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Complex Foot Reconstruction
Clinical Presentation
A 35-year-old White male sustained an accidental gunshot wound (GSW) to his left foot. The GSW (12 × 6 × 4 cm) was through-and-through to the medial aspect of the left midfoot with significant soft tissue loss. He also had a comminuted fracture of the first metatarsal with a 5-cm bony defect and complete destruction of the first metatarsophalangeal joint. The extensor hallucis longus tendon was completely destroyed. After initial wound debridement by the orthopedic trauma service, he was taken back to the operating room 2 days later for a second wound debridement by the orthopedic foot and ankle service. The bony stabilization of the first metatarsal was performed with K-wires at that time and the GSW of the left foot open fracture wound was filled with antibiotic beads. The plastic surgery service was consulted for soft tissue coverage of this complex foot wound with composite tissue loss ( Fig. 52.1 A and B).
Operative Plan and Special Considerations
For this relatively small but through-and-through composite defect of the foot, a free gracilis muscle flap can be an excellent choice for soft tissue reconstruction. The gracilis muscle is a type II flap. It is a narrow strap-like muscle (24 × 5 × 1.5 cm) with a pedicle length averaging 6 cm. It has become the author’s first choice to cover a small or medium-sized defect of the distal third tibial wound or foot. With many advances in surgical technique for flap dissection, the gracilis muscle can be used as a free muscle flap for various reconstructive needs. Its flap dissection can be relatively straightforward and pedicle length and size can be improved by dividing the branches of the medial circumflex femoral vessels to the adductor longus and brevis muscles. In this case, the proximal dorsalis pedis vessels could be dissected and used as recipient vessels for a comfortable and relatively easy end-to-end microvascular anastomosis. About 6 weeks after a free gracilis muscle flap transfer once the foot GSW healed, bone grafts could be performed to achieve fracture union of the first metatarsal.
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