RECENT ADVANCES IN THE RECONSTRUCTION OF HEEL DEFECTS

Abstract

SUMMARY AND CONCLUSION H eel defects are a current challenging reconstructive problem due to increasing numbers of traffic accidents and war injuries. Unfortunately, the most affected group in these types of injury are young adults. Thus, the reconstructive plan followed by proper rehabilitation is crucial to gain the desired quality of life. The challenges in heel reconstruction are the special characteristics of this specialized weight bearing region of the body and the complex nature of the defect in most of scenarios. That’s why a very careful management of these cases should be done in order to get the best possible outcome. In this study, we started by a brief discussion of the relevant anatomy and embryology of the ankle and hind foot in correlation to the reconstructive options and planning of surgical solutions for the heel defects. The pathophysiology of common causes of heel defects was discussed to ensure better understanding of the course of the disease which helps a lot in the pre and post-operative management and in the choice of the reconstructive modality itself. Trauma was the leading etiology of heel defects followed by other causes like neuropathy, infections, vascular insufficiency, tumors, burns, pressure ulcers or any combination of these causes through another disease like diabetes or by co-incidence. Through history taking followed by a meticulous examination of the whole limb and the defect itself as regard the geometry, size, depth, and location of the defect are the basis of successful reconstruction. After that, we considered the relevant investigations required to assess and manage the defect properly without exhausting the resources and patients in un-necessary way. Although no single method of reconstruction proved the ultimate success, strategic planning for the choice of the reconstruction were discussed in the form of the reconstructive ladder, pyramid and elevator. Many common reconstructive surgical modalities were described as common methods for resurfacing ranging from skin grafts passing by pedicled fascio-cutanous flaps like the reversed sural artery flap and muscle flaps like flexor digitorum brevis ending in free microvascular tissue transfer. The former is the top or the reconstructive ladder and has to be selected on purpose and the flap selection has many criteria as the composition of the flap, size of the defect, pedicle length and surgeon preference. Many non-surgical advances aided a lot in the reconstruction like the vacuum assessted dressings and the skin-substitutes which were mentioned along with the other advances in debridement, dressing and offloading devices. We mentioned a few advances in the field of surgery which are applied to the reconstruction as endoscopic and robotic surgery which can be used in flap harvest and anastomosis for easier surgery and better results. Furthermore, a new infant technology (3D bio-printing) is a very promising tool in regeneration of lost tissues and although it is still not widely established, it is aimed to be upcoming era of reconstruction. A combination of treatment modalities as skin graft with a flap, vacuum treatment with skin graft, a combination of two flaps or usage of skin substitutes with another modality can be used to enhance outcome. Finally, we emphasize on that is no single modality was always successful and a careful combined modalities of reconstructive plans with particular attention to every step has to be tailored for every case to ensure the best results as regard the quality of the patient life.