Fat pad replacement
The Graft Jacket, from Wright Medical, was
developed for ulcer repair and tendon repair
and is used to treat fat pad atrophy.
One common complaint that we get in our office is "I feel
like I am walking on my bones." During weight bearing
the plantar foot is cushioned and protected by the plantar
fat pad. This anatomic structure is organized as fat lobules
held in place by surrounding fiberous septa.
Five individual sub-metatarsal pads combine to form the
metatarsal plantar pad. The metatarsal fat pad is
constrained dorsally by attachments to the capsule of the
metatarsal heads and to the more plantar sub-dermal
layer. These fat pads act as a shock absorber to cushion,
defuse force, and resist shear during weight bearing. This
fat pad also acts to protect and cushion the underlying
bone, tendons and neurovascular structures of the foot.
This plantar fat pad can become displaced or atrophied
from any number of traumatic events including multiple
surgical incisions, fractures, or chronic metatarsal plantar
flexion. These conditions often result in a painful plantar
weight bearing surface that can lead to callus, or worse,
ulceration.
Several attempts at surgical correction over the years have
been attempted with little success. Most of these lacked
long-term correction and pain relief due to the migration,
short resorption profile, or inconsistent delivery
characteristics of the material. A couple of years ago, a
novel surgical treatment was introduced using Graft Jacket
from Wright Medical which was developed for ulcer repair
and tendon repair. Graft Jacket is a human dermal
collagen template that is readily incorporated into the
body. The matrix undergoes a patented process that
renders that material essentially acellular and is freeze
dried with a proprietary process that prevents the
formation of ice crystals to preserve the intact matrix
including vascular channels. Graft Jacket Matrix contains
collagen, elastin, hyualuronan, fibronectin, blood vessel
channels, and proteoglycans.
A key factor to Graft Jacket is an intact, three-dimensional
matrix to build on. The three-demensional structure
provides a means for the body to rebuild the area of
missing tissue. Another important aspect of Graft Jacket is
that it is readily revascularized by the body. This means
that new blood vessels gain access through preserved
blood vessel channels and allows the conversion of Graft
Jacket into the host tissue.
The surgical procedure involves a minimal incision near
the area of interest to create a pocket for the graft in the
deep subcutaneous tissue layer. Next, with a suture
technique the graft is pulled into the pre-determined
position. Then the subcutaneous layer is closed, the skin is
repaired, and the foot is placed in a soft compressive
dressing. The patient should remain non weight-bearing
for 2 weeks. Using diagnostic ultrasound pre- and postoperatively, we can see the change in the thickness of the
fat pad.
This minimally invasive procedure provides a new
technique to treat fat pad atrophy when previous surgical
attempts had been unsuccessful.