SLR - September 2018 - Ann Nguyen
A Retrospective Audit of Lesion Excision and Rotation Skin Flap for the Treatment of Intractable Plantar Keratosis
Reference: Saipoor A, Maher A, Hogg L. A Retrospective Audit of Lesion Excision and Rotation Skin Flap for the Treatment of Intractable Plantar Keratosis. The Foot. 2018 Mar;34:23–27.
Scientific Literature Review
Reviewed By: Ann Nguyen, DPM
Residency Program: Montefiore Medical Center, Bronx, NY
Podiatric Relevance: Intractable plantar keratosis (IPK) is a common problem in podiatric practice. These lesions are often quite painful and may also cause alteration of gait. Various etiologies include biomechanics, footwear, trauma, internal bony prominences and metatarsal deformities. This results in external stress applied to the plantar aspect of the foot, leading to excessive growth of epithelium. Nonsurgical treatment options include debridement, topical salicylic acid, cryotherapy and orthotics. However, for severe cases of recurrent IPKs that fail conservative treatment, surgical excision, including a rotational skin flap, has been described.
Methods: Thirty-six patients who underwent a Schrudde’s single-lobed rotational skin flap between November 2011 and May 2015 were retrospectively reviewed. The data was collected from the caseloads of two surgeons working in one center. All patients completed the MOXFQ and PSQ-10 questionnaires six months' postoperatively. There were 43 lesion excisions in total; 33 were confirmed IPKs and 10 were confirmed as viral warts. Postoperatively, patients wore a trauma shoe and were allowed heel weightbearing for three weeks. They subsequently used a silicone-based scar dressing for three months.
Results: The mean MOXFQ scores improved in all three domains: walking/standing, pain and social interaction. With respect to patient satisfaction, 88.9 percent out of the cohort felt that their aims of surgery had been met, 100 percent reported they would have surgery under the same conditions and 78.1 percent felt that that their original problem was now better or much better. In this study, 44.5 percent of patients suffered from recurrent lesions or callus formation.
Conclusions: Although IPKs remain one of the most common clinical problems encountered by the podiatrist, few studies have described rotational skin flaps as a viable surgical treatment option. It is evident that there is no gold standard or definitive procedure for the treatment of IPKs. The current study demonstrated that the Schrudde’s flap is an effective and alternative safe surgical procedure for the treatment of intractable plantar keratosis and viral warts. This flap provides excellent closure for circular defects, is aesthetically pleasing to the patient, relatively simple to perform, has high patient tolerance and is a good alternative to performing a metatarsal osteotomy or other bony procedures. There was only one case of wound dehiscence/scar line hypertrophy. The primary sequela remains reoccurrence and callus or IPK formation. The numbers in this study, however, broadly paralleled reoccurrence rates in similar studies. Factors that may be of relevance but were not included in this study included smoking, occupation, activity, footwear and obesity. Further research may provide insight into the long-term outcomes of such factors on the treatment of intractable plantar keratosis.