Accepted Manuscript Distally-based osteocutaneous dorsal metatarsal artery flap for hallux reconstruction Joseph R. Dusseldorp , MBBS(Hons), BCom James M. Allan , MBBS Madelyn H. Van Der Leeden , BNursing Alex Phoon , FRACS, MS, BSc(Med), BM, BS PII:
S1748-6815(14)00175-2
DOI:
10.1016/j.bjps.2014.04.013
Reference:
PRAS 4158
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 10 January 2014 Revised Date:
13 March 2014
Accepted Date: 22 April 2014
Please cite this article as: Dusseldorp JR, Allan JM, Van Der Leeden MH, Phoon A, Distally-based osteocutaneous dorsal metatarsal artery flap for hallux reconstruction, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.04.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Distally-based osteocutaneous dorsal metatarsal artery
RI PT
flap for hallux reconstruction
Joseph R. Dusseldorp MBBS(Hons), BCom, James M. Allan MBBS, Madelyn H. Van
Royal Prince Alfred Hospital Missinden Road Sydney, NSW
TE D
Australia
M AN U
Department of Plastic and Reconstructive Surgery
SC
Der Leeden BNursing, Alex Phoon FRACS, MS, BSc(Med), BM, BS
Corresponding Author: Joseph R. Dusseldorp
EP
Address: 1A Mount St, Redfern NSW Australia 2016 Telephone: +61411022644
AC C
Fax: +61295156133
Email: [email protected]
Declaration:
This work has not been published or presented, wholly or in part, in any other publication or at any conference or meeting.
1
ACCEPTED MANUSCRIPT
Summary:
Reconstruction of complex defects of the distal portion of the foot
RI PT
remains a challenging problem for plastic surgeons. A traumatic case is presented where reconstruction of a complex plantar defect of the hallux was achieved using a distally-based osteocutaneous metatarsal artery flap based on
SC
the second dorsal metatarsal artery. Local flap repair is a viable reconstructive
M AN U
option for complex defects of the plantar surface of the forefoot.
Keywords: distally based flap; metatarsal artery; osteocutaneous; hallux
AC C
EP
TE D
reconstruction; case report.
2
ACCEPTED MANUSCRIPT
Background:
The concept of utilizing reverse flow flaps for coverage of distal defects of extremities
has
gained
popularity
since
Quaba
and
Maruyama
RI PT
the
simultaneously described clinical applications of this phenomenon in hand surgery in 1990.(1, 2) Hyashi and Maruyama(3) and Sakai(4) were the first to
SC
utilize this local flap option in the foot when they described the distally-based dorsal metatarsal artery flap. There have been no reported cases of a distally-
M AN U
based osteocutaneous flap reconstruction in the foot.
Anatomy:
TE D
The arterial anatomy of the dorsum of the foot has been well studied and exhibits substantial anatomical variability. (5, 6) The first dorsal metatarsal
EP
artery (DMA) is usually a dorsal continuation of the dorsalis pedis artery and travels in the first metatarsal interspace to supply the digital arteries of the first
AC C
and second toes. There are three major contributing arterial sources to the second, third and fourth DMA. Firstly, the arcuate artery, which branches from dorsalis pedis at or below the level of the tarsometatarsal joints, runs laterally along the bases of metatarsals 2-4 supplying each DMA. The lateral tarsal artery may meet with the arcuate artery laterally to form the dorsal arterial arcade of the foot. Finally there are the communicating arteries between the dorsal and plantar vascular networks which contribute to the DMA arterial supply. It is the
3
ACCEPTED MANUSCRIPT distal communicating arteries that form the basis of the blood supply to the DMA flap and to the periosteum of the metatarsal bone (Fig. 1).
RI PT
Case Report:
A 33 year-old man suffered a workplace crush injury to his left foot. He
SC
sustained compound comminuted fractures of the proximal phalanges of toes 14 and the proximal interphalangeal (PIP) joints were also breached. The second
M AN U
toe was amputated at the level of the second metatarsal head. The resultant defect requiring reconstruction was 1) absent plantar glabrous skin overlying the heads of metatarsals 1-3 and 2) absent plantar skin, soft tissue and bony
the hallux (Fig. 2).
TE D
defect of the plantar cortex and distal articular surface of the proximal phalanx of
Reconstructive surgery was undertaken in 2 stages. The first stage
EP
mobilized a large plantar V-Y advancement flap of glabrous skin along the axis of the first metatarsal. This allowed adequate glabrous tissue to cover the
AC C
metatarsal heads for weight bearing and ambulation. The second stage was to reconstruct the hallux. Following audible
Doppler examination a 6 x 2 cm distally-based osteocutaneous flap was harvested under pneumatic tourniquet control. The dissection was performed from proximal to distal to confirm the existence of the second dorsal metatarsal artery. The dorsalis pedis and first dorsal metatarsal artery were identified and preserved as they constituted the sole vascular supply to the hallux. The flap was raised taking care not to damage the vascular connections of the skin paddle to
4
ACCEPTED MANUSCRIPT the periosteum and articular cartilage. The bone flap was harvested from the proximal half of the redundant second metatarsal, the remainder of which was excised on completion of a 2nd ray amputation. Dissection was continued distally until the anastomotic branches from the plantar circulation were
RI PT
encountered and an adequate arc of rotation had been achieved. The bone flap was internally fixed to the proximal phalanx of the hallux. The articular surface of the bone flap was aligned to establish a congruous first IPJ (Fig. 2). The repair
SC
was secured with an oblique trans-articular k-wire. The soft tissue component of the flap was inset and a lateral releasing incision over the dorsum of the 4th ray
M AN U
was required to close the 2nd ray donor site.
The patient was allowed to mobilize after 3 weeks with an ankle-foot orthosis and crutches and was discharged after 4 weeks (Fig. 3). At 6 weeks postoperatively the patient was able to mobilize freely and return to work with
TE D
restricted duties after a further 2 weeks when bony union was confirmed
AC C
Discussion:
EP
clinically and with radiographs (Fig. 4).
Complex defects in the distal third of the foot can be a challenging
problem for the reconstructive surgeon. Familiarity with distally-based flaps of the hand allows similar principles to be employed in the foot and may avoid the need for more complex flap repair. This is particularly apparent when the defect is small. Reconstructive options in this region include toe amputations, fillet flaps, cross leg flaps and free tissue transfer. Each of these has major potential
5
ACCEPTED MANUSCRIPT drawbacks. Toe amputation or fillet flap solve the immediate wound healing problem but distal amputation has been shown to lead to poorer outcomes in diabetic patients (7) and can have deleterious effects on balance in young, healthy patients(8). Cross leg flaps are two-stage procedures and require
RI PT
significant immobilization with resultant stiffness. Free tissue transfer has the disadvantage of being an expensive, time-consuming procedure with a distant donor site. Non-vascularized autogenous bone grafts can be utilized for small
SC
bony defects. However, their use is not recommended in contaminated wounds or in the presence of complex bone and soft tissue defects.
M AN U
In the foot, distally-based flaps have only been utilized previously for softtissue reconstruction. (3, 4, 9) The plantar-dorsal communicating arteries along with the DMA periosteal connections provide adequate blood supply for successful osteocutaneous flap harvest (10) and several clinical cases have been
TE D
reported in the hand surgery literature. (11, 12) Their usage in the forefoot is perhaps limited by the relative infrequency of small complex defects where toe
AC C
EP
salvage is the desired reconstructive outcome.
Acknowledgments: The authors would like to thank Veneliza Salcedo from the Mayo Clinic, Rochester, for production of the medical illustration.
6
ACCEPTED MANUSCRIPT
Conflict of Interest: None
AC C
EP
TE D
M AN U
SC
RI PT
Funding: None
7
ACCEPTED MANUSCRIPT List of References:
AC C
EP
TE D
M AN U
SC
RI PT
1. Maruyama, Y. The reverse dorsal metacarpal flap. British journal of plastic surgery 1990;43:24-27. 2. Quaba, A. A., Davison, P. M. The distally-based dorsal hand flap. British journal of plastic surgery 1990;43:28-39. 3. Hayashi, A., Maruyama, Y. Reverse first dorsal metatarsal artery flap for reconstruction of the distal foot. Ann Plast Surg 1993;31:117-122. 4. Sakai, S. A distally based island first dorsal metatarsal artery flap for the coverage of a distal plantar defect. British journal of plastic surgery 1993;46:480482. 5. Man, D., Acland, R. D. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plastic and reconstructive surgery 1980;65:419-423. 6. Lee, J. H., Dauber, W. Anatomic study of the dorsalis pedis-first dorsal metatarsal artery. Ann Plast Surg 1997;38:50-55. 7. Peters, E. J. G., Childs, M. R., Wunderlich, R. P., Harkless, L. B., Armstrong, D. G., Lavery, L. A. Functional Status of Persons With Diabetes-Related LowerExtremity Amputations. Diabetes Care 2001;24:1799-1804. 8. Chou, S. W., Cheng, H. Y., Chen, J. H., Ju, Y. Y., Lin, Y. C., Wong, M. K. The role of the great toe in balance performance. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 2009;27:549-554. 9. Senyuva, C., Yucel, A., Fassio, E., Cetinkale, O., Goga, D. Reverse first dorsal metatarsal artery adipofascial flap. Annals of plastic surgery 1996;36:158-161. 10. Alagoz, M. S., Orbay, H., Uysal, A. C., Comert, A., Tuccar, E. Vascular anatomy of the metatarsal bones and the interosseous muscles of the foot. Journal of Plastic, Reconstructive & Aesthetic Surgery 2009;62:1227-1232. 11. Santa-Comba, A., Amarante, J., Silva, A., Rodrigues, J. Reverse dorsal metacarpal osteocutaneous flap. British journal of plastic surgery 1997;50:555558. 12. Kakinoki, R., Ikeguchi, R., Matsumoto, T., Nakamura, T. Reconstruction of a phalangeal bone using a vascularised metacarpal bone graft nourished by a dorsal metacarpal artery. Injury 2008;39 Suppl 4:25-28.
8
ACCEPTED MANUSCRIPT Figure Legend:
Figure 1: Diagrammatic representation of the arterial basis of the distally-based osteocutaneous DMA flap. DMA dorsal metatarsal artery, PMA palmar metatarsal
RI PT
artery.
Figure 2: Clinical photographs demonstrating: (left to right) A) the extent of
SC
injury to the plantar surface of the foot following traumatic crush injury by heavy machinery B) the distally-based flap raised on the second DMA and including the
M AN U
dorsal cortex of the second metatarsal bone with a segment of articular surface C) reconstruction of the articular surface of the head of the proximal phalanx of the hallux.
TE D
Figure 3: Clinical photograph demonstrating the healed weight-bearing plantar
EP
surface allowing mobilization without restriction at 8 weeks post-operatively.
Figure 4: Radiographs demonstrating: (clockwise from top left) A) comminuted
AC C
fractures to the 1st and 2nd toe proximal phalanges after severe crush injury B) comminuted fracture and defect of segments of the plantar articular surface and distal cortex of the hallux and C) lateral and D) AP views of the bone union of the reconstructed hallux at 6 months post-operatively.
9
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1748-6815(14)00175-2
DOI:
10.1016/j.bjps.2014.04.013
Reference:
PRAS 4158
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 10 January 2014 Revised Date:
13 March 2014
Accepted Date: 22 April 2014
Please cite this article as: Dusseldorp JR, Allan JM, Van Der Leeden MH, Phoon A, Distally-based osteocutaneous dorsal metatarsal artery flap for hallux reconstruction, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.04.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Distally-based osteocutaneous dorsal metatarsal artery
RI PT
flap for hallux reconstruction
Joseph R. Dusseldorp MBBS(Hons), BCom, James M. Allan MBBS, Madelyn H. Van
Royal Prince Alfred Hospital Missinden Road Sydney, NSW
TE D
Australia
M AN U
Department of Plastic and Reconstructive Surgery
SC
Der Leeden BNursing, Alex Phoon FRACS, MS, BSc(Med), BM, BS
Corresponding Author: Joseph R. Dusseldorp
EP
Address: 1A Mount St, Redfern NSW Australia 2016 Telephone: +61411022644
AC C
Fax: +61295156133
Email: [email protected]
Declaration:
This work has not been published or presented, wholly or in part, in any other publication or at any conference or meeting.
1
ACCEPTED MANUSCRIPT
Summary:
Reconstruction of complex defects of the distal portion of the foot
RI PT
remains a challenging problem for plastic surgeons. A traumatic case is presented where reconstruction of a complex plantar defect of the hallux was achieved using a distally-based osteocutaneous metatarsal artery flap based on
SC
the second dorsal metatarsal artery. Local flap repair is a viable reconstructive
M AN U
option for complex defects of the plantar surface of the forefoot.
Keywords: distally based flap; metatarsal artery; osteocutaneous; hallux
AC C
EP
TE D
reconstruction; case report.
2
ACCEPTED MANUSCRIPT
Background:
The concept of utilizing reverse flow flaps for coverage of distal defects of extremities
has
gained
popularity
since
Quaba
and
Maruyama
RI PT
the
simultaneously described clinical applications of this phenomenon in hand surgery in 1990.(1, 2) Hyashi and Maruyama(3) and Sakai(4) were the first to
SC
utilize this local flap option in the foot when they described the distally-based dorsal metatarsal artery flap. There have been no reported cases of a distally-
M AN U
based osteocutaneous flap reconstruction in the foot.
Anatomy:
TE D
The arterial anatomy of the dorsum of the foot has been well studied and exhibits substantial anatomical variability. (5, 6) The first dorsal metatarsal
EP
artery (DMA) is usually a dorsal continuation of the dorsalis pedis artery and travels in the first metatarsal interspace to supply the digital arteries of the first
AC C
and second toes. There are three major contributing arterial sources to the second, third and fourth DMA. Firstly, the arcuate artery, which branches from dorsalis pedis at or below the level of the tarsometatarsal joints, runs laterally along the bases of metatarsals 2-4 supplying each DMA. The lateral tarsal artery may meet with the arcuate artery laterally to form the dorsal arterial arcade of the foot. Finally there are the communicating arteries between the dorsal and plantar vascular networks which contribute to the DMA arterial supply. It is the
3
ACCEPTED MANUSCRIPT distal communicating arteries that form the basis of the blood supply to the DMA flap and to the periosteum of the metatarsal bone (Fig. 1).
RI PT
Case Report:
A 33 year-old man suffered a workplace crush injury to his left foot. He
SC
sustained compound comminuted fractures of the proximal phalanges of toes 14 and the proximal interphalangeal (PIP) joints were also breached. The second
M AN U
toe was amputated at the level of the second metatarsal head. The resultant defect requiring reconstruction was 1) absent plantar glabrous skin overlying the heads of metatarsals 1-3 and 2) absent plantar skin, soft tissue and bony
the hallux (Fig. 2).
TE D
defect of the plantar cortex and distal articular surface of the proximal phalanx of
Reconstructive surgery was undertaken in 2 stages. The first stage
EP
mobilized a large plantar V-Y advancement flap of glabrous skin along the axis of the first metatarsal. This allowed adequate glabrous tissue to cover the
AC C
metatarsal heads for weight bearing and ambulation. The second stage was to reconstruct the hallux. Following audible
Doppler examination a 6 x 2 cm distally-based osteocutaneous flap was harvested under pneumatic tourniquet control. The dissection was performed from proximal to distal to confirm the existence of the second dorsal metatarsal artery. The dorsalis pedis and first dorsal metatarsal artery were identified and preserved as they constituted the sole vascular supply to the hallux. The flap was raised taking care not to damage the vascular connections of the skin paddle to
4
ACCEPTED MANUSCRIPT the periosteum and articular cartilage. The bone flap was harvested from the proximal half of the redundant second metatarsal, the remainder of which was excised on completion of a 2nd ray amputation. Dissection was continued distally until the anastomotic branches from the plantar circulation were
RI PT
encountered and an adequate arc of rotation had been achieved. The bone flap was internally fixed to the proximal phalanx of the hallux. The articular surface of the bone flap was aligned to establish a congruous first IPJ (Fig. 2). The repair
SC
was secured with an oblique trans-articular k-wire. The soft tissue component of the flap was inset and a lateral releasing incision over the dorsum of the 4th ray
M AN U
was required to close the 2nd ray donor site.
The patient was allowed to mobilize after 3 weeks with an ankle-foot orthosis and crutches and was discharged after 4 weeks (Fig. 3). At 6 weeks postoperatively the patient was able to mobilize freely and return to work with
TE D
restricted duties after a further 2 weeks when bony union was confirmed
AC C
Discussion:
EP
clinically and with radiographs (Fig. 4).
Complex defects in the distal third of the foot can be a challenging
problem for the reconstructive surgeon. Familiarity with distally-based flaps of the hand allows similar principles to be employed in the foot and may avoid the need for more complex flap repair. This is particularly apparent when the defect is small. Reconstructive options in this region include toe amputations, fillet flaps, cross leg flaps and free tissue transfer. Each of these has major potential
5
ACCEPTED MANUSCRIPT drawbacks. Toe amputation or fillet flap solve the immediate wound healing problem but distal amputation has been shown to lead to poorer outcomes in diabetic patients (7) and can have deleterious effects on balance in young, healthy patients(8). Cross leg flaps are two-stage procedures and require
RI PT
significant immobilization with resultant stiffness. Free tissue transfer has the disadvantage of being an expensive, time-consuming procedure with a distant donor site. Non-vascularized autogenous bone grafts can be utilized for small
SC
bony defects. However, their use is not recommended in contaminated wounds or in the presence of complex bone and soft tissue defects.
M AN U
In the foot, distally-based flaps have only been utilized previously for softtissue reconstruction. (3, 4, 9) The plantar-dorsal communicating arteries along with the DMA periosteal connections provide adequate blood supply for successful osteocutaneous flap harvest (10) and several clinical cases have been
TE D
reported in the hand surgery literature. (11, 12) Their usage in the forefoot is perhaps limited by the relative infrequency of small complex defects where toe
AC C
EP
salvage is the desired reconstructive outcome.
Acknowledgments: The authors would like to thank Veneliza Salcedo from the Mayo Clinic, Rochester, for production of the medical illustration.
6
ACCEPTED MANUSCRIPT
Conflict of Interest: None
AC C
EP
TE D
M AN U
SC
RI PT
Funding: None
7
ACCEPTED MANUSCRIPT List of References:
AC C
EP
TE D
M AN U
SC
RI PT
1. Maruyama, Y. The reverse dorsal metacarpal flap. British journal of plastic surgery 1990;43:24-27. 2. Quaba, A. A., Davison, P. M. The distally-based dorsal hand flap. British journal of plastic surgery 1990;43:28-39. 3. Hayashi, A., Maruyama, Y. Reverse first dorsal metatarsal artery flap for reconstruction of the distal foot. Ann Plast Surg 1993;31:117-122. 4. Sakai, S. A distally based island first dorsal metatarsal artery flap for the coverage of a distal plantar defect. British journal of plastic surgery 1993;46:480482. 5. Man, D., Acland, R. D. The microarterial anatomy of the dorsalis pedis flap and its clinical applications. Plastic and reconstructive surgery 1980;65:419-423. 6. Lee, J. H., Dauber, W. Anatomic study of the dorsalis pedis-first dorsal metatarsal artery. Ann Plast Surg 1997;38:50-55. 7. Peters, E. J. G., Childs, M. R., Wunderlich, R. P., Harkless, L. B., Armstrong, D. G., Lavery, L. A. Functional Status of Persons With Diabetes-Related LowerExtremity Amputations. Diabetes Care 2001;24:1799-1804. 8. Chou, S. W., Cheng, H. Y., Chen, J. H., Ju, Y. Y., Lin, Y. C., Wong, M. K. The role of the great toe in balance performance. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 2009;27:549-554. 9. Senyuva, C., Yucel, A., Fassio, E., Cetinkale, O., Goga, D. Reverse first dorsal metatarsal artery adipofascial flap. Annals of plastic surgery 1996;36:158-161. 10. Alagoz, M. S., Orbay, H., Uysal, A. C., Comert, A., Tuccar, E. Vascular anatomy of the metatarsal bones and the interosseous muscles of the foot. Journal of Plastic, Reconstructive & Aesthetic Surgery 2009;62:1227-1232. 11. Santa-Comba, A., Amarante, J., Silva, A., Rodrigues, J. Reverse dorsal metacarpal osteocutaneous flap. British journal of plastic surgery 1997;50:555558. 12. Kakinoki, R., Ikeguchi, R., Matsumoto, T., Nakamura, T. Reconstruction of a phalangeal bone using a vascularised metacarpal bone graft nourished by a dorsal metacarpal artery. Injury 2008;39 Suppl 4:25-28.
8
ACCEPTED MANUSCRIPT Figure Legend:
Figure 1: Diagrammatic representation of the arterial basis of the distally-based osteocutaneous DMA flap. DMA dorsal metatarsal artery, PMA palmar metatarsal
RI PT
artery.
Figure 2: Clinical photographs demonstrating: (left to right) A) the extent of
SC
injury to the plantar surface of the foot following traumatic crush injury by heavy machinery B) the distally-based flap raised on the second DMA and including the
M AN U
dorsal cortex of the second metatarsal bone with a segment of articular surface C) reconstruction of the articular surface of the head of the proximal phalanx of the hallux.
TE D
Figure 3: Clinical photograph demonstrating the healed weight-bearing plantar
EP
surface allowing mobilization without restriction at 8 weeks post-operatively.
Figure 4: Radiographs demonstrating: (clockwise from top left) A) comminuted
AC C
fractures to the 1st and 2nd toe proximal phalanges after severe crush injury B) comminuted fracture and defect of segments of the plantar articular surface and distal cortex of the hallux and C) lateral and D) AP views of the bone union of the reconstructed hallux at 6 months post-operatively.
9
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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EP
TE D
M AN U
SC
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ACCEPTED MANUSCRIPT
