SLR - July 2017 - Candace J. Masso
Reference: Mahmoud WH. Foot and Ankle Reconstruction Using the Distally Based Sural Artery Flap Versus the Medial Plantar Flap: A Comparative Study. J Foot Ankle Surg. 2017 May–Jun; 56(3):514–518.Scientific Literature Review
Reviewed By: Candace J. Masso, DPM
Residency Program: MetroWest Medical Center
Podiatric Relevance: Soft-tissue defects of the foot and ankle often may greatly benefit from reconstruction with skin flaps. Unfortunately, flaps can be difficult to select and harvest due to certain skin characteristics unique to the foot as well as relatively poor skin circulation. Because the foot is a weightbearing unit, it is important for a flap to be able to resist sharing forces and tension. There are several types of surgical reconstructive options for soft-tissue defects of the foot and ankle, including skin grafts, cross leg flaps, local fasciocutaneous flaps and free flaps. This article reviews the risks and benefits of two types of fasciocutaneous flaps: the medial plantar artery flap and the reversed sural artery flap. The goal was to assess whether one is more beneficial than the other in terms of managing soft-tissue defects of the foot and ankle.
Methods: This study reviewed 30 patients aged 18 to 60 with soft-tissue defects of the foot and ankle from 2011 to 2014. Prior to reconstruction, arterial duplex scanning was performed to assess vascular patency. Fifteen patients were selected to have reconstruction using the medial plantar artery flap (MPAF), and 15 patients were selected to have reconstruction using the reversed sural artery flap (RSAF). Criteria for the MPAF included defects that were <5 x 7 cm with an intact instep and patent posterior tibial artery/medial plantar artery. Criteria for the RSAF included defects that were >5 x 7 cm with no injury to the lateral aspect of the lower leg and a patent peroneal artery. Patients did not have any major comorbidities and were excluded if they had a history of PVD or smoking.
Results: Defect size of the MPAF group was smaller with an average of 22 cm squared. The MPAF group had a longer operative time (100 mins avg) and had 100 percent flap survival. Patients of this group were able to bear weight earlier at 5.8 weeks, and there were no recurrent ulcerations. There were fewer complications in the MPAF group (33.3 percent), and this group had better functional outcomes. No debulking was required after the flap incorporated and healed. In the RSAF group, the defect size was larger with an average of 66 cm squared. Operative time was shorter (80 mins avg), and one flap did not survive (likely due to venous congestion). Patients of this group were able to bear weight later at 6.9 weeks, and there were no recurrent ulcerations. However, complications were higher in this group at 80 percent. Three flaps required debulking procedures, and 15 patients required shoe modifications.
Conclusions: There are numerous options for soft-tissue defect reconstruction of the foot and ankle, including skin grafts, fasciocutaneous flaps, free flaps and cross leg flaps. This study compared two fasciocutaneous flaps (MPAF and RSAF) and found that they both provided durable skin and soft- tissue coverage, and neither resulted in recurrent ulcers. While the MPAF is not recommended for large defects or patients with instep injury, functional outcomes were better overall, and there were fewer postoperative complications than with the RSAF. Both flaps are advocated for soft-tissue defect reconstruction of the foot and ankle; however, the MPAF is preferred for moderate-sized defects.