Soft Tissue Reconstruction

with Diabetic Foot Tissue

Loss
Todd A. Hasenstein, DPMa, Timothy Greene, DPMa,
Jennifer C. Van, DPMb, Andrew J. Meyr, DPMb,*

KEYWORDS
 Excisional debridement  Gangrene  Infection  Partial foot amputation
 Soft tissue reconstruction  Fillet of toe  Spaghetti  Reconstructive elevator

KEY POINTS
 Diabetic foot tissue loss often occurs in predictable anatomic patterns. Knowledge of
these patterns can assist physicians in minimizing the initial tissue loss associated with
infection, as well as guide soft tissue reconstruction.
 The forefoot is the anatomic area most commonly involved in diabetic foot disease. A sys-
tematic approach to its evaluation and management might prevent more proximal
amputation.
 The midfoot, rearfoot, and ankle might be more amenable to soft tissue reconstruction us-
ing the principles as outlined by the reconstructive ladder.

Although it is likely that substantial contemporary advances have been made in the
treatment of diabetic foot disease with respect to patient education, preventative
measures, early intervention, and prophylactic procedures, it is still unfortunately
just as likely that most surgical interventions for this condition are reactionary in na-
ture.1–8 Patients still frequently primarily present to outpatient physician offices and
emergency departments with acute infectious events and resultant tissue necrosis.
By definition, the appropriate surgical intervention for this presentation results in a
soft tissue deficit, often with partial foot amputation, through the excisional debride-
ment of pathologic tissue. The science and art of minimizing this initial soft tissue
loss, along with subsequent reconstruction of the defect, forms the focus of this
article.

Disclosure Statement: The authors have nothing to disclose.

a
Temple University Hospital Podiatric Surgical Residency Program, 8th at Race Street, Phila-
delphia, PA 19107, USA; b Department of Surgery, Temple University School of Podiatric
Medicine, 8th at Race Street, Philadelphia, PA 19107, USA
* Corresponding author.
E-mail address: [email protected]

Clin Podiatr Med Surg 36 (2019) 425–440

https://doi.org/10.1016/j.cpm.2019.02.006 podiatric.theclinics.com
0891-8422/19/ª 2019 Elsevier Inc. All rights reserved.
426 Hasenstein et al

One potential advantage that surgeons have in treating this condition is that the tis-
sue loss that occurs secondary to infection presents in relatively predictable ways. In
fact, the pathway to tissue loss is usually simple: chronic pressure over osseous prom-
inences leads to ulceration, which represents a portal for infection and subsequent tis-
sue necrosis. Chronic pressure in the lower extremity further generally occurs in
expected anatomic locations for the forefoot, midfoot, and rearfoot.

FOREFOOT PATHOANATOMY, SURGICAL RESECTION, AND SOFT TISSUE

RECONSTRUCTION

The most frequent location for the occurrence of a diabetic foot ulceration is the fore-
foot.9–11 This is likely because of the unusual shape of the digits with increased surface
area and intimate bone-on-bone contact, the increased likelihood of the presence of
deformity, and the high percentage of the tissue that is bone as opposed to soft tissue
when considering volume. Consider the cross-sectional anatomy of a digit, for
example, and compare the ratio of bone/soft tissue of these appendages with more
proximal areas of the foot (Fig. 1). In other words, there is relatively more bone and
less soft tissue in the distal forefoot compared with other anatomic areas. Therefore,
an ulceration and infection must physically penetrate through less tissue to reach deep
anatomic structures and tissue planes. Specifically within the forefoot, the most com-
mon locations for initial ulceration are the distal tip of the digit, the dorsal aspect of the
proximal interphalangeal joint, and plantarly under the metatarsal heads. If infection
occurs in one of these areas, the subsequent patterns of tissue destruction might
be anticipated with application of anatomic knowledge.

Distal Digital Tip: Pathoanatomy

These ulcerations occur most frequently as a result of ill-fitting shoegear or sagittal
plane digital deformity resulting in increased load on the tip of the toe instead of the
plantar pulp (Fig. 2). Although this might certainly occur in a foot without a history of
diabetic foot disease, it is also likely to occur in a foot that has previously undergone
partial amputation as the musculoskeletal biomechanical balances are altered.12 The
resultant progressive tissue loss occurs primarily in a localized manner within the fat
pad on the plantar pulp. A probe might be expected to course directly deep to the
tuft of the distal phalanx and plantarly underneath the distal phalanx near the insertion
of the long flexor tendon. However, this is often also accompanied by tissue loss

Fig. 1. Cross-sectional anatomy of the foot. Note how the digits have a relatively high ratio
of bone to soft tissue, whereas more proximal areas of the foot have relatively more soft
tissue. Therefore, ulcerations and infections involving the digits have physically less tissue
to penetrate before there is involvement of bone and other deep tissue structures.
 Diabetic Soft Tissue Reconstruction 427

Fig. 2. Distal digital tip ulceration. Wounds commonly form on the distal aspect of digits
secondary to ill-fitting shoegear or sagittal plane deformity.

extension dorsally underneath the toenail leading to onycholysis and the creation of a
potential space between the nail bed and nail plate. It is the clinical experience of the
authors that this represents a common but somewhat underappreciated pathway to
development of infection. In our clinical practice, all distal wounds are aggressively
explored to ensure that there is no extension underneath the nail plate, and the nail
plate is removed in the setting of any clinical suspicion.
If an infectious process develops, then the tissue necrosis tends to initially stay
locally with chronic bone necrosis of the distal phalanx, but might also eventually
involve the tendinous planes of the flexor and extensor tendons. These tendons,
particularly the flexor tendon, are the pathway by which infection can course proxi-
mally into the foot from the distal toes.

Distal Digital Tip: Surgical Resection and Soft Tissue Reconstruction

Complicated soft tissue reconstruction is usually not required for infectious tissue loss
in this anatomic location. A portion or all of the bone of the digit is resected to a viable
bone/soft tissue margin with primary closure usually easily achieved. However, it is
important to investigate and decompress the remaining tendon tissue planes both
dorsally and plantarly to ensure that there has been no proximal infection progression
before closure. This is often done by means of the so-called “spaghetti” technique, in
which the resected distal tendon ends are isolated, pulled distally, and wound around
a hemostat to gain a more proximal resection margin of the tendon and decompress
the remaining tendon sheath (Fig. 3). Depending on the specific location within the
digit, different tendon patterns might be expected. Dorsally, the extensor trifurcation
acts more as relatively static dorsal ligaments to the interphalangeal joints than a lon-
gitudinal and pliable tendon, because the functional insertion of the extensor tendons
is into the extensor hood mechanism at the metatarsal-phalangeal joint level.13,14
Plantarly, multiple tendons might be encountered. Surgeons should expect to see a
single tendon centrally as the flexor digitorum longus that inserts onto the plantar
base of the distal phalanx, but might also expect 2 tendons on either side of this, rep-
resenting the split insertion of the flexor digitorum brevis onto the plantar base of the
middle phalanx.
The bone might be resected at interphalangeal joint level, essentially serving as a
joint disarticulation; another choice might be to remove the head and/or shaft of the
428 Hasenstein et al

Fig. 3. Spaghetti technique for proximal tendon resection. Because tendon planes represent
a common pathway for infection progression, it is important to identify, decompress, and
often proximally resect tendons during excisional debridement. This is commonly done by
isolating an individual tendon, pulling it distally, and winding it around a hemostat to
gain a more proximal resection margin of the tendon and to relatively decompress the re-
maining tendon sheath.

proximal segment (leaving the phalangeal base intact) to decrease the resulting lever
arm. Many find that this latter technique also has the additional benefit of being asso-
ciated with more pliable soft tissue for closure. When resecting the soft tissue directly
at joint level, one is likely to encounter the Grayson’s and Cleland’s ligaments, which
attach the deep structures to the dermis.15,16 These structures normally function to
maintain the position of the skin during digital flexion and extension, but this is of
course moot following amputation. However, the soft tissue between joints does
not contain these structures, and is therefore more supple and pliant, and might
make closure technically easier to perform.

Dorsal Interphalangeal Joint: Pathoanatomy

These ulcerations generally occur within the central digits (2, 3, and 4) and, as the
result of sagittal plane digital deformity with a relatively elevated head of the proximal
phalanx rubbing on shoegear (Fig. 4). There is very minimal soft tissue coverage be-
tween the dorsal skin and the deep tissue structures in this area, which include the
extensor hood mechanism, interphalangeal joint space, head of the proximal phalanx,
base of the middle phalanx, and flexor tendons in advanced cases. A similar infectious
process occurs in this area as the distal digit. The tissue loss initially remains relatively
local, with necrosis of the bone associated with the joint space, but may progress
proximally along the course of the extensor and flexor tendons.
Interdigital, or so-called “kissing lesions,” might also develop in and around the
interphalangeal joints secondary to the close bone-on-bone approximation of the
toes that occurs in the setting of deformity (Fig. 5). The pathway to infectious tissue
loss here is again similar to the preceding paragraph and section.

Dorsal Interphalangeal Joint: Surgical Resection and Reconstruction

This also does not often represent a challenging soft tissue reconstruction. In a similar
manner to distal digital tip ulcerations, the technically easiest procedure to perform is
 Diabetic Soft Tissue Reconstruction 429

Fig. 4. Dorsal interphalangeal joint pathoanatomy. Wounds commonly form on the dorsal
aspect of the proximal interphalangeal joints of the central digits secondary to sagittal
plane deformity. This represents a common portal for infection and tissue loss.

a primary amputation of the digit. This might be achieved in the form of a metatarsal-
phalangeal joint disarticulation, or by leaving the base of the proximal phalanx intact if
viable. This latter technique might help to provide a natural spacer between adjacent
digits and maintain some of the insertion of the extensor hood mechanism,

Fig. 5. Interdigital lesions pathoanatomy. Wounds commonly form between digits in the
presence of deformity secondary to increased pressures caused by abnormal bone-on-
bone contact.
430 Hasenstein et al

interosseous muscles, and plantar metatarsal-phalangeal ligament/plate. This might

be argued to be a more intrinsically stable anatomic construct in comparison with
leaving a relatively large void following metatarsal-phalangeal disarticulation.
Once again it is important to inspect, decompress and proximally resect the remain-
ing tendon tissue planes both dorsally and plantarly to ensure that no proximal pro-
gression of infection has occurred before closure. At this level it might also be of
benefit to investigate and decompress medially and laterally about the metatarsal-
phalangeal joint into the adjacent interspaces.
If the tissue necrosis is localized to the interphalangeal joint and primarily involves
bone without substantial distal soft tissue loss, then one might consider performing
a so-called “internal amputation” for soft tissue reconstruction in this anatomic
area.16 This is essentially similar to an arthroplasty procedure with a dorsal incision
on the toe, resection of all pathologic bone and other soft tissue, and primary closure.
Although the remaining toe might not be expected to maintain substantial function,
this is a reasonable option if most of the soft tissue is viable (primarily evaluated by
intraoperative inspection and distal capillary refill) and there is no infection progression
along tendon tissue planes. At the very least this will provide a natural spacer for the
adjacent tissue and avoid any negative connotations of the patient with respect to hav-
ing an “amputation” performed.

Plantar Metatarsal Heads: Pathoanatomy

Increased plantar forefoot pressure from several potential sources (eg, underlying
equinus deformity, plantar fat pad atrophy, previous amputations resulting in transfer
lesions) might lead to a localized wound directly plantar to a metatarsal head.17–19 In
this location, the flexor tendons are anatomically encountered before the bone and
represent a common course of proximal infection progression (Fig. 6). This occurs
so frequently, in fact, that one might even argue that physicians should assume that
infection is tracking toward the medial plantar vault along the flexor tendons in the
setting of any acute signs or symptoms of infection, and rule it out with their examina-
tion techniques and/or advanced imaging. It is the clinical experience of the authors
that the finding of epidermolysis of ulcerations in this anatomic location in a physical
examination is a concern (see Fig. 6). Even superficial epidermolysis seems to be
strongly associated with underlying infection tracking along flexor tendons toward
the medial plantar vault, despite the presence of an otherwise stable appearing
chronic wound.
This anatomic location is also concerning for progression of infection and tissue loss
distally into the associated digit, superiorly into the metatarsal-phalangeal joint space
and adjacent metatarsal-phalangeal joints, and marginally into adjacent intermetatar-
sal spaces. It is not uncommon, for example, for a cotton-tipped applicator to probe
from a plantar metatarsal head wound straight out of the dorsal tissue.

Plantar Metatarsal Heads: Surgical Resection and Soft Tissue Reconstruction

Soft tissue reconstruction of these areas represents more of a clinical challenge
because of a greater resultant soft tissue deficit, which usually follows appropriate
resection. For isolated central metatarsal head tissue loss and infection, the affected
soft tissue and bone might be resected either directly plantarly through the wound or
through a separate dorsal incision over the metatarsal-phalangeal joint. The dorsal
approach might be argued to offer the advantages of easier visualization of the resec-
tion margin of the metatarsal, the proximal phalangeal base, the adjacent metatarsal-
phalangeal joints, and the adjacent interspaces. The relatively avascular plantar plate
should be completely resected, and exploration, decompression, and proximal
 Diabetic Soft Tissue Reconstruction 431

Fig. 6. Pathoanatomy of plantar metatarsal head ulcerations. Plantar metatarsal head ulcer-
ations are a common area of pathology and infection development. It is imperative to
examine for infection development along the course of the flexor digitorum longus tendons
in these wounds, even in the setting of a stable appearing chronic wound (left). It is the
experience of the authors that any epidermolysis (center) is a very concerning sign of infec-
tion coursing proximally along the tendon to the medial plantar vault. This tendon travels
primarily within the central plantar compartment, meaning that, even in situations of severe
infection (right), the medial and lateral plantar compartment musculature might remain
viable.

resection of the extensor and flexor tendons should be performed using the “spa-
ghetti” technique. In this anatomic location, proximal to the metatarsal-phalangeal
joints, both a short and long extensor and a flexor tendon associated with each digit
would be expected.13
Careful intraoperative attention should be directed to the course of the flexor ten-
dons and the viability of the remaining plantar soft tissue. The flexor digitorum longus
tendons travel within the central compartment of the plantar foot. This means that,
even in the setting of substantial infection within the central compartment, the viability
and vasculature of the medial and lateral plantar compartments might be maintained.
In other words, a more proximal partial foot amputation might not be required if one is
able to preserve this peripheral tissue (see Fig. 6). Preserved medial and lateral plantar
compartments can maintain foot length and serve as a good base for soft tissue
reconstruction. This is because the tissue is primarily muscular in the form of the
abductor hallucis and flexor hallucis brevis muscles medially, and abductor digiti min-
imi muscle laterally. A local rotational flap might even be a good option for reconstruc-
tion of central compartment tissue loss.20
In terms of the initial plantar ulceration, one might choose to allow the wound to heal
by secondary intention (as usually occurs relatively easily once the osseous promi-
nence and pressure are removed), excise and primarily close the wound with a 3:1 el-
lipse, or perform a local rotational skin flap.20–23
Marginal plantar metatarsal head wounds (ie, the first and fifth metatarsal heads)
often pose even more of a challenge for soft tissue reconstruction. Because of their
eccentric location, primary closure is difficult because of the extent and specific loca-
tion of the tissue loss (Fig. 7). Special care should be taken to assess for the viability of
432 Hasenstein et al

Fig. 7. Marginal plantar metatarsal head wounds. Plantar metatarsal head lesions involving
the first and fifth metatarsal heads are associated with a greater degree of tissue loss and
are often not easily amenable to direct primary closure.

the abductor hallucis muscle (medially) and abductor digiti minimi muscle (laterally),
because this will likely determine the level of the metatarsal bone resection. In other
words, in this peripheral location, there is not much advantage to leaving behind a rela-
tively long, but viable remnant metatarsal shaft if the muscle on top of it is nonviable.
For infections involving the first and fifth metatarsal heads, the authors prefer to sac-
rifice remnant metatarsal length for muscular coverage during closure. We have found
that the length of the remaining metatarsal is less important, as long as the tendinous
insertions can be maintained on the metatarsal bases. This includes the tibialis ante-
rior tendon and peroneus longus tendon on the first metatarsal base, and the peroneus
brevis tendon on the fifth metatarsal base. Although there is certainly a risk for the
development of transfer lesions with partial first and fifth ray resections, we have
not found this risk to be substantially increased based on a relatively long or short
remnant segment. This might represent an interesting avenue for future investigation.
It is also important to appreciate that, just because the infection occurs at the level
of the metatarsal-phalangeal joint, the associated digit is not necessarily a lost cause.
If the soft tissue of the distal digit remains viable, then there is no need to amputate it
without exemption. A similar “internal amputation” might be performed here with
resection of only the metatarsal head and not the digit (Fig. 8). Once again the inciting
ulceration might be allowed to heal by secondary intention or excised with primary
closure.16
 Diabetic Soft Tissue Reconstruction 433

Fig. 8. Internal amputation of a marginal plantar metatarsal head wound. These images
demonstrate the progression of a marginal metatarsal head wound. Initially the patient pre-
sented with an infected fifth submetatarsal head wound with clear radiographic evidence
of cortical destruction. Instead of performing a partial fifth ray resection, an internal ampu-
tation of the affected bone was performed with preservation of the digit distally. The
wound healed by secondary intention in a matter of weeks, maintaining the length and
width of the foot.

A final option for soft tissue reconstruction of this anatomic area is by using the fillet
of toe technique when the digit remains viable.24–28 This results in amputation of the
digit, but allows for use of distal viable soft tissue as a local rotational flap to help pri-
marily close a large proximal soft tissue deficit (Fig. 9). This might be considered when
the soft tissue deficit following a single ray amputation is so extensive that a transme-
tatarsal amputation is considered for closure. The procedure involves a marginal inci-
sion down the side of the digit, excision of the nail bed/plate, and removal of the
phalanges of the digit, but preservation of the skin and subcutaneous tissue. This is
then rotated into the soft tissue deficit and remodeled as needed depending on the
specific shape of the deficit. The resulting incision often resembles a baseball, in which
the dorsal foot and plantar foot are joined by rotated digital tissue.

MIDFOOT PATHOANATOMY

Primary midfoot tissue loss is relatively less common and is generally found plantarly, and
associated with substantial underlying osseous deformity such as Charcot neuroarthrop-
athy, but may also be caused by acute trauma such as a puncture wound or shoegear irri-
tation. In this location there is relatively more soft tissue depth between the skin and deep
tissue structures in comparison with the forefoot. The pathway of tissue loss and infection
progression depends on the specific location of the portal, and might have a tendency to
stay within a specific plantar muscular compartment (ie, medial, central, or lateral
compartment) before progressing proximally or distally. In Charcot neuroarthropathy,
for example, the most common location of breakdown is the plantar midfoot, with resul-
tant osseous deformity occurring laterally under the cuboid (Fig. 10) or medially under one
of the bones of the medial column (first metatarsal base, medial cuneiform, navicular, or
talus) depending on the specific pattern of deformity (Fig. 11).
Laterally, physicians should appreciate that this ulceration location is in very close
anatomic approximation to the peroneus longus tendon coursing around the promon-
tory of the cuboid. In a small series of our own patients with midfoot Charcot
434 Hasenstein et al

Fig. 9. Fillet of toe technique for soft tissue reconstruction of forefoot ulcerations. The fillet of
toe technique involves amputation of the digit, but a local rotational flap of distal viable tissue
helps close a proximal soft tissue deficit. (Courtesy of K. Kwaadu, DPM, Philadelphia, PA.)

neuroarthropathy (n 5 14), a musculoskeletal radiologist was able to appreciate ten-

dinopathy of the peroneus longus on magnetic resonance imaging in almost 90% of
cases (see Fig. 10). Hence, acute infection here can quite easily traverse from the
lateral to central to medial compartments of the plantar foot toward the tendon’s inser-
tion on the first metatarsal base, or proximally along the lateral rearfoot and up the
lateral ankle.
Medially, the tissue loss is usually in close approximation to the abductor hallucis
muscle. It is our opinion that the viability of this muscle is of the utmost importance
with respect to soft tissue reconstruction. If viable, then the muscle can be used
directly into any closure with local rotation, or at least indirectly as a base for tissue
ingrowth. If nonviable, then a large section of tissue in the medial foot is at risk from
its calcaneal origin to digital insertion. One should also be aware that communication
is possible from the medial to central plantar compartments through the specific anat-
omy of the Knot of Henry at the crossing of the flexor hallucis longus and flexor digi-
torum longus tendons (see Fig. 11).29
Dorsally, substantial tissue loss might result with acute infections coursing up the
extensor tendons.

MIDFOOT SURGICAL RESECTION AND SOFT TISSUE RECONSTRUCTION

Excisional debridement and surgical tissue resection in the midfoot, whether dorsally
or plantarly, might result in a larger soft tissue deficit than seen in the forefoot. And to
 Diabetic Soft Tissue Reconstruction 435

Fig. 10. Common presentation of lateral midfoot plantar tissue loss. In the setting of under-
lying Charcot neuroarthropathy, chronic wounds commonly present underneath the cuboid
and anterior calcaneus. Physicians should be cognizant of the close anatomic approximation
of these wounds to the peroneus longus tendon, which is often affected and might serve as
a portal to infection.

some degree it is less likely that direct primary closure might be achieved secondary to
this. Therefore, this anatomic area is likely to be more amenable to soft tissue recon-
struction involving the concepts as outlined by the reconstructive ladder. The concept
of the reconstructive ladder was conceived in 1982 when Mathes and Nahai published
the book Clinical Application of Muscle and Musculocutaneous Flaps.30 The goal of the
reconstructive ladder was to create a systematic and stepwise way of approaching
complicated wound closure. Although many specific rungs on this ladder are covered
in greater detail as individual articles of this edition of Clinics, they warrant at least a
mention here.
The first rung on the ladder is basic local wound care allowing for healing by second-
ary intention, essentially consisting of topical bandages and wound care products.
Although saline wet-to-dry bandages were once considered a standard of wound
care, contemporary advances in the form of bioengineered alternative tissues, nega-
tive pressure wound therapy, and other topical treatments have essentially made this
form of intervention obsolete as an initial line of therapy, except in situations of more
palliative or maintenance wound care. In fact, several have instead now advocated for
a concept of a reconstructive “elevator” instead of “ladder.” Within this paradigm one
might “skip ahead” to the most likely effective treatment as opposed to failing each
individual stage before progressing to more advanced options.31,32
The second and third rungs on the ladder are primary wound closure and secondary
(delayed) wound closure. With respect to soft tissue deficits in the setting of diabetic
436 Hasenstein et al

Fig. 11. Common presentation of medial midfoot plantar tissue loss. Medially physicians
should be cognizant of the viability of the abductor hallucis muscle which might be used
for closure, and the potential for communication of infection at the Knot of Henry between
the flexor digitorum longus and flexor hallucis longus tendons.

foot disease, all infection must be resolved before closing the soft tissue envelope. For
this reason, primary closure is relatively rarely performed during the first surgical inter-
vention. Instead, the wound is packed open or left open with negative pressure wound
therapy for 48 to 72 hours. If cultures remain negative and the wound does not demon-
strate continued acute local signs of infection, then it might be closed during a sec-
ondary procedure. This concept of routine serial debridements approximately every
48 to 72 hours has been well studied and represents established practice at many
sites.33 Some evidence, however, has demonstrated that surgical debridement and
closure as a single-stage procedure might not be detrimental as is sometimes
supposed.34
Moving up the ladder, the next transitions are to consider split-thickness and full-
thickness skin grafts. These represent a relatively efficient option for large wounds,
because epithelial cells only migrate from the peripheral margin of wounds toward
the center. Skin grafting allows for a relative reduction in the wound area and can
dramatically decrease the physical distances that need to be covered for complete
epithelialization. Although once considered too fragile for use on the weight-bearing
areas of the plantar foot, more contemporary evidence has demonstrated that skin
grafting might be considered even for plantar foot wounds.35
The final steps on the ladder are local rotational flaps, pedicled flaps, and free flaps.
These are covered in greater detail in other articles of this Clinics edition, but it is
important to consider here that these also should be considered as viable options in
patients with diabetes. Patients with diabetes are certainly at increased risk for post-
operative complication following foot and ankle surgery,36 but again contemporary
 Diabetic Soft Tissue Reconstruction 437

evidence has demonstrated that these procedures can be relatively safe and effective
in this cohort.37,38

REARFOOT/ANKLE PATHOANATOMY

The final anatomic area of interest is the rearfoot and ankle, where potential osseous
prominences include several surfaces of the calcaneus, lateral malleolus, medial mal-
leolus, and fibular head. In these locations, the course of extrinsic tendons of the leg,
which run in close approximation to these osseous structures, must be taken into
consideration. Laterally, this would include the peroneus longus and peroneus brevis
tendons, whereas medially this would primarily include the posterior tibial tendon and
flexor digitorum longus tendon. Directly posterior, ulcerations are more likely to involve
proximal extension along the Achilles and plantaris tendons.
Tissue loss in these areas is likely most commonly the result of chronic pressure in
patients with a history of an acute or chronic nonambulatory state, or from an acute
trauma. Particularly in nonambulatory patients, pressure ulcerations are quite com-
mon in and around the heel. Although generally this is likely to occur posteriorly, it
is important to appreciate that it is probably not directly posteriorly. Most individuals
have a tendency to lay with their limbs externally rotated, and therefore the tissue loss
is most common on the posterior-lateral aspect of the heel, as opposed to posterior-
medially or directly posteriorly.39 This is important from an arterial inflow perspective
as these locations lie in 3 different angiosomes. The more common posterior-lateral
ulcerations are almost completely supplied by the peroneal artery. Assessment of
this artery is often lacking, although it is certainly relatively easy to assess perfusion
through this vessel by means of Doppler examination and noninvasive vascular
testing.40 Whereas posterior-medial ulcerations are within the angiosome of the pos-
terior tibial artery, and directly posterior ulcerations are likely to have a dual flow
through the posterior tibial and peroneal arteries. Just a few centimeters of anatomic
space imply vastly different arterial perfusion patterns in this location.
Heel decubitus ulcerations are somewhat unlikely to occur in active, ambulating,
and highly functional patients. For this reason, it is important to assess the whole pa-
tient in these clinical situations and to develop realistic mutual expectations of inter-
vention. If a patient is nonambulatory before your intervention for a chronic heel
wound, for example, it is unlikely that they will become ambulatory, even with suc-
cessful reconstruction of the soft tissue. For this reason, deep tissue might be rela-
tively aggressively resected whether from the calcaneus, distal fibula, or Achilles
tendon. This level of aggressiveness with respect to deep tissue resection might
help achieve direct primary closure of the soft tissue envelope.
A good example of this is with respect to partial calcanectomy procedures. Oliver
and colleagues41 recently described a technique involving resection of most of the
calcaneus with direct primary closure. They reported success with this technique
including having most patients able to ambulate following the procedure.
Because of the relatively large soft tissue defects that are often present, this area
also represents a good opportunity for advanced techniques relatively high up the
reconstructive ladder. Reverse sural flaps, for example, have been recently described
for coverage of the rearfoot and ankle in the setting of diabetic tissue loss.37,38

SUMMARY

The primary clinical take home point for this article is for physicians to use known
anatomic information to expect, and to some degree predict, the soft tissue loss
that will occur with diabetic foot infections. This knowledge can be applied to minimize
438 Hasenstein et al

deficits during excisional debridement, and guide both simple and complex soft tissue
closures.
One relative problem with respect to the literature on diabetic foot disease has been
a lack of universally established outcome measures. In other words, is it more impor-
tant that a wound heals quickly, or heals completely, or heals completely without
recurrence, or heals without causing patient symptoms, or maintains patient function,
or a dozen other reasonable measures? We do not claim to know the correct answer
to this question, but in our practice we aim to achieve an intact soft tissue envelope as
quickly as possible. Whether a wound be large or small, any wound of any size means
that each morning the patient wakes up and has to deal with it in terms of dressings,
bathing constraints, off-loading shoegear protocols, activity limitations, driving restric-
tions, frequent physician visits, long courses of antibiotics, and so forth. Only once the
soft tissue envelope is intact can the patient begin a return to relative normalcy.

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