Indian J Surg (January–February 2010) 72:61–63 61

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Management of heel ulcers in insensate foot by using free prefabricated radial fascial fl ap - a new fl ap

Vishwa Prakash

Received: 13 April 2009 / Accepted: 23 August 2009© Association of Surgeons of India 2009

Indian J Surg (January–February 2010) 72:61–63DOI: 10.1007/s12262-010-0012-9

V. PrakashDepartment of Plastic Surgeon,Safdarjung Hospital, New Delhi, India

V. Prakash ( )E-mail: vpagarwal@gmail.com

Abstract Heel ulcers are common in insensate foot.The management of such ulcers require tissue not only to resurface the skin defect, which is small in most of the cases; but also well vascularised tissue to fi ll the cavity which results after excision of the ulcer. We have described a new fl ap prefabricated radial fascial fl ap, by which both aims are achieved easily.

Keywords Heel ulcer · Flap · Fascial fl ap

Introduction

Heel ulcers are quite common in insensate foot (Fig. 1). These usually occur in leprosy or other different diseases of the spinal cord including fracture of spine. Various modalities of treatment for these ulcers have been described in literature. We [1, 2] have previously reported the use of tissue stretching [1] and abductor hallucis [2] with rotation

SURGICAL TECHNIQUES AND INNOVATIONS

Fig. 1 Heel ulcer

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Fig. 2 Prefabricated radial facial fl ap raised

Fig. 3 Harvested fl ap

Technique

The operation was performed in two stages. In fi rst stage radial fascial fl ap was prefabricated as described by Prakash et al. [3]. An incision was made over the forearm and the skin fl aps raised exposing fascia which was not included in the skin fl aps. The skin graft was harvested and applied over the fascia. The graft is not applied over whole of the exposed fascia as part of fascia was to be used to fi ll the cavity resulting after excision of the ulcer. Skin was closed over the fascia.

In second stage prefabricated fascial fl ap is harvested (Fig. 2, 3) based on the radial artery under tourniquet.The ulcer was excised and posterior tibial neurovascular bundle was exposed. Prefabricated radial fascial fl ap was transferred by microsurgical anastomosis – end to side anastomosis of radial artery to posterior tibial artery, and end-to-end venous anastomosis between superfi cial vein of fl ap and great saphenous vein. Anastomosis was done under magnifi cation using 8–0 Ethilon. There are two parts of the fl ap-only facsia and prefabricated fascial fl ap. The fascia was used to fi ll the cavity while prefabricated part was placed over the surface as skin cover.

Postoperative management

Postoperatively the patient was put on injection heparin 5,000 units subcutaneously every 8 hourly for 5 days to prevent any thrombosis. Patient was allowed oral fl uids after 6 hours, but intravenous fl uids were continued for 3–4 days. Antibiotics were given for 5–7 days. After fi rst 24 hours the antibiotics were given by oral route.

Result

The patient did well. The fl ap healed in 2 weeks (Fig. 4). She was allowed walking with silicon heel pad kept in the heel of footwear after 3 weeks. However she was told that she should not walk for longer distance at a stretch as aetiology for ulcer i.e. anaesthesia, was still present and if she walked for longer distance, recurrence of ulcer might take place.

Discussion

The management of heel ulcers in insensate feet is different than traumatic heel ulcers. In insensate feet the heel defects are like pressure sores. More depth is involved than the width in such ulcers. The skin loss is not much. What is needed to treat such patients is well vascularised tissue to fi ll the cavity created after excision of ulcer. Therefore, skin fl aps and other fl aps are not good option. Abductor hallucis muscle

advancement of skin for resurfacing the defects of heel ulcers in leprosy patients.

We have used a new modality of treatment – prefabricated radial fascial free fl ap for heel ulcer in insensate foot due to fracture of spine in a young lady. The 20-year-old patient had fracture of spine 7 years back resulting in paraplegia which improved in due course of time except sensory loss over right foot. Subsequently she developed ulcer of heel which did not heal even after 2 years.

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Fig. 4 Well settled fl ap after 3 months

advantages of the procedure are. Well settled fl ap. No other fl ap is so thin. No bobbling during walking, which is seen with other cutaneous fl aps [4]. Bobbling does not allow the patient to walk properly. Availability of well vascularised fascia to fi ll the defect. This is not possible with any other available fl aps.

Study is short (only 6 months) duration involving only one case. More detailed study is required. However, it would prove a good alternative fl ap for ulcers on insensate foot as well as for patients of traumatic ulcers. The main advantage is that the diffi culty in walking due to bobbling and bulk of fl ap as found in other cutaneous fl aps is not found in this fl ap. Our patient could walk without diffi culty.

Conclusion

We used a new fl ap for heel ulcers over insensate foot and found that fascial extension of radial prefabricated fl ap gives additional well vascularised tissue which may be used to fi ll the cavity resulting after excision of ulcer defect.

References

1. Prakash V (1998) New Method of Treatment of Heel Ulcer. Plast Reconstruct Surg 101:1419–1420

2. Prakash V, Hussain S, Malaviya GN (1994) Abductor Hallucis Muscle fl ap with Rotation Advancement of Heel Ulcers in Leprosy Patients. Ind J Plast Surg 27:76–78

3. Prakash V (2003) Prefabricated fascial fl ap for hand and forearm defect. Plast Reconstruct Surg 111:1371–1372

4. Ismail K, Gursel T, Lutfu B, Turkar O, Oya B, Ayan G (2000) Comparison between Sensitive and Nonsensitive Free Flaps in Reconstruction of the Heel and Plantar area. Plast Reconstruct Surg 105:574–580

fl ap [2] is good option. But it gives the scar over the foot, though on non-weight bearing area. However, in insensate foot loss of muscle may contribute to collapse of arches. The radial prefabricated fl ap as described by us is another good option for such defects. The donor site morbidity is not much, as only fascia is taken and neither skin is taken nor muscles. The linear scar over forearm heals well. The