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C OPYRIGHT Ó 2012 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Anchorage of Partial Avulsion of the Heel Pad

with Use of Multiple Kirschner Wires
A Report of Four Cases
Riazuddin Mohammed, MS Ortho, MRCS(Edin,UK), and Sreenivasulu Metikala, MS Ortho, MRCS(Edin,UK), MRCpS(Glasg,UK)

Investigation performed at Sri Venkateswara Ortho & Trauma Clinic, Kadapa -A.P., India

H
eel pad injuries, although uncommon, pose a difficult
challenge because of the unique and complex nature
of the fat pad structure. The tight honeycomb ar-
rangement of elastic fibrous septa enclosing closely packed fat
cells has evolved in order to accept very high loading stresses
during gait. This specialized anatomy renders the heel tissue
irreplaceable in the event of serious injury.
Partial or complete degloving of the heel pad can oc-
cur, often as a result of road accidents. It may be associated
with a skeletal injury or polytrauma1. Complete or subtotal
avulsions of the heel pad, or those with extensive neuro-
vascular damage, will need replantation with use of micro-
vascular surgical techniques2,3 or reconstruction with soft-tissue
flaps1,4,5.
In situations of partial avulsion, when the sensation is
intact and the heel pad is viable, it may be possible to debride
and reattach the flap. Simple suturing to reattach the heel
edges may not be secure enough, or it can lead to increased
wound pressure, resulting in wound breakdown, infection,
and flap necrosis6. This report describes a technique with use
of multiple Kirschner wires (K-wires) to reattach a partial
heel pad avulsion without the use of sutures in four patients.
To our knowledge, this is the first report of this method
of anchoring the partially avulsed heel pad with successful
outcomes. All four patients were informed that data concern-
ing their cases would be submitted for publication, and they all
provided consent.
Surgical Technique
contamination, soft-tissue loss, skeletal injury, and sensation
and viability of the degloved flap. The patient is counseled
about the potential complications of replantation and the
possible necessity for additional surgical procedures, in-
cluding amputation. Radiographs are obtained to identify
any skeletal injury. A third-generation cephalosporin anti-
biotic, along with sulbactam, is administered intravenously
preoperatively.
Under a general or regional anesthetic, the wound is re-
assessed without the use of a tourniquet. Thorough debridement
and copious wound lavage are performed. The heel pad is se-
curely anchored to the calcaneus with multiple 1.8-mm K-wires.
The first few K-wires are inserted with an aim to grossly secure
the avulsed flap in the correct anatomical position. Additional
wires are then inserted as required to ensure that the flap is
secured in a stable fashion to the underlying bone. The distance
between the wires should be approximately 2 cm. In order to
prevent the development of wound tension, we attempt to not
place any wires close to the skin wound edge. Furthermore,
in order to minimize wound tension, the skin wound is not
sutured.
A light compressive dressing is then applied, and the foot
is protected in a plaster splint. An oral antibiotic combination
of a third-generation cephalosporin and clavulanic acid is ad-
ministered for one week.
The patient is allowed toe-touch weight-bearing with the
use of walking supports. Regular normal saline dressings are
used to aid wound healing by secondary intention. The K-wires
are removed after four weeks in an outpatient procedure, and

F ollowing initial assessment and resuscitation of the pa-

tient according to the Advanced Trauma Life Support
protocols, acutely presenting partial heel pad avulsion in-
juries are assessed for the extent of the degloving, wound
the patient is permitted to progress to full weight-bearing as
tolerated by eight weeks. Wound and flap healing is assessed
weekly, and the patient is discharged when no additional prob-
lems are anticipated.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this
work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

JBJS Case Connect 2012;2:e20 d http://dx.doi.org/10.2106/JBJS.CC.K.00114

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TABLE I Case Details

Case 1 Case 2 Case 3 Case 4

Age (yr)/sex* 53/M 56/M 35/F 46/F

Side Right Right Right Right
Mechanism of injury Fall in a shallow well Heavy rock landed Fall from a motor vehicle Run over by a motor vehicle
on the heel
Occupation Farmer Farmer School teacher Housewife
Risk factors Smoker Smoker None None
Time to procedure (hr) 12 6 3 8
Associated fractures None None Lateral cortical Lateral cortical break
break of calcaneus of calcaneus
Other injuries Right distal radius fracture None None None
Operative time (min) 40 40 30 30
Follow-up duration (mo) 22 18 10 4
Wound-healing problems None None Mild delayed healing of None
the island wound flap
Flap vascularity/viability Completely viable Completely viable Completely viable Mild necrosis of the
posterosuperior edge that
eventually healed
Heel sensation Normal Normal Normal Normal
Weight-bearing status Full and pain-free Full and pain-free Full and pain-free Full and pain-free
Returned to work After 3 months After 3 months After 3 months Not applicable

*M = male and F = female.

Case Reports vageable, and the patient underwent debridement and multiple

A summary of the four patients treated with our technique is

presented in Table I.
CASE 1. A fifty-three-year-old man fell approximately six feet
and sustained a partial right heel pad avulsion and an ipsilateral
distal radius fracture. The avulsed segment was deemed sal-
K-wire fixation. The avulsed flap healed without any compli-
cations, and the patient was able to return to heavy work as a
farmer after three months.
CASE 2. A fifty-six-year-old man sustained a partial heel pad
avulsion when a heavy rock landed obliquely on the right heel.

Fig. 1 Fig. 2
Fig. 1 An isolated partial heel pad avulsion caused by a road accident (Case 3). Fig. 2 At three weeks after injury, there was slightly delayed healing of
the island wound flap (Case 3).
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Fig. 3
Completely healed flap at eight weeks after injury, which permitted full
weight-bearing (Case 3).
No other injuries or any fractures were identified. The sensate,
vascular heel flap was secured to the calcaneus with multiple
K-wires. Full weight-bearing was possible at three months; at
the eighteen-month follow-up, the patient was walking without
pain.
CASE 3. A thirty-five-year-old woman sustained an isolated partial
right heel pad avulsion as a result of a fall from a motorbike (Figs.
1 through 4). The avulsed segment had good sensation and vas-
cularity. Another laceration was present over the heel in the region
of the Achilles tendon insertion. At the time of wound debride-
ment, a lateral cortical break was identified in the calcaneus,
which was not visualized on the initial radiographs. Apart from
slight delayed healing of the island of skin between the two lac-
erations, the patient made an uncomplicated recovery. She was
able to bear weight fully at eight weeks after the injury.
Fig. 4
Viable and sensate heel flap at twelve weeks after injury (Case 3).
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CASE 4. A forty-six-year-old woman was run over by a three-
wheeled motor vehicle, resulting in a right heel pad avulsion
with exposure of the distal Achilles tendon. Radiographs
revealed lateral cortical disruption of the calcaneus. After
debridement and K-wire fixation of the avulsed heel pad,
a few skin sutures were used to cover the exposed Achilles
tendon. There was mild necrosis of the posterosuperior edge
that eventually healed. At the four-month follow-up, the
heel pad was viable with intact sensation, and the patient
had no pain and was walking without the use of any walking
aids.
Discussion
D egloving of the heel pad is most commonly caused by a
crush injury7. The separation of the flap usually occurs in
a posterior-to-anterior direction. Blunt tangential forces dis-
rupt the soft tissues in the medial, posterior, and lateral areas of
the heel, leaving a soft-tissue bridge anteriorly7.
Because of the unique load-bearing function of the heel
pad and its complex architecture, every attempt should be
made to retain the original tissues in cases of partial degloving
of the heel with intact vascularity. Attempts to substitute the
heel pad with vascularized or regional flaps are not without
complications5-7, and problems with fine sensations in the
sole, retained soft-tissue bulk, tissue breakdown, and altered
physiological pressure distribution during gait have all been
reported.
Our technique involves thorough debridement followed
by anchorage of the avulsed heel pad to the bone with percu-
taneous K-wires. This method ensures stable reattachment of
the potentially viable heel tissue with the least amount of
possible trauma to the flap. The skin edges are not sutured in
order to facilitate drainage and prevent buildup of fluid pres-
sure under the flap.
Cichowitz et al. have shown that the blood supply to the
heel arises posteriorly from the medial calcaneal branch of the
posterior tibial artery along with a minor contribution from
the lateral calcaneal branch of the peroneal artery8, and the
anterior part is supplied primarily by the lateral plantar artery.
However, there are rich vascular anastomoses among these
vessels at a subdermal and periosteal level in the heel. The
vessels travel within the fibrous septa that anchor the skin of
the heel to the periosteum of the calcaneus. As a result, it may
be that simple stable reattachment of the avulsed heel pad, as
described with our technique, is sufficient to enable survival
of the heel flap. We believe that the use of K-wires provides a
simple and effective technique to salvage partial avulsion of
the heel pad without requiring a complicated microsurgical
procedure. n
Riazuddin Mohammed, MS Ortho, MRCS(Edin,UK)
Hywel Dda NHS Trust, West Wales General Hospital,
Dolg Wili Rd., Carmarthen, SA31 2AF, United Kingdom.
E-mail address: riaz22@hotmail.co.uk
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Sreenivasulu Metikala, MS Ortho, MRCS(Edin,UK), MRCpS(Glasg,UK)
Sri Venkateswara Ortho & Trauma Clinic, 21/620,
References
1. Basile A, Stopponi M, Loreti A, Minniti de Simeonibus AU. Heel coverage using a
distally based sural artery fasciocutaneous cross-leg flap: report of a small series.
J Foot Ankle Surg. 2008;47:112-7.
2. Van Beek AL, Wavak PW, Zook EG. Replantation of the heel in a child. Ann Plast
Surg. 1979;2:154-7.
3. Graf P, Biemer E. [Degloving injuries of the soft tissues of the heel. An indication
for microvascular revascularization!]. Chirurg. 1994;65:642-5. German.
4. Lai MF. Degloved sole and heel. Med J Aust. 1979;1:598-9.
A N C H O R A G E O F P A R T I A L AV U L S I O N O F T H E H E E L P A D
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Near Old Govt Hospital, Kadapa -A.P.,
India, Pin 516001
5. Isenberg JS. Boxcar heel: an unusual etiology of hindfoot amputation requiring
microvascular reconstruction. J Foot Ankle Surg. 1998;37:165-8.
6. Levin LS. Foot and ankle soft-tissue deficiencies: who needs a flap? Am J Orthop
(Belle Mead NJ). 2006;35:11-9.
7. Graf P, Kalpen A, Biemer E. Revascularisation versus reconstruction of degloving
injuries of the heel: case report. Microsurgery. 1995;16:149-54.
8. Cichowitz A, Pan WR, Ashton M. The heel: anatomy, blood supply, and the
pathophysiology of pressure ulcers. Ann Plast Surg. 2009;62:423-9.