Combined flap with Masquelet technique and 3D-printed titanium cage for reconstruction of traumatic composite heel defects: a case report and literature review.

Background: Open calcaneal fractures accompanied by substantial segmental bone loss and severe soft-tissue damage represent a rare clinical presentation. The intricate anatomy of the heel region poses a significant challenge to limb-salvage efforts in such cases, for which a standardized treatment protocol remains to be established. Case summary: Here we report a case of extensive soft tissue defects around the ankle and heel, combined with a large segmental defect of the calcaneus, managed through a staged surgical approach. The first stage involved emergency debridement and coverage with antibiotic-loaded cement, while the residual heel skin was banked in the anterolateral thigh region. In the second stage, to address the composite soft tissue defects across multiple planes, a pedicled flap was combined with a free flap for reconstruction: a propeller flap based on a perforator of the peroneal artery was used to cover the posterior heel and lateral malleolus, followed by a free anterolateral thigh flap, which incorporated the banked skin, to resurface the heel and remaining critical areas. Split-thickness skin grafts were applied to non-critical zones. Antibiotic cement was implanted in the bone defect to prepare the site for later reconstruction. In the third stage, after confirming satisfactory soft tissue healing without signs of infection, a custom 3D-printed titanium cage prosthesis was implanted. To our knowledge, no similar case has been reported in the literature. This study represents the first application of a combined flap technique, the Masquelet induced membrane technique, and a 3D-printed patient-specific calcaneal prosthesis for this type of injury. One-year follow-up revealed well-positioned prosthesis on radiographic imaging, with acceptable foot contour and range of motion meeting the patient's basic functional needs. The American Orthopedic Foot & Ankle Society (AOFAS) score was 90 and the Maryland Foot Score was 89. The patient reported mild heel pain during weight-bearing, with minimal impact on daily activities. Conclusion: This case demonstrates that integrating the anti-infection benefits of the Masquelet technique, the precise structural support of 3D-printed titanium cages, and the revascularization advantages of microsurgery provides a promising combined strategy for achieving both aesthetic and functional reconstruction in complex composite heel defects.