Rotation fasciocutaneous flap for neglected club feet--a new technique.HH D'Souza, AA Aroojis, MG Yagnik, TV Nagda
Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0009715312
Source of Support: None, Conflict of Interest: None
Skin necrosis and wound problems complicate surgical release of severe neglected clubfoot. This is primarily due to excessive tension on the skin edges and a poor understanding of abnormal vascular anatomy in clubfoot. We report a technique of primary skin closure using a local rotation fasciocutaneous flap using the conventional posteromedial skin incision (Turco). Primary uncomplicated wound healing was achieved within 2 weeks in all 16 rigid and neglected clubfeet (1-7 years) operated by this technique. This flap is scientifically logical, technically easy and ensures primary wound healing.
Keywords: Child, Child, Preschool, Clubfoot, surgery,Female, Follow-Up Studies, Human, Infant, Male, Surgical Flaps, Treatment Outcome, Wound Healing,
Skin necrosis and wound problems are dreaded complications following the surgical release of severe, neglected and recurrent clubfeet, Skin necrosis following clubfoot surgery leading to amputation has been reported . After completion of the surgical correction of clubfoot, primary skin closure may be difficult or even impossible, especially in severe and neglected cases Various solutions to this problem have been devised, including primary skin closure in an under-corrected position use of a rotation skin flap, preoperative skin expansion using a tissue expander,.
We report a technique of primary skin closure following surgical correction, using a local rotation fasciocutaneous flap that is both technically simple and effective in avoiding postoperative wound complications.
The technique was employed in 16 feet (13 patients). Mean age was 3.5 years (range 1 to 7 years). There were 8 males and 5 females. The deformity was bilateral in 3 cases. The average score to quantify the severity of deformity was 8 by the Caterall Yoneda scale.
The skin incision used is similar to the technique described by Turco et al for posteromedial release [Figure - 1]. The skin incision is deepened down to the level of deep fascia without dissection in the subcutaneous tissue. The deep fascia is incised in line with the skin incision. The neurovascular bundle is identified and mobilised carefully taking care to preserve the perforators arising from the post tibial artery and supplying the medial skin flap,
A standard posteromedial release is then performed. Care is executed in preserving the perforators especially during the supramalleolar lengthening of the tibialis posterior and flexor digitorum longus tendons where they are most prone to avulsion. If necessary a lateral soft tissue release (2 cases) or lateral bony procedure (Cuboid decancellisation - 4 cases, Dilwyns-Evans procedure - 2 cases, Lichbiau's technique - 1 case) is done. The talonavicular and subtalar joints are stabilised in the corrected position by transfixing with X' wires. Following internal fixation in the corrected position, a defect appears on the posterornedial aspect of the wound corresponding to the severity of the original deformity [Figure:1-top right]. If an attempt at primary closure is made the medial skin flap which is deficient is found to be under marked tension, predisposing the flap to ischaemic necrosis.
A back-cut is now taken at the proximal apex of the wound perpendicular to the vertical limb of the incision. It extends horizontally along the anteromedial aspect of the leg. It is deepened to the level of deep fascia, taking care to preserve the great saphenous vein, which lies just posterior to the posterior border of the tibia. The entire medial flap created is then advanced distally so as to cover the defect and achieve closure without tension [Figure:1:bottom left]. The triangular defect that appears in the proximal part of the wound is either closed primarily [Figure:1: bottom right] or covered with a split thickness skin graft taken from the calf.
Above knee POP cast is given with ankle in equinus to further decrease skin tension. Emphasis is laid on strict limb elevation to prevent post-operative oedema. Wound check is done after 48 hours to look for flap congestion or collection deep to the flap. Cast is changed at the end of 2 weeks and then given in plantigrade position. Sutures are removed at the end of 4 weeks with a cast in over corrected position.
Primary uncomplicated wound healing was achieved in all 16 cases within 2 weeks. At the end of 3 months, all patients had a correction of the deformity and good range of ankle and subtalar movements at fast follow up.
Ischaemic wound necrosis following the surgical release of severe neglected clubfeet results from extreme tension on the skin edges in an attempt to acutely correct the deformity in the face of skin shortage ,, poor understanding of the normal vascular anatomy ,, and ignorance of the abnormal vascular pattern in clubfoot ,,,,.
Various methods of avoiding tension on the medial skin flap have been devised, each with its own advantages and disadvantages.
The simplest method is to place the foot in under-correction at the end of surgery and to gradually correct the deformity by weekly manipulations and casting  The disadvantage lies in the need for prolonged postoperative casting, loss of initial correction, and the inability to under-correct if the subtalar and talonavicular joints have been transfixed in the corrected position.
Alternatively complex cutaneous flaps have been devised by other authors to provide immediate wound coverage and decrease flap tension, These flaps are extensive technically difficult and may require the assistance of a plastic surgeon. Walker and Mittal have devised a local rotation cutaneous flap from the dorsum of the foot. This flap fails to take into cognisance, the abnormal vascular anatomy present in clubfoot,,,,. The flap is based on random blood vessels arising from the dorsalis pedis and anterior tibial arteries. However, angiographic,,, and Doppler ultrasound,, studies have repeatedly demonstrated that the dorsalis pedis artery is hypoplastic or absent in 40-85% of clubfeet depending on severity and age of presentation. This congenital or acquired adaptive absence, of the artery in clubfoot questions the validity of adequate flap vascularity, Furthermore, the flap is to be raised superficial to the dorsal venous arch  which itself may jeopardise the venous supply and cause flap congestion. The incision for raising this flap intrudes into adjacent vascular territories and hence contradicts the angiosome concept.
The use of tissue expander to provide sufficient skin has been reported by Atar. A complication rate of upto 25% with risk of infection has been reported ,. The technique is in the experimental stages as regards its use in clubfoot.
Vascular basis of our flap:
Ours is a local rotation axial fasciocutaneous flap with a random extension. Complete and primary uncomplicated wound healing confirms the adequate vascularity of the flap, but its exact vascular basis requires further elucidation.
We surmise that the success and validity of our flap is based on a combination of various factors which include:
Utilising a full thickness local fasciocutaneous flap, which preserves the suprafascial and subdermal arterial plexuses 12. [Figure:2-top]
Careful preservation of the septocutaneous perforators arising from the post tibial artery ,, [Figure:2-bottom left]
Preserving the great saphenous vein and its accompanying delicate perivenous capillary network which provide additional vascularity and prevent flap
Raising the flap from a single vascular territory angiosome, which helps to 'capture' additional vascularity from the adjacent angiosomes by the system of anastomosing smaller calibre 'choke' arteries.
Further investigations such as angiographic studies and tracer dye uptake studies will probably confirm the vascular basis of the flap.
The technique of using the back-cut provides greater mobility of the anterior skin flap so as to permit kin closure without tension. It is scientifically logical, technically easy and ensures primary wound healing.
We great-fully acknowledge the late Dr. SM Karmarkar; Consultant Plastic Surgeon for his inspiration and support.
We also thank the Dean, Bat Jerbai Wadia Hospital for Children for permission to utilise hospital data.
[Figure - 1]