Introduction: The difficulties encountered on reconstructing the ankle and foot are: 1. lack of regional large bellies available for transfer, 2. need for reconstruction of durable weight bearing surface. A systematic approach is presented.

Material and Methods: During the last 10 years, 72 flaps were performed on 64 patients, age 2 to 75 years (mean 37 years). The choice of the flap was based on the size, nature and location of the defect and the vascular status of the limb. Regional flaps were avoided on severely traumatized extremities, on diabetic limbs or on patients with vascular impairment. If vascular impairment was present, a bypass graft to restore limb circulation preceded the flap transfer, or an AV loop was used to provide circulation to the flap. Twenty regional and 52 free flaps were used:

Regional: Extensor digitorum brevis (4), dorsalis pedis (2), lateral calcaneal (9), medial plantar (4), flexor digitorum brevis (1). Free flaps: a. Fasciocutaneous (8): deltoid (4), scapular (1), radial forearm(1), lateral arm (1), groin (1). b. Myocutaneous (3)

c. Skin grafted muscle (41): latissimus dorsi (26), rectus abdominis (4), gracilis (11).

Fifteen regional and 6 free flaps were sensory; protective sensation was achieved in all cases. Nine regional and 20 free flaps were used on plantar defects. Nine limbs with vascular impairment, 4 of which had arterial bypass grafts, were successfully reconstructed with free flaps.

Results: Complications included a partial loss of a regional flap and one free flap failure. One free flap was aborted, due to recipient vessels fibrosis, because of an extended zone of injury. In long – term follow – up ulceration developed on 2 skin grafted muscle free flaps covering heel defects. These were resolved by refashioning of the flap and using special foot wearing. In addition, one extremity was amputated, in spite of successful free flap coverage, because of persistent osteomyelitis and destruction of the ankle joint.

Conclusions: An algorithm for coverage of ankle and foot is suggested:

Sensory flaps are preferable for plantar surface reconstruction, although skin grafted muscle may be adequate. Custom made foot wearing is frequently necessary in cases of plantar defects.