patients in group 1 and this will be done in another three

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1.814.233.605.872.760.003.602.200.002.190.780.002.302.002.292.172.264.935.353.971.360.250.734.04

0.664.143.515.542.341.022.992.600.002.720.250.932.652.850.691.305.366.035.322.870.000.000.000.25

Se. no. Left Right

Pressure values [N /cm2]

Total impulse 1025.641086.14

52 % 48 %59 % 58 %

41 % 42 %

Fig. 3 Case 2: Static load dis-tribution shows that the pres-sure on the flap (15,16,19,20points) is nearly normal

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Left Steps7

Contact time964 ms

Total impulse377.17 Ns

Right Steps7

Contact time888 ms

Total impulse351.02 Ns

17.6422.4611.7916.93

5.961.329.795.610.006.753.040.256.546.717.86

11.826.71

26.1430.1127.21

5.393.791.39

50.29

20.6421.0417.5014.0711.39

0.2126.11

4.000.00

19.790.290.36

22.1112.00

0.290.75

46.1136.25

8.643.210.250.250.000.25

Step no.

12345

Se. no. Left Right

Pressure values [N /cm2]Fig. 4 Case 2: Dynamic loaddistribution shows that pressureon the flap (15,16,19,20 points)becomes too low comparedwith the same points of a nor-mal foot. As a result of this thepressure, distribution increasespathologically on the lateralpart of the sole (7,10,13,17points)

patients (27,3%), thus eight patients (72.7%) patients ofgroup 1 required debulking. One patient from group 1underwent two debulkings at 6 monthly intervals. Ingroup 2, no cases required debulking. Two types of deb-ulking procedures were used: simple soft tissue excisionand liposuction. Simple soft tissue excision was used infour cases and combination with liposuction in one case.

Ulceration occurred in four (36.4%) patients fromgroup 1, in one (12.5%) patient from group 2 . Patientsfrom group 1 had chronic ulceration with ulcers recurring

every year. The ulcers were deep, involving skin and un-derlying muscle. The ulcers in group 1 occurred on theflap tissue and were associated with an underlying neurop-athy in three patients (27.3%) and os calcaneus osteo-phytes in one patient (9%). One ulcer in group 2 was lo-calized between flap and foot tissue, involved only theskin, and did not recur. Three patients (27.3%) from group1 had foot pain after 4–5 hours of walking. The patient(12.5%) from group 2 noted the same pain. Radiologicalabnormalities were frequent in patients with ulceration:three significant deformities of the calcaneus including os-pheophytes and defects and two subtalar joint deformities.

All patients in both groups had good deep pressuresensation. Recovery of sensation was assessed bySemmes-Weinsten scores. Two (18.2%) patients fromgroup 1 and three (37.5%) patients from group 2 had6.10/75 sensibility. In those cases the flaps had sensationeven without nerve anastomoses. Patients from group 2could wear normal shoes. Unfortunately, four (36.4%) pa-tients from group 1 had to wear special orthopedic shoes.

Gait study

Foot analysis using the Harris mat showed the patients tobe weight bearing directly on the walking bare foot (Fig. 2). The Harris mat showed that the pressure on theflap in patients belonging to group 2 was less than thepressure on the flap in patients of group 1.

Gait analysis using the Parotec system showed that inpatients from Group 1, static load distribution on the re-constructed bare foot is nearly normal (Fig. 3), but dy-namic load distribution is pathological (Fig. 4). Whilewalking, the pressure on the flap becomes too low and asa consequence the pressure distribution becomes patho-logically increased on other points of the foot (Figs. 5,6).In patients from group 2, both static and dynamic loaddistribution were close to normal (Figs. 7–9).

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46.50[N / cm2]

Contact time: 930 ms

Fig. 5 Case 2: The pressure peaks confirm pathological pressuredistribution on the lateral part of the plantar aspect of the recon-structed foot

50.29[N / cm2]

Contact time: 964 ms

Fig. 6 Case 2: The pressure peaks confirm pathological pressuredistribution on the big toe in the normal foot

a b

Fig. 7a,b Case 3: a (Left)Plantar view of the right footshowing healed rectus abdo-minis skin grafted muscle flapon the heel. b (Right) Harrismat prints of both feet. Line de-notes heel area covered withmuscle flap

Discussion

The plantar surface is unique, its multidirectional fibroussepta function as a shock-absorbing system of the foot,which helps minimize horizontal and vertical shear forc-es [13]. May et al. [13] demonstrated that the two inter-faces between bone and muscle, and muscle and skingraft help minimize vertical and horizontal mechanicalshear forces applied to the muscle flap. We agree withWyble et al. [26] that flaps replacing skin and subcutane-ous tissue are unable to simulate the structural support ofthe fibrous septa of the plantar surface. The latissimusdorsi musculocutaneous flaps in the weightbearing sur-face created a mobile platform as compared with rela-

tively rigid muscle flaps. Musculocutaneous flaps in ourstudy frequently needed debulking. Liposuction is a safetechnique for the delayed debulking of a free flap [25],but we consider soft tissue excision to be more effectivein delayed free flap reconstruction of the foot [17]. Whyshould this be? Liposuction improves flap contour [5],but only skin and sometimes muscle excision correctsexcess laxity of the flap. Although it is generally be-lieved that cutaneous sensation is necessary to preventbreakdown and ulceration in the foot [2,3,6,8,21,22],previous studies [4,5,7,13,15,17,20,24] are not availableto confirm this. Long-term results show that deep pres-sure sensation is necessary for successful foot recon-struction, but not light touch sensation. Sensation may be

115

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2.843.213.603.232.030.251.301.480.251.030.000.250.850.990.501.471.031.382.001.822.420.250.973.12

2.213.945.765.554.970.975.033.000.501.450.000.002.250.250.000.752.442.221.962.422.000.003.294.20

Se. no. Left Right

Pressure values [N /cm2]

Total impulse 1005.34658.62

40 % 60 %50 % 42 %

50 % 58 %

Fig. 8 Case 3: Static load dis-tribution shows that the pres-sure on the flap (right foot 1,2 points) is normal comparedwith the left foot

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Left Steps19

Contact time850 ms

Total impulse237.82 Ns

Right Steps19

Contact time720 ms

Total impulse197.48 Ns

17.5316.3714.5112.61

6.471.254.642.860.343.200.000.126.432.631.837.579.03

10.2611.8214.92

7.046.51

11.6429.89

9.6810.8815.7611.82

7.592.966.513.681.462.550.000.093.490.330.002.124.586.078.45

19.885.911.03

21.7646.01

Step no.

12345

Se. no. Left Right

Pressure values [N /cm2]Fig. 9 Case 3: Dynamic loaddistribution shows that thepressure on the flap (1,2 points)is close to normal

less important for flap durability than flap contour andunderlying foot pathology [6,13,15]. The ability to pre-vent tissue breakdown depends on exogenous factorssuch as footwear and patient education, and endogenousfactors such as osteophytes. The removal of a bonyprominence at the time of free flap placement leads tosuccessful foot reconstruction. Patient education on footcare [1,2,4,5,13,20] is very important in the preventionof tissue breakdown. Frequent follow-up visits are essen-tial to maintain a healthy reconstructed foot. Sometimesosteophytes may occur after reconstruction and flap ul-ceration occurs, thus X-ray examination is mandatorybefore foot reconstruction.

Gait analysis by the Parotec system was very infor-mative in postoperative foot care. Twenty-four pressurepoints on the foot were measured in static and dynamicpositions. This investigation shows the points on thefoot, where the pressure is pathologically increased andit allows special insoles to be made; these distributepressure evenly over all points of the foot. This workswell and reduces the possibility of ulcers developing.

Conclusion

Free muscle transfer with skin graft cover provides footstability and satisfactory appearance after massive injuries,especially those with significant bacterial contamination.

Dynamic foot-pressure measurements confirmed nor-mal patient gait after foot weightbearing areas were re-constructed with free skin grafted muscle flaps.

The latissimus dorsi musculocutaneous flap is notsuitable for reconstruction of the weightbearing area ofthe foot because it is bulky, frequently ulcerates, and hasa poor level of sensation.

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