Use of de-epithelialized free perforator flaps for simultaneous bone and soft-tissue reconstruction in chronic calcaneus osteomyelitis

Treating chronic calcaneal osteomyelitis (OM) is complex and challenging. After aggressive surgical debridement of the infected tissue, filling the bone's dead space and covering the defect may be necessary. This study describes the successful treatment of chronic calcaneal OM using a de-epithelialized perforator flap to reconstruct soft-tissue and bone defects simultaneously. The study retrospectively reviewed the medical records of 10 patients diagnosed with Cierny-Mader type III-IV calcaneus OM treated with de-epithelialized free perforator flaps between 2015 and 2023. The data included patient demographics (age, sex, and comorbidities), OM duration, perforator flap type, intraoperative and postoperative complications, flap survival, additional surgical interventions, OM recurrence, and functional outcomes. The American Orthopedic Foot and Ankle Society ankle and hindfoot scale was used to assess the functional results 6 months after surgery. The study included 10 patients with a mean age of 49.2 years (range: 29-62 years). The average OM duration before surgical intervention was 18 months (range: 11-24 months). Flap​ ​survival​ ​was​ ​90%,​ ​with​ ​one​ ​case​ ​of​ ​partial​ ​necrosis​ ​requiring​ ​secondary​ ​full-thickness​ ​skin​ ​grafting. No OM recurrence was observed during the follow-up period, except for minor wounds in the weight-bearing region. Perforator flaps offer a viable option for obliterating dead space in cases where chronic infection compromises the blood supply in chronic OM. A thinned de-epithelialized perforator flap supports a multidisciplinary approach for managing chronic calcaneal OM, balancing the amount of surgical intervention with functional preservation and infection control.