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tissue necrosis, reduce edema, control infection, support
healing, and prevent reperfusion injury. [9]
At the authors’ institution, a strategy has been developed
to overcome these difficulties and to successfully manage
these patients with a combined approach that maximizes
tissue perfusion and oxygenation, allowing for surgical
correction of such injuries. The current treatment
algorithm [Figure 6] begins with surgical debridement and
initiation of HBO therapy in the immediate postoperative
period. HBO provides supersaturation of the plasma with
oxygen, allowing a several‑fold increase in the oxygen
diffusion gradient. Combination of the modalities allows
preservation of marginal tissue, prevention of advancing
ischemia and hypoxia and maximum preservation of heel
pad tissue. This approach has been used in the current
Figure 5: Angiosomal pattern of the heel pad and plantar foot region
series of 27 patients, achieving maximal preservation of
the heel pad with a return to ambulation.
the plasma is increased through hemoglobin‑bound
oxygen, facilitating oxygenation of the deprived tissue, Out of 27 patients, the avulsed flap was distally‑based in
stimulating angiogenesis, fibroblast proliferation, leukocyte 12 patients, distally and laterally based in 7 patients and
oxidative killing, antibiotic synergy, toxin inhibition and distally and medially based in 5 patients. In 2 patients the
vasoconstriction. Vasoconstriction significantly reduces flap had proximal and distal connections with disruption
tissue edema without hindering oxygenation. Decreasing in the medial and lateral aspects, and in 1 patient the flap
edema is desirable in complicated plastic surgical wounds to was continuous in only the lateral and medial aspects. In
relieve pressure on the surrounding vessels and structures. all cases, initial wound debridement was carried out and
Oxygen delivery also leads to mature collagen formation HBO therapy sessions were started. If flap coverage was
and stimulates angiogenesis. Ulkür et al. illustrated the required, surgery was scheduled as soon as the patient
[6]
[7]
usefulness of HBO treatment during the delay period of was stable. HBO therapy was withheld on the day of
the flap which can both decrease the time period needed surgery and recommenced on postoperative day one. When
for the delay procedure and increased the effect of the flap skin grafting was performed at a later date, surgery was
delay. The current study illustrates the utility of hyperbaric followed by six sessions of HBO therapy. Out of 20 cases
therapy in the treatment of heel pad avulsion injuries. of partial avulsion, one flap was anchored with a K‑wire
Most heel pad avulsion injuries with partial continuity act from the orthopedic department, and then referred to
similar to a delayed flap. Hence, considering the valuable plastic surgery for soft tissue management. Nineteen cases
heel pad tissue and the need for its preservation at any of partial heel pad avulsion were closed primarily. Eight
cost, management should include a modality which can patients out of 20 required skin grafting as a secondary
potentially enhance vascularity and wound healing potential procedure at a later date. Split‑thickness skin grafting was
during the period of demarcation of necrotic tissue. the method of choice when adequate soft tissue padding
Hyperbaric oxygen therapy utilizes 100% oxygen at was present. In the authors’ experience, the risk of calcaneal
pressures greater than atmospheric pressure. In the bone exposure was decreased in patients treated with HBO
current study, HBO was administered in a Monoplace therapy. Split thickness grafting can suffice if adequate soft
[2]
chamber in which a single patient is placed in a chamber tissue padding is present. However, there is a need for a
that is then pressurized with 100% oxygen. The pressure randomized controlled study of the preservation of heel
inside the chamber is adjusted, ranging from 2.0 ATA to fat pad tissue following HBO therapy. Out of 7 cases of
2.4 ATA for duration of 90 min. As an adjunct to surgery complete avulsion, 1 patient was managed by full‑thickness
and antibiotics, HBO therapy can significantly decrease skin grafting. The benefit of HBO therapy is greatest in
costs and complications. Vasoconstriction reduces edema cases in which relatively large areas of tissue are grafted,
[8]
[8]
and tissue swelling while ensuring adequate oxygen as in full‑thickness skin grafting. One patient with a heel
delivery and is thus useful in acute trauma wounds. pad defect was treated by reverse sural artery flap coverage,
Hyperoxygenation of the crush injury and compartment and four patients were managed by free tissue transfer.
syndrome followed by flap salvage results in immune Among the free tissue transfer cases, 2 were latissimus
stimulation by restoring white blood cell function and dorsi muscle flaps, 1 was a gracilis muscle flap and one was
enhancing phagocytic capabilities. Neo‑vascularization in an anterolateral thigh flap. There were no complications
hypoxic areas is augmented by fibroblastic activity and following any flap transfers. The patients in the current
capillary growth. Adequate shock management, direct series did not experience the common side effects of HBO
[8]
surgical intervention with debridement, repair of soft therapy, including aural or pulmonary barotrauma and
tissues and any damaged vessels, and stabilization of transient reversible myopia during the treatment session.
bony elements are of paramount importance. Adjuvant No recent literature is available on management of heel
HBO can be given early to prevent large regions of pad avulsion injuries using surgery and HBO therapy
ischemic necrosis, minimize the frequency and extent of as a combined modality. Other advanced wound care
60 Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015