Foot Wounds and the Reconstructive Ladder

BACKGROUND: Foot soft tissue coverage represents a challenge to reconstructive surgeons due to a lack of donor sites for this specialized skin. This glabrous tethered thick skin is designed to withstand weight bearing stress and is hard to replace. The limited arch of rotation of foot local flaps contributes to further difficulties. In this study, we share our experience in foot soft tissue loss coverage using techniques tailored to each wound presentation. METHODS: This case series presents eight patients with wounds of the plantar and dorsal surfaces of the foot, heel, and ankle. Closure techniques were selected and planned based on wound presentation and comorbidity status. RESULTS: Patients’ mean age at surgery was 61 years. Etiologies of wounds include trauma, frostbite, diabetic ulceration, malignancy, pressure ulcer with osteomyelitis, and necrotizing infection. Coverage techniques included split and full-thickness skin graft, medial plantar arch pinch graft, cultured epithelial autograft, Hyalomatrix wound device, EpiFix tissue matrix, pedicle flap, and free rectus flap. Complete soft tissue coverage was achieved in each case within reasonable postoperative periods, and ambulation was preserved and/or restored. CONCLUSIONS: Foot soft tissue reconstruction is challenging and should be planned carefully due to the required specialized skin replacement. Primary closure should be considered first and attempted if possible. Technique escalation in accordance with the reconstructive ladder should be undertaken based on wound etiology, presentation, amount and nature of tissue loss, available resources, and surgeon experience.