REPAIRS OF THE HEEL. By D. O. MAISELS, M.B., F.R.C.S.E? From The Mount Vernon Centre for Plastic Surgery, Northwood, Middlesex

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REPARS OF THE HEEL By D. O. MASELS, M.B., F.R.C.S.E? From The Mount Vernon Centre for Plastic Surgery, Northwood, Middlesex THs review was undertaken in an attempt to assess the various methods of

1 REPARS OF THE HEEL By D. O. MASELS, M.B., F.R.C.S.E? From The Mount Vernon Centre for Plastic Surgery, Northwood, Middlesex THs review was undertaken in an attempt to assess the various methods of resurfacing the heel in cases of chronic ulceration or of skin loss. For the purposes of this study the heel has been divided into three areas which differ one from another both functionally and anatomically. The first of these areas is the " sole " or plantar region which is covered by thick horny skin which is attached to the underlying bone and fascia by fibrous sept~e. ts function is to bear weight. The second area is the" back," which is the region over the posterior aspect of the calcaneum and is anatomically similar to the sole. t differs in function from the sole as it is not required to bear weight although it is subject to rubbing against the heel of the shoe. The third area is that overlying the Achilles tendon, which, while it is also subject to rubbing in its lower part, approaches normal skin in texture. t is important that this skin should be free from the Achilles tendon which glides beneath it to allow normal function and to prevent excessive trauma from friction. Material.--The review is based upon thirty-eight patients who were treated for lesions of the heel during the ten-year period 195o to 1959 in the Plastic Surgery Unit at Hill End Hospital, St Albans, and later at the Mount Vernon Centre for Plastic Surgery when the unit moved there. Since two of the patients had bilateral lesions, the total number of heels treated is forty. Age and Sex.wAn examination of the age and sex distribution of the cases has merely revealed that, as was to be expected, although the ages of the patients ranged from 3 to 74 years, the vast majority were males under 5o. The bulk of the traumatic cases occurred in the younger age groups while the decubitus cases fell in the older. Distribution and Cause.--The commonest sites of these lesions were the back, the Achilles tendon area and a combination of these two. Since pressure sores of the heel usually occur in these areas, it is not surprising to find that the commonest cause of the lesions was pressure from plaster of Paris casts, splints, elastic bandages, or in patients confined to bed (Table ). Such cases should be preventable and an incidence of fifteen out of forty due to these causes should serve as a salutary reminder and warning. Stripping injuries were also a major cause and usually resulted in an extensive area of skin loss involving more than one region. Burning accounted for the third largest group and, as might have been expected, did not affect any one area more than another. 1 Present address : Plastic Surgery Centre, Odstock Hospital, Salisbury, Wilts, x 7

2 118 BRTSH JOURNAL OF PLASTC SURGERY TABLE To Show the Distribution and Cause of the Lesions Sole Back. Achi Tenc les on. Sole and Back. Achilles TendoJ and Back. Sole, Back, and Achilles Tendon. Total Stripping.. Compound fracture Laceration Pressure (plaster of Paris) Pressure (elastic bandage) Pressure (decubitus) Paraplegic Burns Malignant O O 4 6 Total 5 r3 8 5 ] 7 40 METHODS OF REPAR Table shows the seven methods of repair used and the number of occasions on which they were employed. Before proceeding to a more detailed analysis of these methods it should be mentioned that in nine cases a portion of calcaneum was removed in addition to the soft tissue repair. The amount of bone removed varied from a small spur to excision of the bulk of the posterior part, and this seemed to contribute significantly to the success of the operation. TABLE To Show the Methods of Repair and the Number of Cases on which each Repair was Used Method of repair-- Excision of ulcer Split-skin graft Dermatome graft Local flap Cross-leg flap Cross-thigh flap Abdominal tube pedicle Number of Cases. i. Excision of the Uleer.--Excision was carried out on two occasions; in each case on a chronic ulcer resulting from pressure by a plaster of Paris cast. One case failed completely and the other, which was a small sinus, responded well to excision coupled with trimming of the underlying bone.. Split-skin Grafts.--n a number of cases split-skin grafts were used as a first stage in order to obtain healing prior to one of the more complicated methods

3 REPARS OF THE HEEL 9 of repair. Also, many of the cases referred from other hospitals had already had one or more attempts made with such grafts. However, on seventeen of the heels in this series, split-skin grafts were used apparently in the hope of getting a final repair. What then was the result in these seventeen cases? Nine of them failed and have subsequently had some other method of repair carried out, and one other is at present in the process of having an abdominal tube pedicle replacement. The indications for further repair were either failure to heal completely, or an unstable or adherent scar. n half the cases the need for further repair became apparent within a few weeks or months, but in the other half the initial split-skin repair was left for up to as long as three and a half years in the hope that it would eventually stabilise. One of the bilateral cases was in a man of 74 years who had congestive cardiac failure, and developed decubitus ulcers on the backs of his heels. Bilateral excision of the posterior part of the calcaneum and split-skin grafting left him with unstable repairs a year later when his general condition precluded any further treatment. n five cases, however, a stable and satisfactory result was obtained. Of these, two were pressure sores from plaster of Paris, and were relatively superficial. One was a compound fracture of the calcaneum with a granulating wound on the back of the heel, and the other two were burns of the sole of the heel. Thus in five cases out of seventeen a successful result was obtained with splitskin grafts. But it must not be supposed that because this method is simple it will necessarily be quick, for the average time spent in hospital for these repairs was seven weeks. One might also have expected the best results to occur in the youngest patients, but this was not so, the ages of the patients in whom success was obtained being 6, r6, 36, 38, and 39 years. 3. Dermatome Grafts.--Dermatome grafts were used on two occasions only. A man of 57, with a stripping injury of the sole and back of the heel, with an underlying fracture of the calcaneum, had the posterior part of the bone removed and a dermatome graft applied. He obtained a satisfactory result although he had to wear special protective boots for more than a year post-operatively. A woman of 47, with a stripped back of heel and Achilles tendon area, had two operations for split-skin graft cover. This proved to be unstable until it was replaced by a dermatome graft, since when it has caused no trouble for many years. 4. Local Flaps.--n seven cases the heel was repaired by local flaps, and despite the commonly held belief that local flaps in this region are dangerous or worse, a successful result was obtained in all seven cases. A simple transposed flap based on the lateral aspect of the ankle with the base upwards (Fig. i) gave an excellent result in an old pressure sore of the back of the heel. The patient was in hospital for only two weeks. A similar case was treated by two vertically opposed transposition flaps with an equally good result and also was discharged from hospital in two weeks (Fig. ). A malignant melanoma excised from the sole of the heel left a defect which was closed by a bipedicled, bucket-handle flap swung down from the skin over the back and lower Achilles tendon areas. This secondary defect was covered with a split-skin graft and the repair gave an excellent heel after only two weeks in hospital. This patient has since had a further small operation for excision of the

]3, After repair by a transposition flap from the lateral aspect of the ankle.

A, A plaster of Paris pressure sore of the back of the heel.

4 10 BRTSH JOURNAL OF PLASTC SURGERY FG. A, A chronic plaster of Paris pressure sore of the back of the heel. ]3, After repair by a transposition flap from the lateral aspect of the ankle. Note how the resultant defect lies in the hollow behind the lateral malleolus. FG. A, A plaster of Paris pressure sore of the back of the heel. B, Shows the repair by two vertically opposed transposition flaps. C, The final result. scar at the junction of the split-skin graft with the skin over the Achilles tendon which was causing slight discomfort (Fig. 3). Another pressure sore of the back and sole of the heel was treated by aa

At the first operation the flap was outlined and completely raised until the med.

5 REPARS OF THE HEEL unspecified type of rotation flap with a satisfactory end-result although a portion of the flap was lost. Three lesions of the sole or back of the heel were treated by a rotation flap based on the medial calcaneal vessels. All were done in two stages. At the first operation the flap was outlined and completely raised until the med.ial calcaneal vessels and nerve were seen, and at the second stage the flap was rotated leaving a narrow defect anteriorly which was covered with a split-skin graft (Fig. 4). The results with this flap were uniformly excellent. FG. 3 A, A malignant melanoma of the sole of the heel. B, After excision and repair by a bucket-handle flap. 5. Direct Flaps.rain all, sixteen cases were treated by direct flaps, these being eleven cross legs and five cross thighs. n no case was a cross-leg flap used on a female because of the unsightly scarring of the donor leg which results. Of the five cross-thigh flaps used, two were on males and three on females. There has been a reluctance to use the cross-thigh method on men because it was felt that the awkward positioning required was more likely to lead to joint stiffness than with cross-leg flaps. This is reflected in the fact that of the two males who had cross-thigh flaps, one was a child of 4 and the other had an associated wound of the donor leg which made it unsuitable for a cross-leg flap. The results of direct flaps have been on the whole very satisfactory, although they have required a certain amount of care for many months post-operatively. n the initial post-operative period before the development of protective sensation in the flap, they have tended to become rubbed and in several cases actually developed superficial ulcers in the flap. Most of these cases wore special surgical boots or shoes to provide additional protection until the flap was stabilised. The late results of these flaps have been most satisfactory. n three cases it proved necessary to carry out further surgery for thinning of the flap, and a common

1 BRTSH JOURNAL OF PLASTC SURGERY complication of no more than nuisance value was the occurrence of hyperkeratosis of the normal skin at its junction with the flap.

$A man of 6, with a chronic ulcer overlying a compound fracture of the calcaneum, who had had a failed cross-leg flap elsewhere, had a further cross-leg flap applied.$

6 1 BRTSH JOURNAL OF PLASTC SURGERY complication of no more than nuisance value was the occurrence of hyperkeratosis of the normal skin at its junction with the flap. This has been controlled quite easily by the use of pumice stone by the patient. However, direct flaps are major procedures and have not been entirely free from complications. A man of 6, with a chronic ulcer overlying a compound fracture of the calcaneum, who had had a failed cross-leg flap elsewhere, had a further cross-leg flap applied. This, too, failed and he ended up by having an FG. 4 A, A granulating wound of the sole of the heel. B, Shows an unstable repair by split-skin grafts and the outline of the medial calcaneal flap. C, After repair by the medial calcaneal flap. Note how the resultant defect lies in the non-weight-bearing part of the sole of the foot. above-knee amputation. Since he suffered from severe obliterative vascular disease, this should be regarded as an error of selection, rather than a failure of the method. About half the cases lost a small portion of the " trailing edge" of the flap, despite a variety of methods of insetting this edge. n four cases there was loss along the "leading edge" but it is noteworthy that in no case was the amount of flap which survived inadequate to cover the defect. n one case there was complete failure of the split-skin grafts on the donor leg due to infection, and several small losses also occurred in other cases. One patient developed an acute infective arthritis of the tarsal joints of the donor leg although he had had only a minor degree of infection in the flap. Another patient, whose flap became grossly infected, developed a septicmmia and septic arthritis of the donor hip joint. One patient had temporary limitation of extension of the knee of the injured leg, but no other instances of joint stiffness were noted. The piaster of Paris fixation led to superficial pressure sores in several patients and to a lateral popliteal nerve palsy in one,

REPARS 017 THE HEEL i3 With the exception of the man of 6 above, the oldest patient was 54, a fact which illustrates the reluctance to immobilise older patients for several weeks in awkward positions.

7 REPARS 017 THE HEEL i3 With the exception of the man of 6 above, the oldest patient was 54, a fact which illustrates the reluctance to immobilise older patients for several weeks in awkward positions. The average time spent in hospital by all patients in the series undergoing a direct flap repair was twelve weeks, despite the fact that two boys of 6 and 17 were in hospital for only five weeks. These figures give an indication of the magnitude of this procedure. 6. Abdominal Tube Pediele Repairs.--Abdominal tube pedicle replacement was used four times in the series ; it is at present being undertaken on one of the other cases in the series in which split-skin grafts proved unstable ; and it is also being carried out on a further patient who falls outside the time limit for the series. n all of these six cases there was extensive skin loss due to stripping which removed the soft tissues down to bone and fascia. n three of these cases all three regions of the heel were denuded, and in the other three in addition to one or two regions being affected, adjacent areas of the foot, ankle, and leg were also damaged and required repair. n only one of the tubes was the length-to-breadth ratio greater than ½ to i. This tube measured i by 4 in. and despite several " delays " in. were lost, thereby reducing the size to ½ to. While it is impossible to draw any conclusions from such a small number of cases this may be a significant observation. The sole skirt adjacent to tube repairs showed the same tendency towards hyperkeratosis as with direct flaps, and its control was similar. One patient developed a crop of boils in the tube repair but this settled quite quickly and gave no further trouble. An ulcer, which appeared in one repair before adequate sensation had returned, was amenable to excision and suture without extensive undermining and thus with minimal disturbance of the ingrowing nerve supply. That this is a most time-consuming undertaking is borne out by the fact that the average time spent in hospital by these patients--excluding the time for primary cover with split-skin grafts--was twenty-four weeks. Furthermore it involves numerous operations, the average number to effect the repair--again excluding split-skin grafts--being eight. The results have been satisfactory once protective sensation developed in the tube. But this takes time and in one case even after eight years sensation was crude and there were signs of incipient ulceration in the repair. DSCUSSON have been unable to find a similar review of heel repairs in the English literature so that even if surgical series from different centres were ever comparable, the question does not arise in this case. Perhaps the most important information to be gleaned from this review would be an answer to the question : "What is the best method of repairing a heel?" But, as is so often the case in surgery, there is no " best method." There are a number of methods of repair available and it is for the surgeon to decide which of these many methods will be most suitable for a particular patient. n plastic surgery especially, this question resolves itself not into a measure of the method~ but rat.her of the surgeon's ability to select the corre ~ one,

4 BRTSH JOURNAL OF PLASTC SURGERY With this important reservation it is nonetheless possible to draw some very general conclusions about the indications for the various types of repair.

8 4 BRTSH JOURNAL OF PLASTC SURGERY With this important reservation it is nonetheless possible to draw some very general conclusions about the indications for the various types of repair. Before these indications arc considered it would be as well to remember the high proportion of these cases which should have bccn preventable. Quite apart from direct pressure to the heel, Guttmann (955) pointed out that the commonly used heel rings or "halos," far from preventing hccl sores in fact predispose towards them by occluding the vessels to the region. The addition of bone excision to the soft tissue repair seems also to bc an important point. This is a well-recognised part of the repair of pressure sores over the ischial tubcrositics and greater trochanters in paraplegics (Battle, 949 ; Yeoman and Hardy, 954) but it does not appear to have bccn used elsewhere for lesions of the heel although the principles involved arc similar in all these areas. n deciding upon the type of repair to be undertaken, the first decision is whether the repair is to be by free graft or by a flap. t appears from an examination of the cases in this series that as long as there is a pad of normal tissue insulating the bone and tendon, then free grafts have a reasonable chance of success. This is particularly true in burns where the fibro-fatty pad of the sole of the heel survives, and a similar state of affairs has bcen noticed in patients with whole skin loss burns of the sole of the foot. This agrees with the views of Blair et al. (937), Brown and Cannon (944 a,b), Ghormley (944) and Lewis (944), who all mention the importance of adequate padding if frec grafts are to suffice. Most of the patients in this series wcrc treated with thin split-skin grafts cut by a free-hand knife. The two " dermatomc grafts " were thick split-skin grafts cut with a Padgett type dermatomc, and it is interesting to note that in one case the thicker graft succeeded where a thin one had failed. One cannot help wondering what would have been the results if whole-skin grafts had been used. Lewis (944), who took a very gloomy view of flap repairs and favoured frec grafts in almost all cases, reported a whole-skin graft of an ulcer over the Achilles tendon ; but other writers do not describe the use of these grafts. When no cushion of subcutaneous tissue remains, all writers agree that a flap is required, and this view is borne out by the findings of the present review. The sole of the heel particularly is highly differentiated tissue designed specifically for weight-bearing and all distant flaps suffer from a number of defects. First, they do not contain the fibrous elements which bind the skin to the underlying tissues in the normal sole, thereby limiting shearing stresses. Secondly, the flaps must pass through a period of denervation which subiects them to the hazards of trophic ulceration. Guttmann (955) discussed the so-called extrinsic and intrinsic factors in this ulceration and one must also bear in mind thc absence of sweat and sebaceous secretions in a dencrvated flap (Brown and Cannon, 944a ). Thirdly, it has bccn sccn in this serics that distant flap repairs are both time-consuming and not devoid of serious complications. Local flaps in other parts of the body have wcll-recogniscd advantages over distant flaps, and this series has shown that they arc both practicable and safe for lesions of the back or sole of the heel. Both the flap on the lateral aspect of the ankle which is nourished by the terminal branches of the pcroncal artery and the medial calcancal flap fulfil most of the criteria of Esser's "biological flaps " (934) and arc thus safe. Furthermore, both these flaps leave a defect, which is easily covered by a split-skin graft, in a region which is not subjected to weightbearing or to rubbing. n addition to its blood supply the inncrvation is carried

REPARS OF TlE leel i5 in the medial calcaneal flap through the corresponding nerve and possibly also in the lateral flap through elements of the sural nerve.

9 REPARS OF TlE leel i5 in the medial calcaneal flap through the corresponding nerve and possibly also in the lateral flap through elements of the sural nerve. From this study, the chief indications for the use of a direct flap appear to be, first, lesions of the Achilles tendon area and, secondly, lesions which were obviously too large to be repaired by a local flap. n the last eight years all direct flaps have fulfilled these criteria although earlier in the series they were also used for small lesions on the back of the heel. The reasons for deciding to use a cross-leg or a cross-flfigh flap have already been indicated in the text. Mir y Mir (1954) described the use of a direct flap from the non-weight-bearing part of the opposite sole, and while this method has not been used in the present series it would seem to offer a number of advantages. t is pointed out that the flap consists of the right type of tissue; leaves no functional disability ; adheres better to the underlying tissues ; and does not entail immobilisation in an awkward or uncomfortable position. Finally, the indications for employing an abdominal tube pedicle would seem to be loss of skin and subcutaneous tissue over an area which is too extensive to be repaired by a direct flap, or loss of a smaller area in a patient who is unable to undergo a direct flap repair for one reason or another. SUMMARY. A series of forty heel repairs is reviewed.. The various methods of repair are discussed. 3. An attempt is made to present the indications for the choice of repair. These patients were all under the care of Mr Rainsford Mowlem, Mr R, L. G. Dawson, Mr S. H. Harrison, and Mr. F. K. Muir, to whom am grateful for permission to carry out this review. My special thanks are due to Mr Mowlem for his help and advice in the preparation of this paper. would also like to thank Miss N. Walker, who took the photographs. Addendum.--Since this paper was submitted have had the opportunity of carrying out a medial calcaneal flap repair in one stage. At no time was there any sign of vascular impairment in the flap which gave a very satisfactory result with complete and normal sensation. The patient, a man of 47, was admitted to the Plastic Surgery Centre, Odstock Hospital, under the care of Mr J. E. Laing to whom am grateful for permission to publish. REFERENCES BATTLE, R. (1949). Brit. ft. plast. Surg.,, 68. BLAR, V. P., BROWN, J. B., and BYARS, L. T. (1937). J. Amer. mecl. Ass., io8, 4. BROWN, J. B., and CANNOq, B. (944 a). American Academy of Orthopedic Surgeons: nstructional Course Lectures, Vol., p (1944 b). Ann. Surg., io, 417. ESSER, J. F. S. (1934). " Biological or Artery Flaps of the Face." Monaco : nstitut Esser de Chirurgie Structive. GHORMLEY, R. K. (1944). American Academy of Orthopedic Surgeons : nstructional Course Lectures, Vol., p. lo7. GUTTMANN, L. (1955). Brit. J. plast. Surg., 8, 196, LEWS, G. K. (1944)- American Academy of Orthopedic Surgeons: nstructional Course Lectures, Vol., p. 9. MR Y MR, L. (1954). Plast. reconstr. Surg., x4, 444. YEOMAN, M. P., and HARDY, A. G. (954). Brit. J. plast. Surg., 7, 79.

FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS

m FRACTURES OF THE TIBIA COMPLICATED BY SKIN LOSS By STEWART H. HARRISON, F.R.C.S., L.D.S.R.C.S.(Ed.) From the Windsor Group of Hospitals and the Mount Vernon Centre for Plastic Surgery, Northwood, Middlesex