Coverage problems of the foot and ankle.

Difficult wound coverage problems about the foot and ankle can occur secondary to trauma, osteomyelitis, foot deformities, tumors, or neuropathies (in particular, diabetes mellitus). Coverage can be difficult because of the special weight-bearing properties of the foot, the lack of intervening muscle between the skeletal elements and the integument, and the limited mobility of the overlying integument. Sorting out the 40 to 50 flap options for the foot and ankle requires a classification that describes the wound, the patient, and the available surgical options. The wound is classified based on size, anatomic location, and the presence or absence of infection. The anatomic location also describes the weight-bearing characteristics of the wound. Associated arterial, nerve and skeletal injuries are noted. A very small wound is less than 2 X 2 cm. A small wound is from 2 X 2 to 4 X 5 cm. A medium wound is from 4 X 5 to 7 X 7 cm. A large wound is from 7 X 7 to 10 X 20 cm, and a very large wound is from 10 X 20 up to 15 X 40 cm. Does the wound involve weight-bearing skin? Patient considerations include age and the presence of systemic or local compromise. Tobacco use, cosmetic concerns, occupation, rehabilitation potential, and amputee prejudices should be ascertained. Flap options can be classified as local transpositional, island pedicle, distant pedicle, and free-tissue transfers. The flaps may or may not incorporate muscle that may be needed for revascularization and dead space management in osteomyelitis. Some flaps are inappropriate because of local artery or nerve injuries. Some flaps will provide sensate coverage, and others can provide reinnervation potential. The potential to create new neuromas, ease of dissection, flap reliability, and cosmesis of the donor site are all important considerations.