Salvage Reconstruction of the Severely Traumatized Foot and Ankle

Posttraumatic foot and ankle salvage is a major reconstructive challenge particularly in the weight bearing area. In recent years, still respecting the concept of the reconstructive ladder and a large armamentarium of local and regional flaps, free flap transfer has become more and more important in the severely traumatized distal extremity. An interdisciplinary approach involving orthopedic, vascular and plastic surgeons is mandatory. Aggressive debridement and early flap coverage within the first 3 to 4 posttraumatic days carries the lowest risk for soft tissue infection, osteomyelitis, and flap failure. The weight bearing area needs a stable and durable coverage with adequate bulk to allow normal shoewear. Sensitivity in terms of reinnervation is not necessary for a stable long-term outcome. The non-weight-bearing area requires a thin coverage for an appealing esthetic outcome. Neither the weight-bearing nor the non-weight-bearing area of the foot and ankle is a widely accepted gold standard for free flap coverage. We prefer adipocutaneous flaps particularly the anterolateral thigh flap. Adipocutaneous flaps make revisional surgery easier. Skin to skin coverage provides an esthetically more satisfying result. Muscle flaps such as the gracilis flap can provide comparable results even though the overall esthetic aspect might be lower. Muscle flaps are best suited for 3-dimensional defects. In case of infection, muscle flaps are well suited but the clinical outcomes of adipocutaneous flaps show comparable results. Also important for choosing the adequate free flap for coverage is not only the type of tissue, but its application, intraoperative trimming, and postoperative thinning.