Reconstruction of an Extensive Plantar Defect with Two Simultaneous Free Flaps: A Case Report.

Heel reconstruction after tumor ablative surgery or trauma presents the patient and the clinician with difficult treatment choices1-3. The heel region has complex osseous interactions, ligamentous slings, and unique skin coverage that provides sufficient cushion, all of which are crucial for normal gait4. Although there are regional pedicle flap options, reconstruction of these complex tissue defects usually requires free flaps. Regional fasciocutaneous flaps can resurface the defect efficiently. However, when there is a complex tissue defect that includes the calcaneus, more complex treatment options are needed5. In this case report, we describe how we reconstructed the heel region in a patient with an extensive plantar defect, with simultaneous use of free iliac crest and latissimus dorsi muscle flaps. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A forty-nine year-old man presented with a Marjolin ulcer on the right heel. He had an ulcerated and vegetating mass that measured 14 × 7 cm (Fig. 1). An incisional biopsy revealed squamous-cell cancer. Physical examination and preoperative computed tomography (CT) demonstrated calcaneal invasion and excluded lymph node involvement. He had difficulty walking and had moderate pain. The American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score was 626. The tumor was stage III, which necessitated amputation of the foot. However, because the patient would not consent to amputation, the surgical team formulated an alternative plan. Fig. 1 Preoperative photograph of the ulcerated mass, which covered nearly the entire sole region. The calcaneus, the flexor hallucis longus tendon, the posterior tibial tendon, and the flexor digitorum longus tendon were resected along with two-thirds of the sole of the foot. The Achilles tendon was stripped off of the calcaneus. After wide resection of the tumor and …