Page 68 - Read Online

METHODS heel pad avulsion were managed by primary closure. Eight
patients out of 20 required skin grafting as a secondary
Twenty‑seven patients with heel pad avulsion (isolated/ procedure at a later date. Out of 7 cases of complete
combined) were treated over a period of avulsion, one was managed by full‑thickness skin
7 months (December 2012 to June 2013). The avulsed heel grafting, one case by reverse sural artery flap coverage,
pad flaps were classified on the basis of the angiosomal and four cases were managed by free tissue transfer.
concept. Heel pad flaps based distally were classified as Among the free tissue transfer, two were latissimus dorsi
tissue receiving its vascular supply from the medial plantar muscle flaps, one was a gracilis muscle flap, and one
and lateral plantar artery angiosomal territories. Flaps was an anterolateral thigh flap [Table 1]. There were no
based distally and medially were considered to receive complications following flap transfer and graft take was
their vascular supply from the medial and lateral plantar adequate. The patients in our series did not experience
arteries and the calcaneal branch of the posterior tibial the common side‑effects of HBO therapy such aural or
artery. Flaps based distally and laterally were considered pulmonary barotrauma or transient reversible myopia
to have a vascular supply based on the medial and lateral during the treatment sessions. No complications were
plantar arteries and the calcaneal branch of the peroneal noted during the follow‑up period.
artery. Those flaps with proximal continuity were classified Case 1
as having their blood supply from perforators of either A 43‑year‑old female was admitted with a crush injury
the posterior tibial or peroneal vessels. to the right leg and foot region following a crush injury
Following initial assessment and resuscitation of by a heavy vehicle [Figure 1a]. The patient presented
the patient according to the ATLS protocols, acutely with soft tissue loss over the anterior aspect of the
presenting heel pad avulsion injuries were assessed for leg and dorsum of the foot. The heel pad was avulsed
the extent of degloving, skeletal injury, associated soft from the calcaneum but was continuous to the proximal
tissue loss, vascularity to the heel pad flap, and flap and the distal aspect by the skin and subcutaneous
avulsion patterns. Patients were informed about the line of tissue [Figure 1b]. Stabilization of the ankle and heel
management, possible treatment modalities, and the need pad was performed with an external fixator following
for additional surgery procedures pertaining the pattern wound debridement. Soft tissue coverage of the anterior
of injuries. Patients were started on empirical antibiotic aspect of the leg and dorsum of the foot was provided
by a latissimus dorsi free flap and split‑thickness skin
therapy, including a third‑generation cephalosporin and grafting [Figure 1c and d]. The vessels of the latissimus
anaerobic coverage. Adequate analgesia was assured. dorsi flap were anastomosed end‑to‑side to the
Thorough wound debridement and fixation of the posterior tibial vessels as the anterior tibial vessels were
fractures was performed. In cases of partial avulsion avulsed up to the level of middle third of the leg. HBO
requiring the anchorage, HBO therapy was initiated during therapy was administered in 6 sessions postoperatively.
the immediate postoperative period. Six sessions of HBO Following demarcation of the avascular tissue over the
therapy, each session lasting 1 h and continued for 6 days, medial part of the leg and proximal heel pad, nonviable
was administered to the patients postoperatively. In cases tissue was debrided. Because there was adequate soft
of complete avulsion, the nonviable tissues were debrided, tissue padding over the calcaneum, skin grafting was
and depending upon the patient’s condition, soft tissue performed [Figure 1e‑g]. Six sessions of HBO therapy
reconstruction was performed as early as possible. were administered following skin grafting.
Postoperatively, 6 HBO therapy sessions were administered
for all patients. Immobilization of the limb was done in all Case 2
cases. Outcomes following each type of management and An 18‑year‑old male was admitted with a crush injury of
secondary procedures performed were noted. the right leg and foot with heel pad avulsion. Skin and
subcutaneous tissue were connected in the proximal and
The review board of Jubilee Mission Medical College and distal aspects [Figure 2a]. The heel pad was anchored
Research Institute approved this study. with K‑wires by the orthopedic department, and the
RESULTS patient was then referred to plastic surgery for further
management [Figure 2b]. HBO therapy was administered
The mode of injury for all patients was road traffic for six sessions. Following demarcation of the nonviable
accident. Out of 27 patients, there were 5 female (18.1%) tissue, the avascular tissue was debrided [Figure 2c and d].
and 22 male patients (81.9%). Mean age was 34.18 years
(range: 5‑53 years). For 12 patients the avulsed flap was Most of the foot pad tissue was found to be preserved,
based distally, in 7 patients the flap was based distally and skin grafting was sufficient for coverage of the soft
and laterally, in 5 patients the flap was based distally and tissue defect following debridement [Figure 2e and f]. Six
medially, in 2 patients the flap had proximal and distal additional sessions of HBO therapy were administered
connections with disruption in the medial and lateral following skin grafting.
aspects and in 1 patient the flap was continuous only in
the lateral and medial aspects. Out of 20 cases of partial Case 3
avulsion, one of the flaps was anchored with K‑wires by A 52‑year‑old male was admitted with heel pad avulsion
the orthopedic department, and then referred to plastic based distally [Figure 3a]. Primary closure was performed
surgery for soft tissue coverage. Nineteen cases of partial following debridement [Figure 3b and c]. HBO therapy was

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 57