Original Article

59

Muscle versus Fasciocutaneous Free Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis

1 Department of Surgery, Monash University, Clayton, Victoria,

Australia 2 Department of Plastic and Reconstructive Surgery, Monash Plastic Surgery Unit, Dandenong Hospital, Dandenong, Victoria, Australia 3 Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia

Address for correspondence Warren M. Rozen, MBBS, BMedSc, PhD, Department of Surgery, Monash University, Level 5, E Block, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia (e-mail: [email protected]).

J Reconstr Microsurg 2015;31:59–66.

Abstract

Keywords

► ► ► ►

weight-bearing heel reconstruction fasciocutaneous musculocutaneous

received March 6, 2014 accepted after revision May 17, 2014 published online November 11, 2014

Background Management of soft tissue injuries of the heel is challenging and the composition of free tissue transfer that provides optimal aesthetic and functional outcomes in heel reconstruction is not clear. While fasciocutaneous flaps may result in shear planes that cause instability with mobilization, insensate muscle flaps may not be able to withstand the pressures of weight bearing and thus ulcerate. Methods A systematic literature search was performed using Medline and PubMed databases. Primary outcome measures were time to mobilize, ulceration, revision or debulking surgery, and the requirement for specialized footwear. Analysis of pooled outcomes was undertaken using fixed-effects meta-analysis, calculating the incidence rate ratio for included articles. Results Overall 576 articles were identified; out of which 11 articles met the final inclusion criteria, detailing 168 free tissue transfers in 163 patients. The study size ranged from 4 to 72 cases. There was a trend toward higher rates of ulceration (17 vs. 26%), requirement for revision (23 vs. 31%), and the requirement for specialized footwear (35 vs. 56%) in muscle flaps, but these differences were not statistically significant. Conclusion The current review provided a summary of reported outcomes of free heel reconstruction in the literature till date. With the current evidence largely limited to small cohort studies (level IV evidence), there were no significant differences found between reconstructive options. These findings serve as a call to action for more reconstructive surgeons to collaborate on multi-institutional prospective studies with robust outcomes assessment. As such, an ideal flap for reconstruction of the weightbearing heel has not yet been made clear.

Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1384674. ISSN 0743-684X.

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Carly M. Fox, MBBS, BSc, PGDipSurgAnat1,2,3 Henry M. Beem, MBBS, BSc3 Jonathon Wiper, MChB, FRCS3 Warren M. Rozen, MBBS, BMedSc, PhD1,2 Michael Wagels, MBBS, FRACS, PhD3 James C. Leong, MBBS, FRACS, MS1,2

Muscle versus Fasciocutaneous Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis A soft tissue defect of the heel presents a difficult problem. The functional requirements of reconstruction in this anatomical location include the capacity to bear the weight of the entire body, to tolerate the metabolic demands of transient reduced circulation as a consequence, a low modulus of shear across the constituent tissue planes, protective sensation, and an elegant spheroid curve to facilitate the carriage of footwear. The glabrous skin of the heel pad consists of a very thick epidermis. The epidermal–dermal complex is firmly anchored to the plantar aponeurosis by perpendicular fibrous septa, effectively anchoring the skin to the bone. This specialization of structure prevents shear. The shock-absorbing function of the heel is provided by loculi or islands of fat between the vertically orientated septa. The subcutaneous fat can be divided into deep and superficial layers, which are separated by a septum of horizontally oriented fibers.1,2 The medial and lateral calcaneal arteries, branches of the posterior tibial and peroneal arteries, respectively, supply blood to the heel, with reliable contributions from the medial and lateral plantar arteries. Vessels at each level contribute to rich periosteal and subdermal plexuses. A vast anastomosis network passes within the fibrous septa connecting the plexuses, however the interspersed fat islands are relatively avascular.3 The only other repository of glabrous skin in the body is in the hand, an organ whose functional demand exceeds that of the heel and can thereby be discounted as a source of donor tissue. The reconstructive principle of replacing like with like is achievable only for small-to-medium–sized soft-tissue defects of the heel, wherein a medial plantar island flap can be used with good outcomes reported.3–5 Acellular dermal matrices have also been employed to provide coverage for complex soft-tissue defects of the lower limb involving exposed tendon and bone. Bioengineered tissue provides a matrix for organized cellular migration and proliferation needed to facilitate wound healing. The use of dermal matrices in lower limb reconstruction is becoming increasingly widespread, but there is a paucity of literature addressing its use in wounds of the weight-bearing heel, and which address the long-term outcomes to make specific recommendations regarding its widespread use. Their use is reviewed elsewhere.6 A large soft-tissue defect with exposed bone, tendon, neurovascular structures, and/or surgical hardware requires coverage with distant tissue (►Fig. 1). Though the specific flap chosen may vary, there are two constituent options. Fasciocutaneous flaps can provide a thin, pliable tissue that is easily contoured and can be neurotized, but have a high modulus of shear in the subcutaneous plane, causing instability when mobilizing.7,8 Muscle flaps do not have a subcutaneous plane and although the modulus of shear within the flap is high to begin with, this decreases as the muscle undergoes atrophy and fibrosis. By virtue of this, muscle may provide a better contour than fasciocutaneous flaps. The argument that muscle adheres to the wound bed better than flaps composed of fasciocutaneous tissues is unfounded.9 However, muscle flaps cannot be neurotized to provide Journal of Reconstructive Microsurgery

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Fig. 1 Grade 3b subfascial avulsion with distally based flap for secondary reconstruction.

protective sensation and may be prone to recurrent ulceration as a result.10 Flap selection in heel reconstruction is guided by evidence that is level IV or V only. This systematic review aims to determine whether or not a clear advantage exists for one flap constituent over another by amalgamating existing evidence for the outcomes of flap ulceration, flap revision, time to mobilize, and the requirement for specialized footwear.

Methods A systematic review was conducted using the Medline and PubMed databases. The keywords “heel,” “foot,” “weightbearing,” “trauma,” “free flap,” and “reconstruction” were used as search strings. Relevant secondary references were retrieved using bibliographic linkage. Publications reporting on surgical outcomes of free muscle or fasciocutaneous flap reconstruction of grade 3b injuries or equivalent2 of the weight-bearing heel were included. The minimum outcome dataset for inclusion were type of reconstruction, total number of patients, the total number of reconstructions, short-term surgical complications following reconstruction, and long-term outcomes, including ulceration, revision surgery, the requirement for specialized footwear, and innervation status. Exclusion criteria were established to exclude cases that were not able to make a comparison between reconstructive techniques—as such, these included reports regarding defects of parts of the sole other than the heel, single case reports, isolated abstracts, reviews, editorials, communications, correspondence, discussions, and letters that were not considered primary research articles; non-English language articles were excluded; and articles that specifically excluded reconstructive options such as those that excluded microsurgical techniques. Musculocutaneous flaps were also excluded, felt by the investigators to not represent either group uniquely. Two reviewers performed the initial article title search. After duplicate deletion, each article abstract was reviewed. Articles that were included or could not clearly be included or excluded after abstract review underwent full text review (►Fig. 2).

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Muscle versus Fasciocutaneous Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis

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61

exclusions, 68 articles were included in the full text review. Of these, 57 articles were excluded because they again failed to meet the review criteria as above (►Fig. 2). A total of 11 articles were thus included in the analysis, and these reported on 168 free tissue transfers for heel reconstruction in 163 patients. Study sizes ranged from 4 to 72 cases. The largest study accounts for 43% of the dataset.

The mean reported age was 30.2 years with a range of 5 to 65 years. Two studies did not report patient age.12,13 The mean follow-up was 42 months with a range of 24 to 78 months.

Fig. 2 Flowchart describing the literature review.

An analysis of the pooled outcomes of muscle and fasciocutaneous free flap reconstruction of the heel was undertaken using a fixed effects meta-analysis calculating the incidence rate ratio for all included articles, using the Mantel–Haenszel algorithm in the metafor package—a meta-analysis package for R.11 One included study reported a follow-up duration of less than 12 weeks. This study was excluded from statistical analysis.12

Results A total of 576 abstracts or titles were identified in the preliminary literature review and bibliography linkage, with 508 rejected because they did not fulfill the inclusion/ exclusion criteria as highlighted above, and/or did not primarily address free flap reconstruction of the heel. After

Etiology of Heel Injuries Soft tissue defects of the weight-bearing heel most commonly arose from the trauma (107/168, 63.7%). Tumor extirpation was a less common etiology (19/168, 11.3%) (►Table 1).

Reconstructive Options The most muscle flaps harvested were latissimus dorsi (38.1%), rectus abdominus (22.6%), gracilis (8.9%), medial gastrocnemius (1.2%), biceps femoris (0.6%), and tensor fascia latae (0.6%). The most common fasciocutaneous flaps included the radial artery forearm flap (19.6%), free temporal fasciocutaneous flap (3.6%), dorsalis pedis flap (3%), anterolateral thigh flap (1.2%, ►Fig. 3), and scapular flap (0.6%) (►Table 2). One article14 reported the use of a musculocutaneous latissimus dorsi flap. This flap was excluded from the analysis.

Table 1 Summary of demographic data and injury etiology of included series Flaps

Patients

Age Mean

Range

Follow-up (Mo)

Etiology Trauma

Burn

Ulcer

Tumor

Chronic wound

El-Shazly et al 2008

6

6

NR

NR

20a

0

0

0

0

6

Oztürk et al 2005

72

72

25.6

20–38

78

72

0

0

0

0

Langstein et al 2002

9

8

NR

NR

27.3

0

0

0

8

0

Heymans et al 2005

6

6

40.2

27–52

32

0

0

0

1

5

Yücel et al 2000

19

17

30

5–65

26.8

5

7

3

4

0

Harris et al 1994

13

12

9.4

2.5–18

57

9

2

1

0

1

Potparić and Rajacić 1997

15

14

34

3–68

45.4

7

0

0

2

6

Noever et al 1986

5

5

48b

12–64

10.5c

2

0

2

0

1

11

11

40.5

18–73

47

7

0

0

4

0

4

4

29.5

18–54

72

5

0

0

0

0

Chang et al 1986

8

8

27

19–42

24

NR

NR

NR

NR

NR

Total

168

163

31.6

2.5–73

42

107

9

6

19

19

Santanelli et al 2002 Duncan et al 1985

24

25

Abbreviation: NR, not reported. a Minimum follow-up. b Median age. c Median follow-up. Journal of Reconstructive Microsurgery

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Patient Characteristics

Muscle versus Fasciocutaneous Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis

Fox et al.

Oztürk et al15 reported ulceration in 28% (20/72) of muscle flaps. This rate is high compared with most other reported series and is likely due to the severity of patients’ injuries at presentation. Higher rates of ulceration in muscle flaps remained when the cases from the Oztürk et al article were removed from the analysis (incidence rate ratio ¼ 0.76, p ¼ 0.5).

Shear Two articles reported outcomes relating to excessive mobility of the flap on the calcaneus. Heymans et al reported that no patient had gait impediment due to excessive flap mobility in their series of six free temporal fasciocutaneous flaps.17 Noever et al recorded the mobility of six radial forearm flaps by hooking a 100 g weight to the center of the flap and measuring the yield with the flap in a vertical position. They found a median shift of 1.3 cm (range 1.0–1.7 cm).

Fig. 3 Anterolateral thigh fasciocutaneous flap to right heel and medial foot.

General Free Flap Complications The overall free flap failure rate was 9%. Two studies did not report incidence of complete flap failure. In one study, the complete flap failure rate was 16.7% and accounted for the majority of reported failures in the analysis (12 out of 15).15 The reported failure rate in this study is higher than many modern series of free flaps. All flaps in this series were delayed reconstructions of traumatic wounds resulting from land mine injuries where complication rates are known to be high.16

Revision No significant difference was observed between rates of revision in fasciocutaneous and muscle flaps (incidence rate ratio ¼ 1.42, p value ¼ 0.31) (►Table 3). The test for homogeneity was not rejected (p ¼ 0.35). Flap debulking and excision of ulcers were the most common indications for flap revision.

Specialized Footwear Ulceration While there was a higher ulceration rate in muscle flaps (17 vs. 26%), no statistically significant difference was observed for this outcome when compared with fasciocutaneous flaps (incidence rate ratio ¼ 0.87, p ¼ 0.7) (►Table 3). The test for homogeneity was not rejected (p ¼ 0.13).

The incidence of a need for specialized footwear ranged from 0 to 60% in the included series. The difference in incidence between patients reconstructed with muscle and fasciocutaneous flaps was not statistically significant (incidence rate ratio ¼ 0.79, p value ¼ 0.56) (►Table 3). The test for homogeneity was not rejected (p ¼ 0.13).

Table 2 Flap types used in included series Muscle (n ¼ 121)

Fasciocutaneous (n ¼ 47)

LD

Gracilis

Rectus

BF

TFL

MG

RAFF

ALT

Temporal

Scapular

DP

0

0

3

0

0

0

3

0

0

0

0

Oztürk et al 2005

42

0

30

0

0

0

0

0

0

0

0

Langstein et al 2002

1

3

1

1

0

0

2

1

0

0

0

Heymans et al 2005

0

0

0

0

0

0

0

0

6

0

0

Yücel et al 2000

2

8

1

0

0

0

7

1

0

0

0

El-Shazly et al 2008

Harris et al 1994

10

1

2

0

0

0

0

0

0

0

0

Potparić and Rajacić 1997

6

0

1

0

0

2

5

0

0

1

0

Noever et al 1986

0

0

0

0

0

0

5

0

0

0

0

Santanelli et al 2002

0

0

0

0

0

0

11

0

0

0

0

Duncan et al 1985

0

0

0

0

0

0

0

0

0

0

4

Chang et al 1986

3

3

0

0

1

0

0

0

0

0

1

Total (n ¼ 168)

64

15

38

1

1

2

33

2

6

1

5

Percentage of total number of flaps (%)

38.1

8.9

22.6

0.6

0.6

1.2

19.6

1.2

3.6

0.6

3.0

Abbreviations: ALT, anterolateral thigh; BF, biceps femories; DP, dorsalis pedis; LD, latissimus dorsi; MG, medial gastrocnemius; RF, radial forearm; TFL, tensor fascia lata muscle. Journal of Reconstructive Microsurgery

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Table 3 Reported rates of ulceration, revision, and requirement for specialized footwear in included series Rates of revision

Requirement for specialized footwear

FC

Muscle

FC

Muscle

FC

Muscle

El-Shazly et al 2008

0/3

0/3

NR

NR

3/3

3/3

Oztürk et al 2005

0/0

20/72

0/0

23/72

0/0

52/72

Langstein et al 2002

0/3

1/6

1/3

0/6

NR

NR

Heymans et al 2005

1/6

0/0

1/6

0/0

1/6

0/0

Yücel et al 2000

2/8

0/11

3/8

0/11

2/8

0/11

Harris et al 1994

0/0

6/13

0/0

7/13

0/0

0/13

Potparić and Rajacić 1997

1/6

4/9

4/6

6/9

2/6

6/9

Noever et al 1986

1/5

0/0

1/5

0/0

2/5

0/0

Santanelli et al 2002

3/11

0/0

0/11

0/0

1/11

0/0

Duncan et al 1985

0/4

0/0

0/1

0/0

4/4

0/0

Chang et al 1986

0/1

0/7

0/1

0/7

NR

NR

Total

8/47 (17)

31/121 (26)

10/44 (23)

36/118 (31)

15/43 (35)

61/108 (56)

Incidence rate ratio (FC vs. muscle)

0.87 (p ¼ 0.7)

1.42 (p ¼ 0.31)

0.79 (p ¼ 0.56)

Abbreviations: FC, fasciocutaneous; NR, not reported.

Time to Mobilize

tissue and the lack of an ideal donor. Where free tissue transfer is necessary, muscle with split skin graft or fasciocutaneous flaps have emerged as the candidate reconstructive options. There is a paucity of evidence to clearly recommend one flap constituent over another, where the patient and primary defect factors do not direct choice. Although, 68 articles addressed the issue of free flap reconstruction of the foot, only 11 of these met the inclusion criteria. All were case series. Overall, 42% of included flaps were muscle flaps utilized following land mine trauma to the heel, which comprises a very specific subset of patients.

Only four articles reported time to ambulation in their patient cohorts. Time to weight bearing varied from 7 weeks13 to 5 months. There were insufficient data to compare muscle and fasciocutaneous flaps for this outcome. Injury severity and patient factors such as medical comorbidities were not reported and therefore cannot be controlled for in this analysis (►Table 4).

Discussion Soft-tissue defects of the heel are difficult to reconstruct because of the cosmetic and functional demands of heel

Table 4 Reported time to mobilization in included studies Reported time to mobilization FC

Muscle

El-Shazly et al 2008

< 12 wks

< 12 wks

Oztürk et al 2005

NA

10 wks median (range 8–12 wks)

Langstein et al 2002

7.5 wks (mean)

10.8 wks (mean)

Heymans et al 2005

NR

NA

Yücel et al 2000

< 12 wks

< 12 wks

Harris et al 1994

NA

4 wks (mean)

Potparić and Rajacić 1997

Variable; dependent on orthopedic procedures

Noever et al 1986

All patients tolerating 2–6 h of walking at end follow-up

NA

Santanelli et al 2002

10 wks median (range 4–24 wks)

NA

Duncan et al 1985

NR

NR

Chang et al 1986

NR

NR

Abbreviations: FC, fasciocutaneous; NA, not applicable; NR, not reported. Journal of Reconstructive Microsurgery

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Rates of ulceration (%)

Muscle versus Fasciocutaneous Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis Ulceration Ulceration is one of the most commonly observed complications of free flap reconstruction of the heel. No significant difference was observed between groups in terms of rate of flap ulceration. Although flap-specific factors may contribute to its development, it is likely that flap extrinsic factors such as the recipient bed, bony prominences, flap inset, and footwear may be more important. Two studies that met the inclusion criteria reported relatively high ulceration rates in their flaps. Harris et al18 reported ulceration in 46% (6/13) of muscle flaps used for reconstruction of heel injuries in children. It is possible that patients in this cohort were less compliant with mobilization restrictions given their age. Potparić and Rajacić reported ulceration in 33% (2/6) fasciocutaneous flaps and 33% (3/9) muscle flaps. Although, there is no clear difference in ulceration rates between fasciocutaneous and muscle flaps in the included articles, several general observations can be made about factors that predispose to the development of ulceration in heel flaps. The bony anatomy deep to the flap is a critical factor in the development of skin breakdown.15 Mechanical stress is concentrated over the area of bony prominence, leading to problems with flap breakdown. This is confirmed on podographic studies, which show pressure spikes over such areas.15 Appropriate orthopedic procedures should be undertaken in conjunction with free flap surgery to maximize normal gait pattern and minimize ulceration.9,19 Several authors concluded that restoring normal foot and ankle anatomy was essential for successful reconstruction of the weight-bearing heel.9,15,19,20 Often debated is the role of sensation in the development of flap breakdown. This has been reviewed in detail elsewhere.21 Most patients develop a deep pressure sensation that replaces the protective cutaneous sensation in healthy subjects regardless of flap constituent. Although, sensibility of the weight-bearing surface was thought to be necessary to prevent breakdowns in analogy to neuropathic feet, multiple studies have failed to demonstrate an absolute requirement for cutaneous sensation and in most cases, deep protective sensation is sufficient to protect against flap breakdown.8,9

Fox et al.

heel tissue, the epidermal–dermal complex is firmly anchored to the plantar aponeurosis by perpendicular fibrous septae. Unlike the neighboring skin, recruited free tissue does not possess strong connections to the calcaneus. Free muscle flaps develop two separate shear planes—one at the muscleskin graft interface, and one at the muscle-wound bed interface. Over time, the muscle-wound bed interface “sticks,” resulting in a stable construct. Although, the fascia in free fasciocutaneous flaps can be anchored to the periosteum in an effort to reduce shear, the subcutaneous tissue represents a mobile tissue plane between the fascia and skin and may contribute to instability with mobilization. The effect of shear on mobilization remains underexplored, though it is commonly used as a key justification for selecting muscle flaps over fasciocutaneous flaps. Further biomechanical study is required to investigate the role of shear, which should lead to larger prospective clinical series with more thorough follow-up encompassing all relevant outcome measures.

Revision There was no significant difference between rates of revision in muscle and fasciocutaneous free flaps. It appears that the nature of the recipient bed and flap inset are significant contributors to the requirement for later surgery, rather than factors inherent to the flap itself. This finding echoes result from previous investigators.9 Appropriate attention to flap tailoring and inset at the time of initial surgery may reduce the need for revision down the track (►Figs. 4 and 5).

Specialized Footwear No difference was seen in the requirement for specialized footwear in patients who underwent muscle and fasciocutaneous flaps. However, it is used in up to 60% of patients who require free flap reconstruction of the heel. Specialized footwear has been advocated as a means of preventing ulceration of free flaps on the foot. Proper footwear can protect weight-bearing surfaces by providing additional padding, reducing shear, or shifting weight to a more stable area. Pressure-gait analysis has been used to design custom-made footwear, by determining areas of pressure and designing

Shear No included studies specifically addressed the issue of shear as an impediment to mobilization. Noever et al examined the vertical mobility of fasciocutaneous flaps using a 100 g weight strapped to the center of the flap.14 They concluded that the mobility of the flap was not an impediment to gait. There was no comparison group, but this method could be used to measure flap mobility in future series. Rautio et al22 used ultrasound to examine movement in a series of scapular flaps on the foot. The authors found that these flaps, even with tightening, resulted in an unsatisfactory amount of movement and therefore were not a good treatment option for weight-bearing defects. Shear has been implicated as a factor in the development of ulceration on the flaps of the weight-bearing heel. In native Journal of Reconstructive Microsurgery

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Fig. 4 Anterolateral thigh reconstruction to right medial foot and heel 8 weeks postoperatively.

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Fox et al.

Fig. 5 Anterolateral thigh reconstruction to right medial foot and heel 1 year postoperatively. The reconstruction demonstrates good heel contour and minimal bulk that allows fitting of normal footwear.

footwear accordingly.23 Silicone padding has also been used successfully to reduce peak vertical pressure forces.12 Some authors recommend monitoring of the foot by a podiatrist to prevent or detect ulceration early.9 Early involvement of podiatrists and allied health professionals is likely to improve ulceration rates in reconstructed heels and deserves further study.

Further biomechanical study is required to investigate the role of shear, which should lead to larger prospective clinical series with more thorough follow-up encompassing all relevant outcome measures. The findings of this review serve as a call to action for more reconstructive surgeons to collaborate on multi-institutional prospective studies with robust outcomes assessment. As such, an ideal flap for reconstruction of the weight-bearing heel has not yet been made clear.

Time to Mobilize Our analysis shows variation in time to mobilize between studies and for different types of reconstruction, but is largely dependent upon time to healing. El-Shazly et al reported partial weight-bearing on all flaps whether fasciocutaneous or muscle, 3 weeks after healing. As a result, all patients, regardless of flap type were reported to have returned to active walking less than 3 months postreconstruction.12 Oztürk et al reported an average return to ambulation of 2.5 months (range 2–3 months) in a series of 72 muscle flaps for reconstruction after high-energy land mine injuries. Langstein et al13 reported that patients with muscle flaps attained full weight-bearing status at 10.8 weeks, whereas patients with fasciocutaneous flaps returned to full weightbearing at a mean duration of 7.5 weeks. Most articles did not provide data for the outcome of time to mobilize, despite its importance. The small number reported precluded analysis.

Conclusion The current review has provided a summary of reported outcomes of all cases of free heel reconstruction in the literature till date. While the key benefits and pitfalls of each reconstructive option have been made evident within this literature review, the current literature was unable to adequately address the research question. With the current evidence largely limited to small cohort studies (level IV evidence), there were no significant differences were found between rates of ulceration, time for mobilization, or requirement for revision surgery or specialized footwear between patients who underwent reconstruction with fasciocutaneous free flaps versus muscle free flaps with split skin grafts.

Declarations The content of this article has not been submitted or published elsewhere. There was no source of funding for the article. The authors declare that there is no source of financial or other support, or any financial or professional relationships that may pose a competing interest. None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this article. The institutional and journal policy of ethical consent and standards of care have been adhered to. The authors have seen and agreed to the submitted version of the article, and bear responsibility for it; that all who have been acknowledged as contributors or as providers of personal communications have agreed to their inclusion; that the material is original; and that it has been neither published elsewhere nor submitted for publication simultaneously. If accepted, the article will not be published elsewhere in the same or similar form, in English or in any other language, without written consent of the copyright holder. Conflict of Interest None. Disclosures None.

References 1 McCabe WP, Kelly AP Jr, Behan FC. Reconstruction of the plantar

pad after degloving injuries of the foot. Surg Gynecol Obstet 1973; 137(6):971–974 Journal of Reconstructive Microsurgery

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Muscle versus Fasciocutaneous Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis

Muscle versus Fasciocutaneous Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis 2 Jeng SF, Wei FC. Classification and reconstructive options in foot

3

4 5

6

7

8

9

10

11 12

13

plantar skin avulsion injuries. Plast Reconstr Surg 1997;99(6): 1695–1703, discussion 1704–1705 Cichowitz A, Pan W-R, Ashton M. The heel: anatomy, blood supply, and the pathophysiology of pressure ulcers. Ann Plast Surg 2009; 62(4):423–429 Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin Plast Surg 1986;13(4):663–680 Oh SJ, Moon M, Cha J, Koh SH, Chung CH. Weight-bearing plantar reconstruction using versatile medial plantar sensate flap. J Plast Reconstr Aesthet Surg 2011;64(2):248–254 Iorio ML, Shuck J, Attinger CE. Wound healing in the upper and lower extremities: a systematic review on the use of acellular dermal matrices. Plast Reconstr Surg 2012;130(5, Suppl 2): 232S–241S Sinha AKA, Wood MBM, Irons GBG. Free tissue transfer for reconstruction of the weight-bearing portion of the foot. Clin Orthop Relat Res 1989;(242):269–271 Sönmez A, Bayramiçli M, Sönmez B, Numanoğlu A. Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps. Plast Reconstr Surg 2003;111(7):2230–2236 May JW Jr, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985;75(5): 627–641 Chang KN, DeArmond SJ, Buncke HJ Jr. Sensory reinnervation in microsurgical reconstruction of the heel. Plast Reconstr Surg 1986; 78(5):652–664 Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw 2010;36(3):1–48 El-Shazly M, Yassin O, Kamal A, Makboul M, Gherardini G. Soft tissue defects of the heel: a surgical reconstruction algorithm based on a retrospective cohort study. J Foot Ankle Surg 2008; 47(2):145–152 Langstein HN, Chang DW, Miller MJ, et al. Limb salvage for softtissue malignancies of the foot: an evaluation of free-tissue transfer. Plast Reconstr Surg 2002;109(1):152–159

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Fox et al.

14 Noever G, Brüser P, Köhler L. Reconstruction of heel and sole

defects by free flaps. Plast Reconstr Surg 1986;78(3):345–352 15 Oztürk S, Bayram Y, Möhür H, Deveci M, Sengezer M. Evaluation of

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late functional results of patients treated with free muscle flaps for heel defects caused by land-mine explosions. Plast Reconstr Surg 2005;116(7):1926–1936 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78(3): 285–292 Heymans O, Verhelle N, Lahaye T. Covering small defects on the weight bearing surfaces of the foot: the free temporal fasciocutaneous flap. Br J Plast Surg 2005;58:460–465 Harris PG, Letrosne E, Caouette-Laberge L, Egerszegi EP. Long-term follow-up of coverage of weight bearing surface of the foot with free muscular flap in a pediatric population. Microsurgery 1994; 15(6):424–429 Yücel A, Senyuva C, Aydin Y, Cinar C, Güzel Z. Soft-tissue reconstruction of sole and heel defects with free tissue transfers. Ann Plast Surg 2000;44(3):259–268, discussion 268–269 Potparić Z, Rajacić N. Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps. Br J Plast Surg 1997;50(3):176–181 Ducic I, Hung V, Dellon AL. Innervated free flaps for foot reconstruction: a review. J Reconstr Microsurg 2006;22(6):433– 442 Rautio J, Asko-Seljavaara S, Laasonen L, Härmä M. Suitability of the scapular flap for reconstructions of the foot. Plast Reconstr Surg 1990;85(6):922–928 Lord M, Reynolds DPD, Hughes JRJ. Foot pressure measurement: a review of clinical findings. J Biomed Eng 1986;8(4):283–294 Santanelli FF, Tenna SS, Pace AA, Scuderi NN. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002;109:2314–2314 Duncan MJ, Zuker RM, Manktelow RT. Resurfacing weight bearing areas of the heel. The role of the dorsalis pedis innervated free tissue transfer. J Reconstr Microsurg 1985;1:201–208

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Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis.

Management of soft tissue injuries of the heel is challenging and the composition of free tissue transfer that provides optimal aesthetic and function...
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