Flexor Digitorum Brevis Muscle Flap to Treat Non-Healing Heel Wound with Underlying Chronic Osteomyelitis

Introduction: Heel wounds secondary to osteomyelitis present a unique challenge to a surgeon. In the presented case, the patient had a heel wound secondary to chronic osteomyelitis of the calcaneus, which failed multiple rounds of debridements/graft appplications, Negative Pressure wound therapy (NPWT), and various other local wound care modalities. Patient refused any resection of bone, however he kept having multiple episodes of local infection of the wound which eventually resulted in multiple hospitalizations due to systemic symptoms.   Due to the consistent failure of less aggressive treatment modalities, in accordance with the soft tissue reconstructive ladder, a local flap is now warranted. The goal of this case study is to show the viability of intrinsic muscle flaps in the lower extremity while maintaining proper gait.Methods:The infected bone was curettaged until hard bone was felt, antibiotic cement was applied into the area of bony defect, and NPWT was applied onto the wound. The patient was brought back to the operating room three days later, at which time a flexor digitorum brevis muscle flap was performed to entirely cover the wound, and NPWT was applied. After significant enough granulation was noted overlying the muscle, the patient was brought in 1 month later for a Split Thickness Skin Graft (STSG).Results:Complete wound healing was noted without any complications. At one-year post-operative visit, no recurrence of wound was noted. Although, the patient was able to perform all his activities of daily living, he did report increased fatiguability to the operative side when performing rigorous activities.Discussion: Although the patient did report increased fatiguability to the operative foot, and he does have an increased propensity to develop digital contractures due to loss of his intrinsic musculature, this procedure still seems to be a promising treatment modality for heel wounds unresponsive to less aggressive treatments. For non-healing heel wounds, although reverse sural fasciocutaneous flaps and peroneus brevis muscle flaps are well documented (1,2), there is very scarce literature documenting the success of flexor digitorum brevis muscle flaps. Further replication of this technique is warranted to solidify it as a valid alternate treatment modality for this pathology.References:1. Kneser, U., Bach, A. D., Polykandriotis, E., & Horch, R. E. (2011). Delayed reverse sural flap for staged reconstruction of the diabetic foot and ankle. Plastic and Reconstructive Surgery, 127(1), 1e-2e. 2. Khouri, R. K., Egeland, B. M., Daily, S. D., Harake, M. S., & Kaye, E. K. (2011). The reverse flow peroneus brevis muscle flap for complex wounds of the foot and ankle. Annals of Plastic Surgery, 67(2), 125-128.