SLR - December 2019 - Abimbola Johnson
Reference: Eubanks RD, Bowker HD, Al-Mufarrej. Innervated Dorsalis Pedis Advancement Flap for Burn Foot Contractures. Journal of Burn Care and Research. 2019. Jul [Epub ahead of print]Scientific Literature Review
Reviewed By: Abimbola Johnson, DPM
Residency Program: Regions Hospital/HealthPartners Institute – St. Paul, MN
Podiatric Relevance: Management of foot contractures secondary to burn scar tissue often presents with various complications, especially within the pediatric population. These contractures can result in hyperextension of the toes and cause secondary gait disturbances. Such contractures are even more debilitating in the pediatric population where patients are more active and possibly still learning how to walk. A V-Y dorsalis pedis advancement flap with concomitant metatarsophalangeal capsulotomy and extensor tenolysis allows for both release of contractures and provides adequate soft tissue coverage. Podiatric surgeons can benefit by using this technique to treat burn contractures while maintaining native vasculature and innervation to the area. This procedure can be more powerful than a z-plasty, but without the added operative time, donor site morbidity, cost, and hospital stay length of stay of a free flap.
Methods: This is a retrospective case series which took place from 2017-2019. Three (3) pediatric patients (ages five, six and nine) with gait dysfunction due to dorsal foot burn contractures underwent a V-Y advancement flap containing the dorsalis pedis artery and superficial peroneal nerve. All patients had failed prior treatments with steroid injections, split thickness skin grafts and physical therapy. This procedure was only utilized in patients with contracture release wounds of 3.5 centimeters width or less. The dorsal contracture is incised transversely over the metatarsophalangeal joints (MTPJ), then tenolysis and capsulotomy as of MTPJ is performed. K-wires are placed to hold the toes in neutral position. A triangular shaped myofasciocutanous skin flap, created from distal to proximal and preserving the extensor halluces brevis, is advanced 4 centimeters distally and laterally, covering the defect. The plantar artery and 1st dorsal metatarsal artery is typically ligated to increase mobility of the flap. Post-operatively, patients were non-weightbearing for three to four weeks, toes touching at four to six weeks, and return to full weightbearing at six to eight weeks. They had an average follow-up time of 1.5 years.
Results: All patients’ flaps healed without need for additional surgical intervention. Two patients developed small areas of superficial epidermolysis which healed with local wound care. Improved gait was noted by 9-12 weeks post-operatively in all three patients, and there were no re-occurrences during follow-up.
Conclusions: A single stage, dorsal foot V-Y advancement flap, containing the dorsalis pedis artery and superficial peroneal nerve, is a good option for severe dorsal foot contractures who have failed prior skin grafts, steroid injections, and z-plasties.
Contracture release does require a concomitant MTPJ capsulotomy and tenolysis to address elevated toe deformities, and the flap is limited to contractures with deficit width less than 3.5 centimeters. However, the flap can produce powerful results and the morbidity to the patient appears to be lower than with free flaps. This study provides also provides a technique that is reproducible and can be performed safely as an outpatient procedure.