Operative Technique in Plastic Surgery – Kevin C.Chung

occur as a result of a number of disease processes, including post-traumatic
arthritis, degenerative joint disease (DJD), posterior tibial tendon insufficiency,
trauma, congenital deformity, inflammatory or crystalline arthropathy, Charcot
neuropathy, diabetes, avascular necrosis, tumor, and many other causes.
■ Bone graft is generally incorporated to aid in healing when the risk of
nonunion is unacceptably high. This is the case in patients who might have a
suboptimal biologic healing response, including those with a history of
smoking, diabetes, neuropathy, obesity, or a history of nonunion.3–5
■ The procedures in the foot and ankle that most commonly involve bone graft
application include ankle, subtalar (ST), tibiotalocalcaneal (TTC), triple,
tibiocalcaneal (TC), talonavicular (TN), calcaneocuboid (CC),
naviculocuneiform (NC), and tarsometatarsal (TMT) arthrodesis, and most
nonunion repairs. Due to the paucity and inconsistency of literature on the
topic, the decision to use bone graft, and which type or material to use (ie,
cancellous vs structural, harvest site, autograft vs allograft, bone graft
substitutes, etc.), is dependent upon a host of patient factors and surgeon
experience.
■ Generally speaking, cancellous autograft generally has a higher surface area
and greater content of growth factors and remains the standard for its ability to
induce more new bone formation than cortical (ie, structural) autograft or
allografts.6 Structural autograft is often required when significant bone loss or
deformity is present, as a means of restoring length, height, and/or alignment.
The fast-growing arsenal of “orthobiologics” as substitutes for autograft are
purported to rival autograft in terms of timing and rate of healing, without the
morbidity of autograft harvest.
ANATOMY
■ The foot and ankle is composed of 28 bones. There are multiple joints,
muscles, tendons, and ligaments. The foot can be divided into the medial and
lateral columns. The medial column includes the talus, navicular, cuneiforms,
and medial three metatarsals. The lateral column is made up of the calcaneus,
cuboid, and lateral two metatarsals. Any injury, deformity, or defect can result
in length alterations or stiffness in one or more columns of the foot. This can
lead to pain, imbalance, and problems with weight bearing on a foot that is not
plantigrade, unstable, or painful.
■ The ankle joint allows for most of the extension and flexion. The subtalar joint
provides inversion and eversion, whereas the transverse tarsal joint

(talonavicular and calcaneal cuboid) gives adduction and abduction.
■ The foot and ankle is responsible for gait. The heel is the first point of contact
in the normal gait cycle. As the foot rolls forward, the foot changes from a
flexible valgus position to a rigid varus position for push off.
■ The anatomy of the iliac crest, for the purposes of graft harvest discussed
herein, is fairly easy to identify and superficial. The graft harvests described
below are generally harvested from 2 to 4 cm above the anterior superior iliac
spine (ASIS). The crest at this location can usually be palpated. Keeping the
incision and dissection at least 2 cm proximal to the ASIS to avoid injury to the
lateral femoral cutaneous nerve.
PATHOGENESIS
■ The foot and ankle are the most peripheral structures in the body and are
dependent during most physical activities. As a result, the foot and ankle are at
higher risk of peripheral neuropathy, peripheral vascular disease, and other
contributors to delayed or nonhealing of fusions or fracture fixation.
■ The weight-bearing role of the foot and the complexity of biomechanics for
normal foot and ankle function place many regions of the foot and ankle at
higher risk for abnormal loading, further contributing to delayed- or nonunion
of fractures, arthrodesis, or osteotomies.
■ Patient risk factors known to contribute to nonhealing of bone include
smoking, diabetes, age and osteoporosis, peripheral vascular disease,
neuropathy, noncompliance, infection, and soft tissue injury.4
NATURAL HISTORY
■ The disorders of the foot and ankle are broad and significant and include
trauma, arthritis, congenital, acquired, sports injuries, and degenerative
conditions. With severe deformities or trauma, structural loss or nonhealing of
fractures or fusions frequently lead to worsening of the disorder and pain and
function, over time. Reconstructive operations may be required to repair such
problems. In cases where there is need to add structural bone, or add biology,
bone grafting procedures are commonly considered.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history is essential preoperatively. Patients are asked about
injuries, chronicity, comorbidities, previous operations, and nonoperative
treatment. Also, the patient’s occupation and social situation are important
considerations.

■ Medical history should be considered when determining risk factors and the
best bone graft to use. Social history is also important because patients may
have particular traditions and beliefs governing whether autograft or allograft
materials are acceptable. The beliefs should, and generally can, be respected
during development of a treatment plan.
■ The physical examination takes place with the patient undressed from the
knees to the toes. Gait is evaluated, as well as the skin, noting edema, scars,
erythema, masses, and bony deformities. The neurovascular status is carefully
examined. Evaluating potential graft sites is also important.
■ The foot and ankle examination can help guide surgical approach and
counseling. Incisions should be made where soft tissue disruption, particularly
of the well-vascularized periosteum, can be minimized. Old incisions should be
incorporated whenever possible, especially when the procedure was recent.
IMAGING
■ Most nonunions and malunions of fractures, fusions, and osteotomies can be
diagnosed on plain radiographs (FIG 1A).
■ For joints that are difficult to see on plain radiographs, or for complicated
procedures with a large fixation construct, a CT scan is the best study to
diagnose nonunion (FIG 1B).
■ MRI scan plays little role in diagnosing nonunion but can be helpful to
evaluate soft tissue structures, which may contribute to symptoms, and is a
sensitive study for osteomyelitis.
■ Nuclear medicine studies can aid in diagnosis of infection and osteomyelitis,
which is a common contributor to nonhealing of bone (FIG 2).
FIG 1 • A. Plain lateral radiograph. B. Coronal and

sagittal CT scan images depicting a nonunion of ankle
arthrodesis.
FIG 2 • Tagged WBC study demonstrating increased
uptake in the left ankle compared to the right.
DIFFERENTIAL DIAGNOSIS
■ Hypertrophic nonunion
■ Oligotrophic nonunion
■ Septic (infected) nonunion
■ Malunion
■ Avascular necrosis of bone
■ Failure of fixation
NONOPERATIVE MANAGEMENT
■ Nonoperative treatment for many foot and ankle disorders include activity
modification, ambulatory aid, such as a cane or crutch. Physical therapy, brace,
or orthotic device may be helpful. Oral medications can help reduce pain,
although one must be aware of risks (eg, NSAIDs can contributed to delayed
healing, narcotic analgesics carry risk of dependency).
■ Severe deformities may be difficult to accommodate or fit into a brace, and
surgical options should be considered.
■ In general, if patients have persistent pain, dysfunction, problems working or
participating in activities of daily living, or if there are risks to other structures
or to the patient by continuing nonoperative management, surgery should be
considered.

SURGICAL MANAGEMENT
■ The decision to augment a fusion, osteotomy, or fracture with graft is
dependent on many factors, including surgeon preference and experience.
Grafts should, in general, be added to increase both the likelihood and the
timing of bone union in cases where nonunion or delayed union is
unacceptably high. Examples include revision cases and patients with risk
factors outlined above.
■ The authors prefer autograft iliac crest bone graft for most indications where
there is high risk of nonunion. When structural grafts are necessary to span a
cortical gap in bone, structural autograft from the iliac crest is generally
sufficient for most procedures in the foot. Ankle and hindfoot bone loss often
requires larger allografts, such as femoral head or fibular grafts.
■ Orthobiologics can be used in lieu of, or in addition to, other graft materials, or
to add a large dose of specific growth factors to the fusion site. Examples of
such orthobiologic therapies include platelet-rich plasma (PRP), bone marrow
aspirate concentrate (BMAC), bone morphogenetic proteins (BMP), and
platelet-derived growth factor (PDGF). The enormous recent growth of the
number of available biologic products carries with it a high cost and a paucity
of data on safety, effectiveness, and clinical outcomes for many products,
particularly compared to the iliac crest bone graft standard. It is the
responsibility of the surgeon to judiciously utilize these products with a
thorough knowledge of their mechanism(s) of action, approved indications,
side effect profiles, and cost.
■ The ultimate goal of any fusion, osteotomy, or fracture repair operation is bone
healing, pain relief, and return to optimal function while avoiding
complications, prolonged hospitalization, and revision operations. When a
graft is selected, the surgeon must balance necessity, cost, comorbid factors,
and risk and have a keen understanding of the selected graft(s) and technique.
Preoperative Planning
■ Plain weight-bearing radiographs of the foot and/or ankle are necessary for
complete evaluation (FIG 3A).
■ Other imaging studies may be helpful. MRI may show extent of infection or
the presence of avascular necrosis. CT scans confirm nonunion and show bone
quality and structural bone loss, bony defects and deformities (FIG 3B,C).
■ A complete evaluation of the skin and adjacent structures must be performed,

using radiographs when prudent. This should include the surgical site in the
foot or ankle and any potential graft harvest site.
■ A thorough discussion of risks and the postoperative course (which can be
prolonged) should be had with the patient because compliance is vital to
success.
■ Ensure that appropriate equipment is available prior to starting the case. A
good coring reamer is helpful for cancellous graft harvest (FIG 4). Osteotomes
and retractors can help to expose and harvest cortical grafts. Allografts and
biologics should be requested if these might be required.
■ Plan for size and volume. It is important to estimate the amount of graft that
will need to be harvested for a given procedure.
FIG 3 • A. Anteroposterior radiograph of nonunion of the
first metatarsal. Axial (B) and sagittal (C) CT scans
confirming the nonunion.
FIG 4 • Photograph illustrating components of a coring
reamer setup for harvesting of autograft cancellous

bone graft. These include a coring reamer (7 mm
diameter pictured here), a tipped trochar, and a T
handle. Alternatively, power tools can be utilized with
caution.
Positioning
■ Most cases are performed with the patient in a supine position. This also
facilitates graft harvest for most sites.
■ The patient is typically positioned toward the edge of the bed to facilitate
access to the foot and ankle.
■ Generally, the autograft is harvested on the ipsilateral extremity. The graft site
undergoes sterile preparation and draping along with the surgical extremity
(FIG 5A).
■ With distal lower extremity autografts, we advised that the patient have
protected weight bearing in a cast or brace for the primary procedure, which
also allows for healing of the harvest site.
Approach
■ In the primary surgery setting, the decision to use bone graft is complex and
based on the criteria outlined above. Once this decision is made, preoperative
planning using available imaging should be undertaken. The surgical approach
should ensure avoidance of injury to neurovascular structures and minimizing
soft tissue disruption.
■ For nonunion surgery, once a symptomatic nonunion is diagnosed and
appropriate conservative measures have been taken toward healing and
restoration of function, the use of bone graft is considered for revision surgical
options.
■ The approach for graft harvest is based on access to sufficient graft volume for
the indication while avoiding large bone defects, bleeding, and injury to
surrounding structures. We will specifically discuss and illustrate the four most
common graft harvest sites for foot and ankle indications: the anterior iliac
crest (structural and/or cancellous), the proximal tibia, and the calcaneal
tuberosity.

FIG 5 • A,B. Prep and draping of iliac crest harvest site.
T E C H N I Q U E S
■ Technique 1: Iliac Crest Autograft Harvest
(Tricortical Structural)
■ This technique is described in another chapter.
■ Briefly, the ipsilateral hip is positioned with a well-padded bump. The area is
draped after sterile surgical prep. An iodine barrier may be placed (FIG 5B).
■ The incision site may be injected with lidocaine plus epinephrine to decrease
bleeding.
■ The anatomic landmarks are palpated, and a longitudinal incision is made
along the iliac crest, starting 2 cm above the ASIS. The soft tissue is bluntly
dissected until the periosteum is exposed.
■ The periosteum is incised in line with the incision and the crest. Once bone
is identified, subperiosteal dissection is performed to expose the crest. Great
care must be taken to avoid penetration of the medial structures, especially if
the inner table is required as part of the graft harvest.
■ The size of the graft must be determined at this point, based on the defect
size (TECH FIG 1A,B).
■ Structural cortical or tricortical graft is removed with a saw or osteotomes
(TECH FIG 1C).
■ The graft is shaped to fit the defect (TECH FIG 1D–F). Additional

cancellous graft can be harvested from the crest if needed to fill gaps.
■ Appropriate fixation is applied to stabilize the graft (TECH FIG 1G,H).
■ Following harvest, the iliac crest area can be packed with Gelfoam and
thrombin to aid in hemostasis.
■ Allograft cancellous chips can be used to pack the harvest site. This can
provide hemostasis as well as filling of the defect.
■ Periosteum is closed after hemostasis is achieved followed by layered
closure of the overlying soft tissue and skin (TECH FIG 1I)
TECH FIG 1 • A. Clinical photograph of bone defect
requiring structural graft. B. Intraoperative fluoroscopic
image showing the defect. C. Photograph of sagittal

saw used for iliac crest structural harvest. D–F.
Harvesting of iliac crest bone segment measuring 1.3
cm, appropriate to fill defect. G. Anteroposterior. H.
Lateral radiographs showing fixation of structural graft.
I. Closure of iliac crest harvest site with absorbable
subcuticular stitch.
■ Technique 2: Iliac Crest Autograft Harvest
(Cancellous)
■ This technique is for cases where cancellous autograft is indicated. The iliac
crest cancellous bone contains the highest concentration of growth factors of
the sites described in this chapter. Because it is a non–weight-bearing bone,
this also mitigates risk of fracture postoperatively.
■ As above, the ipsilateral hip is positioned with a well-padded bump. The
area is draped after sterile surgical prep. An iodine barrier may be placed.
■ The incision site may be injected with lidocaine plus epinephrine to decrease
bleeding.
■ The landmarks are palpated, and a small longitudinal incision is made along
the iliac crest (usually about 1 cm in length), starting 2 cm above the ASIS.
The soft tissue is bluntly dissected until the periosteum is exposed.
■ The periosteum is incised in line with the incision and the crest. Once bone
is identified, a trochar is used to create a defect in cortical bone (TECH FIG
2A).
■ Next, a coring reamer is used to penetrate cortical bone penetrating up to 2
cm deep into the crest (TECH FIG 2B–D).
■ Up to three passes (central, distal, proximal) can be made through one bone
window. If additional graft is required, a second bone window should be
created proximal to the end of the most proximal reaming pass.
■ The periosteum is closed after hemostasis is achieved followed by layered
closure of overlying soft tissue and skin.

TECH FIG 2 • A. Trochar and mallet used to create
starting point in iliac crest for cancellous harvest. B–D.
Coring reamer used to harvest iliac crest cancellous
bone.
■ Technique 3: Proximal Tibia Autograft Harvest
■ As with iliac crest autograft, it is ideal to obtain proximal tibia autograft
from the ipsilateral tibia.
■ The patient is placed in the supine position. A thigh tourniquet is used to
create a bloodless field.
■ A longitudinal incision is made medial to the tibia tubercle, about 1 cm
(TECH FIG 3A).
■ The periosteum is elevated, and the tibia metaphysis is identified. Small drill
holes are made in a circular pattern.
■ An osteotome is used to connect the drill holes, beveling the cortical
window. The window is saved (TECH FIG 3B).
■ Curettes or gouges are used to remove cancellous bone (TECH FIG 3C,D).
■ The window is replaced and the wound closed in layers.

TECH FIG 3 • A. Incision for proximal tibia cancellous
graft harvest. Marked V indicates tibial tubercle, (B)
cortical window allowing access to cancellous bone of
proximal tibia. C. Photograph illustrating curettage of
cancellous bone from the proximal tibia, and (D)
sample of typical harvest yield from proximal tibia.
■ Technique 4: Calcaneal Autograft Harvest
■ Calcaneal bone graft is generally obtained from the ipsilateral calcaneus.
■ In order to mitigate the risk of donor site fracture, this graft harvest is best
selected in the setting of a procedure that will require a period of nonweight
bearing.
■ The patient is placed in the supine position. A calf or thigh tourniquet is
used.
■ Landmarks are identified first, including the tip of the calcaneal tuberosity,
the peroneal tendons, and the distal fibula.
■ A 2-cm oblique incision is made parallel and inferior to the peroneal tendons
through the skin only, with blunt dissection down to bone and protection of
the branches of the sural nerve (TECH FIG 4A).
■ Elevation of the periosteum of the lateral calcaneus is performed to expose
the cortical bone.
■ A small diameter (7–8 mm) coring reamer is used to harvest cancellous bone
from of the posterior tuberosity of the calcaneus (TECH FIG 4B). Multiple
passes can be made through the same window, depending on volume need.
■ The graft is collected in a small cup or receptacle such that appropriate
volume can be assessed before discontinuing graft harvest (TECH FIG 4C).
■ If required, additional bone can be curetted from the area, but use caution not
to penetrate the far cortices.
■ The skin is closed with 4-0 monofilament absorbable subcutaneous sutures,
skin tape, and a period of nonweight bearing determined by the primary
procedure.

TECH FIG 4 • A. Incision for calcaneal graft harvest.
B. Coring reamer for calcaneal graft harvest. C.
Resulting yield of calcaneal graft harvest.
■ Technique 5: Bone Marrow Aspirate Concentrate
In cases where structural graft is not necessary, but there is a desire to
supplement biology with autograft marrow rich in stem cells, autograft bone
marrow can be a valuable adjunct. This is usually harvested from the ipsilateral
iliac crest, because this is the location with the greatest concentration of
growth factors.7
■ Bone marrow aspirate can be administered in three ways:
■ As an isolated graft injection
■ Combined with demineralized bone matrix (DBM)
■ Bone marrow aspirate concentration (BMAC) of growth factors
■ Harvesting of bone marrow from the iliac crest:
■ The iliac crest undergoes sterile prep at the same time as the ipsilateral
foot.
■ A separate sterile drape is used after prep, using sterile towels, followed by
sterile iodoform drape. After the final sterile drape is placed, a small hole is
cut in the drape and a second iodoform drape is used to seal the crest site
(see FIG 5).
■ Bone marrow should be harvested just prior to its administration to
optimize the viability of cells. A small incision is made with a no. 15 blade.
It is essentially a puncture, just the width of the blade, providing room for
the Jamshidi needle.
■ A Jamshidi needle is advanced to the iliac crest. Direct palpation assures
that the needle is centered in the crest and directed centrally, between the

inner and outer tables (TECH FIG 5A). It is important to ensure that the
inner table is not penetrated during harvest.
■ Advance the needle about 1 to 2 cm into the crest and aspirate 2 cc. Then,
redirect and advance the needle about 2 cm and withdraw an additional 2
cc. This can be repeated until sufficient volume has been harvested (TECH
FIG 5B). The highest concentration of cells is in the first 2 cc at each
location.8
■ The BMA can be combined with DBM to create a cellular putty (TECH
FIG 5C). This can be administered where small defects are present in
joints and fractures with oligotrophic nonunions. This can be injected
percutaneously in some cases to avoid disruption of blood supply.9
■ Alternatively, larger volumes of bone marrow can be harvested and
concentrated using a commercially available system and injected into the
fracture or fusion site.10
TECH FIG 5 • A. Jamshidi needle placed in iliac crest
through percutaneous incision. B. Syringe attaches to
Jamshidi needle and 2 cc of iliac crest withdrawn. C.
Bone marrow aspirate can be combined with DBM to
create a cellular putty to fill small defects.
■ Technique 6: Concentrated Synthetic Growth
Factors
There are many synthetic growth factors available to help augment
healing of nonunions and at-risk procedures in the foot and ankle.
Although a more thorough discussion is beyond the scope of this
chapter, this is an important consideration for bone graft options.

More detailed descriptions can be found elsewhere in the
literature.11–13
■ Examples of available bone graft substitutes along with a brief description
include the following:
■ Bone morphogenetic protein (BMP-2)
■ Platelet-derived growth factor (PDGF)
■ Demineralized bone matrix (DBM)
■ Hydroxyapatite
■ Limitations to utilization of these substances can include cost, FDA approval
status (often limited for foot and ankle indications), and availability.
PEARLS AND PITFALLS
Hemostasis
■ Hemostasis must be obtained at the graft site prior to closure of skin
in order to avoid bleeding, hematoma, and wound complications.
Controlling
hemostasis
■ Lidocaine with epinephrine helps to control bleeding from the
subcutaneous tissue.
■ Gelfoam and thrombin helps reduce postoperative bleeding.
Volume
yield
■ The iliac crest bone graft harvest yields the greatest amount of
cancellous graft.
■ Autograft from the proximal tibia may yield sufficient cancellous
graft for many foot and ankle procedures.
Technique
■ Beveling the cortical window will prevent the window from falling
into the tibia.
Wound
closure
■ Closure with an absorbable monofilament subcuticular stitch and
skin tape can provide a more cosmetic and less painful scar.
Plan ahead
■ Ensure that appropriate equipment for harvest and/or graft material is
available for the procedure.
■ Estimate the volume and quality of graft required such that
appropriate harvest sites and techniques can be utilized.
POSTOPERATIVE CARE
■ Generally, the autograft is harvested from the ipsilateral limb, to facilitate
protected weight bearing and frequently with a splint or cast. Crutches or knee

scooter devices are used in many of the procedures. The harvest site may heal
in 6 to 12 weeks. Sutures may be removed at 2 weeks. Range of motion
exercises may then begin at that time.
OUTCOMES
■ There are a considerable number of reports in the literature addressing bone
grafting techniques and their impact on fusion rates following reconstructive
surgeries. Contributing factors include the breadth of procedures and
diagnoses, the impact (or poor reporting) of patient factors, and inconsistent
indications for bone grafting. Although most available data come from level IV
and V data, some meaningful conclusions can be drawn.
■ Lareau et al.14 reported a systematic review of the literature on bone grafting
for the foot and ankle. While underscoring the need for more level I and II
evidence to better guide our use of bone graft adjuvants during foot and ankle
surgery, their pooled data demonstrated a trend toward favoring the use of
cancellous autograft, structural autograft, or cancellous allograft over using no
graft material during fusion surgery.14 They suggest that using no graft leads to
nonunion rates of only about 10% (ie, a greater than 90% union rate), whereas
the addition of cancellous autograft, structural autograft, or cancellous allograft
reduced the nonunion rate by half.
COMPLICATIONS
■ Complications from autograft from the iliac crest include infection, nerve
injury, painful scar, nonunion, and pain. Harvest from the proximal and distal
tibia or calcaneus may result in infection, numbness, and rarely fracture
through the graft site. Superficial infections may be treated with local wound
care and oral antibiotics. Rarely, the infection is deep, requiring surgical
debridement and intravenous antibiotics.
REFERENCES
1. Mann RA, Prieskorn D, Sobel M. Mid-tarsal and tarsometatarsal arthrodesis
for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone
Joint Surg Am. 1996;78(9):1376-1385.
2. Thevendran G, Younger A, Pinney S. Current concepts review: risk factors for
nonunions in foot and ankle arthrodeses. Foot Ankle Int. 2012;33(11):1031-
1040.
3. O’Connor KM, et al. Clinical and operative factors related to successful
revision arthrodesis in the foot and ankle. Foot Ankle Int. 2016;37(8):809-815.

4. Thevendran G, et al. Nonunion risk assessment in foot and ankle surgery:
proposing a predictive risk assessment model. Foot Ankle Int. 2015;36(8):901-
907.
5. Bettin CC, et al. Cigarette smoking increases complication rate in forefoot
surgery. Foot Ankle Int. 2015;36(5):488-493.
6. Friedlaender GE. Bone grafts. The basic science rationale for clinical
applications. J Bone Joint Surg Am. 1987;69(5):786-790.
7. Hyer CF, et al. Quantitative assessment of the yield of osteoblastic connective
tissue progenitors in bone marrow aspirate from the iliac crest, tibia, and
calcaneus. J Bone Joint Surg Am. 2013; 95(14):1312-1316.
8. Muschler GF, Boehm C, Easley K. Aspiration to obtain osteoblast progenitor
cells from human bone marrow: the influence of aspiration volume. J Bone
Joint Surg Am. 1997;79(11):1699-1709.
9. Hunt KJ, Anderson RB. Treatment of Jones fracture nonunions and refractures
in the elite athlete: outcomes of intramedullary screw fixation with bone
grafting. Am J Sports Med. 2011;39(9):1948-1954.
10. Murawski CD, Kennedy JG. Percutaneous internal fixation of proximal fifth
metatarsal jones fractures (Zones II and III) with Charlotte Carolina screw and
bone marrow aspirate concentrate: an outcome study in athletes. Am J Sports
Med. 2011;39(6):1295-1301.
11. Arner JW, Santrock RD. historical review of common bone graft materials in
foot and ankle surgery. Foot Ankle Spec. 2014;7(2):143-151.
12. DiGiovanni CW, Lin S, Pinzur M. Recombinant human PDGF-BB in foot
and ankle fusion. Expert Rev Med Devices. 2012;9(2):111-122.
13. Rearick T, Charlton TP, Thordarson D. Effectiveness and complications
associated with recombinant human bone morphogenetic protein-2
augmentation of foot and ankle fusions and fracture nonunions. Foot Ankle Int.
2014;35(8):783-788.
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analysis of data from 159 papers in the foot and ankle literature. Foot Ankle
Surg. 2015;21(3):150-159.

12
CHAPTER
Reconstruction of the
Forefoot
Rachel E. Hein and Scott T. Hollenbeck
DEFINITION
■ The primary goal in forefoot reconstruction is to preserve function of the lower
extremity. Given the unique bony and skin arrangements in the foot as well as
the high functional demand for this area, an understanding of multiple
reconstructive approaches is necessary.
ANATOMY
■ The forefoot contains the distal third of the foot from the base of the
metatarsals to the distal phalanges of the toes on both the plantar and dorsal
surfaces of the foot.
■ The plantar surface of the foot has highly specialized glabrous skin with a
thick epidermis. Beneath the skin and subcutaneous tissue is the plantar
aponeurosis, which is a thick fibrous band adherent to the skin. This resists
shearing forces as it attaches to the skin via the retinaculum cutis ligaments
distal to the metatarsals. In contrast, the dorsal skin of the forefoot is extremely
thin and relatively mobile.
■ The bones of the forefoot are somewhat analogous to the hand with the first
toe containing only a distal and proximal phalanx. The second through the fifth
toes have a middle phalanx. There are five metatarsal bones, which span from
the midfoot bones (cuneiforms and cuboid) to the proximal phalanx of each
digit.
■ There are four separate plantar fascia compartments and one dorsal fascial
compartment that are divided by intermuscular septa. These separate the
intrinsic muscles of the foot.
■ The medial and lateral compartments are the most relevant for reconstruction

as the muscles are most superficial and amenable to flap use. Of note, the
medial compartment contains the abductor hallucis (AH) and flexor hallucis
brevis (FHB) whereas the lateral compartment contains the abductor digiti
minimi (ADM) (FIG 1).
■ There are extrinsic and intrinsic muscles of the foot.
■ The extrinsic muscles originate in the leg and insert onto the bones of the
foot.
■ The peroneus tendons insert onto the 5th metatarsal and allow for foot
eversion.
■ The extensor digitorum longus (EDL) tendons insert onto an extensor
mechanism of each of the lateral four digits.
■ The extensor hallucis longus (EHL) tendon has its own muscular unit and
inserts onto the first phalanx.
■ In addition to the digit extending muscles, the foot may be brought into
extension by the tibialis anterior (TA), which inserts onto the medial
cuneiform/first metatarsal junction.
■ Preservation of at least one of these three systems is needed to prevent a
functional footdrop. The digital flexors have a similar arrangement to the
extensors, with the flexor digitorum longus (FDL) inserting onto each of the
lateral four digits and the flexor hallucis longus (FHL) tendon inserting onto
the first toe.
■ Plantar flexion is primarily driven by the Achilles mechanism of the heel, but
digit flexors do have some importance as it pertains to the toe push off phase
of the gait cycle.
• The intrinsic muscles are contained in the compartments of the foot and
primarily act on the toes.
■ The flexor digitorum brevis (FDB) occupies the central aspect of the
superficial muscles of the plantar surface of the foot. There are two additional
deep layers of muscles in the plantar foot that are not commonly used in
reconstructive surgery.
■ Secondary action of intrinsic muscles includes maintaining posture and foot
concavity.
■ The dorsal aspect of the foot is primarily made up of the extrinsic tendons,
deeper intrinsic digit extensors, and still deeper interosseous muscles.
■ The main vascular supply to the foot comes from the posterior tibial artery.
The artery splits into the medial and lateral plantar arteries beneath the flexor
retinaculum. These two arteries join at the base of the metatarsals to form the

deep plantar arch.
■ The lateral plantar artery is the dominant artery supplying the fourth and fifth
toes through metatarsal and then proper digital arteries.
■ The medial artery supplies the first through third toes in a similar fashion.
The dorsalis pedis artery supplies the dorsum of the foot and also gives
terminal branches completing the plantar arch. For reconstructive purposes,
the plantar intrinsic muscles of the foot are typically supplied via the medial
and lateral plantar arteries (FIG 2).
■ Cutaneous sensation to the forefoot is supplied via terminal branches of the
sciatic nerve. The plantar surface of the forefoot sensation is mainly derived
from the medial plantar nerve (tibial origin) and the lateral plantar nerves
(tibial origin).
■ The dorsal forefoot sensation is mainly derived from the superficial peroneal
nerves (common peroneal origin) and the unique first web space distribution of
the deep peroneal nerve (common peroneal, sciatic, L5 origin).
■ Motor innervation of the intrinsic foot muscles is mainly through the medial
and lateral plantar nerves1 (see FIG 2).

FIG 1 • Sole of foot.
FIG 2 • A,B. Anatomy of the foot, vessels, and nerves.
PATHOGENESIS
■ Traumatic foot injuries are typically associated with high-energy events. This
may lead to extensive and complex wounds involving lacerations, contusions,
skin degloving, open fractures, and severe crush injuries.
■ Cancerous lesions may require extensive surgical resection and reconstruction
within the foot. Many of these are amenable to isolated digit or ray amputation
but some may require large skin resections on weight-bearing areas of the foot.
■ Postsurgical complications following foot and ankle surgery may also present
with complex problems involving necrotic skin, exposed tendons, colonized
hardware and bony nonunion.
■ Chronic vascular disease including venous stasis and peripheral vascular
disease can be a cause of tissue loss within the forefoot. This should mainly be
addressed by controlling the inciting factor. Amputation and debridement are
often needed in these cases prior to any consideration of reconstruction.
■ Diabetes is a major contributor to forefoot wounds and ulcers. Many of these
patients have diabetic neuropathy and develop pressure-related ulcers over the

metatarsal heads. Prior to consideration of reconstruction, the patient’s status
should be optimized and nonsurgical options should be considered. This may
include weight-bearing restrictions and/or use of shoe inserts to deflect
pressure away from the affected area.2
NATURAL HISTORY
■ The lower extremity is commonly involved in motor vehicle injuries, and this
is the most common scenario requiring forefoot reconstruction. These are often
complex injuries and may involve multiple levels of the lower extremity and
multiple systems within the patient. Standard principles of trauma care must be
followed. Once the patient has been stabilized, foot reconstruction may involve
a multidisciplinary limb salvage team including plastic and orthopedic
surgeons.
■ A unique trauma scenario involving the forefoot is that related to lawn mower
injuries and amputations. These are often isolated foot injuries but may be
severe in nature.
■ Replantation of amputated digits is not typically performed in the lower
extremity.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Gait cycle and biomechanics
■ Reconstructive surgeons managing wounds of the foot should be familiar
with the gait cycle as it pertains to functional outcomes. Classically, there are
three cycles of the stance phase of ambulation including heel strike,
midstance, and propulsion. This is followed by the noncontact swing phase.
■ For the purpose of forefoot injuries, it is important to note that high pressures
occur during propulsion and include the final contact point at the first toe.
Higher pressures and abnormal gait may lead to skin breakdown and
development of wounds over the forefoot.3
■ Evaluation of forefoot wounds
■ Initial evaluation of a patient with an acute traumatic injury to the foot
includes assessment of the mechanism, energy, and contamination associated
with the event. This often occurs during the initial washout and debridement
of the wound. The associated soft tissue injury and underlying bony injury
should be appreciated as well as the integrity of the vascular and neurologic
systems within the foot.
■ Understanding a patient’s underlying comorbidities as well as preinjury

functional status and work demands is also important.
■ Doppler examination is useful to determine arterial perfusion as well as
planning for operative intervention. However, severe edema may prevent
accurate Doppler assessment, and additional angiographic studies may be
required. Any presumed acute arterial injury warrants a vascular surgery
consultation and subsequent evaluation for compartment syndrome.4
■ Neurologic evaluation of the injured foot may be limited due to associated
neuropraxia and tissue edema. Declaration of a nonsalvageable foot based on
neurological injury should be deferred during the acute injury phase.
■ For chronic wounds, duration of wound and measurements should be taken
including length, width, and depth. Involvement of skin, dermis, fascia,
muscle, tendon, and bone should be noted as well as any concurrent cellulitis.
Photographs should be taken, and previous therapies should be noted. Gait
analysis is also important in these patients as disease processes can affect
weight bearing over the forefoot. Vascular and neurological status is also
important to take into account.
IMAGING
■ The physical exam will dictate the imaging studies needed when evaluating
foot wounds. In the trauma setting, plain films are typically obtained first to
rule out fractures. In some circumstances, a CT scan or MRI is obtained for
better bony and ligamentous imaging. Angiography is typically reserved when
evaluating more proximal injuries, but may be useful on certain occasions.
■ Chronic infectious wounds such as diabetic ulcers and postoperative wound
breakdown require plain films to rule out pathologic fractures and gas in the
subcutaneous tissues along with MRI to rule out osteomyelitis. Bone biopsies
are the standard, but MRI may help delineate operative management in these
cases. Ankle-brachial indices and duplex arteriogram should be obtained to
assess arterial insufficiency and need for possible vascular intervention.
DIFFERENTIAL DIAGNOSIS
■ Traumatic
■ Postsurgical
■ Infectious
■ Diabetic
■ Acute arterial
■ Venous ulceration

■ Connective tissue disorder
NONOPERATIVE MANAGEMENT
■ Traditionally, dressing changes are helpful for managing small superficial
wounds through healing by secondary intent. Negative pressure wound therapy
(NPWT) may also be used to achieve secondary healing or to prepare a
complex wound bed for a skin graft or flap.
■ Newer wound dressings have also aided in the treatment of open forefoot
injuries including semipermeable dressings, hydrocolloids, and hydrogels.
These new dressings can aid in chemical debridement as well as hydration of
the wound. Additionally, synthetic products and xenograft products exist and
may have some utility in managing these wounds. More data are needed to
prove the clinical efficacy of these treatments.
■ Hyperbaric oxygen (HBO) treatment may be used as an adjunct to traditional
wound healing methods but remains somewhat unproven in its efficacy for foot
wounds. HBO works by promoting angiogenesis and ultimately increasing the
amount of vascularity in the wound bed, thereby promoting wound healing. It
may be indicated in crush injuries, refractory osteomyelitis, and gas gangrene.
SURGICAL MANAGEMENT
Preoperative Planning
■ Debridement remains one of the most important preoperative principles in
lower extremity salvage. For an acute wound, it is important to perform serial
debridement if necessary until all nonviable tissue has been removed. Chronic
wounds should be serially debrided until negative cultures are obtained.
Comorbidities should be managed for optimization.
■ Once a decision has been made to proceed with reconstruction, the timing of
intervention should be determined. Typically, this will be based on the
underlying source of the wound.
■ In acute trauma settings, debridement and bony fixation should be complete.
An understanding of vascular and nerve injury should be established. At this
point, the extent of the reconstruction will be known and a proper approach
may be determined.
■ The ideal window to operate on traumatic injuries is within the first week, if
not sooner. Bacterial contamination and traumatic edema make reconstruction
more difficult and warrant delay.

Positioning
■ A modification of standard supine positioning is required for most procedures.
For plantar defects, it is often best to place the patient in a lateral decubitus or
possibly prone position. Of course the positioning will be influenced by the
planned reconstruction. A thigh or calf tourniquet is often used during these
procedures to optimize visualization. Bipolar cautery should be available when
procedures involve deep structures near the neurovascular bundles.
Approach
■ Reconstructive options for forefoot wounds include secondary closure, skin
graft or skin substitute, local or random patterned flap, pedicled flap, or free
flap with microvascular anastomosis.
■ Function and aesthetics must be taken into account. For example, a split-
thickness skin graft to a wound bed is not likely to be a durable option for a
plantar defect. Likewise, a large bulky flap placed on the dorsal forefoot is
likely to make shoe fitting difficult. The specific approach for each
reconstructive option is listed below.
■ Delayed primary closure is often difficult to perform secondary to refractory
edema and minimal skin laxity of the foot.
■ Tissue expansion is often not an option for the same reasons listed above.
■ Skin substitutes have become popular in recent years and are used as dermal
replacements in patients who would otherwise require flap reconstruction. A
secondary skin graft is often needed. These products are directly applied to
the wound bed after debridement.
■ Local random patterned flaps are an option in patients with small foot
wounds who may not be good free flap candidates. These flaps are inherently
difficult to move in the foot.
■ Pedicled flaps are useful in the forefoot due to rapid harvest and inset;
however, for many of these flaps to reach the forefoot they must be based on
unreliable distal perfusion. Another approach is to slide the flap with a
component of plantar tissues in a V to Y pattern. These flaps can include both
muscle and fasciocutaneous elements.
• The reverse abductor digit minimi (ADM) flap is harvested along the lateral
aspect of the plantar surface near the 5th metatarsal. The distally based flap
and reverse based flap are useful for plantar forefoot wounds.
• The reverse AH flap may be used for plantar defects of the forefoot. This
muscle originates from the medial border of the calcaneus and inserts on the

base of the proximal phalanx of the great toe.
• The reverse FDB flap and the FDB based V-Y advancement flap are used in
distal plantar surface wounds of the arch. For the reverse flap to be used, the
dorsalis pedis and anterior tibialis must be intact as the medial plantar artery
perforator is divided.
• The toe fillet flap is a form of pedicled flap and is used after a toe
amputation to cover a plantar- or volar-based wound associated with the
effected digit.
• The reverse dorsalis pedis fasciocutaneous flap can be designed up to 10 cm
in size and is based on the dorsalis pedis artery. The pedicle of a standard
dorsalis pedis flap is based on the dorsalis pedis artery; however, its reverse
is based on the deep plantar arch and thus completeness of the arch must be
assessed.
• Reverse medial plantar artery flap: This flap contains the skin of the instep
or non–weight bearing area of the plantar surface from the head of the first
metatarsal to the navicular bone proximally.5-7
■ Free flaps entail harvesting tissue from a different site along with its blood
supply and transferring it to the recipient site. This requires a microvascular
anastomosis. Both fasciocutaneous and muscle flaps work well on the forefoot
and depend on goals of reconstruction.
• Important aspects of the approach for free flap reconstruction include
choosing a donor flap that will easily cover the defect. If the flap is too
small, the closure will be tight.
• Vessel size needs to be considered to match the flap with the foot recipient
vessels. Also, the vascular anastomosis needs to be performed outside of the
zone of injury which may even be at or above the ankle. Finally, the flap
must be of sufficient bulk to obliterate any underlying dead space.
• Free flap choice: Considerations on choice of free flap include size of
wound, defect composition, pedicle size and length, and state of wound.
Location of wound also precludes itself to choice of flap. The foot may be
broken into seven subunits, which have been established for functional and
aesthetic reconstructive goals. With respect to the forefoot, there are four
relevant subunits (FIG 3). Each has its own aesthetic and functional
concerns with regards to reconstruction.

FIG 3 • Four separate views of foot and ankle
demonstrating different aesthetic and functionally
different subunits. There are four different relevant
subunits of the forefoot. (Reprinted from Hollenbeck S,
et al. Longitudinal outcomes and application of the
subunit principle to 165 foot and ankle free tissue
transfers. Plast Reconstr Surg. 2010;125(3):924-934,
with permission.)

T E C H N I Q U E S
■ Secondary Healing Using Regenerative Matrix
■ Skin substitutes have become more popular in the recent years and are used
in patients who may otherwise require flap reconstruction.
■ Contraindications include exposed hardware; relative contraindications
include exposed tendon or bone.
■ Begin by obtaining adequate debridement. All nonviable tissue should be
removed. Healthy bleeding tissue or bone should be visualized. If covering a
chronic wound, ensure that negative cultures have been obtained (TECH FIG
1A).
■ Apply the wound matrix to the exposed area generously. Similar principles
to application of a skin graft applies and includes ensuring adequate contact
of matrix to wound bed.
■ After application, the matrix is fixated per surgeon preference including
absorbable sutures such as chromic or staples that may be removed
postoperatively. A hydrated dressing should be applied. This includes a
negative pressure wound dressing or semipermeable colloid dressing. This
remains in place for 1 to 4 weeks (TECH FIG 1B).
■ Depending on the type of matrix applied, a bilayer may require removal
around 4 weeks with the final result being total skin closure or a granulation
bed that requires skin grafting (TECH FIG 1C)

TECH FIG 1 • A. The left foot with a full-thickness
defect down to bone following elective orthopedic
surgery. Adequate debridement is obtained to healthy
bleeding tissue. B. After 4 weeks of application of
regenerative matrix (porcine bladder elements), an
appropriate dressing should be applied that obliterates
the dead space and keeps the wound hydrated to
encourage granulation. C. Six weeks postoperatively.
Full closure with minimal eschar remains.
Regenerative matrix may be sufficient for small
wounds that would otherwise require flap coverage.
■ Reverse Fasciocutaneous Flap (Reverse First
Dorsal Metatarsal Artery [1st DMTA] Flap)
■ Begin by obtaining adequate debridement. All nonviable tissue should be
removed. Healthy bleeding tissue or bone should be visualized. If covering a
chronic wound, ensure that negative cultures have been obtained (TECH FIG
2A).

■ A Doppler should be used to identify the first dorsal metatarsal artery on the
dorsum of the foot. The flap is then designed around this using the
measurements needed to fill the defect. The proximal extension of the flap is
designed so that once rotated it will fit into the defect (TECH FIG 2B).
■ Dissection begins around the marked flap, first beginning over the dorsal
skin and continuing through the fascia exposing the underlying tendons. Care
is taken to preserve the paratenon associated with the tendons (TECH FIG
2C).
■ The flap is then rotated around the axis of the 1st DMTA, which is located
typically underneath the first interosseous muscle and adjacent to the
metatarsal bone. The flap can be kept as a peninsula or as an island (TECH
FIG 2D).
■ It is important to ensure that the inset is relatively tension free. The flap
donor defect is covered with a split-thickness skin graft (TECH FIG 2E).9
TECH FIG 2 • A. Chronic dorsal great toe wound,

debrided back to healthy tissue. Negative cultures
obtained. B. First dorsal metatarsal artery flap,
marked and dissected to level tendon, keeping
paratenon intact. Flap is undermined taking care to
ensure the perforator is not inadvertently divided. C.
Proximal end of flap is rotated 180 degrees to fill the
defect. One must ensure a relatively tension-free
closure. D. A split-thickness skin graft is harvested to
fill the donor site. There is typically some venous
congestion of the distal portion of the rotated flap;
however, in our experience this has done well with
time. E. Six weeks postoperatively with a completely
healed wound and donor site.
■ Free Gracilis for Osteomyelitis
■ The gracilis free flap may be used over the plantar surface of the forefoot in
weight-bearing areas. It is a Mathes and Nahai II flap with its main blood
supply from the medial circumflex artery off of the profunda femoral artery.
The muscle itself is 30 cm long, 5 cm wide and 2 cm thick.
■ The gracilis muscle is an excellent option for chronic defects of a weight-
bearing area in association with osteomyelitis (TECH FIG 3A). Debridement
should include all nonviable tissues and affected areas. Negative cultures
should be obtained.
■ For this type of defect (TECH FIG 3B), local types of closure are not an
option. A free tissue transfer (gracilis) has been chosen.
■ The dorsalis pedis artery is dissected proximally out of the zone of injury
and is isolated. Attention is now turned to the donor site.
■ For harvest, the patient is placed in supine and frog-leg position. A line is
drawn from the medial pubic tubercle to the medial femoral condyle.
■ The gracilis should include the proximal portion along with the length
needed to obliterate the defect.
■ Transfer and inset takes place (TECH FIG 3C) via the dorsalis pedis artery.
Primary closure of the donor site is obtained, and a split-thickness skin graft
is used to cover the newly inset flap. This provides stable coverage and good

shoe fitting (TECH FIG 3D).10
TECH FIG 3 • A. This patient suffered from chronic
osteomyelitis of the first metatarsal head as a
postoperative complication and eventually underwent
ray amputation of the first toe as pictured. B.
Debridement of entire affected segment and
remaining metatarsal head and shaft. This has left the
patient with a large defect that is not amenable to local
types of closure. C. After inset of free gracilis. It is
important that the tissue transfer obliterates dead
space of the wound. Closure should be relatively
tension free. D. Two months postoperatively. The
patient has completely healed the wound and has an
overall aesthetically pleasing result.
■ Free Flap for Distal Skin Defect
■ The radial forearm free flap is the flap of choice for most forefoot
reconstruction defects. This flap meets both the aesthetic and functional
needs including being both thin and pliable. It varies in size and can be
harvested from the wrist to the antecubital crease. This flap is primarily a

fasciocutaneous flap but may be harvested also as a myocutaneous or
osteocutaneous. Its blood supply is the radial artery.
■ In this example, free tissue transfer may be used in chronically infected
wounds or in wounds with exposed hardware. This patient did not have a
sizeable tissue defect and thus radial forearm flap was a great match due to
pliability, coverage, and aesthetic result (TECH FIG 4A).
■ First, obtain adequate debridement; in this patient debridement was
conservative due to acute osteotomies with nonunion and exposed hardware.
■ For harvest, the nondominant arm is typically utilized. An Allen’s test is
performed preoperatively to ensure that the palmar arch is intact.
■ Doppler is utilized to identify the radial artery. A flap matching the size of
the defect is marked with the radial most aspect over the radial artery.
■ Dissection proceeds distally through skin, elevating fascia with the flap.
Ensure to leave paratenon intact. The radial artery is dissected out proximally
and ligated according to pedicle length need.
■ The flap is then inset over the defect and anastomosed to the dorsalis pedis
artery (TECH FIG 4B). Antibiotics are utilized due to exposed and
presumed infected nature of the hardware. This will be kept for up to 6
weeks. Long-term coverage of the dorsal foot with a radial artery flap
provides excellent contour (TECH FIG 4C).
■ Donor site may be closed primarily depending on defect size and if
tourniquet was used (TECH FIG 4D). If defect is large, split-thickness skin
graft may be utilized.11

TECH FIG 4 • A. This patient has exposed hardware
after orthopedic procedure presumed to be infected.
This was unable to be removed due to nonunion. The
patient was taken to the operating room for proper
debridement. B. Radial forearm free flap after
anastomosis and inset. Good size and thickness
match is noted. C. Defect 2 months postoperatively.
The forefoot is well healed with no signs of exposed
hardware or chronic infection. The patient remained
on a course of IV antibiotics for 6 weeks. D. Donor
site. The patient’s donor site was amenable to primary
closure due to the small size of the defect. The patient
has completely healed donor site with good perfusion
of the hand and no chronic paresthesias.
■ Free Flap For Mangled Foot—Latissimus
■ Latissimus is one of the largest muscles in the body and is used for covering
large defects. The muscle may be harvested up to 35 cm in size and may be
used as a muscle or myocutaneous flap. This is a Mathes and Nahai type V
flap with the main blood supply coming from the thoracodorsal artery and

vein.
■ In this example, the patient suffered from a severe mangled foot after a crush
injury. Acute debridement is performed in several stages along with external
fixation. It is important to determine the viability of the surrounding tissue
prior to reconstruction (TECH FIG 5A).
■ The free latissimus is chosen for reconstruction. The patient is placed in a
lateral decubitus position for both harvest and inset.
■ The harvest site is prepared; in this case, the anterior tibial vessels are used
and dissected out proximally out of the zone of injury.
■ The latissimus is now harvested as a muscle flap in its usual fashion. The
donor site may be closed primarily over a suction drain.
■ The muscular flap is inset over the defect and anastomosed to the anterior
tibial vessels, taking care to obliterate the dead space (TECH FIG 5B). A
split-thickness skin graft is used to cover the muscular flap. A tension-free
closure should be obtained.
■ A muscle flap with a split-thickness skin graft may provide excellent durable
long-term coverage of the dorsal and plantar foot allowing for ambulation
(TECH FIG 5C,D).12
TECH FIG 5 • A. The right lower extremity after a
severe crush and degloving injury. The patient
undergoes external fixation along with adequate
debridement performed in several days. B. After inset

and skin grafting of latissimus flap over mangled foot.
External fixator still in place. C. Two months
postoperatively with acceptable contour. Wound well
healed. D. Six months postoperatively, fully healed
and with great aesthetic result that will fit in shoe or
prosthesis.
PEARLS AND PITFALLS
Function
■ Amputation may be a reasonable option for wounds involving the
forefoot. However, there will be some degree of functional loss
associated with disruption of the propulsion phase of the gait cycle.
Tendon
coverage
■ Reconstruction of the forefoot may involve wounds that are associated
with flexors or extenders of the ankle. Preservation of these insertion
points may impact leg function significantly.
Local
flaps
■ Local flaps may be limited in the foot as there is minimal skin laxity
for advancing and rotating these flaps. Ideally, incisions should not be
placed on the weight-bearing areas of the foot.
Flap
options
■ Free flap choices can be guided by consideration of the defect location
and functional demand of the area in combination with aesthetic
considerations and shoe fitting requirements. Microvascular
anastomosis should be performed out of the zone of injury. Secondary
thinning may be required especially for bulky fasciocutaneous flaps.
Outcomes
■ Free flap failure in the foot and ankle may be as high as 10% and is
often related to a tight skin closure or poor distal extremity perfusion.
Success is measured in stable skin coverage, bony healing, painless
ambulation, and shoe fitting.
POSTOPERATIVE CARE
■ At the time of reconstruction, patients are typically placed in a posterior slab
splint to minimize movement. A hole may be cut as a window to view the
surgical site. This splint is typically kept until the patient begins transfers at
which a formal splint will be applied.
■ Leg elevation is an important aspect of foot reconstruction, especially in the

setting of trauma. A typical protocol for free flaps is strict bed rest and leg
elevation until postoperative day 4. At this point, the patient may begin
working with physical therapy for dangling the lower extremity during
transfers for 5 minutes 3 times daily. Weight-bearing status is dictated by
orthopedic restrictions. Activity and dependent positioning should progress
over the next several weeks. At this point, a compression garment may be
applied to help with edema. During this course, it is important to utilize a
prophylactic anticoagulant dose to prevent venous thromboembolism.
■ CAM boots are typically used to offload pressure from the forefoot as the
patient begins weight bearing. Sutures are typically kept in place for 3 to 4
weeks, but should be removed prior to ambulation to prevent callus formation
or postoperative ulceration.
■ Range of motion exercises are typically initiated in the noninvolved joints
immediately postoperatively to prevent stiffness. Exercises in involved joints
of reconstruction are begun somewhere between 5 days and 2 weeks.
■ Postoperative follow-up should be frequent and consistent. This should
involve a multidisciplinary team including plastic surgery, orthopedics,
vascular surgery, podiatry, physical therapy, and wound care as needed. Many
centers have limb salvage programs that incorporate these aspects of care for
their patients.
OUTCOMES
■ The majority of patients undergoing flap reconstruction with local or free flap
transfer have a successful recovery. Free flap viability rates have been quoted
to be 90% to 93% in lower extremity reconstruction. In those with primary flap
failure, treatment consists of debridement and wound care with consideration
for further reconstruction. Patients that experience flap failure are at increased
risk for amputation.
■ Some patients will have long-term wound healing issues, with ulceration
around the site of flap inset. This may occur anywhere from months to years
after surgery and typically occurs on the weight-bearing surfaces of the foot at
the flap interface.
■ Secondary procedures are common in forefoot reconstruction and are most
commonly associated with debulking procedures, especially when free tissue
transfer is performed. Instability or nonunion is infrequently seen in the
forefoot.
■ Amputation may be indicated in the primary setting or after reconstruction

failure. Functional loss of an amputation needs to be weighed against
morbidity of limb salvage. For the forefoot, options include isolated digit
amputation, ray amputation, or transmetatarsal amputation. For those with
vascular disease or open fractures, a higher level of amputation may be
required.8,12
COMPLICATIONS
■ Given the high risk nature of the patient population, complications can occur.
Acute complications may be related to poor perfusion within the flap. This may
occur when distally based flaps are used or when free flaps become
compromised from pressure. Infections related to fractures and hardware
placement are not uncommon in foot reconstruction. These are treated with flap
elevation and further debridement.
■ Long-term complications include flap ulceration or callus, typically around the
flap–native skin interface. In these circumstances, excision of the ulcer with
flap advancement is usually sufficient.
REFERENCES
1. Themes U. Comprehensive lower extremity anatomy. February 21, 2016.
Retrieved September 18, 2017, from

2. Wrobel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity
major amputation in individuals with and without diabetes in the Medicare
population. Diabetes Care. 2001;24(5):860-864.
3. Alexander IJ, Chao EY, Johnson KA. The assessment of dynamic foot-to-
ground contact forces and plantar pressure distribution: a review of the
evolution of current techniques and clinical applications. Foot & Ankle.
1990;11(3):152-167. doi:10.1177/107110079001100306
4. Lassen NA, Tonnesen KH, Holstein P. Distal blood pressure. Scand J Clin Lab
Invest. 1976;36:705.
5. Attinger CE, Ducic I, Cooper P, et al. The role of intrinsic muscle flaps of the
foot for bone coverage in foot and ankle defects in diabetic and non diabetic
patients. Plast Reconstr Surg. 2002;110:1047-1054.
6. Man D, Acland RD. The microarterial anatomy of the dorsalis pedis flap and
its clinical applications. Plast Reconstr Surg. 1980; 65(4):419-423.
7. Emmett A. The filleted toe flap. Br J Plast Surg. 1976;29(1):19-21.
doi:10.1016/0007-1226(76)90083-7

8. Hollenbeck ST, Woo S, Komatsu I, et al. Longitudinal outcomes and
application of the subunit principle to 165 foot and ankle free tissue transfers.
Plast Reconstr Surg. 2010;125(3):924-934.
doi:10.1097/prs.0b013e3181cc9630
9. Hallock GG. The first dorsal metatarsal artery perforator propeller flap. Ann
Plast Surg. 2016;76(6):684-687. doi:10.1097/sap.0000000000000264
10. Eom JS, Sun SH, Hong JP. Use of the upper medial thigh perforator flap
(gracilis perforator flap) for lower extremity reconstruction. Plast Reconstr
Surg. 2011;127(2):731-737. doi:10.1097/prs. 0b013e3181fed789
11. Chicarilli ZN, Price GJ. Complete plantar foot coverage with the free
neurosensory radial forearm flap. Plast Reconstr Surg. 1986;78: 94-101.
12. Zhu Y, Wang Y, He X, et al. Foot and ankle reconstruction: An experience on
the use of 14 different flaps in 226 cases. Microsurgery. 2013;33(8):600-604.
doi:10.1002/micr.22177

13
CHAPTERThe Medial Plantar Flap
Arash Momeni and Subhro K. Sen
DEFINITION
■ The medial plantar flap is suitable for reconstruction of heel and lateral plantar
defects.1,2
■ The medial plantar flap is harvested from the non–weight-bearing instep area
of the foot.
■ In the majority of cases, the donor site must be skin grafted. Narrow flaps up
to 2 cm in width may be closed primarily.
■ Volar hand and finger, as well as contralateral foot defects, may be
reconstructed with the free medial plantar flap, as it is an excellent source of
glabrous skin.3,4
ANATOMY
■ The medial plantar flap is centered on an axis extending from the medial
aspect of the first metatarsal head distally to the medial horizontal calcaneal
eminence (talar shelf) proximally (FIG 1).
■ Perfusion to the flap is via perforators from the medial plantar artery and
venae comitantes that course between the abductor hallucis and flexor
digitorum brevis muscles (FIG 2).
■ Subcutaneous veins can be incorporated into the flap to augment venous
drainage.
■ The medial plantar flap may be raised as a sensate flap by including branches
of the medial plantar nerve.
■ It is critical to avoid including the weight-bearing regions of the foot (plantar
forefoot, lateral plantar area, and heel) when harvesting this flap (FIG 3).

FIG 1 • Design of medial plantar flap.
FIG 2 • Perfusion to the medial plantar flap is via
perforators from the medial plantar artery and venae
comitantes that course between the abductor hallucis
and flexor digitorum brevis muscles.
PATIENT HISTORY AND PHYSICAL FINDINGS

■ Preoperative evaluation of patients with plantar foot wounds includes a
detailed history, focused physical examination, as well as assessment of the
functional limitations associated with the foot defect.
■ History
■ A thorough history of pre-existing medical conditions as well as their severity
must be obtained. Important conditions to identify and address preoperatively
include peripheral vasculopathy, diabetes mellitus, and smoking.
• Peripheral vasculopathy must be corrected prior to any attempt at
reconstructing an existing ischemia-related soft tissue defect.
• Diabetes mellitus management needs to be optimized to increase the
likelihood of an uneventful recovery.
• Preoperative smoking cessation is mandatory to decrease the risk of delayed
wound healing.
■ A focused history of the foot wound with particular emphasis on etiology,
duration, changes in size, previous wound-related complications (eg,
infections), and previous attempts at treatment is critically important.
■ Physical examination
■ The foot wound is inspected and its location and dimensions documented.
■ The foot is inspected for pre-existing scars that may preclude harvest of the
medial plantar flap.
■ A thorough neurovascular exam of the lower extremity is performed.
• Pulses, that is, dorsalis pedis and posterior tibial artery, are palpated.
• Doppler examination is used to confirm the presence of the medial plantar
artery and identify its course.
• Absence of perfusion to the foot via the dorsalis pedis artery represents a
possible contraindication to utilizing the medial plantar flap, depending on
arterial inflow via the peroneal artery.
• Sensory examination using Semmes-Weinstein monofilaments is performed
in the distribution of the tibial as well as deep and superficial peroneal
nerves.
■ The foot is evaluated for any acquired or congenital deformities, as these
could influence the weight-bearing areas of the foot, thus, affecting flap
design.

FIG 3 • Note that the medial plantar flap is designed in a
manner to not include the weight-bearing regions of the
foot.
IMAGING
■ Preoperative imaging is not routinely required prior to harvest of the medial
plantar flap.
■ Traditional or CT angiography can be obtained to confirm the presence of
suitable pedicle vessels for patients with peripheral vasculopathy in whom
there is concern for involvement of the pedicle vessels or patients with
traumatic defects with the possibility of involvement of the medial plantar
artery/posterior tibial artery.
■ Handheld pencil Doppler examination is typically sufficient to localize the
medial plantar artery as well as intermuscular perforators emanating between
the abductor hallucis medially and the flexor digitorum brevis muscle laterally.
SURGICAL MANAGEMENT
■ Patients with defects of glabrous skin containing areas are generally
considered for reconstruction with the pedicled medial plantar flap based on the
principle of “replacing like with like.”
■ Typical indications include heel and lateral plantar midfoot defects (FIGS 4
and 5).
■ It may be transferred as a free flap for reconstruction of the contralateral foot
as well as volar hand and finger defects.
■ It is critical to examine the foot and identify weight-bearing areas so not to
include these regions in the flap. The weight-bearing areas include the plantar

forefoot over the metatarsophalangeal heads, lateral plantar foot, and the heel.
FIG 4 • Heel defect.
Preoperative Planning
■ Preoperative radiographs of the affected extremity are obtained to assess the
bone underlying the defect. It is critical to establish whether osteomyelitis is
present. If osteomyelitis is present, it should be adequately treated with
debridement and antibiotics prior to reconstructing any existing soft tissue
defect.
■ Preoperative magnetic resonance imaging (MRI) may be indicated to
preoperatively delineate the extent of osseous and soft tissue involvement.5
■ Handheld pencil Doppler examination is performed to outline the course of the
medial plantar artery.
■ The medial plantar flap is centered on an axis extending from the base of the
first metatarsal distally to the sustentaculum tali. The sustentaculum
corresponds to the medical eminence of the calcaneus.
■ It is critical to avoid incorporating weight-bearing skin areas of the foot into
the flap.
■ The flap can be designed with its proximal skin bridge intact or as an island
flap depending on the needs of the defect.6

FIG 5 • Lateral plantar midfoot defect.
Positioning
■ The patient is typically placed in the supine position with the leg externally
rotated and knee flexed (“frog leg”). Prone positioning is likewise possible
depending on defect location and surgeon preference.
■ A well-padded tourniquet is placed on the thigh to provide for a bloodless
operative field, which substantially facilitates identification of key structures
during flap dissection.
T E C H N I Q U E S
■ Medial Plantar Flap Harvest
■ Landmarks: first metatarsal head, medial calcaneal eminence, midline of the
plantar surface of the foot, navicular bone.
■ The flap is designed within the boundaries of these landmarks, with
particular attention paid not to include any weight-bearing areas of the foot
(see FIGS 1 and 3).
■ The foot wound is debrided until healthy-appearing tissue is encountered.
■ The lower extremity is elevated, exsanguinated with an Esmarch bandage,
and the tourniquet inflated to 100 mm Hg above the systolic blood pressure
value.
■ Skin incision is made along the borders of the flap, extending through the
plantar aponeurosis.

■ Although the authors prefer to include the plantar aponeurosis, inclusion of
this structure is not mandatory.
■ Distally, the abductor hallucis and flexor digitorum brevis muscles are
identified.
■ Perforators between these muscles are identified, the abductor hallucis
muscle is retracted medially, and the perforators are traced to their origin
(TECH FIG 1).
■ The medial plantar artery is visualized, along with the accompanying
medial plantar nerve and venae comitantes.
■ The medial plantar artery is distally ligated and divided, followed by a distal-
to-proximal flap dissection.
■ It is important to maintain all superficial attachments between the medial
plantar artery and the overlying skin to ensure flap vascularity.
■ In order to avoid sensory loss of the distal medial plantar foot and toes, the
medial plantar nerve is not routinely transected.
■ Instead, a nerve-splitting internal neurolysis technique is employed, in
which the nerve fibers entering flap are split from the medial plantar nerve,
thus preserving distal sensory innervation as well as providing for a sensate
flap.
■ Dissection is continued proximally until a sufficient arc of rotation is
obtained to allow transposition/rotation into the defect.
■ Occasionally, it may be necessary to divide the lateral plantar artery, the
abductor hallucis muscle, and the flexor retinaculum to increase the arc of
rotation in pedicled flap transfer or to increase pedicle length in cases of
microvascular transfer.
■ Release of the tarsal tunnel may be necessary. It may be necessary to
follow the medial plantar artery to its origin from the posterior tibial artery.
The posterior tibial vessels can also be used for microsurgical anastomosis
in the case of free tissue transfer.

TECH FIG 1 • A. During flap harvest, the perforators
between the abductor hallucis and flexor digitorum
brevis muscles are identified. B. The abductor hallucis
muscle is retracted medially, and the perforators are
traced to their origin.
■ Donor Site Closure
■ The donor site of narrow medial plantar flaps up to 2 cm in width may be
closed primarily.
■ The majority of donor sites require skin grafting for closure.
■ The exposed abductor hallucis and flexor digitorum brevis muscles are
reapproximated to provide for a well-vascularized wound bed, amenable to
receipt of a split-thickness skin graft (TECH FIG 2).
■ A negative pressure wound dressing can be applied over the skin graft as a
bolster.

TECH FIG 2 • A. Split-thickness skin graft to donor
site. B. Split-thickness skin graft to donor site
PEARLS AND PITFALLS
Indications
■ Heel and lateral plantar defects (pedicled flap transfer).
■ Any defect requiring reconstruction with glabrous skin
(microvascular-free tissue transfer).
Contraindications
■ Previous surgical intervention or injury that violate the area of
medial plantar flap harvest.
■ Peripheral vascular disease with occlusion or stenosis of
pedicle vessels of significant microvascular disease.
■ Occlusion of dorsalis pedis artery.
Imaging
■ Handheld pencil Doppler examination outlining the course of
the medial plantar artery typically sufficient.
■ Routine use of preoperative imaging is not indicated.
■ In cases of peripheral vascular disease or traumatic defects
with the pedicle vessels at risk, traditional or CT angiography
is useful.
Flap dissection
■ Avoid incorporating weight-bearing skin areas into the flap.
■ Distal-to-proximal flap dissection.
■ Preserve the medial plantar nerve, ie, employ a nerve-splitting
approach.
■ May increase pedicle length/arc of rotation by dividing the
lateral plantar artery, abductor hallucis muscle, and flexor
retinaculum, and dissect the pedicle to the posterior tibial
artery.
Donor site
closure
■ Up to 2 cm width can be closed primarily.
■ Typically donor site closure requires the use of a skin graft.
POSTOPERATIVE CARE
■ The patient is instructed to keep the donor leg elevated for 2 weeks.
■ The bolster dressing on the donor site skin graft is typically removed on

postoperative day 5, and routine skin graft care is initiated.
■ In cases of soft tissue reconstruction only without any underlying fractures,
patients are allowed to ambulate once the flap suture lines and donor site skin
graft have healed and are stable. In cases on underlying fractures, weight-
bearing status will be determined by orthopedic surgery.
■ Meticulous foot care, particularly in patients with diabetes mellitus, is
paramount.
■ Referrals should be made to an experienced podiatrist for evaluation and
possible alterations of foot wear to decrease the likelihood of wound
recurrence.
OUTCOMES
■ FIGS 6 to 8 demonstrate representative cases of long-term postoperative
outcomes following plantar reconstruction using the medial plantar flap (FIGS
6 to 8).
■ Siddiqi et al. presented their experience in 18 patients who underwent
reconstruction of the weight-bearing heel with the medial plantar artery flap.2
■ Indications for reconstruction included trauma, pressure sores, and unstable
plantar scars.
■ No flap loss was reported. Merely one case of partial skin graft loss that
healed by secondary intention was observed.
■ Patients were able to wear normal footwear.
■ No functional donor site morbidity was reported.
■ Schwarz and Negrini reported on 51 medial plantar artery flaps that were
performed in 48 patients.7
■ Indications included defects of the posterior heel (N = 25), lateral border of
the foot (N = 12), anterior heel (N = 10), and an over the Achilles tendon (N =
4).
■ Complications were encountered in 25.5% of the procedures (13/51), with
the most common complications being delayed wound healing (N = 6) and
infection (N = 3).
■ One flap loss was reported in addition to 9 ulcer recurrences in 7 ft.