The novel use of a hatchet flap to treat a chronic plantar foot ulcer: a case report

Abstract

Introduction:

Chronic plantar wounds of the foot are difficult to heal. It is not uncommon for conservative treatment based on debridement and topical dressings to fail. The plantar skin is unique in its resistance to load pressures, such as weight-bearing. Local flaps for immediate definitive coverage are rarely available. This case highlights the novel indication and the successful use of a hatchet flap in the challenging plantar location.

Case presentation:

A 38-year-old male with no history of diabetes presented with a chronic, non-healing 1.5 × 1.5 cm plantar ulcer on a macrodactylic toe, refractory to non-surgical off-loading and serial debridement. A hatchet flap was planned to cover the entirety of the defect in a single-stage procedure. Complete healing was achieved, and the patient regained independent ambulation. No complications were encountered at 6 months of follow-up.

Clinical discussion:

Although hatchet flaps have been described for scalp, facial, lip, trochanteric, or ischial defects, their use on the plantar weight-bearing surface of the foot has not been reported. This case demonstrates the efficacy of using a hatchet flap for small to moderate chronic wounds of the foot.

Conclusion:

This novel adaptation of the hatchet flap could be added to the surgical armamentarium when facing hard-to-heal wounds of the plantar foot. Its simplicity, reliability, and low donor-site morbidity make it an attractive option for small to moderate plantar defects.

Introduction

Although the majority of chronic plantar ulcers are related to complications of diabetes mellitus, only a limited number of other etiologies account for the remaining cases, including peripheral arterial or venous disease, non-diabetic neuropathies, systemic disorders, and foot deformities^[1^]. Traumatic wounds in otherwise healthy individuals generally heal without complications; however, wound healing may be impaired in the presence of an underlying deformity. The first distinctive aspect of the present case is the coexistence of a congenital deformity, toe macrodactyly, which is believed to have impaired plantar wound healing and contributed to its chronicity.

HIGHLIGHTS

• This case report describes a novel application of the hatchet flap in the treatment of chronic foot wounds.

• The plantar skin is unique with respect to its resistance to load pressures, such as weight-bearing, and skin grafts are not usually appropriate.

• Local flaps for immediate definitive coverage are rare and often require microsurgical skills.

• A hatchet flap using neighboring similar plantar skin was found to successfully cover a medium sized defect with primary closure of the donor site.

Mechanical off-loading, adequate debridement, infection control, and durable soft tissue coverage are essential components for achieving long-term healing of chronic wounds^[2^]. In diabetic foot ulcers, however, complications frequently occur despite these standard-of-care measures, with high rates of recurrence being reported^[3,4^]. Consequently, conservative surgical approaches have been proposed for the management of hard-to-heal or recurrent ulcers, with good to excellent outcomes^[5–7^]. In specific cases, split-thickness skin grafting^[8^] and island flaps, such as the sural flap, are necessary^[9–12^]. However, some flaps require microsurgical expertise, such as the medial plantar artery flap^[13^]. In contrast, options for local transposition flaps remain limited for the forefoot and toe regions. For example, the fillet flap has demonstrated favorable outcomes for soft tissue coverage in the forefoot following certain types of minor amputations^[14^], based on the “spare parts” concept^[15^].

Therefore, there remains a need for reliable local flaps for plantar ulcer coverage. This constitutes the second distinctive feature of the present case: a novel indication for the hatchet flap, a flap designed to replace “like with like” skin tissue. The hatchet flap, an adjacent triangular flap with a skin bridge, was originally intended for the reconstruction of small- to moderate-sized soft tissue defects of the scalp and face^[16^]. Its application has subsequently expanded to various anatomical locations, including trochanteric, sacral, and ischial pressure ulcers^[17^]. However, to the best of our knowledge, no previous reports describing its use for plantar wound coverage were identified following a PubMed literature review.

This study was conducted in accordance with the SCARE guidelines^[17^].

Case report

A 38-year-old man presented to our foot and ankle clinic with a painful, non-healed plantar ulcer on the right foot. The patient had no history of diabetes, and his medical history was notable for congenital syndactyly of the second and third toes, along with macrodactyly of the second toe. The syndactyly had been corrected surgically during childhood, while the second toe was left unchanged. The patient noted the disappearance of the corresponding nails since the procedure. He reported leading a normal life, including participation in sports, with no prior limitations. Eight months prior to presentation, he sustained direct trauma to the forefoot while climbing stairs, resulting in a full-thickness skin defect on the plantar surface of the second macrodactylic toe. Conservative management, including multiple in-office debridements, topical dressings, and partial off-loading, was conducted without success. It is noteworthy that the patient had no history of diabetes mellitus or other systemic diseases.

Clinical exam

There was a full-thickness plantar soft tissue defect at the level of the proximal region of the first phalanx. The ulcer was 1.5 × 1.5 cm in size, painful, with atonic margins. No clinical signs of infection were present, and the probe-to-bone test was negative. Peripheral arterial supply was adequate (dorsalis pedis/posterior tibial pulses were clearly palpable) with no signs of peripheral neuropathy. A swab culture was taken, and Streptococcus dysgalactiae (subspecies equisimilis) growth was found. The patient was treated with oral co-trimoxazole for 7 days prior to the soft tissue reconstruction surgery. Given the relatively large plantar surface of the macrodactylic toe, a hatchet flap was planned to cover the wound.

Surgical technique

A sciatic and popliteal nerve block was conducted by the anesthesia team. The patient was placed in a supine position on the operating table. A tourniquet was applied to the ipsilateral thigh and inflated after exsanguination. The first step consisted of a surgical debridement of the wound bed and edges (Fig. 1a and b). Then, the hatchet-shaped local flap was first marked distal to the defect since the wound was closer to the crease of the metatarsophalangeal joint (Fig. 1c). The planned incision started at the edge of the longitudinal axis of the wound, continuing distally to the tip of the toe, then curved to the opposite side while leaving a base of 1.5 cm. With a sharp cut, the incision was made down to the digital fascial plane to include the subcutaneous fat but remained superficial to the neurovascular bundle (Fig. 2a). The dissection was carried out till the base of the flap (Fig. 2b). The flap was elevated in the sub-fascial plane, preserving the pedicle. A traction combining rotation and proximal advancement was able to cover the quasi-totality of the wound. At this stage, the tourniquet was deflated, and the proper irrigation of the flap was checked. The flap was then sutured with no tension (Fig. 2c) and a semi-compressive dressing was applied.

Figure 1.

First phase prior to hatchet flap surgery: (a) pre-debridement, (b) post-debridement, and (c) incision drawing.

Figure 2.

Hatchet flap steps: (a) sharp incision, (b) dissection to the flap base, and (c) tension-free closure.

Postoperative care and outcome

The post-operative course was uneventful. The patient was kept non-weight-bearing for 2 weeks using protective forefoot offloading shoes. The dressing was changed three times over 18 days before suture removal. Weight-bearing was allowed at this phase, as tolerated. There were no signs of necrosis, infection, or dehiscence during the entire follow-up period. At 6 months, wound healing was excellent with no recurrence. The patient was very satisfied and was able to walk without limitations using comfortable shoes.

Discussion

This case highlights the novel use of the hatchet flap for the coverage of a plantar forefoot ulcer, a region where reconstructive options are often limited due to the unique biomechanical and anatomical characteristics of plantar skin. Plantar skin is thick, glabrous, and firmly adherent to the underlying fascia, playing a critical role in weight-bearing and protection. Skin grafts and traditional flaps are either too fragile or insufficiently padded to withstand the repetitive mechanical stress associated with ambulation.

The principal advantages of hatchet flaps include a simple design, minimal donor-site morbidity, and the combination of rotational and advancement tissue movement with a skin-base pedicle that provides reliable vascularity^[9,18^]. It has been widely used for defects in more pliable anatomical regions such as the scalp and face, where adjacent tissue can be mobilized relatively easily^[13,16,18,19^]. Its design, characterized by a triangular or V-shaped “blade” with a broad skin pedicle forming the “handle,” provides excellent vascularity and minimal donor-site morbidity^[18^]. In addition, primary closure of the donor site is almost always achievable, thereby avoiding the need for skin grafting.

In the present case, the decision to use a hatchet flap was based on several important considerations. The defect was moderate in size and located in an area with limited surrounding tissue laxity but with adequate vascular supply. The flap allows tension-free closure while minimizing the risk of breakdown under mechanical load. An additional advantage of this technique is the possibility of primary donor-site closure without the need for skin grafting.

Free flaps used for lower-limb diabetic wound reconstruction have been associated with a total flap failure rate of 7.14%, a partial flap failure rate of 7.54%, and a major complication rate requiring additional surgery of 19.0%^[20^]. More recently, mini free flaps have been proposed as effective solutions for small- to moderate-sized defects; however, the reported recurrence rate of 40.5%^[21^] and wound complication rate of 45%^[22^] could limit their indication and use. Free flap reconstruction also requires advanced microsurgical expertise, which may not always be available, particularly in community hospitals or rural settings.

The postoperative outcome in the present case supports the feasibility and reliability of the hatchet flap for selected plantar defects. The flap provided durable and stable coverage that tolerated early rehabilitation and gradual return to weight-bearing without ulcer recurrence. These findings suggest that, when combined with careful flap design and appropriate postoperative off-loading, the hatchet flap may represent a practical and effective alternative to more complex reconstructive techniques, such as free tissue transfer or perforator flaps.

We believe that the indications for the hatchet flap may extend to defects involving the forefoot and midfoot, where skin elasticity is generally greater than in the hind foot. In contrast, several factors may limit its use, including heel defects, severe neuropathy, compromised vascularity, or the presence of adjacent skin infection. Furthermore, long-term follow-up remains necessary to assess flap durability under continuous mechanical stress and to monitor for ulcer recurrence.

In summary, this case presents a novel adaptation of the hatchet flap for the reconstruction of a plantar foot ulcer. Its simplicity, reliability, and low donor-site morbidity make it an attractive option for small- to moderate-sized plantar defects. Although further clinical experience is needed to define its broader applicability, this report suggests that the hatchet flap may represent a valuable addition to the reconstructive armamentarium for challenging plantar wounds.

Ethical approval

Ethical review and approval were not required for the case report since the hospital waives ethical approval. The case report does not contain any personal information about the patient. There is a requirement for consent before using images of the patient, which was obtained from the patient.

Ethical approval

Obtained from the Institutional Review Board, patient consent was obtained.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images.

Sources of funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author contributions

K.Y.: conceptualization, methodology, writing-original draft preparation, supervision. T.K.: investigation, writing-original draft preparation.

Conflicts of interest disclosure

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Research registration unique identifying number (UIN)

None.

Guarantor

Kaissar Yammine.

Provenance and peer review

Not applicable.

Data availability statement

Relevant data is reported in the study.

Declaration of generative AI and AI-assisted technologies in the writing process

No generative AI or AI-assisted technologies were used in the writing process.