Reconstruction of Foot: Analysis of 60 Cases

INTRODUCTION: Reconstruction of foot is an area of formidable challenge due to the innate nature of the coverage tissues, sensation and vascularity. Various options are available, each has its advantages and disadvantages. In this study pros and cons of each reconstruction done in our hospital analyzed. Weight-bearing areas of the foot still represent one of the most difficult options for the plastic surgeon because of the unique mechanical properties of the sole of the foot. Reconstruction of non-weight-bearing areas such as the instep, the dorsum of the foot, or the ankle area, is also demanding because the reconstructed parts have to withstand mechanical stress from shoes and walking-boots.. A wide variety of flaps available now facilitates an “optimal” solution for each patient including parameters, such as social and medical profile, body constitution, or donor site morbidity. Careful planning of reconstructive options from the most simple to the more complex should be within the armamentarium of the reconstructive surgeon’s expertise. The simplest reconstructive method is still the best technique. There will always be instances where a more complex reconstruction will be needed, and with the advances in microsurgery larger defects can be reconstructed and restore function after tumor ablation. By using a standardized functional outcome assessment the best reconstructive option for the patient can be determined. AIM OF STUDY: The aim of this clinical study 1) To study the age and sex incidence 2) To study the etiological factors responsible for the soft tissue defect of the leg. 3) To study the anatomical site of soft tissue defect. 4) To study the type of soft tissue reconstruction done. 5) To study the duration of hospital stay for the procedure 6) To study follow up – sensation, pliability and contracture 7) To compare skin graft Vs. flap in foot reconstruction. MATERIALS AND METHODS: Study Design: This is a prospective study conducted on 60 patients with soft tissue injury to foot involving the dorsum and sole. Place and duration of study The study was conducted in Department of Plastic Surgery at Government Rajaji Hospital, Madurai through a period of two years and four months – November 2006 to February 2009. Patients and Methods: Over a period of 2 yrs 4 months 60 patients were studied. In this study etiology of the defect, region of foot involved, age group commonly affected, type of skin cover were analysed. Preoperative work up done to rule out uncontrolled diabetes, hypertension and sepsis. Injury/pathology to underlying tendon or bone was evaluated. Patients with a tissue defect of foot due to injury / infection/ vascular disorder were stabilized initially, underlying cause controlled, wound swab done, antibiotics given. These patients were referred after all this from corresponding department, once wound was fit for cover, secondary reconstruction done. Patients with carcinoma of foot were evaluated, metastatic work up done by team of surgical oncologist. Primary reconstruction done after wide local excision. Inclusion criteria: 1. Patients with exclusive foot injuries and sequelae, 2. Soft tissue defect with stabilized bone injury, 3. All age groups, 4. Tissue defect due to trauma, burns, infection, tumor, vascular disorders, 5. Wound with controlled infection, 6. Abstinence from smoking 3 weeks prior to procedure. Exclusion criteria: 1. Injury to other parts of lower limb, 2. Uncontrolled DM/HT/Sepsis, 3. Wound with infection, 4. Raw area with vascular compromise. Type of cover, take of graft, survival of flap were assessed. Duration of hospital stay for each procedure analysed. On follow up, sensation and pliability of cover, complication, cover dehiscence and rate of contracture assessed. Average follow up of patients were for 6 months. Statistical analysis: The entire data was analyzed using Statistical product and service solution software. OBSERVATION: The following are results of the study done between November 2006 to February 2009 Age and Sex Incidence: Of the 60 cases, 44 occurred in males and 16 occurred in females. Male to female ratio is 2.7:1. Soft tissue of foot are more common in 31- 40 years of age group accounting for 31.11% of the cases in our study. Sex Incidence: Male 44 73.3%, Female 16 26.6%. Trauma accounts for the major cause of soft tissue defect of foot involving 30 cases (50%), with next on ladder being the post burns raw area and contracture involving 14 cases (23.3%.) The soft tissue defects of foot were classified into dorsum and sole of foot. In this study, the predominant area to be involved was dorsum, followed by sole. Split thickness skin grafting was done for 38 cases (71%) and flap cover was given for 22 cases (29%) CONCLUSION: 1. Split skin graft gives a reliable, pliable cover and acceptable sensation to raw area dorsum of foot without exposed tendon/ bone. 2. In injuries with exposed/ injured tendon or bone dorsum of foot, thin skin flap gives good functional outcome and aesthetic appearance. 3. Reverse sural artery flap was a bulky flap requiring secondary thinning, hence cannot used as one stage cover for tissue defect dorsum of foot. 4. The sole of foot, split skin grafting is acceptable in non-weight bearing area. 5. In weight bearing area sole of foot sensate flap is preferred