Can The Medial Plantar Artery Flap Be Beneficial For Diabetic Heel Ulcers?

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Author(s): 
Ronald J. Belczyk, DPM, AACFAS, Lee C. Rogers, DPM, and George Andros, MD

   After mobilizing the flap, extend an incision to the ulcer or tunnel beneath the skin. A tunnel is not required or preferred since this places tension on the pedicle. Rotate the flap 90 to 180 degrees. Once the flap is transposed into the defect, secure it with a single layer closure and utilize a suction drain. Close the donor defect with a split thickness skin graft (STSG). The split thickness skin graft will only take if you preserve the peritenon over the fascia. In some cases, one may excise the fascia and place the split thickness skin graft over the underlying intrinsic muscles. Surgeons can also use the split thickness skin graft over the pedicle to prevent compression from primary skin closure.

Additional Considerations With The Medial Plantar Artery Flap

Considerations to incorporate the fascia or muscle are based on the need for a thicker flap, which can be helpful when closing defects on the weightbearing surface. However, there are advantages to leaving the fascia intact such as preserving the function of the plantar fascia. Inclusion of the plantar fascia into the flap may result in swiveling of the reconstructed heel pad. A thick flap may not be ideal for non-weightbearing areas. Excluding the fascia, adding triangles and defatting the flap can result in a thinner flap.5

   Some other pearls for the procedure include delaying the flap and adjunctive use of external fixation. When performing the proximally based medial plantar artery flap, adequate antegrade flow is necessary prior to division. Mobilization of the flap can be delayed in the clinical scenario in which adequate vascularity to the flap is in question. Flap delay interrupts a portion of the blood supply in a preliminary stage prior to tissue transfer. The purpose of delay is to augment the surviving portion of the flap.

   There are two schools of thought regarding the pathophysiology of the delay phenomenon. The first holds that delay subjects tissue to ischemic conditions so it is able to survive with less vascular inflow. The second believes that delay actually increases vascularity by dilating reduced caliber “choke” anastomotic vessels and stimulating additional vascular ingrowths. The use of external fixation permits immobilization, flap and vascular surveillance, access to wound care and offloads both the pedicle and the flap.

   Some potential complications of this procedure include delayed wound healing of the flap, decreased sensation, hyperkeratosis, flap/skin necrosis, venous congestion, donor site complications, infection and the need for additional surgery. Also, the surgeon should exercise caution with routine use of this flap as future midfoot collapse may occur and initiate ulceration through the skin grafted site.

In Summary

Diabetic ulcers involving the heel can be quite challenging. Emerging literature and surgical experience suggest that the medial plantar artery flap can provide distinct advantages and serve as a viable option for covering diabetic heel defects.

   Dr. Belczyk is a Fellow of the American College of Foot and Ankle Surgeons, and is board qualified in both foot surgery and reconstructive rearfoot/ankle surgery by the American Board of Podiatric Surgery. He is a consultant physician at the Amputation Prevention Center at Valley Presbyterian Hospital in Van Nuys, Calif.

   Dr. Rogers is the Associate Medical Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. He is the Chair of the Foot Care Council for the American Diabetes Association. Dr. Rogers has more than 50 publications in press or in print on diabetic foot disorders including several book chapters.

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