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Modifications of the Great Toe Fibular Flap for Diabetic Forefoot and Toe Reconstruction
Diabetic wounds of the foot and ankle are notoriously difficult to heal in a timely fashion and to keep closed once they do heal.1-4 A myriad of management options involving local wound care measures, conservative wound healing agents, and plastic surgery techniques has been described in the literature.
The ultimate goal of soft tissue coverage is to restore form, function, and prevent amputation. However, owing to anatomic complexity, soft tissue coverage of foot and ankle wounds often falls short of Sir Harold Gillies’ axiom to “...replace like with like.”5,6 This is especially true of plantar forefoot and lesser toe wounds, which represent difficult challenges with limited options due to the specialized and relatively immobile nature of skin available, as well as to the precarious location of the underlying neurovascular and tendinous structures. Few local rotation, advancement, and/or transposition flaps are available for reconstruction of the distal forefoot and toes.7-11 Donor site morbidity is another important factor restricting flap alternatives, which often makes more complex free tissue transfers with microvascular anastomosis necessary.
The usual treatment consists of irrigation, debridement, and amputation with limited soft tissue and osseous reconstruction.1-4,12 Although early amputation of the toe in the patient with diabetes has been shown to be cost-effective in the short-term,13,14 the natural history of toe amputations does not bode well over the long-term.15-24 Toe ulcerations have been shown to be a major causative factor in major lower limb amputations.25-28 Isakov et al17 followed 212 patients with diabetes and found that 62.2% of the lesions responsible for lower leg amputations were located on the toes. Nehler et al18 followed 92 patients with diabetes and 97 toe wounds treated with primary toe amputations for a mean of 21 months. Of those 97 wounds, 34 (34%) completely healed, with the remainder undergoing either major amputation or remaining unhealed at the final follow-up examination.18 If the forefoot or toe wound heals, the development of gait abnormalities and adjacent toe and forefoot wounds leading to more proximal partial foot or lower limb amputation is the rule rather than the exception.20-25 Little et al20 prospectively followed 53 patients with diabetes treated with toe amputation and although each patient healed primarily, at a mean follow-up of just 13 months, 26 out of 53 (49%) had undergone a major amputation. This number steadily rose; at the 3.5 year follow-up point, 38 out of 53 patients (72%) had undergone a major amputation.20 Murdoch et al22 showed that following amputation of the great toe, 36 out of 48 patients (75%) underwent a more proximal amputation at a mean of 9.6 months. Similarly, Greteman and Dale23 showed that following disarticulation of the great toe, 11 out of 17 patients (65%) developed a new ulceration and nine out of 17 (53%) underwent a more proximal amputation.
In light of these statistics, it should be apparent that excision of all infected soft tissue and osseous structures followed by reconstruction of the toes and forefoot should be attempted whenever possible in the patient with diabetes. As noted, few options exist for soft tissue forefoot and lesser toe reconstruction and even fewer for osseous reconstruction. Use of the great toe fibular (ie, first web space) flap for soft tissue coverage of neuropathic ulcerations under the first metatarsal head and sesamoids is a well described procedure with few reported complications, which include partial or total loss of the flap and partial take of the skin graft employed to cover the donor defect.26-34 The flap can be based on the lateral plantar digital or lateral dorsal digital arteries — constant terminal branches of the dorsal medial branch and lateral branch of the first dorsal metatarsal artery, respectively.35,36 The authors have utilized two simple modifications of the traditional great toe fibular flap to allow for reconstruction of infected diabetic plantar forefoot wounds and lesser toes. The first technique, the adipofascio-cutaneous modification, provides ample and stable soft tissue coverage of plantar forefoot ulcerations and ablation of the associated osteomyelitis.34 The second technique, the osteo-cutaneous modification, allows for simultaneous soft tissue and osseous reconstruction of lesser toe and metatarso-phalangeal joint ulcerations associated with underlying osteomyelitis.30
Great Toe Fibular Adipofascio-cutaneous Flap: Plantar Forefoot Reconstruction
To begin, index wound debridement and flap coverage usually are performed in a single stage under a regional field infiltrative anesthesia block proximal to the proposed flap under intravenous sedation. However, the procedure can be performed under either spinal or general anesthesia as necessary.37-40 A pneumatic tourniquet is usually not employed in order to fully assess the wound during debridement, allow for proper identification of the vascular pedicle, and verify proper arterial inflow and venous outflow from the flap.40 The underlying osseous structures are debrided until robust and free bleeding is evident from the surrounding cortices and within the medullary canal.37-40 In extensive osseous infection, the resultant osseous defect usually is filled with the ipsilateral plantaris tendon, which is rolled into an “anchovy” and covered with an acellular epidermal-dermal matrix (Graft Jacket, Wright Medical Technology, Inc., Arlington, Tenn.).41 However, if the cortices have been spared, the wound can be packed with polymethylmethacrylate vancomycin (4 g) and gentamycin (480 mg) antibiotic-loaded bone cement34,42-44 or allogenic bone graft (Opteform, Exactech, Gainesville, Fla.) impregnated with platelet-rich plasma drawn from the patient’s whole blood (Gravitational Platelet System, Cell Factor technologies/Biomet Orthopaedics, Inc., Warsaw, Ind.).
Once the recipient wound has undergone proper debridement to prepare the site for soft tissue coverage and osseous reconstruction as previously described, the cutaneous segment of the flap is outlined on the lateral aspect of the great toe directly along the course of the vascular pedicle, which is usually identified pre-operatively with a Doppler probe (see Figure 1a).45,46 A segment of skin measuring up to 3.0 cm by 3.0 cm can be raised safely and includes the skin from just plantar to the fibular (ie, lateral) labial nail fold to the mid-plantar aspect of the great toe. The cutaneous segment and underlying tissues are elevated, full-thickness, from the underlying distal phalanx with or without inclusion of the associated periosteum. The advantage of including the periosteum within the flap is to create a stable soft tissue complex that can enhance vascularization of the osseous reconstruction around the recipient site as previously described.47,48 The disadvantage is that unless the donor defect is debulked and closed primarily, as follows, skin grafting over exposed cortex devoid of periosteum is difficult.49 Regardless, the skin overlying the pedicle is then incised in zigzag fashion and undermined at the immediate subdermal level, with care taken to avoid repeated traumatic insult to the undersurface of the tissues to preserve the delicate subdermal plexus (see Figure 1b).50-52 This is facilitated by leaving a thin layer of adipose tissue firmly adherent to the undersurface of the dermis throughout. The cutaneous portion of the flap is then incised, including the underlying adipofascial tissues. Rather than isolate the vascular pedicle, the authors prefer to base the pedicle of the flap on the entire subcutaneous contents of the first web space surrounding the lateral plantar digital neurovascular bundle.10,11 This modification has been shown to significantly diminish venous congestion and has the added benefit of providing adipose padding to the soft tissue defect, which aides in covering the osseous voids created during resection of adjacent osseous structures infected with osteomyelitis.34
The dissection is continued until the cutaneous portion of the flap can be freely rotated into the defect without any tension (see Figure 1c). Throughout dissection, hemostasis is achieved with bipolar electrocautery and the pedicle of the resultant “adipofascio-cutaneous” flap10,11,53,54 is intermittently bathed with 2% xylocaine plain to limit arterial spasm common during dissection of small caliber vessels. Once hemostasis has been achieved and adequate vascular supply confirmed, the adipofascio-cutaneous flap is rotated into the wound and sutured to the deep tissues starting centrally and then about the perimeter of the flap using buried simple interrupted absorbable sutures in order to firmly seat the flap and limit the potential for postoperative hematoma formation. The cutaneous portion of the flap is then sutured to the perimeter of the wound using multiple, widely spaced simple interrupted nonabsorbable sutures (see Figure 1d, e).
The donor defect is assessed and either closed primarily or covered with a split-thickness skin graft (see Figure 2). However, if either of these situations is not possible (ie, the periosteum has been included within the flap) or desired, a partial resection of the lateral one-third of the distal and proximal phalanges can be performed to allow for direct primary closure of the donor site without any tension or apparent complications.34
The advantages of using this flap include: 1) a robust yet malleable flap with an abundance of subcutaneous adipose and the ability to include periosteum; 2) a hidden donor site with minimal to no postoperative donor site morbidity; 3) a relatively large potential flap size up to 2 cm x 3 cm with direct primary closure of the donor site, 4 cm x 6 cm if the donor site is covered with a skin graft, and 7.5 cm x 14 cm if adjacent tissue from the dorsal first web space and second digit are included; and 4) a reliable neurovascular supply, especially when a cuff of adipose tissue is left surrounding the bundle as described.26-34
Great Toe Fibular Osteo-cutaneous Flap: Lesser Toe and Metatarso-phalangeal Joint Reconstruction
As previously described, index wound debridement and flap coverage are usually performed in a single stage under a regional field infiltrative anesthesia block proximal to the proposed flap under intravenous sedation. However, the procedure can be performed under either spinal or general anesthesia as necessary. A pneumatic tourniquet is usually not utilized for the reasons previously described. Debridement of the underlying osseous structures is performed until robust and free bleeding is evident from the surrounding cortices and within the medullary canal (see Figure 3a, b). Once the recipient wound has undergone proper debridement to prepare the site for soft tissue coverage and osseous reconstruction as described, the cutaneous segment of the flap is outlined on the lateral aspect of the great toe directly along the course of the vascular pedicle, which has been identified pre-operatively with a Doppler probe as described. A segment of skin measuring up to 3.0 cm by 3.0 cm is incised as previously described full-thickness to the underlying periosteum of the distal phalanx. Under direct image intensification, utilizing a combination of power and hand-held instrumentation, the lateral one-third to one-half of the distal phalanx is resected, leaving the articular surface intact at the hallux interphalangeal joint level (see Figure 3c, d). This creates an osteo-cutaneous flap that can be easily transferred to the second toe as well as to the first and second metatarso-phalangeal joint levels without difficulty.30,40 The skin overlying the pedicle is then incised in zigzag fashion and undermined at the immediate subdermal level with care taken to avoid repeated traumatic insult to the undersurface of the tissues to preserve the delicate subdermal plexus as described. Throughout dissection, hemostasis is achieved with bipolar electrocautery and the pedicle of the resultant osteo-cutaneous flap is intermittently bathed with 2% xylocaine plain in order to limit arterial spasm as described. Once hemostasis has been achieved and adequate vascular supply confirmed, the osteo-cutaneous flap is rotated into the wound and stabilized, most commonly with a small external fixation unit54-56 or axial smooth wire fixation (see Figure 3e). The cutaneous portion of the flap is then sutured to the perimeter of the wound using multiple, widely spaced, simple interrupted nonabsorbable sutures. The donor defect is assessed and either closed primarily or covered with a skin graft as described.34
The advantages of using this flap include: 1) a robust flap with an abundance of subcutaneous adipose that has similar properties of the resected tissues; 2) a hidden donor site with minimal to no postoperative donor site morbidity; 3) a well-perfused, vascularized bone graft capable of replacing a several-centimeter defect without difficulty; and 4) a reliable neurovascular supply, especially when a cuff of adipose tissue is left surrounding the bundle as has been described (see Figure 3f).30,34
Discussion
Treatment of diabetic forefoot and toe wounds associated with underlying osteomyelitis represents a reconstructive challenge with limited readily available options. Use of the traditional great toe fibular flap for soft-tissue coverage of plantar first metatarsal head ulcerations is a well described procedure with few reported complications.27-34 The most commonly reported complications involve partial or, less commonly, total loss of the flap secondary to either venous congestion or partial take of the skin graft applied to the donor defect.26-28,31-33 Similarly, the use of osteo-cutaneous flaps harvested from the toes, foot, and ankle represent common procedures performed for finger, thumb, and hand reconstruction.57,58 However, little has been written about use of either free autogenous bone grafting59,60 or vascularized bone grafting for forefoot and toe reconstruction.30,61-64 In light of the above, the authors have employed two simple modifications of the great toe fibular flap that afford stable soft tissue coverage and ablation of the associated osteomyelitis. These modifications have virtually eliminated venous congestion of the flap as a complication and have the added benefit of providing adipose padding to the soft tissue defect, which aides in filling the voids created during resection of adjacent osseous structures infected with osteomyelitis.34 Additionally, the design and elevation of the great toe fibular adipofascio-cutaneous flap is simple because formally identifying the neurovascular bundle is not necessary owing to the greater volume of adipose tissue accompanying the neurovascular pedicle. Furthermore, the combination of procedures described has allowed patients to be discharged from the hospital on culture- and sensitivity-based oral antibiotic treatment following a brief stay of approximately one calendar week. Rather than requiring a formal forefoot, ray, or toe amputation, patients leave the hospital with a functional and cosmetically appealing intact forefoot that is easily protected in an appropriate extra-depth, rocker-soled shoe with soft insoles along with frequent clinical follow-up.
Utilizing the technical modifications described, the authors have had limited complications strictly isolated to partial take of the skin graft applied to cover the donor defect, all of which healed with proper local wound care. Although to the authors’ knowledge the second toe plantar digital webspace has not been used for forefoot reconstruction, it has been reported as a site for free-tissue transfer for finger pulp reconstruction. This may represent a suitable form of tissue coverage for small defects that are not appropriate for local flap coverage or for the modifications described involving the fibular border of the great toe.65
Conclusion
In a society where “normal” appearance, even of the toes and forefoot, is highly prized, foot and ankle surgeons should be able to provide more than ablation of these highly specialized but often disregarded tissues. To the creative foot and ankle surgeon, the use of either the modified great toe fibular adipofascio-cutaneous or osteo-cutaneous flap offer novel options based on sound, time-honored procedures available for planning and executing reconstruction of the forefoot and toes of appropriate patients with diabetes. By reconstructing these tissues, the rapid development of adjacent forefoot deformities and resultant partial foot or lower limb amputation is avoided. However, no long-term outcomes studies exist following toe and forefoot reconstruction using the above techniques and the potential long-term benefits of these techniques in preventing recurrent toe deformity and forefoot ulcerations remain a cause for concern. Additional prospective studies are necessary to compare the use of these techniques to other more traditionally performed procedures.
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