SLR - December 2021 - Aleksey Kozlov
Reference: Hashmi PM, Musaddiq A, Ali M, Hashmi A, Zahid M, Nawaz Z. Long Term Clinical and Functional Outcome of Distally Based Sural Artery Flap: A Retrospective Case Series, JPRAS Open. 2021 Dec; 30(1): 61–73Level of Evidence: III
Scientific Literature Review
Reviewed By: Aleksey Kozlov, DPM
Residency Program: Highlands/Presbyterian St. Luke's Medical Center – Denver, CO
Podiatric Relevance: Reconstruction of soft tissue defects of the lower extremity depends on the location, size, and depth of the wound and often presents a complex challenge for foot and ankle surgeons. While a variety of techniques and products exist for smaller wounds, larger defects with exposure of deep structures (tendon, muscle, and bone) remain difficult to address. This article offers a long-term retrospective review of a large pool of patients who underwent distally based sural artery flap reconstruction over the course of 25 years and presents a robust body of evidence for the high efficacy of these flaps. The authors describe their surgical technique and demonstrate how sural artery flaps offer an excellent option for versatile soft tissue restoration in the setting of trauma and infection.
Methods: Data on 89 patients with 92 sural artery flaps performed by a single surgeon over a 25-year period were reviewed. The subjects were divided into those undergoing reconstruction of lower leg defects (group 1) versus foot and ankle defects (group 2). The primary outcome measures included survival of the flap, cosmetic appearance, weight-bearing status and functionality of the limb. Authors recorded demographics, mechanism of injury, location and size of soft tissue defects, associated injuries, comorbidities, concomitant surgical procedures, as well as complications (venous congestion, hematoma formation, partial or complete necrosis, and wound dehiscence). A four-component Self-Designed Assessment Tool was utilized to assess flap survival, cosmetic appearance, capacity for activities of daily living and weight bearing status.
Results: The authors demonstrate excellent outcomes with an overall flap survival rate of 96.8 percent. Of the 92 total flaps reviewed, 37 (90 percent) in group 1 and 47 (92 percent) in group 2 showed complete healing and functional recovery with no complications. The overall rate of complications was 8.6 percent with three cases of partial flap necrosis, three infections, and two with venous congestion of the flap. The subjects in both groups were satisfied with the functional and cosmetic outcomes without any significant differences. Flap donor sites were closed primarily in 25 percent of cases and with skin grafting in 75 percent of cases without any recorded donor site complications. Self-Designed Assessment Tool analysis revealed that group 1 demonstrated a larger degree of overall “excellent” results (92.6 percent vs 80.4 percent in group 2) suggesting slightly better subjective outcomes with lower leg reconstruction.
Conclusions: This article present compelling evidence for the utilization of distal-based sural artery flaps in lower extremity soft tissue defect reconstruction. The authors divulge a plethora of surgical tips and provide a blueprint for consistent success with this technique. These versatile flaps offer a reliable and reproducible option for large defects secondary to trauma and infection. Foot and ankle surgeons interested in wound care and limb salvage need to have multiple options for addressing tissue defects and the sural artery flap is tried-and-true. The robust population size, follow-up duration, and surgical technique discussion are key strengths of this study.