Kubilay Erol, Can Yener, Erdem Er, Özgün Barış Güntürk, Tulgar Toros
Joint Diseases and Related Surgery - 2026;37(2):422-430
Reconstruction of traumatic soft tissue defects of the forefoot poses a challenge for orthopedic surgeons. This area has thin, yet durable and elastic soft-tissue coverage which can withstand prolonged pressure and impact forces. Due to the scarcity of neighboring soft tissues, local flaps have limited use in the foot and are mainly used to cover limited defects. Although superficial soft tissue loss without bone and tendon exposure is amenable to secondary closure and skin grafting for certain injuries, deeper defects with exposed bones, tendons, nerves, and arteries necessitate flap coverage from distant donor sites for satisfactory results. Pedicled or local flaps harvested from the neighboring soft tissues are usually regarded as first-line flaps for reconstruction; however, due to the small size and limited reach of these flaps, sizeable defects cannot be reconstructed successfully using these alternatives. In most injuries, the donor site of local flaps lies within the injury zone, increasing the complication rates and even flap failures compared to their free counterparts. In addition, sacrificing a feeder artery at the injury zone to harvest a local flap may increase the vascular compromise of the injured segment of the foot and endanger the viability of the traumatized tissues. The soft tissue coverage of the dorsal and distal sides of the foot is thin and pliable, which is an essential factor for function and ambulation. Reconstruction of forefoot necessitates thin flaps to achieve proper function and unrestricted shoe wearing. Although modern supra fascial dissection techniques may decrease the soft tissue bulk of the majority of free flaps, this practice is not used commonly by many surgeons, since it endangers micro circulation within the flap in the acute phase and may decrease the rate of flap survival. Due to the unmatched thickness of the proximally located flaps harvested from the lower extremities (such as the commonly used anterolateral thigh (ALT) flap or groin flap), these options are not regarded as perfect alternatives for coverage of the dorsal side and distal end of the injured foot. Recently, early flap coverage has become the gold standard in traumatic soft tissue reconstruction to limit scar tissue formation at the injury site, preserve the elastic properties of soft tissues, prevent infection and additional soft tissue necrosis. Secondary coverage by regeneration of granulation tissue and skin grafting is prone to development of chronic infection at the reconstruction site and results with a fragile soft tissue coverage which is prone to ulceration that cannot tolerate prolonged stress imparted at the weight-bearing areas and distal end of the foot. Secondary wound closure creates a non-elastic soft tissue coverage that limits the range of motion (ROM) of the metatarsophalangeal joints which is considered an essential factor for physiological ambulation. It may also cause adhesion of the tendons further limiting movement and physiological motion of the forefoot. At this point, the lateral arm flap becomes a prominent alternative for the reconstruction of sizeable forefoot soft tissue defects, fulfilling the major requirements of reconstruction that have been discussed previously. This flap is thin and pliable and can be harvested in dimensions of up to 6 x 12 cm. It has a constant and large pedicle, causes minimal donor site morbidity, does not sacrifice a major artery, its dissection is quick and straightforward and has a rich vascular supply. In the present study, we aimed to evaluate the results of traumatic soft tissue defects of the forefoot reconstructed using the lateral arm flap and to examine the advantages and disadvantages of this flap.
