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      The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds: A retrospective review of 16 patients

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          Abstract

          The authors present their experience with the use of sural fasciocutaneous flaps for the treatment of various soft tissue defects in the lower limb. This paper is a review of these flaps carried out between 2003 and 2008. The series consists of 16 patients, 11 men and 5 women with an average age of 41 years (17-81) and with a follow-up period between 2 and 7 years. The etiology was major velocity accident in six cases, diabetes mellitus with osteomyelitis after ORIF for fractures (2), work accident in five, and another two cases with complications of lower limb injuries. The defect areas were located on calcaneus, malleolar area, tarsal area and lower tibia. Associated risk factors in the patients for the flap performance were diabetes (five patients) and cigarette smoking (ten patients).

          The technique is based on the use of a reverse-flow island sural flap combined with other flaps in three cases (cross-leg, peroneal, gastrocnemius). The anatomical structures which constituted the pedicle were the superficial and deep fascia, the sural nerve, the lesser saphenous vein and skin.

          The flap was viable in all 15 patients. On 8 cases was achieved direct closure, on three cases occurred a superficial necrosis and was skin grafted, on one case was observed partial necrosis which was treated with a second flap (posterior tibial perforator flap) and another one occurred delayed skin healing.

          The sural fasciocutaneous flap is useful for the treatment of severe and complex injuries and their complications in diabetic and non diabetic lower limbs. Its technical advantages are easy dissection, preservation of more important vascular structures in the limb and complete coverage of the soft tissue defects in just one operation without the need of microsurgical anastomosis. Thus this flap offers excellent donor sites for repairing soft tissue defects in foot and ankle.

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          A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group.

          P Baumeister, Detlev Erdmann, Roberto Spierer … (2003)
          The popularity of the sural artery flap has increased markedly throughout the years, and favorable results are reported almost uniformly. Previous publications have mainly presented results of small groups and of predominantly younger patients with posttraumatic defects, or they have reported technical modifications of the sural artery flap. The authors have increasingly used the reversed sural artery flap in a high-risk, critically multimorbid, and older patient population, and in contrast to the results of other authors, a considerable necrosis rate of 36 percent was seen. For the first time, a detailed, critical, retrospective complication analysis of 70 sural artery flaps is presented. The results reveal the following risk factors, which can potentially impair successful defect coverage and thus contribute to flap complications: concomitant diseases, particularly diabetes mellitus; peripheral arterial disease or venous insufficiency, which increase the risk of flap necrosis five-fold to six-fold; and patient age of over 40 years, because of an increased rate of comorbidity, underlying osteomyelitis, and the use of a tight subcutaneous tunnel. However, age alone did not seem to represent a risk factor by itself. Given the results of the analysis, the operative procedure was altered, as follows. In cases in which a lesser saphenous vein cannot be found, a delay procedure is recommended, or the flap is not utilized. In addition, an external fixation device seems to facilitate postoperative care markedly without adding specific complications; it is recommended in most patients. This analysis emphasizes specific risk factors that result in higher complication rates of the sural artery flap, and it leads to more realistic and appropriate expectations for this flap.
          Article 0 comments Cited 50 times – based on 0 reviews     Review now
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            The distally based superficial sural artery flap.

            M. Hasegawa, S Esaki, H Katoh … (1994)
            The distally based superficial sural artery flap, first described as a distally based neuroskin flap by Masquelet et al., is a skin island flap supplied by the vascular axis of the sural nerve. The aim of this paper is to refine the surgical technique in order to establish the reliability of this flap. We treated 20 patients with 21 distally based superficial sural artery flaps, including 2 fascial flaps. All flaps survived. Most flaps showed slight venous congestion. In the largest flap (10 cm wide by 13 cm long), edema lasted 2 months. In the flap whose pedicle was raised without the deep fascia, there was necrosis at the distal tip of the flap. The advantages are the following: The blood supply is reliable, elevation is easy and quick, and major arteries are not sacrificed. This new flap may be useful in selected circumstances.
            Article 0 comments Cited 31 times – based on 0 reviews     Review now
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              The distally based superficial sural artery island flap: clinical experiences and modifications.

              M. Yilmaz, O Karatas, A. Rasim Barutcu (1998)
              The coverage of defects of the Achilles tendon, malleoli, and heel remains a challenge to reconstructive surgeons. The distally based superficial sural artery island flap is vascularized by the median superficial sural artery, posterolateral septal perforators originating from the peroneal artery, neurovascular arteries of the sural nerve, and combinations of these systems as suprafascial plexus. We used distally based superficial sural artery island flaps for the reconstruction of defects of ankle, malleolus, and heel in 17 patients between 1991 and 1997. The largest flap we have used until today was 12 cm in width and 15 cm in length. All flaps have survived. However, we observed venous congestion and edema in two flaps. Also, marginal necrosis occurred in two flaps for which we had not taken the sural nerve with the flap. After these complications, we made some modifications. We left a skin extension over the fasciovascular pedicle and used it as a roof of the tunnel. We took the sural nerve and the deep fascia in all cases. The main advantage of this flap is a constant and reliable blood supply without sacrifice of a major artery. In addition, this is a one-stage, safe and easy procedure that can be used for large defects.
              Article 0 comments Cited 20 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Diabet Foot Ankle
                Journal ID (publisher-id): DFA
                Title: Diabetic Foot & Ankle
                Publisher: Co-Action Publishing
                ISSN (Electronic): 2000-625X
                Publication date (Electronic): 12 January 2011
                Publication date Collection: 2011
                Volume: 2
                Electronic Location Identifier: 10.3402/dfa.v2i0.5653
                Affiliations
                [1 ]Hand Surgery-Upper Limb and Microsurgery Department, KAT General Hospital, Athens, Greece
                [2 ]4th Orthopedic Department, KAT General Hospital, Athens, Greece
                [3 ]Vascular Surgery Department, Timisoara University Hospital, Timisoara, Romania
                Author notes
                [* ] Ioannis A. Ignatiadis, Hand Surgery-Upper Limb and Microsurgery Department, KAT General Hospital, Athens, Greece. Email: ignatioa@ 123456yahoo.com
                Article
                Publisher ID: DFA-2-5653
                DOI: 10.3402/dfa.v2i0.5653
                PMC ID: 3284289
                PubMed ID: 22396826
                SO-VID: a4adde11-640a-4ea9-aab3-901615944032
                Copyright © © 2011 Ioannis A. Ignatiadis et al.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 20 September 2010
                Date revision received : 01 November 2010
                Date accepted : 16 November 2010
                Categories
                Subject: Clinical Research Article

                ScienceOpen disciplines: Endocrinology & Diabetes
                Keywords: sural flap,neuropathy,wounds,defects,foot-ankle,diabetic foot necrosis,necrosis
                Data availability:
                ScienceOpen disciplines: Endocrinology & Diabetes
                Keywords: sural flap, neuropathy, wounds, defects, foot-ankle, diabetic foot necrosis, necrosis

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