A predictable comparison of ideal skin cover for sole defects of various etiology.

INTRODUCTION On an average, a person takes about 10,000 steps a day. No tissue in the human body is like the sole which experiences such stress. Due to the specialized plantar tissue, our feet can withstand such a repetitive direct and shear stress forces. Defects in the sole can cripple a person as it can adversely affect the patient’s mobility. Inability to salvage an injured foot can lead to major amputation and a lifetime dependence on the prosthesis. Since man has taken upright position, foot gained more importance. It supports the entire body weight and aids in standing, walking, and running, jumping and climbing. The foot has lost its primitive function of grasping significant in our evolutionary ancestors namely, chimpanzees and gorillas. The changes include both the skeleton framework and the surrounding skin. Skeleton changes include a reduction in the distal area of the phalanges & the enlargement of the proximal bones. The skin and soft tissue of the sole has acquired non-shearing and padding properties which strengthens the feet to support the entire body weight. Reconstructing these sole defects are extremely challenging. Till date, there is no ideal replacement for the sole skin. Unless the sole is replaced by a sole skin there will be recurrent problems. The search for ideal replacement is ongoing. Based on the available flaps, the ideal reconstruction options for different types of defects, in different locations of the sole are explored in this dissertation. Based on the data a practical algorithmic approach to sole reconstruction has been elucidated. AIM OF THE STUDY: To find the ideal reconstruction for sole defects and formulate an algorithm for the management of sole defects. Objectives: 1. To use different types of existing reconstruction techniques for sole defects of various etiology. 2. Enumerate the advantage and disadvantage of the identified reconstruction methods. 3. Find the ideal reconstruction for sole defects. MATERIALS AND METHODS: This study was conducted at the Department of plastic and reconstructive surgery in Government Rajaji Hospital, Madurai on patients who are referred for reconstruction of sole defects during the period from December 2011 to December 2013. Over this period of two years, 60 consecutive patients underwent reconstruction for various type of defects in various regions of sole. All the patients who are referred to our department for sole reconstruction are included in this study, and those who had undergone previous surgeries on the sole, patients with active infection and patients with ischemic limbs are excluded from this study. Defects are classified anatomically into Hind foot, mid foot and fore foot regions based on its location. The types of reconstruction i.e. skin graft, local flap, distant flap and free flap are planned based on the clinical judgment, patient’s requirement and the availability of local tissues. All the patients are operated under appropriate anesthesia with tourniquet. Post operatively leg end of the patient is elevated and immobilized with a below knee pop slab for two weeks. Flaps are monitored periodically in the immediate post-operative period. For Skin grafts, first dressing is changed on the 3rd post-operative day and is followed on 5th day liquid paraffin dressings. Patients are advised regarding the foot care and daily self-examination of the foot. They are given with compression and appropriate offloading devices. Compression is given with a 6 inch crepe bandage. Appropriate offloading to the operated site is given with customized sandals and splints when the patients start to bear weight around 4 weeks post operatively. Offloading and compression are advised for a period of six months. All the patients are followed-up for a period of one year. Patient are evaluated for flap condition, complications, durability of the reconstruction, return of sensation and patient satisfaction at one, six and twelve month postoperative period. The details are collected in a proforma and the results are analyzed. DISCUSSION: Large sector of the patients fall under to 21-40 age group. That is (n=24) 40% of cases belong to this group. Trauma is the most common etiology in this group. These are the active working population. Defects in these patients will incapacitate them. So they need to return to their work environment as early as possible. Malignancy is the common etiology in people above 60 years age group. In pediatric age group, the common etiology seems to be trophic ulceration due to foot deformity resulting from previous meningomyelocele. 73% of cases (n=44) are male whereas 27% of cases (n=16) are female. The occurrence of accidents are more frequent these days. Since, men are mostly involved in road traffic accidents, the prevalence of the sole defects are common in male population. CONCLUSION: Medial plantar artery flap is the flap of choice for sole defects in mid and hind foot region resulting from any cause. It provides multiple advantages as follows, 1. Replacement of sole skin by sole skin. 2. Sensate flap 3. Single stage procedure 4. Good patient satisfaction 5. Donor site morbidity is negligible. • For small defects the next best flaps are the local flaps from the nearby tissue. These local flaps can be used only for defects less than 3 cm. Rotation are best suited for heel defects, transposition flap from mid foot defects, and v-y advancement for forefoot defects. Care should be taken while using these local flaps. The skin graft, if used for donor site closure, should be on the non-weight bearing area. Similarly the suture line should be on the non-weight bearing area. • Filleted toe flap and neurovascular island flaps are ideal flaps for defects in fore foot as it provides sensate skin to the pressure points. • Non weight bearing areas of the sole can skin grafted if adequate granulation tissue is present to prevent contour deformities.If it is used for weight bearing areas strict offloading should be followed. • Reverse sural artery flap should be done as last resort when all the local flaps and in places where microvascular facilities are not available as it has multiple disadvantages. • Microvascular free flaps should be done for extensive defects where no local flaps from native sole is present. • Cross foot flap is an ideal option available for large sole defects, but less used these days as immobilization is required. Alternatively, microvascular free instep flap from the other leg can be done without the need for immobilization in peculiar position. • Muscle flaps can be used to fill cavities in trophic ulcers. • Whatever the type of reconstruction is used, unless appropriate offloading is not done recurrent ulcerations tend to occur. • Foot wear inspection and foot self-examination is mandatory for these patientto prevent recurrent ulceration