Free-flap reconstruction is an established strategy for limb salvage in patients with diabetic heel ulcers. However, complications may occur even after technically successful surgery, particularly in the heel, where soft tissue coverage is limited and mechanical stress is concentrated. Here, we report two cases of wound dehiscence and partial flap necrosis following free anterolateral thigh flap reconstruction. In both cases, the complications resulted from displacement of previously unrecognized calcaneal fractures associated with diabetic bone insufficiency. The migrated fracture fragments exerted internal pressure on the overlying flaps, leading to wound dehiscence and prolonged healing. To our knowledge, this is the first report demonstrating that internal protrusion of a migrated bone fragment may represent a critical mechanism of flap failure. These cases underscore the importance of strict postoperative offloading, routine radiographic surveillance, and comprehensive patient education to reduce skeletal complications and improve outcomes after heel reconstruction.
Jun et al. (2026) studied this question.