Tag Archives: foot and ankle

Use of an external vibratory device as a pain management adjunct for injections to the foot and ankle

by Joseph D. Rundell, BS1, Joshua A. Sebag, BA1, Carl A. Kihm, DPM, FACFAS2, Robert W. Herpen DPM3, Tracey C. Vlahovic DPM3*pdflrg

The Foot and Ankle Online Journal 9 (4): 6

Objectives:  Pain modulation through the combined effect of vibratory stimulation of Aβ mechanoreceptors and cold thermal stimuli has been demonstrated to reduce the pain associated with injections and IV cannulation.  Although past reports have focused on its use on the upper extremity, there are no current studies to evaluate the efficacy of these combined modalities for lower extremity injections.    The authors propose the combined use of vibratory stimulation with cold thermal stimulation will yield lower reported pain values associated with injection compared to cold thermal stimulation alone.  
Methods:  In this multicenter, randomized, prospective clinical trial, 108 patients necessitated a lower extremity injection for the treatment of their presenting condition and was randomized into a treatment (vibration and cold spray) or control (cold spray only) groups.  The primary outcome was pain, subjectively measured on a 10-point numerical pain rating scale (NPRS) by the patient.  Pain was also ranked by an observing physician via the Wong-Baker Pain Faces Ranking Scale (WBPFRS).
Results:  Forty treatment subjects and 68 control subjects were included in this study.  Pain scores were significantly lower in the treatment group receiving the vibratory device and the cold spray compared to the cold spray alone (NPRS mean values:  Treatment: 3.39, Control: 4.46; p=0.022.  WBPFRS mean values: Treatment: 2.29, Control: 4.05; p=0.030).  
Discussion:  Utilizing a combination of cold spray with vibratory stimulation produced a statistically significant decrease in pain associated with lower extremity injections.  Due to the relatively small size of our study, further investigation is needed to assess effect on specific injection site.  

Keywords:  injection, vibratory stimulation, foot and ankle, lower extremity, buzzy

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0006

1 – Fourth year student, Temple University School of Podiatric Medicine, 148 N 8th Street, Philadelphia, PA 19107
2 – Private practice, University Foot & Ankle, 3 Audubon Plaza Dr Ste 510, Louisville, KY 40217
3 – Faculty, Temple University School of Podiatric Medicine, Philadelphia, PA, 19107
* – Corresponding author: traceyv@temple.edu

Injection therapy has been a mainstay intervention for addressing musculoskeletal pain for over 50 years [1]. Foot and ankle physicians commonly perform office procedures which are made tolerable by first injecting local anesthetics. Unfortunately, injections to the foot and ankle often elicit exquisite pain due to a greater density of sensory nerve endings in that area of the body [2] and the depth of some of the injections. The pain and anxiety from needle injections can have deeper consequences such as impaired patient compliance[3], deferral due to needle phobia [4] or lack of follow-up due to fear of future injections [5]. There can be value in utilizing interventions to reduce the pain associated with injections. Therapeutic outcomes could possibly improve by increasing patient compliance and reducing fear avoidance if injections are perceived as less painful. Increased patient satisfaction and the overall patient experience could be maximized.

Although there are distinct benefits from decreasing the pain associated with needle injections, there remains a dogma that injection pain reduction modalities are deficient [6].  There are options available that deserve consideration utilizing various mechanisms.  Pharmacological intervention via topical or injectable anesthetics, are commonly used.  While this intervention has been shown to alleviate pain associated with injections [3,7,8], it is not without drawbacks.  The use of topical anesthetics can cost $20 or more [9].  Additionally, these can prolong time in the office and procedure times, since it takes time for the induction of effective analgesia [7]. The drug cost can present concerns regarding the stewardship of already strained healthcare resources.  In addition to pharmacological interventions, there exist other modalities which utilize the gate theory of pain control.  Cold therapy [10] and activation of Aβ sensory fibers through vibratory stimulation [11] of mechanoreceptors are believed to cause presynaptic inhibition of the dorsal horn.  This therefore “closes the gate” and reduces the transmission of nociceptor signals.  Cold therapy has demonstrated efficacy in reducing injection pain in both adult [12] and pediatric [7, 13] groups.  Cold therapy sprays are commonly used in an office setting for immediate but temporary analgesia for the time of injection.  In addition, vibratory stimulation to manage pain from injections has yielded positive results in adult [9,14] and pediatric [15-17] populations.  

Reusable devices that produce a combination of cold and vibratory stimulation to manage injection pain have been developed; one such device is called “Buzzy®” (MMJ Labs Atlanta, GA).  There have been a number of studies which have demonstrated its efficacy in reducing injection pain, but these studies have focused particularly on pediatric IV access [9,16,18,19].  This device has the advantage of being reusable, easy to use and does not require much additional time.  The clinician uses a built-in Velcro strap to apply the device proximal to the injection site.  While there is evidence this device can reduce injection pain related to venipuncture access, no studies have investigated the efficacy of this device for pain management of injections to the foot and ankle.  It was the goal of this study to determine whether pain associated with injections to the foot and ankle is decreased when using the Buzzy® (or vibratory) device.   

Materials and Methods

Our study was a multicenter, prospective clinical trial using 108 patients needing an injection to the foot or ankle.  The study was explained to every patient and consent to participate was obtained.  This study was performed at the Temple University School of Podiatric Medicine’s Foot and Ankle Institute (FAI) clinic (n=42) and in a separate private practice podiatry clinic (n=66).  Participants were excluded if they had: skin compromise over the vibratory device application site, history of peripheral neuropathy, fibromyalgia, complex regional pain syndrome, cognitive or verbal impairment, patients who were blind or not fluent in English, and those impaired via narcotics/analgesics within 4 hours prior to the office visit.

Data Collection and Outcomes

The primary outcome variable was pain, which was measured utilizing an 11-point Numerical Pain Rating Scale (NPRS).  The patient reported their pain on a scale of 0-10 where 0 is no pain and 10 is the worst pain imaginable.  As a secondary variable outcome, pain was assessed via the Wong-Baker Pain Faces Rating Scale (WBPFRS).  It should be noted WBPFRS was only collected on the FAI patients by an observing physician.   The patients were not made aware of the WBPFRS measurement to minimize chances of altering their facial expressions in front of the physicians.   


After informed consent was obtained, patients were randomly assigned into the treatment or control group.  The treatment population was treated with external vibratory stimulation delivered through the vibratory device and cold spray prior to injection.  The control population was treated solely with cold spray prior to injection.  Determination of randomization was performed immediately before injection.  At the FAI, randomization was performed via drawing an opaque envelope whereby the instructions inside would assign the group.  At the private practice clinic, randomization was achieved by randomly assigning subject numbers with control or treatment groups.  As patients presented for an injection, the patients were assigned the next consecutive subject number.


Demographic information consisting of age, gender, and whether they have had an injection to the foot or ankle previously was recorded on the questionnaire.  The attending physician instructed the patient on using the NPRS.  In order to maintain consistency of the pain data, the patient was instructed to rank the pain associated with the initial needle stick, but to not watch the injection being performed.  The injection site was first prepped with alcohol or betadine.  If the patient was assigned to the treatment group, then the vibratory device unit was applied 5-10cm proximal to the injection site over the anatomical location of the appropriate sensory nerve(s).  The vibratory device was turned on for approximately 1 minute prior to and maintained during the injection.  

In both groups, Gebauer’s Ethyl Chloride® (Cleveland, OH) was applied to the injection site, and then a 25 gauge needle was inserted.  The injection was performed under the supervision of an attending physician (TV or RH).  At the private practice clinic, all injections were performed by 1 attending physician (CK).  During the injection, the attending physician at the FAI assessed pain utilizing the WBPFRS.  In the private practice setting, the attending was visually focused on the injection and not the face; therefore WBPFRS was not recorded.  After the injection, the patient was asked to rank their pain on the NPRS, and if the injection was better or worse than anticipated.  It should be noted, the vibratory device does come with reusable ice-packs to provide the cryothermal stimulation; however, cold spray was utilized in its place in order to minimize deviation from the clinic’s standard of care.  

Statistical Evaluation

The outcome variable was pain.  This was ranked primarily via the NPRS between the treatment and control groups.  Pain ranked by WBPFRS was utilized as a secondary outcome variable.  The unpaired t-test was used to evaluate the statistical significance of the NPRS and WBPFRS values between the treatment and intervention groups.  The criteria for significance between the values was a p value <0.05.   Statistical calculation was performed utilizing GraphPad® statistical software.


One hundred and eight consenting patients were recruited to participate in this study.  Based on our parameters, no patients required exclusion from the study.  The treatment group (n=40) was composed of 18 (45.0%) males and 22 (55.0%) females with a mean age of 39.2 ± 20.9 years (range 12-79 years).  The control group (n=68) was composed of 32 (47.0%) males and 36 (53.0%) females with a mean age of 43.5 ± 23.2 years (11-92 years).  There was no statistically significant difference in age or gender between the groups (Table 1).   The material injected was as follows:  for the intervention group 14 received a steroid cocktail (acetate and phosphate-based steroid, diluted in local anesthetic) and 54 were injected with only local anesthetic (1% lidocaine or 0.5% marcaine plain).   


Table 1 Demographic and Injection Data.


Table 2 Pain Measurements using both scales.


Table 3 Pain Rating Mean Values.

For the treatment group, the mean NPRS value was 3.39 ± 2.67 (0-10) and the mean WBPFRS was 2.29 ±1.59 (0-6).  Seventeen patients reported the injection was “better” than expected while 6 reported it was “same” and 1 “worse” than expected.

With regards to the control group, the mean NPRS value was 4.64 ± 2.72 (0-10) and the mean WBPRFS was 4.05 ± 3.13 (0-10) (Table 2).  Twenty six reported the injection was “better” than expected while 8 reported it was “same or worse” than expected.  

In terms of anatomical location of the injection, an injection into an intermetatarsal space the addition of vibratory stimulation to cold spray provided the largest percent difference in NPRS scores, whereas hallux block showed the least reduction in pain (Table 3).


It is recognized that control of pain contributes to improved clinical outcomes and patient satisfaction.  This right unfortunately comes with added costs monetarily (i.e. cost of of topical lidocaine) and in time (delay for topical anesthesia induction)[20, 21].  These can provide added cost and personnel burdens to an already resource-strained healthcare system.  These barriers, combined with attitudes that injections will cause pain, hamper the use of interventions to reduce injection pain.  It has been reported that only 6% of pediatricians utilize available interventions to reduce the pain associated with injection therapy [21].

In our study, we investigated the use of eliciting the pain gating theory to activate descending noxious stimuli inhibition to manage pain associated with injections to the foot and ankle.  The pain gating phenomenon was first described in 1965 where Aδ pain fibers shared a final common pathway with thermal and Aβ, and stimulation of thermal and Aβ would effectively “close the gate” to noxious stimuli from Aδ nociceptors [10].  By combining the use of vibratory stimulation and cold spray it may be possible to maximize pain reduction.  The hope of our study is to demonstrate if this is possible in our clinics (Table 3).

Through the combined use of the vibratory device with cold spray, we demonstrated an appreciable decrease in pain associated with injections to the foot and ankle.  Our primary outcome was pain reported by the patient utilizing the NPRS.  We report a mean drop in NPRS scores from 4.64 to 3.39; this represents a 31.3% decrease in pain associated with injections between the treatment and control group.  Our secondary outcome was an observer physician-recorded pain utilizing the WBPFRS; mean scores dropped from 4.0 to 2.29 representing a 54.4% decrease in mean pain recorded through this scale.  Both of these outcomes were statistically significant with p values of 0.022 and 0.03 respectively.

While a statistically significant decrease in pain through this or any intervention might seem like a definitive success, it is still imperative to consider whether this significance translates into a clinically relevant context versus a purely numerical context.  There exists a number of studies that address this matter.  Todd et al [22] determined a decrease of 13mm on the 100mm VAS yielded a clinically relevant decrease in pain.  There are other arguments that relative decrease in pain is more clinically relevant than the decrease in the absolute value of the pain.   Campbell et al [23] within the setting of a dental surgery practice, determined a decrease in VAS score by “between 31% and 48%, depending on its initial intensity” is requisite to be considered clinically relevant.  In a study by Farrar et al [24] 10 clinical control trials for chronic pain interventions were reviewed, and it was concluded a 30% decrease in pain scores indicated a significant decrease; furthermore, this 30% decrease was determined to correspond to a 2-point decrease on the NPRS.  Comparing our data to that of the studies mentioned here, utilizing the vibratory stimulation in addition to cold spray did produce a clinically significant reduction in pain.   

Comparing patients’ expectations (better or worse than expected) between treatment and control groups was performed by Fisher’s Exact Test which yielded a p value of 0.76, thus no statistical significant outcome can be drawn from this.  In terms of patient’s tolerance of the vibratory stimulation, it was tolerated well as only one commented that, “It felt annoying.”  With regards to ease of use, no one in either clinic reported any difficulty in using the vibratory device.    

This study is not without limitations.   The first of which is pain scores were only from one patient encounter.  Pain is well noted to be an extremely subjective sensation in terms of perception and tolerance with wide variation between people. Additionally, it is well known that pain has multidimensional contributing factors, such as anxiety or recent pain sensations [25].   As such, measuring the pain of a heel injection between various people can elicit widely different values, even if no intervention is used.  Another limitation of this study was for the injections performed at the FAI.  There may be differences in injection technique, ability, and apparent confidence between attending physicians.  Finally, this study included injections to any anatomical location to the foot and ankle.  It is likely an injection to certain parts of the foot or ankle will naturally just elicit more pain than other areas would.  This is expected due to the possible sources of sensory nerve distribution and the vibratory device’s ability to effectively target more than one sensory nerve simultaneously.  In the future, the device may be better contoured for the ankle so as to prevent slippage and simultaneously affect numerous nerves. Injection techniques were not standardized as well.  For instance, one of the clinicians prefers a medial glabrous skin junction approach for painful heel injections while the other prefers a plantar approach.  Also, there may be inherent differences based on the composition of local anesthetic and injectable corticosteroid, which varied greatly in makeup proportion and delivered amount.  Temperature of injectable, pH of injectable, needle gauge and quantity injected are possible covariables which were not studied.

The investigators did find that it was harder to apply the vibratory device to some parts of the foot versus others due to anatomical contouring of the unit. This may have affected the ability of the device to work optimally and target the desired areas.  As seen in Table 3, there is marked variation between pain scores and location of the injection.  Lastly, although it was attempted to not influence a known effect of the vibratory unit, it is possible that natural bias was placed on the patient to downplay perceived pain.  This could have been avoided with a double-blind study protocol.

The authors believe further studies are needed to better understand and quantify potential benefit of such devices.  Future modifications of such units may optimize use and benefit also.  This pilot study suggests that the combination of vibratory stimulation and cold sensation does reduce the pain associated with injections to the foot and ankle.  Further control of cofactors is necessary to conclude how effective and specifically which injections (injectable and location) and patient demographics are most affected.  


The combination of external vibratory stimulation in addition to cold spray produced an appreciable reduction in the pain in comparison to cold spray alone for our patients undergoing foot and ankle injections.  Further investigation is warranted for injections of the lower extremity.   


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Functional Outcomes of Reconstruction for Soft Tissue Sarcomas of the Foot and Ankle

by Emmanuel P. Estrella, MD1 , Edward HM Wang, MD1, MSc, Leo Daniel D. Caro, MD1, Vicente G. Castillo, MD2

The Foot and Ankle Online Journal 2 (3): 2

Objective: We present the functional outcome of six cases of soft tissue sarcomas of the foot and ankle area treated with limb-sparing surgery and soft tissue reconstruction.
Materials and Methods: Six patients with soft tissue sarcoma of the foot and ankle who were treated with limb-sparing surgery and soft tissue reconstructions from 1993 to 2007 were evaluated. On recent follow-up, patients function were scored using a Functional Evaluation Scoring System.
Results: There were three males and three females with an average age of 36.3 years (range, 11-56 years) at the time of surgery. The mean follow-up period was 49 months (range: 4-91 months). The average size of the soft tissue defect was 124.3 cm2 (range, 48-182 cm2). All flaps survived. As of final evaluation, three patients are alive without evidence of disease, two patients are alive with evidence of disease and one patient died of disease. The average Enneking Functional Score for the six patients was 92.8%.
Conclusion: Limb-sparing surgery and soft tissue reconstruction for foot and ankle sarcomas can provide good functional outcomes and will continue to play an important role in the management of these tumors.

Key Words: Sarcoma, foot and ankle, soft tissue reconstruction

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: February, 2009
Published: March, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0203.0002

Soft tissue sarcomas of the foot and ankle continue to pose a limb and life-threatening disease. In the past, amputation was the resulting outcome when sarcomas of the limb were diagnosed. Advances in reconstructive and limb-sparing surgical techniques have given patients with soft tissue sarcomas of the extremity another option of treatment besides amputation.

The treatment combination of wide resection, adjuvant chemotherapy or radiotherapy and reconstructive surgery has been reported to not increase the incidence of local recurrence, metastasis, or mortality. [1,2, 3]

The foot and ankle is a common location where there is usually a soft tissue defect after sarcoma resection. This is an area difficult to reconstruct because of its unique anatomy and paucity of soft tissues. [4] Various soft tissue reconstructions are described to cover foot and ankle defects either due to trauma or tumor resection. [5-7,8,9,10]

Coverage of these defects should be able to withstand the mechanical stress of weight bearing, as well as to tolerate postoperative chemotherapy or radiotherapy. Local and systemic control and overall function of the individual should also be evaluated after sarcoma surgery.

The objective of this article is to present the functional outcome of six cases of soft tissue sarcoma of the foot and ankle treated with limb-sparing surgery and soft tissue reconstruction.

Patient and Methods

A retrospective review of all soft tissue sarcomas of the foot and ankle treated by limb-sparing surgery, chemotherapy or radiotherapy, and soft tissue reconstruction from 1993 to 2007 was undertaken at the Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines. Inclusion criteria included all patients with a histologic diagnosis of soft tissue malignant tumor of the foot and ankle area who had limb salvage surgery.

Tumor location, size of defect, reconstructive procedures, histological diagnosis and functional outcome were all critically evaluated. Each patient was contacted for follow-up and was evaluated using The Functional Evaluation of Reconstructive Procedures after Surgical Treatment of Tumors of the Musculoskeletal System for the upper and lower extremity. (Table 1) [11] Specific numerical values of 0 to 5 were assigned for each factor, based on established criteria and are equated with certain levels of achievement or performance. Each score was presented as a percentage of the total.

Table 1 The Revised Musculoskeletal Tumor Society Rating Scale. (Upper extremity-top, Lower extremity-bottom)

The Functional Evaluation of Reconstructive Procedures: Definition of Terms

Pain: The value for pain is determined by the amount and effect of pain on functional activities. Required information is the medication used by the patient for pain relief.

Function: The value for function is determined by the restriction in activities. The required data are the pretreatment occupation and the degree of occupational disability.

Emotional Acceptance: The value for emotional acceptance is determined by the patients’ emotional reaction to or perception of the functional result.

Support: The value for support is determined by the use of external support to compensate for weakness and instability as they affect standing or walking. The required data are the type of support and the frequency of use.

Walking Ability: The value for walking ability is determined by the limitations on walking imposed by the procedure. The required data are the walking distance and limitations in type (inside/outside, uphill, stairs, etc.).

Gait: The value for gait is determined by the presence or absence of gait alterations and its effect on restrictions or function. The required data are the type of gait abnormality and resultant restrictions or deformity.


From 2001 – 2007, we had a total of six patients with soft tissue sarcoma of the foot and ankle area requiring soft tissue reconstruction after tumor resection.

All six patients were treated with wide resection, soft tissue reconstruction and adjuvant chemotherapy or radiotherapy. There were three males and three females. The mean age was 36.3 years at the time of the surgery (range, 11 – 56 years). The mean follow-up period was 49 months (range, 4 – 91 months). All soft tissue reconstructions were done at the time of tumor resection. We had one free flap, four reverse pedicle flaps and one cross leg flap. All flaps survived. The cross leg flap was released after two weeks and was uneventful. All patients are now ambulating independently. The mean time from surgery to independent ambulation was 12.5 weeks (range, 2 – 24 weeks). Pertinent data for each patient is summarized in Table 2.

Table 2  Pertinent data on the six patients.

Three patients (patient no. 1, 4 and 6) had previous resections. As of latest follow-up, five patients are alive. Three are alive without evidence of disease, two are alive with evidence of disease, and one died from disease. There were no local recurrences in five patients. Two patients (no. 1 and 2) developed pulmonary nodules after tumor resection. Both are alive with evidence of disease and recieved chemotherapy with a decrease in the number of pulmonary nodules for both. Another patient (no. 3) had a recurrence on the same extremity where another wide resection was done and a soleus flap was used to cover the defect on the anterior leg. The patient died of disease at 60 months after sural flap.

Case Reports

Case #2

A 56 year-old male presented with an enlarging mass at the lateral aspect of the left heel. He was initially diagnosed to have gouty arthritis. Biopsy showed a high-grade liposarcoma. A wide resection was done and a free rectus abdominis flap was used to cover the soft tissue loss. Three months after the resection and reconstruction, computed tomography (CT) of the chest showed multiple metastatic lesions to the lungs. Patient underwent chemotherapy. The Enneking Functional Score was 29/30. Figure 1 illustrates the late post-operative view at 19 months. (Fig 1)

Figure 1  Case no. 2. This is a late post-operative view of a 56 year-old male after wide resection of a liposarcoma of the ankle region at 19 months after rectus abdominis free muscle flap. The flap remained stable. The patient underwent chemotherapy for pulmonary nodules with a decrease in the number of nodules.

Case #4

A 40 year-old female presented with a recurring mass over the medial, posterior and lateral aspect of the non weight-bearing heel. The mass had been resected previously on both the lateral and medial aspects of the ankle by a previous surgeon. Review of slides and repeat biopsy revealed a fibrosarcoma. Wide excision was done. The final defect was 12 cm x 13 cm (Fig 2A). A reverse sural artery flap was used to cover the defect. Post-operative radiotherapy was uneventful. Independent ambulation was started at 16 weeks. Enneking Functional Score was 27/30. Result at 24 months post-op. (Fig. 2B)


Figures 2A and 2B  Case no.4.  A 40 year-old female presented with a recurring mass over the ankle area.  After wide excision, the final defect was 12 x 13 cm. Histopathology showed a fibrosarcoma. (A)  The sural flap at 48 months after coverage. The flap remained stable. (B)

Case #5

A 43 year-old female with a fungating mass on the medial aspect of the left ankle was diagnosed to have synovial sarcoma on biopsy (Fig.3A). After a wide resection, a 12 x 15 cm soft tissue defect was made. (Fig.3B) The defect was covered with reverse sural flap with medial tibio-talar ligament reconstruction using a plantaris tendon graft. At 17 months follow-up, there was no recurrence of the mass. (Fig. 3C)


Figures 3A, 3B and 3C  Case no. 5.      A 43 year-old female presented with a fungating mass on the medial aspect of the right ankle. Biopsy showed a synovial sarcoma. (A)  After a wide resection, the medial tibio-talar ligament was excised together with the mass and a defect of 12 x 15 cm was evident. The ligament was reconstructed using a plantaris tendon free graft (black arrow). (B)  The reverse flap remained stable at 18 months and there was no recurrence of the tumor. (C)


We reviewed six cases of soft tissue sarcoma of the foot and ankle, treated by limb-sparing surgery and soft tissue reconstruction. The standard of treatment for soft tissue sarcoma of the extremity is limb-sparing surgery, soft tissue reconstruction, and chemotherapy or radiotherapy. Few studies on soft tissue reconstruction for foot and ankle soft tissue sarcoma have been reported. [7,9,12] Likewise, few studies have evaluated their results with an established functional measurement outcome scale. [12] In this small series of four patients with foot and ankle sarcoma treated with limb-sparing surgery and soft tissue reconstruction, we presented the functional outcome of these patients using a standardized outcome measurement scale.

Flap choices for soft tissue reconstruction after tumor ablation are mainly dependent on what is available, what is needed or on the experience of the reconstructive surgeon. Ideally, the same type of tissue should be replaced during reconstruction. Local tissues give the advantage of near tissue typing and avoidance of lengthy microvascular procedures. However, the limited size and arc of rotation precludes their practical use.

Distant flaps are more often required to overcome these limitations. [4] Langstein, et al., [7] reported that free flaps help facilitate limb salvage and that they help preserve meaningful limb function in patients who undergo resection of soft tissue malignancies of the foot. It is possible that the choice of flap is quite different between defects from tumor excision and from traumatic defects. This is because in the event that there would be a local recurrence, reverse pedicled flaps would have increased the contamination of the extremity.

In the case of a reverse sural artery flap, the next surgery that the patient will undergo would probably a below knee amputation in order to have a wider margin of resection.

This is one of the reasons why free flaps have become popular choices for foot and ankle coverage after tumor resection. [7,12] Reverse sural artery flaps are extremely useful and do not need microsurgical anastomosis of vessels. Among the disadvantages of this flap is donor site morbidity, paresthesias on the lateral aspect of the foot, painful neuromas if the sural nerve stump is not buried properly and in some cases, bulkiness of the flap. On the other hand, the sural flap is easier to harvest, has a shorter operative time and can cover a relatively mid-sized defect.

These studies, however, used only independent ambulation as a measure of the functional outcome of their reconstructions. Serletti, et al., [12] evaluated their results with a standard outcome measure.

The present study made use of a standardized functional outcome measurement scale to evaluate reconstructive procedures done on the foot and ankle area after tumor resection. Although the overall scores of our patients are high, the only complaint was the deformity due to early physeal closure and the skin graft donor site of the reconstructive procedure. Serletti, et al., [12] had a similar Functional Outcome Measurement scale and found no difference between pedicled and free flaps in soft tissue reconstruction after tumor excision. However, they tend to favor free flaps to avoid further dissection of the recipient site, and to add vascularity on the already compromised recipient bed.

In summary, successful tumor excision with subsequent reconstructive surgery of foot and ankle sarcomas continues to challenge both the tumor and the reconstructive surgeon.

Careful planning of reconstructive options from the most simple to the more complex should be within the armamentarium of the reconstructive surgeons expertise. We believe that the simplest reconstructive method is still the best technique that will likely produce the best outcome. There will always be instances where a more complex reconstruction will be needed, and with the advances in microsurgery, we are now able to reconstruct larger defects and able to restore function after tumor ablation. By using a standardized functional outcomes assessment for evaluation, we can now redefine our reconstructive options that will best suit our patients in order to produce the best possible results.


1. Lindberg RD, Martin RG, Romsdahl MM, Barkley HT, Jr. Conservative surgery and postoperative radiotherapy in 300 adults with soft tissue sarcomas. Cancer. 47(10): 2391 – 2397, 1981
2. Talbert ML, Zagars GK, Sherman NE, Romsdahl MM. Conservative surgery and radiation therapy for soft tissue sarcoma of the wrist, hand, ankle, and foot. Cancer 66 (12): 2482 – 2491. 1990
3. Wexler AM, Eilber FR, Miller TA. Therapeutic and functional results of limb salvage to treat sarcomas of the forearm and hand. J. Hand Surg. 13A: 292 – 296, 1988.
4. Clark N, Sherman R. Soft-tissue Reconstruction of the Foot and Ankle. Orthopedic Clinics of North America. 24 (3): 489 – 503, 1993.
5. Goldberg JA, Adkins RN, Tsai TM. Microvascular reconstruction of the foot: Weight-bearing patterns, gait analysis, and long-term follow-up. Plast. Reconstr. Surg 92 (5): 904 – 910, 1993.
6. Hidalgo DA, Disa JJ, Cordiero PG, Hu QY. A Review of 716 consecutive free flaps for oncologic surgical defects: Refinement in donor-site selection and technique. Plast. Reconstr. Surg 102 (3): 722 – 732, 1998.
7. Langstein HN, Chang DW, Miller MJ, Evans GR, Reece GP, Kroll SS, Robb GL. Limb Salvage for soft-tissue malignancies of the foot: an Evaluation of free-tissue transfer. Plast. Reconstr. Surg 109 (1): 152 – 159, 2002.
8. Potparić Z and Rajačić N. Long-term results of weight-bearing foot reconstruction with non-innervated and innervated free flaps. Br J Plast Surg 50: 176 – 181, 1997.
9. Reath DB, Taylor JW. The segmental rectus abdominis free flap for ankle and foot reconstruction. Plast Reconstr Surg 88 (5): 824 – 828, 1991.
10. Weinzweig N, Davies BW. Foot and ankle reconstruction using the radial forearm flap: A review of 25 cases. Plast Reconstr Surg 102 (6): 1999 – 2005, 1998.
11. Enneking F, Dunham W, Gebhardt MC. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin. Orthop 286: 241 – 246, 1993.
12. Serletti, JM, Carras AJ, O’Keefe, RJ, Rosier RN. Functional Outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery. Plast Reconstr Surg 102 (5): 1576 – 1583, 1998.

Corresponding Author: Emmanuel P. Estrella, MD
Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Manila Philippines 1000.
Tel. No. (632) 5242203
Fax No. (632) 5260149
Email Add: estee96@yahoo.com

Consultant, Department of Orthopedics, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines
Consultant, Department of Surgery, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines

© The Foot and Ankle Online Journal, 2009

Tips and Techniques: A Modified Cross Leg Flap for Large Triangular Defects of the Foot and Ankle

by B. Jagannath Kamath, M.S. (Ortho) 1 , Thangam Varghese, Mch (Plastic Surgery) 2,
Praveen Bhardwaj, M.S., (Ortho) 3

The Foot & Ankle Journal 1 (8): 5

An important technical modification in the conventional medial based cross leg flaps is described by the authors. The technique involves resurfacing large triangular defects in the medial lower leg, ankle and foot. This modification, by virtue of narrowing the pedicle, will help the surgeon to maximize the inset avoiding delaying of the flap or flap loss. Secondary defects created by raising the triangular flaps are amenable to considerable narrowing and leaving behind smaller defects that can easily be covered with a split thickness skin graft. Another advantage of the triangular flap is the primary inset portion of the flap provides more than 75-80 % coverage to the injury site. This not only promotes early division of the flap without delay, but also enables the surgeon to maximize the secondary inset during the division of the flap and to cover the recipient area completely with the flap obviating the need for the split skin graft at the crucial triangular area of the original defect.

Key Words: Modified cross leg flap, medial based, triangular defect, foot and ankle, skin graft

Accepted: July 2008
Published: August 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0108.0005

Cross leg flaps have stood the test of time ever since its first description by Hamilton in 1854. It has always found an important place in the surgeon’s armamentarium in reconstructive surgeries of the lower limb even in the era of micro and super-microsurgery. It is still a safe and viable option in primary and secondary care centers for the reconstructive surgery of the lower limb in situations such as larger distal defects in the leg and foot where distally based flaps from the ipsilateral leg calf are not feasible.

Even in tertiary care centers cross leg flaps is a viable procedure in failed free flap surgeries. This is quite relevant because the highest percentage of failure of free flaps is encountered in cases of resurfacing the traumatic defects of the distal leg and foot.

Like most of the proven procedures, cross leg flaps have also undergone refinement and modifications. With the advent of fasciocutaneous flaps described by Ponten in 1983 [1], the cross leg flaps have been raised safely and easily with 1:3 to 1:3.5 width to length ratio. Several authors have advocated routine use of external fixators in maintaining the position of cross leg and ease of nursing care and post operative wound management.

This modification has been used both in children and adults with good results. Cross leg flaps have been used with their bases proximal, distal, medial and lateral depending on the size and shape of the recipient site and ease of planning in reverse. Some surgeons have used myocutaneous cross leg flaps to provide bulk, safety and to obliterate dead space in the recipient area. Conventional posterior tibial artery flap, sural artery flaps have been used as ‘cross leg flaps’. Recently Pandey, et al., [2] has used virtually the whole leg medially based fasciocutaneous cross leg flap with or without fibula for reconstructing large defects. Also, Bhattacharya, et al., [3] have used distal perforator based cross leg flaps successfully for leg and foot defects with narrow pedicles and larger inset with greater patient comfort.

To the best of our knowledge, large triangular medially based cross leg flaps nourished by two or three posterior tibial perforators have not been described. These flaps are most suited in large triangular defects on the medial side of the foot and ankle, which are quite commonly encountered in children and adults following trauma. By virtue of creating a very narrow pedicle large triangular fasciocutaneous flaps involving different angiogomes can be raised to improve the perimeter or the circumference of the inset of the flap. This obviates the need for delaying of the flap before division. This is important because traumatic distal leg and foot defects leave behind a very poorly vascularised bed contributing very little to the neovascularisation of the cross leg flap. These defects demand a larger and more reliable inset preferably more than 70 % of the original injury site or defect.

If the shape of the defect is triangular it will be difficult to meet the requirement dimensions of the conventional broad based cross leg flaps. Medial fasciocutaneous cross leg flaps based on perforators can be used without altering the original shape of the wound. Unlike the conventional broad based rectangular cross leg flaps, the narrow based triangular or oval flaps permit considerable narrowing of the secondary wound and can be covered with split thickness skin graft. This also adds to the cosmetic benefits of the flap both at the donor and the recipient sites.

The authors recently had an opportunity to use cross leg flaps with a technical modification to suit the need of resurfacing triangular defects of the lower leg after the trauma. Three patients with large triangular medial defects over the lower leg, ankle and foot were treated in our surgery department between December 2004 and January 2006. (Table 1)

Table 1  Demographics of three distinct cases describing the modified cross leg flap for large triangular defects of the foot and ankle.

All three defects were covered with a medially based narrow pedicled triangular cross leg flap based on 2-3 adjacent posterior tibial perforators about 1-2 cm from the medial border of the tibia in its middle third. The perforators are identified preoperatively by a hand held Doppler. No attempt is made to isolate or skeletonize the perforator and hence by definition these flaps could be termed as perforator plus flaps as described by Sharma, et al. [4] Flaps are raised as fasciocutaneous flaps involving not only posterolateral but also anterior compartmental tissue.

The secondary wound created is considerably reduced as the triangular edges are primarily sutured using the visco-elastic property of the calf skin. The rest of the donor site is covered with a split thickness skin graft and the larger, triangular flap is used to cover the injured site. The inset region provides more than 75 –80% coverage to the perimeter of the injury site in all three cases. The cross-legged position is maintained be external fixators and the flap is divided at the end of 2 ½ weeks. All three defects healed primarily providing stable skin cover.

An illustrative example using this triangular technique is described in the following figures.

Photo Description of Technique

Figure 1  Preoperative photograph showing the traumatic defect over the medial aspect of the foot with exposed bone.

Figure 2  Picture showing the ‘planning in reverse’.

Figure 3 Flap with primary inset providing more than 75 –80% coverage to the perimeter of the injury site.

Figure 4 Follow up result, showing stable skin cover.


1. Ponten B. The fasciocutaneous flap. Its use in soft tissue defects of lower leg. Br. J Plast Surg. 34: 215, 1981.
2. Pande S, Kohli JS, Arora S, Bajaj SP. The osseofasciocutaneous flap: a new method to transfer fibula along with a sufficient amount of skin. Br. J Plast Surg. 55: 312-319, 2002.
3. Bhattacharya V, Reddy GR. Distal perforator based cross leg flaps for leg and foot defects. Indian J Plast Surg. 38(1): 18-21, 2005.
4. Sharma RK, Mehrotra S, Nanda V. The perforator “plus” flap: a simple nomenclature for locoregional perforator-based flaps. Plast Reconstr Surg. 116(6): 1838-9, 2005.

Address correspondence to: Dr. B. Jagannath Kamath. Jyothi Mansion, Opposite Prabhat Theatre, K. S. Rao Road, Mangalore, India. Pin- 575001. Phone: 91-0824-2440233; Mobile: 91-9845235747
E-mail: bjkamath@satyam.net.in

Professor of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India.
Professor of Plastic Surgery, Kasturba Medical College, Mangalore Karnataka, India.
Fellow in Hand and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, India.

© The Foot & Ankle Journal, 2008