Plantar forefoot reconstruction: A proposal of a management algorithm based on a case series analysis: Plantar forefoot reconstruction.

[BACKGROUND] Several loco-regional flaps have been described for plantar forefoot coverage. We, herein, report our single-centre experience in plantar forefoot reconstruction and propose a decision-making process based on the defect's size.

[METHODS] This is a retrospective case series study of all patients who underwent plantar forefoot reconstruction in a 10-year period. We propose a treatment algorithm, based on the defect size. Defects are classified into small, moderate and large. Small defects (<10cm) can be covered with the hemi-pulp toe flap. Patients with moderate defects (10-25cm) can be treated with the reverse medial plantar artery flap (MPAF) from the instep area. For large defects (>25cm), we recommend regional flaps, that is the distally based sural flap (DBSF) from the ipsilateral calf, or free flaps, such as the anterolateral thigh flap (ALT) or the skin-grafted gracilis flap.

[RESULTS] The data of 51 patients were collected and analysed. The median age was 58 years (range 19-84). Nine patients had small defects and underwent hemi-pulp toe flap reconstruction. Three patients presented with moderate defects that were covered with reverse MPFs. The vast majority of the patients (39 patients) had large defects. Of these, eight cases were treated with DBSF and 31 cases with free flaps. Free flap transfers were successful in 97% of the cases. Overall complication rate was 25%.

[CONCLUSION] We conclude that local flaps should be preferred in plantar forefoot reconstruction as they provide like-tissue for small to moderate defects, for large defects regional flaps or free flaps were indicated. A defect-based approach can facilitate the decision-making process.