SLR - November 2015 - Sham Persaud
Reference: Dhamangaonkar AC, Patankar HS. Reverse Sural Fasciocutaneous Flap With a Cutaneous Pedicle to Cover Distal Lower Limb Soft Tissue Defects: Experience of 109 Clinical Cases. J Orthop Traumatol. 2014 Sept;15(3):225-29.Scientific Literature Review
Reviewed By: Sham Persaud, DPM
Residency Program: Western Pennsylvania
Podiatric Relevance: Soft tissue defects of the distal third of the lower extremity, whether it be secondary to trauma or a diabetic foot infection is a challenge for any physician. Therefore, it is important to understand the options available to close such deficits and prevent exposure to potential infection and/or necrosis. This article, discusses an underutilized way in which such deficits can be closed effectively, sural fasciocutaneous flaps with a cutaneous pedicle. The authors discuss their experience with multiple conditions and comorbidities treated with sural flap coverage. Their results and experience show that sural flaps are a viable option for treating soft tissue deficits of the distal third of the lower extremity.
Methods: One hundred and nine patients had soft tissue deficits treated with sural flap coverage. All of the patients had moderate (5-15cm) to large (>15cm) wounds, which required surgical coverage. The defects were located over the anterior, medial and lateral ankle; medial, lateral, rear and plantar heel; dorsum, plantar aspect of the foot; anteromedial and anterolateral middle and distal third tibia; over the tendo-achilles; and over an amputation stump. The wounds were caused by trauma (59.80 percent), diabetic ulcers (11.76 percent), post-traumatic scar contracture (7.84 percent), venous ulcer (3.92 percent), wound dehiscence (9.80 percent), leprotic non-healing ulcer (0.98%), post-infective wound (0.98 percent), radiation-induced ulcer following radiotherapy for synovial cell sarcoma (0.98 percent), post-fibromatosis excision (0.98 percent)), post-dermatofibrosarcoma excision (0.98 percent), post-heel melanoma excision (0.98 percent)) and actinomycosis foot (0.98 percent). Flaps were only performed after erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were normalized.
A single surgeon performed all procedures. The flap was outlined to always be 2.5cm larger either longitudinally or laterally to prevent tension on the graft. The flap was rotated distally and dissected no further than 5 cm proximal to the ankle mortise. The sural artery, nerve, and vein were dissected distally with the graft. The flap was then rotated as proximal as possible and sutured into the deficit using loose tension free sutures. The pedicle was then closed using primary intention closure or split thickness skin graft as well as the donor site. Complications during that time were noted as well as time in which it took for the flap to take.
Results: Out of the 109 patients treated, seven were lost to follow up. Of the remaining 102, the average age was 32.7 years (2-65), the average flap size was 148.1cm2 ± 59.54 cm2, the average duration of surgery was 121.29 min ± 31.16 min. During the recovery process, 91 of the 102 cases healed with no complications. Average healing time equated to 20.88 days ± 6.71 days. Nine of the eleven patients with complications showed signs of distal edge necrosis of the flap. Of those nine patients, three patients showed necrosis =3cm. One patient with a plantar diabetic foot ulcer showed 6 cm necrosis. One flap required repositioning secondary to poor host tissue for suturing. Lastly, one patient with fibromatosis had recurrence of the tumor along the flap edge, which caused necrosis. There were no cases of infection. Seven patients required repeat donor site grafting. Six of the seven had diabetes, venous insufficiency, or leprosy. Sixty-nine cases showed sural cutaneous hypoaesthesia, but no patients showed loss of function.
Conclusions: This study showed that the use of a sural fasciocutaneous flap in a viable option in treating soft tissue defects of the distal third of the lower extremity. Though there were complications, none of the complications led to failure of the procedure and all healed via secondary intention with local wound care. The study also revealed that there were higher rates of complications when the defect was distal to the level of the ankle and with patients with comorbidities such as diabetes or venous insufficiency. Limitations to this study include poor outline of their follow up timing. Another limitation to this study is short term follow up. Further studies to assess long term outcomes of these patients including complications and quality of life measurements would be valuable in determining the efficacy and viability of this procedure for soft tissue defects.