Background Reconstruction of the weight-bearing surface of the foot represents a challenging task. With very little scope to borrow glabrous tissue from adjacent areas means that achieving a "like for like" reconstruction is rarely possible. In this setting, alternative approaches need to be considered. In this article we present our experience with various differing designs of the anterolateral thigh flap (ALT) in the reconstruction of 20 large defects of the weight-bearing sole. Methods Twenty patients with complex soft tissue defects of the weight-bearing sole underwent reconstruction over a 5-year period. Five cases were complicated by osteomyelitis resulting in significant calcaneal defects. The follow-up period ranged from 8 to 48 months and outcomes were assessed by two-point discrimination and protective sensation, observation of gait, and the ability of the patient to return to wearing normal footwear. Results All flaps survived with the exception of two partial skin necrosis. Sensory nerve coaptation was performed in 12/20 cases. One patient underwent second-stage total calcaneal reconstruction with a fibula osteocutaneous flap. Five large defects were reconstructed with the split skin paddle technique to allow for direct donor-site closure. No evidence of postoperative ulceration was noted in any of the patients over the follow-up period and all were satisfied regarding the functional and aesthetic results achieved. Conclusion Complex defects of the weight-bearing sole can be successfully reconstructed using the free ALT flap resulting in very favorable functional outcomes. Even when calcaneal osteomyelitis has set in, excellent outcomes can be achieved.
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