Limb Elevation by Transcalcaneal Steinmann Pin in Lower Extr… : Plastic and Reconstructive Surgery

Lower limb elevation after free flap reconstruction is essential to achieve a satisfactory outcome, avoid pressure (on the flap or over the anastomosis), reduce edema, and prevent venous insufficiency during the first postoperative week. In the upper extremity and head and neck regions, postural measures are easier for the patient. However, achieving the required elevation and immobility for lower extremity free flaps can be a challenge. Different methods have been reported for this purpose, such as simple kickstands, kickstand external fixators,1 and transtibial pins.2,3

In our experience, a Steinmann transcalcaneal pin, described for lower limb traction,4 may offer advantages (Fig. 1).

Fig. 1.:

Steinmann transcalcaneal pin placed in position. The limb is raised with a Bohler stirrup and a gauze bandage.

It is technically simple and rapid to place. Usually far from the surgical field, it can be used in case of tibial reconstruction. It has a low infection rate, and it can be performed under local anesthesia at the bedside if needed. Further advantages of the Steinmann pin are that it allows easier dressing changes in the postoperative period, thereby relieving patients from strict positioning and allowing them to move somewhat while in bed.

The pin is placed through the calcaneus, 2 cm below the apex of the inner malleolus and 2 cm from the posterior aspect of the calcaneus in a medial to lateral direction, to avoid the calcaneal branch of the tibial nerve and the retromalleolar neurovascular bundle.5 No radiographic control is needed. The pin is tied with a Bohler stirrup and a gauze bandage to the bed box frame, thus controlling the position of the lower limb, without any pressure on the flap, and allowing correction of the equine foot tendency if needed. In the absence of stirrups, the pin can be fixed directly to a cast.

This low-demand mechanical device grants a safer method than simple kickstands, is easier to use than kickstand external fixators, which require multiple pins, and prevents tibial osteomyelitis risk caused by a transtibial pin. [See Figure, Supplemental Digital Content 1, which shows tibia osteomyelitis caused by transtibial pin placement,] The only precaution to be taken should be to protect the tips of the pin.

In conclusion, use of a transcalcaneal Steinmann pin allows for safe and comfortable elevation in lower extremity free flaps.


The authors declare no conflicts of interest, and did not receive any form of financial or nonfinancial support.


1. Maruccia M, Elia R, Caizzi G, et al. Free flap and kickstand external fixator in foot and ankle soft tissue reconstruction: The versatility of a microsurgical-friendly application of an orthopedic device. Injury 2018;49(Suppl 3):S105–S109.

2. Cavadas P. Use of limited external fixation for limb elevation in lower extremity free flaps. J Plast Reconstr Aesthet Surg. 2008;61:1411–1412.

3. Kapadia SM, Gust MJ, Alghoul MS, Dumanian GA. Suspension of leg via a single tibial pin provides postoperative elevation and pressure off-loading for lower extremity free flaps. Plast Reconstr Surg Glob Open 2013;1:e3–e4.

4. Heim D, Weymann A, Schütz M, Matter P. Pinless calcaneus traction: A preliminary report. J Orthop Trauma 1994;8:338–342.

5. Mekhail AO, Ebraheim NA, Heck BE, Yeasting RA. Anatomic considerations for safe placement of calcaneal pins. Clin Orthop Relat Res. 1996;332:254–259.


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