Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review

Abstract

Background Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. Methods A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. Results A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Conclusion Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application

“…Sensory recovery, among important functional outcomes, has consequently received increasing attention during flap selection (Graham & Dellon, 1995). However, the requirement of the nerve coaptation for sensate reconstruction during the free tissue transfer remains an area of debate (Rinkinen et al, 2020). It has been reported that crude sensation could be noted in noninnervated flaps (Rothenberger et al, 2019), possibly by means of nerve ingrowth from the recipient wound bed into the flaps (Graham & Dellon, 1995).…”

“…On the other hand, an innervated flap, in which a nerve coaptation is performed during the free tissue transfer (Kaplan, 1969), has been reported to provide functionally meaningful sensory recovery such as light touch, pain sensation, and 2PD. The return of sensory in innervated flaps is also earlier than that of noninnervated flaps (Rinkinen et al, 2020; Santanelli, Tenna, Pace, & Scuderi, 2002). Santanelli et al (2002) compared the outcomes of free forearm flaps with or without sensory nerve coaptation for sole reconstruction.…”

“…Several free flaps have been used as sensate flaps with improved sensory recovery, such as radial forearm flaps (Baas, Duraku, Corten, & Mureau, 2015; Ma, Cheng, & Liu, 2011; Médard de Chardon, Balaguer, Chignon‐Sicard, et al, 2009), lateral arm flaps (Kalbermatten, Wettstein, von Kanel, et al, 2008), medial plantar flap (Hosseinian, Gharibi Loron, & Nemati, 2018; Löfstrand & Lin, 2018), and anterolateral thigh flaps (Luenam, Prugsawan, Kosiyatrakul, Chotanaphuti, & Sriya, 2016; Ribuffo, Cigna, Gargano, Spalvieri, & Scuderi, 2005; Rinkinen, Diamond, Lans, Cetrulo, & Eberlin, 2020). The PTAP flap has not been used as a sensory flap.…”

Fluorescence angiography-assisted debridement of critically perfused glabrous skin in degloving foot injuries

“…The epidermal layer is significantly thicker with ∼1.4 mm when compared to the integument of other anatomical areas. [ 5 , 6 ] Moreover, numerous fibrous septae anchor the cutaneous tissue to the plantar aponeurosis, resulting in lower shearing forces during ambulation and lobules of subcutaneous adipose tissue serve as an optimal shock absorbent. [ 7 , 8 ] Finally, the plantar sensitivity allows precise pressure detection, which is essential for weight redistribution while standing.…”

Synergistic effect of nanofat and mouse nerve-growth factor for promotion of sensory recovery in anterolateral thigh free flaps

“…Successful surgical repair and flap survival after transplantation are primary concerns, but reducing complications at the recipient site and achieving perfect reconstruction have long been the ultimate goal of reconstructive surgeons. Sensory disorders associated with ALT free‐flap reconstruction can result in poor functioning of repairs in regions such as the face, hands, feet, and perineum 5‐7 . Achieving a perfect repair with accelerated sensory recovery of recipient site has become a challenge to reconstructive surgeons.…”