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Ostectomy and Medial Plantar Artery Flap Reconstruction for Charcot Foot Ulceration Involving the Midfoot

      Abstract

      Charcot foot is a serious complication of diabetes, characterized by deformity and overlying ulceration. The condition most commonly affects the midfoot. However, little information is available on the use of a medial plantar artery flap to treat diabetic midfoot ulceration. The purpose of the present study was to evaluate the versatility of ostectomy and medial plantar flap reconstruction for midfoot plantar ulceration associated with rocker-bottom deformity secondary to Charcot foot. Four patients underwent ostectomy and medial plantar flap reconstruction. Before flap reconstruction, the devitalized soft tissues and bone were radically resected. After the infection had been controlled, the ulcerated portion was minimally excised, and the bony prominence underlying the ulcer was removed. A medial plantar artery flap was applied to the ulcer. The donor site was covered with a split-thickness skin graft or artificial dermis. In all patients, the ulcers healed and independent ambulation was achieved. However, 1 patient experienced ulcer recurrence, and subsequent infection necessitated a major amputation. Limb salvage is challenging in the setting of deformity and intractable plantar ulceration. The advantages of medial plantar artery flap reconstruction are that tissues with a rich blood supply are used to cover the exposed bone, and the flap can withstand the pressure and shear stress of the patient’s body weight. However, a dominant artery in the foot is sacrificed. Therefore, the patency of the dorsalis pedis artery must be confirmed in every patient. The results of the present study have demonstrated that a medial plantar artery can be an effective alternative for diabetic patients with a plantar ulcer secondary to Charcot foot.

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      References

        • Varma A.K.
        Charcot neuroarthropathy of the foot and ankle: a review.
        J Foot Ankle Surg. 2013; 52: 740-749
        • Frykberg R.G.
        • Rogers L.C.
        Charcot arthropathy in the diabetic foot.
        in: Veves A. Giurini J.M. LoGerfo F.W. The Diabetic Foot: Medical and Surgical Management. Humana Press, New York2012: 369-393
        • Frykberg R.G.
        • Zgonis T.
        • Armstrong D.G.
        • Driver V.R.
        • Giurini J.M.
        • Kravitz S.R.
        • Landsman A.S.
        • Lavery L.A.
        • Moore J.C.
        • Schuberth J.M.
        • Wukich D.K.
        • Andersen C.
        • Vanore J.V.
        • American College of Foot and Ankle Surgeons
        Diabetic disorders. A clinical practice guideline (2006 revision).
        J Foot Ankle Surg. 2006; 45: S1-S66
        • Laurinaviciene R.
        • Kirketerp-Moeller K.
        • Holstein P.E.
        Exostectomy for chronic midfoot plantar ulcer in Charcot deformity.
        J Wound Care. 2008; 17: 53-55
        • Shanahan R.E.
        • Gingrass R.P.
        Medial plantar sensory flap for coverage of heel defects.
        Plast Reconstr Surg. 1979; 64: 295-298
        • Harrison D.H.
        • Morgan B.D.
        The instep island flap to resurface plantar defects.
        Br J Plast Surg. 1981; 34: 315-318
        • Mourougayan V.
        Medial plantar artery (instep flap) flap.
        Ann Plast Surg. 2006; 56: 160-163
        • Acikel C.
        • Celikoz B.
        • Yuksel F.
        • Ergun O.
        Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle.
        Ann Plast Surg. 2003; 50: 498-503
        • Duman H.
        • Er E.
        • Işík S.
        • Türegün M.
        • Deveci M.
        • Nişancí M.
        • Sengezer M.
        Versatility of the medial plantar flap: our clinical experience.
        Plast Reconstr Surg. 2002; 109: 1007-1012
        • Schwarz R.J.
        • Negrini J.F.
        Medial plantar artery island flap for heel reconstruction.
        Ann Plast Surg. 2006; 57: 658-661
        • Yang D.
        • Yang J.F.
        • Morris S.F.
        • Tang M.
        • Nie C.
        Medial plantar artery perforator flap for soft-tissue reconstruction of the heel.
        Ann Plast Surg. 2011; 67: 294-298
        • Larsen K.
        • Fabrin J.
        • Holstein P.E.
        Incidence and management of ulcers in diabetic Charcot feet.
        J Wound Care. 2001; 10: 323-328
        • Johnson J.E.
        • Thomson A.B.
        Charcot neuroarthropathy of the foot: surgical aspects.
        in: Bowker J.H. Pfeifer M.A. Levin and O'Neal's the Diabetic Foot. Mosby, Philadelphia2008: 461-484
        • Catanzariti A.R.
        • Mendicino R.
        • Haverstock B.
        Ostectomy for diabetic neuroarthropathy involving the midfoot.
        J Foot Ankle Surg. 2000; 39: 291-300
        • Pakarinen T.K.
        • Laine H.J.
        • Honkonen S.E.
        • Peltonen J.
        • Oksala H.
        • Lahtela J.
        Charcot arthropathy of the diabetic foot: current concepts and review of 36 cases.
        Scand J Surg. 2002; 91: 195-201
        • Sayner L.R.
        • Rosenblum B.I.
        External fixation for Charcot foot reconstruction.
        Curr Surg. 2005; 62: 618-623
        • Zgonis T.
        • Roukis T.S.
        • Stapleton J.J.
        • Cromack D.T.
        Combined lateral column arthrodesis, medial plantar artery flap, and circular external fixation for Charcot midfoot collapse with chronic plantar ulceration.
        Adv Skin Wound Care. 2008; 21: 521-525
        • Pinzur M.S.
        • Sammarco V.J.
        • Wukich D.K.
        Charcot foot: a surgical algorithm.
        Instr Course Lect. 2012; 61: 423-438
        • Nather A.
        • Bee C.S.
        • Huak C.Y.
        • Chew J.L.
        • Lin C.B.
        • Neo S.
        • Sim E.Y.
        Epidemiology of diabetic foot problems and predictive factors for limb loss.
        J Diabetes Complications. 2008; 22: 77-82
        • Lavery L.A.
        • Armstrong D.G.
        • Wunderlich R.P.
        • Mohler M.J.
        • Wendel C.S.
        • Lipsky B.A.
        Risk factors for foot infections in individuals with diabetes.
        Diabetes Care. 2006; 29: 1288-1293
        • Malhotra S.
        • Bello E.
        • Kominsky S.
        Diabetic foot ulcerations: biomechanics, Charcot foot, and total contact cast.
        Semin Vasc Surg. 2012; 25: 66-69
        • Lavery L.A.
        • Armstrong D.G.
        • Walker S.C.
        Healing rates of diabetic foot ulcers associated with midfoot fracture due to Charcot's arthropathy.
        Diabet Med. 1997; 14: 46-49
        • Helm P.A.
        • Walker S.C.
        • Pullium G.F.
        Recurrence of neuropathic ulceration following healing in a total contact cast.
        Arch Phys Med Rehabil. 1991; 72: 967-970
        • Faglia E.
        • Caravaggi C.
        • Clerici G.
        • Sganzaroli A.
        • Curci V.
        • Vailati W.
        • Simonetti D.
        • Sommalvico F.
        Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial.
        Diabetes Care. 2010; 33: 1419-1423
        • Caravaggi C.
        • Sganzaroli A.
        • Fabbi M.
        • Cavaiani P.
        • Pogliaghi I.
        • Ferraresi R.
        • Capello F.
        • Morabito A.
        Nonwindowed nonremovable fiberglass off-loading cast versus removable pneumatic cast (AircastXP Diabetic Walker) in the treatment of neuropathic noninfected plantar ulcers: a randomized prospective trial.
        Diabetes Care. 2007; 30: 2577-2578
        • Ramanujam C.L.
        • Zgonis T.
        Versatility of intrinsic muscle flaps for the diabetic Charcot foot.
        Clin Podiatr Med Surg. 2012; 29: 323-326
        • Rosenblum B.I.
        • Giurini J.M.
        • Miller L.B.
        • Chrzan J.S.
        • Habershaw G.M.
        Neuropathic ulcerations plantar to the lateral column in patients with Charcot foot deformity: a flexible approach to limb salvage.
        J Foot Ankle Surg. 1997; 36: 360-363
        • Oh S.J.
        • Moon M.
        • Cha J.
        • Koh S.H.
        • Chung C.H.
        Weight-bearing plantar reconstruction using versatile medial plantar sensate flap.
        J Plast Reconstr Aesthet Surg. 2011; 64: 248-254
        • Koshima I.
        • Narushima M.
        • Mihara M.
        • Nakai I.
        • Akazawa S.
        • Fukuda N.
        • Watanabe Y.
        • Nakagawa M.
        Island medial plantar artery perforator flap for reconstruction of plantar defects.
        Ann Plast Surg. 2007; 59: 558-562
        • Morgan J.M.
        • Biehl III, W.C.
        • Wagner Jr., F.W.
        Management of neuropathic arthropathy with the Charcot Restraint Orthotic Walker.
        Clin Orthop Relat Res. 1993; 296: 58-63