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

1.9 MB·English

by  Ignatiadis, Ioannis A.

(cid:1)CLINICAL RESEARCH ARTICLE
The reverse sural fasciocutaneous flap
for the treatment of traumatic, infectious
or diabetic foot and ankle wounds: a
retrospective review of 16 patients
Ioannis A. Ignatiadis, MD, PhD1,*, Vassiliki A. Tsiampa, MD1,
Spyridon P. Galanakos, MD1, Georgios D. Georgakopoulos,
MD1, Nicolaos E. Gerostathopoulos, MD, PhD1, Mihai Ionac,
MD, PhD3, Lucian P. Jiga, MD, PhD3 and Vasilios D. Polyzois,
MD, PhD2
1Hand Surgery-Upper LimbandMicrosurgeryDepartment, KATGeneral Hospital,Athens, Greece; 24th
Orthopedic Department, KATGeneral Hospital,Athens, Greece; 3Vascular Surgery Department, Timisoara
University Hospital,Timisoara,Romania
Theauthorspresenttheirexperiencewiththeuseofsuralfasciocutaneousflapsforthetreatmentofvarious
softtissuedefectsinthelowerlimb.Thispaperisareviewoftheseflapscarriedoutbetween2003and2008.
Theseriesconsistsof16patients,12menand4womenwithanaverageageof40years(17(cid:1)81)andwitha
follow-up period between 1 and 8 years. The etiology was major velocity accident in six cases, diabetes
mellitus with osteomyelitis after ORIF for fractures (3), work accident in five, and another two cases with
complicationsoflowerlimbinjuries.Thedefectareaswerelocatedoncalcaneus,malleolararea,tarsalarea
andlowertibia.Associatedriskfactorsinthepatientsfortheflapperformancewerediabetes(fivepatients)
andcigarette smoking (elevenpatients).
Thetechniqueisbasedontheuseofareverse-flowislandsuralflapcombinedwithotherflapsinthreecases
(medialplantar,peroneal,gastrocnemius).Theanatomicalstructureswhichconstitutedthepediclewerethe
superficial anddeep fascia,the sural nerve, the lessersaphenousveinandskin.
Theflapwasviableinall16patients.Fivecases hadasuperficialnecrosisthatwereskingrafted,2cases
experiencedapartialskinnecrosiswhichweretreatedwithasecondaryflap(posteriortibialperforatorand
medial plantar artery)andanothercasedemonstrated a delayedskinhealing.
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
donorsitesforrepairing soft tissuedefects in footandankle.
Keywords: foot-ankle;necrosis;defects;suralflap;diabeticfootnecrosis;neuropathy,wounds
Received:20 September 2010; Revised:1 November 2010; Accepted:16 November 2010;Published:12January2011
Introduction (1, 2) 1992, Masquelet et al. described the use of the neurocu-
The management of soft-tissue defects in the lower taneous flap for reconstruction of soft-tissue defects of
limbs due to an increase of high energy trauma thedistalthirdoftheleg(1).Amongthemainindications
currently has become a very frequent procedure. for a sural fasciocutaneous flap are soft-tissue defects of
Thereconstructivesurgeonshouldbecapableofcarrying the heel and the lateral or medial perimalleolar regions
out an integral treatment of these wounds, including (2). This flap can also be combined with other flaps
notonlyopenreductionandinternalorexternalfixation in cases with some special soft-tissue defects (e.g. cases
of the fracture fragments, but also the management with simultaneous osteomyelitis, bone defect, and avas-
of possible complications such as local skin necrosis. In cular necrosis).
DiabeticFoot&Ankle2011.#2011IoannisA.Ignatiadisetal.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons 1
Attribution-Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-commercialuse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited. Citation:DiabeticFoot&Ankle2011,2:5653-DOI:10.3402/dfa.v2i0.5653
(pagenumbernotforcitationpurpose)
IoannisA.Ignatiadisetal.
Materials and methods softtissues.Thepatients’follow-upwasbetween1and8
Thisstudyisaretrospectivereviewofthesuralfasciocu- years.
taneous and neurocutaneous flaps carried out in 16
patients (Table1):12 menand 4 womenwith anaverage Surgical technique
ageof40years(ages17(cid:1)81)andapostoperativefollow-up The sural fasciocutaneous flap is made up of skin and
between1and8years.Thesoft-tissuedefectinthelower subcutaneous fat, the superficial and deep fascia of the
limb in this study was located on the heel and calcaneal posterior part of the leg, sural nerve, the sural vein, and
areainfivecases,onthemalleolarandparamalleolararea the superficial sural artery. The flap is based initially on
(Fig. 1a, b) in three cases, on the distal tibia in another the vascularization that runs with the sural nerve. Flap
three cases, dorsal tarsal area in four cases, and medial vascularization is accomplished by distal reverse flow of
plantar area in one case. Five patients were diabetic the superficial sural artery dependent on perforators of
theperonealarterialsystem.Therearenumerousanasto-
and suffered from osteomyelitis (four pressure sores and
mosis between the peroneal artery and the vascular axis
one post-traumatic osteomyelitis). Eleven patients were
oftheflap.Themostdistalisusuallyfoundatadistance
smokersandonlyfivewerenon-smokers.
of 4(cid:1)5 cm above the tip of lateral malleolus; thus, it
In two cases where the fracture was treated with
consists of the pivot point of the flap. Flap harvesting
external fixation, the sural flap was performed to treat:
techniques have been well described in the literature
(3(cid:1)6).
1. The soft-tissue defect in combination with the
Theflapwasoutlinedaccordingthesizeofthedefecton
external fixation.
azigzaglinedrawnfromthepoplitealfossatotheAchilles
2. The post-traumatic infection due to pin track
tendonalongtheposteriormiddleone-thirdoftheleg.The
infection.
pedicleconsistedofsubcutaneoustissue, deepfascia,the
Inanothercase, theflapwasperformedinordertotreat small saphenous vein, the sural nerve (in 2 cases), and
the remaining soft-tissue defect due to residual osteo- accompanying arteries. The small saphenous vein and
the sural nerve were ligated (proximally and distally) at
myelitis from post-traumatic infection of a distal tibial
the proximal borderof the flap and then the lateral and
fracture,whichwastreatedwithsurgicaldebridementand
medial borderof the flap and pedicle were incised down
distractionosteogenesiswiththeIlizarovtechnique.Inthe
to the muscle. Then the flap was rotated over its pedicle
caseswherethesuralflapwasusedtocoverdefectsdueto
upto1808(Fig.2a,b)andadaptedtothedefect(Fig.3a,b).
osteomyelitis infection, the patients were diabetic except
In two cases the pedicle of the flap included the distal
onecasewheretheinfectionwasacomplicationfroman
peroneal perforator of the peroneal artery. Skin closure
anklearthroplasty.
was achievedwith sutures on the reapproximated tips of
Onesuralflapinacasewithlargelocalhematomawas
eachtriangleofthezincision,andfreeskingraftscovered
preceded by a cross-leg emergency flap. The majority of
the created defects. At the end of the procedure the
flaps were fasciocutaneous except two (patients with
tourniquet was deflated and adequate circulation of the
calcaneal osteomyelitis) that were neurofasciocutaneous.
flapverified.Numerouspuncturesoftheflapusinga25G
During surgery all patients were positioned prone and
needle were made to allow bleeding thus minimizing
were anaesthetized with spinal anesthesia. A tourniquet
hyperemia andvenous congestion. The limbwas dressed
was placed in the proximal lower limb.
withcottonandelasticbandages.
Forthethreediabeticpatientswithcalcanealosteomye-
litis, the osteomyelitis was diagnosed with clinical and
Results
radiographic examinations and typical Radiographies.
Demographicinformation,complications,andresultsare
Intraoperative cultures and/or histological examinations
presentedinTable1.Allflapssurvivedcompletely(Fig.4a,
confirmed the diagnosis for each of them. The dorsalis
b). In one case a slight venous congestion was managed
pedisandposteriortibialarterypulseswerepalpableinall
with the vasodilating agent Buflomedil Hydrochloride
patients. Broad spectrum antimicrobial therapy was ad-
(600mg(cid:2)1/24h)andoralmicronizedpurifiedflavonoid
ministered to all patients. Postoperative antimicrobial
fraction(MPFF)(Daflon)(cid:1)avasoprotectorandvenotonic
treatmentswereadjustedaccordingtotheresultsofculture agent. In four cases, a small superficial necrosis was
antibiograms for the microorganisms isolated from the observed that was managedwith minor revision and the
deep-tissue specimens. The average therapy consisted of use of split thickness skin graft. In another two complex
3 to 4 weeks of intravenous treatment followed by 2(cid:1)3 cases,thesuralflapwascombinedwiththeposteriortibial
weeksoforaltreatmentinmoderateinfectionsandlonger arteryperforatorflapforcompletedefectclosureandwith
protocols of treatment in case of osteomyelitis. The a medial plantar neurovascular flap in order to provide
durationofantibiotictherapywasdeterminedonthebasis sensationandanklearthrodesis(casewithcalcanealbone
ofcultureresultsandclinicalassessmentsofthewoundand defectandAchillestendonrupture).
2
Citation:DiabeticFoot&Ankle2011,2:5653-DOI:10.3402/dfa.v2i0.5653
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C
ita
tio
n
:
Dia Table1. Patientstreatedwiththereverseflowsuralflap
b
e
tic
F Age,genderand Typeandlocation Typeofflapand Timingofdefectprior Complicationsand
o
o
t Case historyofsmoking ofdefect dimensions Fracturesand/orinfection MechanismofInjury tosuralflapsurgery treatment Lastfollow-up
&
A
n
kle 1 49,Male Calcaneus Suralflap Calcaneal Diabeticneuropathy 12months None 8years
20 SmokingHistory 5(cid:2)8cm osteomyelitis andInfection
1
1, 2 26,Female Malleolus Suralflap Softtissuenecrosis MotorVehicle 2weeks None 7years
2
:5 SmokingHistory 5(cid:2)7cm Accident(MVA)
6
53 3 56,Male LowerDistalTibia Suralflap Lowerdistaltibia MVAandHistoryOf 2months DelayedSkinhealing 1year
-
D SmokingHistory 4.5(cid:2)8cm posttraumatic Diabetesmellitus (4weeks)
O
I: osteomyelitis
1
0
.3 4 26,Male Tarsaldorsalarea Suralflap Secondandthird Workrelatedinjury 1month Superficialnecrosis 4years
4
0
2/d 6(cid:2)9cm metatarsalfractures treatedwithsplit
fa.v2 thicknessskingraft
i0.5 (STSG)10days
6
5 postoperatively
3
5 31,Male Dorsumofthe Suralflap AnkleFracturetreated Workrelatedinjury 12months Superficialnecrosis 3years
SmokingHistory ankle 6.5(cid:2)10cm witharthrodesisand treatedwithSTSG
postsurgicalosteomyelitis 5dayspostoperatively
6 51,Female Diabeticdecubitus Suralflap Calcaneal Diabeticneuropathy 2months Superficialnecrosis 4.5years
SmokingHistory calcaneus 6.5(cid:2)16cm osteomuelitis andInfection treatedwithSTSG R
e
v
2weekspostoperatively e
rs
7 17,Male Medialplantarand Crossleg7(cid:2)11cm Calcanealavulsion Workrelatedinjury 3.5weeksforthe None 4years e
s
tarsalarea followedbySural fracture cross-legflap ura
l
flap followedbyasural fa
s
6(cid:2)10cm flap4weekslater cio
c
8 35,Male Lowertibia Gastrocnemius Opentibiacomminuted MVA 3weeks None 3years u
ta
anteromedial 4(cid:2)15cmfollowed fracture n
e
o
(pagenumb 9 33,Male Casaplceacnteusand Cb4y(cid:2)omS6ubcrinamlefdlaSpural& Failedopenreduction Workrelatedinjury 1month Partialnecrosistreated 3.5years usflaps
er fo
notforcitationp Achillesarea Pf7lae(cid:2)pro1sn0ecamlperforator icnatlecrannaelafilxfartaioctnuroefa wa1r0ittehdrayayptsiebprifaoolsrpatootopsreterfalraitopivrely rtreatingin
urpose)3 fectio
n
s
Io
a
(p4 n
age nis
numbernotforcitation A.Ignatiadiset
purp Table1(Continued) al.
o
se)
Age,genderand Typeandlocation Typeofflapand Timingofdefectprior Complicationsand
Case historyofsmoking ofdefect dimensions Fracturesand/orinfection MechanismofInjury tosuralflapsurgery treatment Lastfollow-up
10 29,Female Dorsunofthe Combined-Sural& SubluxationofMidfoot MVA Uponinitial Superficialnecrosis 3years
SmokingHistory ankle Peronealperforator andRearfootjointsand presentation treatedwithSTSG
flaps extensortendon 1weekpostoperatively
7(cid:2)9cm lacerations
11 81,Male Diabeticdecubitus Suralflap Calcaneal Diabeticneuropathy 3months None 3years
calcaneus 6(cid:2)8cm osteomyelitis andInfection
12 40,Male External Suralflap Tibiocalcaneal MVAandHistoryOf 1month None 4years
SmokingHistory paramalleolar 5(cid:2)7cm arthrodesiswithsevere Diabetesmellitus
areas softtissuenecrosis
13 42,Male OpenTibia Suralflap Posteromedialtibialarea MVA 1month Superficialnecrosis 1.5years
C
ita SmokingHistory FractureMidshaft 5(cid:2)7.5cm treatedwithSTSG
tion 2weekspostoperatively
:
D 14 35,Male Malleolarsoft Suralflap Previouslytreatedtibial Postraumatic 2months None 2years
ia
b
e SmokingHistory tissuenecrosis 4.5(cid:2)7cm fractureand
tic
F postoperative
o
o
t osteomyelitis
&
A 15 65,Female DorsalTarsal Suralflap Previoustotalankle Postraumatic 2months None 4years
n
k
le SmokingHistory aspect 5(cid:2)6cm arthroplasty
2
01 16 24,Male Calcaneusand Suralflap Severecalcanealand Workrelatedinjury 2months Secondarymedial 1year
1
,2 SmokingHistory Achillesarea 6(cid:2)10cm Achillestendondefects plantarflap3(cid:2)5cm
:
56 frominjury 5weeksaftertheinitial
5
3 surgeryfollowedbya
-
DO 3rdoperationofa
I:
1 tibiocalcanealarthrodesis
0
.34 3monthslater
0
2
/d
fa
.v2
i0
.5
6
5
3
Reversesuralfasciocutaneousflapsfortreatinginfections
Fig.1. (a)Case1(female)and(b)case2(male)youngpatientswithexternalmalleolarandlateraltarsalareanecrosis.
The average surgery time was 60(cid:1)100 min (including flap,butsomeauthorsstatedthatthedistallybasedsural
flap dissection) and the average size of the flap 5.6(cid:2) flap is morereliable than the lateral supramalleolar flap,
8.7 cm. The flaps provided a successful coverage in all especially regarding the venous congestion and have
cases.Between1.5monthsand3monthspostoperatively, showntheusefulnessofthesuralflapforweight-bearing
all patients walkedwithout crutches (Fig. 4a, b) or with areas even when resensibilization is not performed.
the utilization of external fixation devices. A lateral supramalleolar skin flap is not recommended
for coverage in this areas. The global proportion of
Discussion
failures is almost four times as great for the supramal-
Thereis a largevarietyof pedicled or muscular flaps for leolarskinflap(7).Theposteriortibialperforatorflapis
thereconstructionofpost-traumaticsoft-tissuedefectsof
anotheroption (8). It is avery reliable lap and indicated
the lower limb. These techniques are not all familiar to
in lower limb defects, especially in reconstruction of
reconstructivesurgeons.Thepotentialforflapfailureand
chronic Achilles tendon defects. A more difficult dissec-
donor side morbidity are common risk factors.
tion and a larger learning curve are the main disadvan-
Themainalternativestosuralflapsarefreeflaps,lateral
tages. A medial distal septocutaneous flap (9) based on
supramalleolarskin flaps, and posterior tibial perforator
the intramuscular posterior tibial perforators is an
flaps.Freeflapreconstructionofdefectsrequireslengthy
alternative.
and costly hospitalization, microsurgery training and
Theadvantagesofthesuralflapcomparedtotheabove
experience,specialinstruments,andatwo-teamapproach.
mentioned flaps are the simplicity of the design and
The long operative time and functional donor-site
dissection of the pedicle that can be carried out with a
morbidity are the major disadvantages of this method.
loupemagnificationandwithouttheneedofmicrosurgi-
Freeflapsareadvisedforextensiveskindefects(1).
cal instrumentation or anastomosis, the preservation of
The lateral supramalleolar skin flap offers a range
the principal vascularization of the lower limb, and the
of coverage similar to that of the sural flap, but the
dissectionismoredifficultthanforasuralflapandoffers needforonlyoneoperation.Itcanalsobecombinedwith
no advantages and the remaining non-sensitive area in various osteosynthesis techniques as external fixation of
sural flaps is smaller than the one left after the transec- comminuted fractures and Ilizarov, and also with other
tion of the superficial peroneal nerve. Theoretically, the fasciocutaneous flaps (tibial, medial plantar), muscle
sural flap doesn’t cover as distal as the supramalleolar flaps (gastrocnemius), or distant flaps (cross-leg).
Fig.2. (aandb)Cases1and2,suralflapharvesting.
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IoannisA.Ignatiadisetal.
Fig.3. (aandb)Cases1and2,flapadjustmentonthedefectsareas.
According to the treatment of calcaneal osteomyelitis The fasciocutaneous sural flaps that were successfully
(except the sural flap), various surgical methods have used in our series (Table 1) have many advantages for
been used like debridement and coverage with local the treatment of calcaneal osteomyelitis including easy
muscle or free muscle flaps (10(cid:1)13), partial calcaneal dissection, short operative time, wide rotation arc, and
resection (14(cid:1)17), and total calcanectomy (18). Below- acceptable donor-site morbidity. There is no need to
the-knee amputation has been recommended for cases sacrifice the major artery of the leg. Unlike free flaps,
with extensive and/or progressive involvement of the os thereisnoneedforavascularanastomosis;thus,thereis
calcis (19). no risk for the blood supply of the foot. They can be
Useful local muscle flaps for calcaneal osteomyelitis elevated in relatively large sizes, so that part of the
treatment are the abductor digiti minimi and abductor flap can be deepithelialized and used for obliteration
hallucismuscles.Themajordisadvantageoftheseflapsis
ofabonecavity.Diabetesmellitusalonedoesnotusually
theirsmallsizeespeciallywhenthereisanextensivetissue
compromise the vascularityof these flaps if they present
loss. When local viable tissue is inadequate, free muscle
with adequate blood supply. In addition, other reports,
transfersallowcoverage.Therectusabdominisandgracilis
ontheliteratureconfirmthattheycanbeusedsafelyfor
muscle flaps are usually preferred for the treatment of
soft-tissue reconstruction of diabetic patients (21).
calcaneal osteomyelitis (20). Coverage with the above
In conclusion, the reverse flow sural flap constitutes a
mentionedflapshasdemonstratedgoodfunctionalresults
reliableandversatiletechniquethatmaybeapartofthe
andadequateweight-bearingsurfaces(11(cid:1)13).
reconstructive surgeon’s armamentarium and thus facil-
Muscle flaps have good vascularity for the treatment
itating the integral treatment of complex lower limb
of infection, a positive effect on bone healing, and an
injuries with large defects in diabetic or non-diabetic
obliteration effect because of their bulky tissue. However,
patients.
free muscle flap reconstruction of calcaneal osteomyelitis
associateddefectsrequireslengthyandcostlyhospitalization,
microsurgical training and experience, special instru-
ments, and a two-team approach. The major disadvan- Conflict of interest and funding
tages of this method are the long operative time and The authors have not received any funding or benefits
functional donor-site morbidity. from industryor elsewhere to conduct this study.
Fig.4. (aandb)Cases1and2:finalresults.
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Reversesuralfasciocutaneousflapsfortreatinginfections
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