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Whiting PS, Obremskey W, Johal H, Shearer D, Volgas D, Balogh ZJ. Open fractures: evidence-based best practices. OTA Int 2024; 7:e313. [PMID: 38708043 PMCID: PMC11064778 DOI: 10.1097/oi9.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 05/07/2024]
Abstract
Open fracture management is a common challenge to orthopaedic trauma surgeons and a burdensome condition to the patient, health care, and entire society. Fracture-related infection (FRI) is the leading morbid complication to avoid during open fracture management because it leads to sepsis, nonunion, limb loss, and overall very poor region-specific and general functional outcomes. This review, based on a symposium presented at the 2022 OTA International Trauma Care Forum, provides a practical and evidence-based summary on key strategies to prevent FRI in open fractures, which can be grouped as optimizing host factors, antimicrobial prophylaxis, surgical site management (skin preparation, debridement, and wound irrigation), provision of skeletal stability, and soft-tissue coverage. When it is applicable, strategies are differentiated between optimal resource and resource-limited settings.
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Affiliation(s)
- Paul S. Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin Hospital and Clinics, Madison, WI
| | - William Obremskey
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
| | - Herman Johal
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - David Shearer
- Department of Orthopaedic Surgery, University of California, San Francisco, UCSF Pride Hall, San Francisco, CA
| | - David Volgas
- University of Missouri—Columbia, Springfield, MO
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW, Australia
- Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
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Dorji K. Local or regional flaps in developing country: Experience from Eastern Bhutan. Int Wound J 2024; 21:e14905. [PMID: 38699934 PMCID: PMC11066765 DOI: 10.1111/iwj.14905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024] Open
Abstract
Soft tissue reconstruction plays an integral part in orthopaedic surgery. For developing country like Bhutan, where no micro-surgical or plastic surgeons are available, orthopaedic surgeons perform the local or regional flaps for the soft tissue defects. In this paper, we describe the use of different kinds of local and regional flaps and its outcome at Eastern Regional Referral Hospital, Bhutan.
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Affiliation(s)
- Kinzang Dorji
- Eastern Regional Referral Hospital (ERRH)MongarBhutan
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3
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Antúnez M, Huyen C, Neiman R. Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects. J Orthop Trauma 2024; 38:e105-e110. [PMID: 38158599 PMCID: PMC10868666 DOI: 10.1097/bot.0000000000002751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments. METHODS DESIGN Retrospective review. SETTING Rural outpatient surgical facility in Honduras. PATIENT SELECTION CRITERIA Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot. OUTCOME MEASURES AND COMPARISONS Flap healing, complications, and reoperations. RESULTS Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication. CONCLUSIONS The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Merlin Antúnez
- Holy Family Surgery Center, One World Surgery, Tegucigalpa, Honduras; and
| | - Cormac Huyen
- Holy Family Surgery Center, One World Surgery, Tegucigalpa, Honduras; and
| | - Rafael Neiman
- Holy Family Surgery Center, One World Surgery, Tegucigalpa, Honduras; and
- Sutter Roseville Medical Center, Trauma Services, Roseville, CA
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Lee JY, Lee HJ, Yang SH, Ryu JH, Kim HT, Lee BH, Kim SH, Kim HS, Lee YK. Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1751. [PMID: 37893469 PMCID: PMC10608781 DOI: 10.3390/medicina59101751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023]
Abstract
Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.
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Affiliation(s)
- Jun Young Lee
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Hyo Jun Lee
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Sung Hoon Yang
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Je Hong Ryu
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Hyoung Tae Kim
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Byung Ho Lee
- Department of Orthopaedic Surgery, Daejung Hospital, 180 Daein-ro, Dong-gu, Gwangju 61473, Republic of Korea;
| | - Sung Hwan Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (S.H.K.); (H.S.K.)
| | - Ho Sung Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (S.H.K.); (H.S.K.)
| | - Young Koo Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (S.H.K.); (H.S.K.)
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5
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Türker T, Hines E, Haddad D. Hemodynamics in Distally Based Sural Flaps for Lower Leg Reconstruction: A Literature Review. J Hand Microsurg 2023; 15:253-257. [PMID: 37701313 PMCID: PMC10495205 DOI: 10.1055/s-0042-1749445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Coverage of posttraumatic and chronic wounds at the distal leg is a difficult problem due to limited soft tissue available for local flaps. The sural flap is a versatile and effective method for reconstruction in this area since it does not need a significant amount of time or assistance to complete. Improving the survival of these flaps is critically dependent on understanding the basics of flap circulation and why recent modifications were introduced. This review will serve as a much-needed comprehensive analysis of these topics for surgeons looking to increase the reliability of their sural flaps.
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Affiliation(s)
- Tolga Türker
- Department of Orthopaedic Surgery, The University of Arizona-Banner University Medical Center Tucson, Tucson, Arizona, United States
| | - Eric Hines
- Department of Plastic and Aesthetic Surgery, University of California-Irvine School of Medicine, Irvine, California, United States
| | - David Haddad
- The University of Arizona College of Medicine-Tucson, Tucson, Arizona, United States
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6
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Adendjingue DM, Andjeffa V, Okim AM, Siniki F, Touré A. [Our experience of the sural flap with distal pedicle in the repair of foot plantar and heel of foot lesions]. ANN CHIR PLAST ESTH 2023; 68:346-353. [PMID: 36328869 DOI: 10.1016/j.anplas.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/20/2022] [Accepted: 09/29/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE The sural flap has often been used to cover the weight-bearing and non-weight-bearing areas of the foot and ankle. This study reports our experience in the coverage of these defects in the foot in weight-bearing areas. PATIENTS AND METHOD This is a retrospective and descriptive study of 70 months. This study includes 16 patients presenting a loss of plantar substance and/or heel of the foot covered by a sural flap with a distal pedicle. The sampling technique described by Masquelet served as our reference. An increase in the length of the pedicle of at least two centimeters during the dissection made it possible to avoid any stretching or compression for the most distal lesions. RESULTS The average age was 35 years with a sex ratio of three in favor of men. Traumatic lesions predominated (n=10) with an average area of lesions of 68.8cm2. The average partial and total support times were 1.8 and 3.6 months respectively. We noted one case of flap necrosis. The natural evolution of the flap took place in three progressive stages: regeneration, keratinization and squamous metaplasia. Normal bipodal support and stable gait without footwear anomaly were noted in 15 cases. CONCLUSION The distal pedicle sural flap technique is accessible. Its reliability makes it an ideal choice for distal loss of substance to the leg and foot.
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Affiliation(s)
- D M Adendjingue
- Service de chirurgie, hôpital Provincial de Sarh-Tchad, N'Djamena, Tchad.
| | - V Andjeffa
- Service de chirurgie, hôpital Provincial de Sarh-Tchad, N'Djamena, Tchad
| | - A M Okim
- Service de chirurgie, hôpital Provincial de Sarh-Tchad, N'Djamena, Tchad; Service de chirurgie orthopédique et traumatologie, centre hospitalier universitaire de référence nationale, N'Djamena, Tchad
| | - F Siniki
- Centre hospitalier universitaire la renaissance, N'Djamena, Tchad
| | - A Touré
- Service de chirurgie, hôpital Provincial de Sarh-Tchad, N'Djamena, Tchad
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7
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Park KH, Oh CW, Kim JW, Lee HJ, Kim HJ. Reliability of reverse sural artery fasciocutaneous flap in older adult patients: Comparison study between older and younger patients. Injury 2023; 54:110915. [PMID: 37421835 DOI: 10.1016/j.injury.2023.110915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND The reverse sural artery fasciocutaneous (RSAF) flap is a popular option for patients with soft tissue defects of the distal lower extremities. However, most studies have focused on young patients without comorbidities. This study aimed to report the clinical application of the RSAF flap and to evaluate its reliability in older adult patients. METHODS A retrospective study of fifty-one patients who underwent RSAF flap was included in this study between September 2016 and October 2021. Reconstruction outcomes and wound complications were compared between groups A (21 patients over 60 years of age) and B (30 patients under 60 years of age). RESULTS Overall, 74.5% of the flaps healed primarily. The demographics of the two groups were similar, except for comorbidities (P = 0.01). The risk factors that affected the survival of RSAF flaps were not significantly different between the two groups (P > 0.05). The rate of wound complications in group A (42.85%) was significantly higher than that in group B (13.3%) (P = 0.04). However, all wound complications were treated using a simple procedure (skin grafting or simple suturing). CONCLUSIONS The RSAF flap can be a reliable salvage option to repair soft tissue defects of the lower extremities in older adult patients. It is safe and easy to harvest and transfer the flap; however, surgeons should be aware of the possibility of wound complications in older patients with comorbidities.
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Affiliation(s)
- Kyeong-Hyeon Park
- Department of Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea.
| | - Joon-Woo Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Hyun-Joo Lee
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| | - Hee-Jun Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
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8
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Palukuri L, Ireni RKKG, Jabbar FA, Nair SS, Jambula PR, Kommu V. Reverse Peroneal Artery Flap-A Workhorse Flap for Reconstruction of Large, Distal Defects of Ankle and Foot. Indian J Plast Surg 2023; 55:383-390. [PMID: 36683885 PMCID: PMC9859685 DOI: 10.1055/s-0042-1760091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Reconstruction of large foot and ankle defects is a difficult task due to less available local soft tissue and more critical from functional point of view. To overcome the limitations associated with locoregional flaps and free flaps, reverse peroneal artery (RPA) flap was selected and its usefulness in reconstruction of distal large defects of the ankle and foot and its complications were studied. Materials and Methods This is a prospective observational study done in 20 patients treated as cohort within 2 years and 8 months from January 2018 to August 2020. Large defects of foot and ankle were reconstructed with RPA flap and evaluated for its usefulness. Three cases were evaluated with computed tomography angiography postoperatively, to assess the vascular pattern. Conclusion RPA flap is a versatile and very reliable flap for the reconstruction of large and distal defects of foot and ankle. It is safely done in children and in acute trauma without any major complications.
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Affiliation(s)
- Lakshmi Palukuri
- Department of Plastic and Reconstructive Surgery, Osmania Medical College and Hospital, Hyderabad, Telangana, India,Address for correspondence Lakshmi Palukuri, MCh Department of Plastic and Reconstructive Surgery, Osmania Medical College and Hospital5-96/3/a/ Road No. 11, Bhavani Nagar, Dilsukh Nagar, Hyderabad 500060, TelanganaIndia
| | - Raja Kiran Kumar Goud Ireni
- Department of Plastic and Reconstructive Surgery, Osmania Medical College and Hospital, Hyderabad, Telangana, India
| | - Faiyaz Abdul Jabbar
- Department of Plastic Surgery, Osmania Medical College, Hyderabad, Telangana, India
| | - Shaleena Sukumaran Nair
- Department of Plastic and Reconstructive Surgery, Osmania Medical College and Hospital, Hyderabad, Telangana, India
| | - Pranav Reddy Jambula
- Department of Plastic and Reconstructive Surgery, Osmania Medical College and Hospital, Hyderabad, Telangana, India
| | - Vijaybabu Kommu
- Department of Plastic Surgery, Osmania Medical College, Hyderabad, Telangana, India
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9
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Yammine K, Eric M, Nasser J, Chahine ASSI. Effectiveness of the Reverse Sural Flap in Covering Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2022; 30:368-377. [PMID: 36212103 PMCID: PMC9537716 DOI: 10.1177/22925503211019617] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/16/2021] [Indexed: 11/03/2023] Open
Abstract
Background: The reverse sural fasciocutaneous flap (RSFCF) has been used with success to cover noncomplicated foot and ankle soft tissue defects. However, there are some controversies when it is used in patients having chronic diabetic foot ulcers. This aim of this meta-analysis was to evaluate the efficacy of RSFCF in covering diabetic foot and ankle ulcers. Methods: A systematic review was undertaken from MEDLINE, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Only diabetic foot and ankle ulcers were accepted for inclusion and all study designs were included. Proximally based flaps, nondiabetic ulcers, and assisted negative pressure therapy were excluded. Suitability for inclusion was assessed by 2 reviewers. The random-effect estimate was reported for the set outcomes whenever high heterogeneity was present. Metaregression analysis was performed to identify independent risk factors for failure. Results: The search identified 33 relevant studies comprising 187 patients and flap interventions; all but 1 were case-series. The weighted outcomes were as follows: (1) the flap healing rate was 93.3% while 6.6% resulted in total necrosis, (2) the rate of partial flap necrosis was 12%, (3) venous congestion was reported in 6.6% of cases, (4) the infection rate was 8.3%, and (5) the donor site morbidity was 4.6%. No association was found between pedicle width or presence of a subcutaneous pedicle tunnel and the primary outcome of total loss. Conclusions: This review demonstrated excellent results of the flap when covering complicated or large diabetic foot and ankle ulcers. When compared to those published in the literature, our results found RSFCF to be relatively less successful in diabetic wounds than in trauma patients but more successful than in those having associated osteomyelitis and those who were treated with random local flaps.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University
Medical Center-Rizk Hospital, Lebanese American University School of Medicine,
Beirut, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical
Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research,
Beirut, Lebanon
| | - Mirela Eric
- Department of Anatomy, University of Novi Sad, Serbia
| | - Jason Nasser
- Lebanese American University School of Medicine, Beirut,
Lebanon
| | - ASSI Chahine
- Department of Orthopedic Surgery, Lebanese American University
Medical Center-Rizk Hospital, Lebanese American University School of Medicine,
Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research,
Beirut, Lebanon
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10
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Mansour AM, Jacobs A, Raj MS, Lee FG, Terrasse W, Wallace SJ, Miller NF. Lower Extremity Soft Tissue Reconstruction Review Article. Orthop Clin North Am 2022; 53:287-296. [PMID: 35725037 DOI: 10.1016/j.ocl.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Reconstruction plays a valuable role in the management of lower extremity wounds for limb salvage. The goals of reconstruction are to improve function and quality of life, return to work, and pain reduction while providing a long-lasting durable reconstruction. The plastics and reconstructive surgical approach in conjunction with the orthopedic or trauma team, referred often as the "orthoplastic" approach, can yield the best outcomes for patients. The following sections discuss reconstruction principles and techniques that can be applied broadly for lower extremity wounds secondary to trauma, infection, and tumor resection.
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Affiliation(s)
- Ahmed M Mansour
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA.
| | - Aaron Jacobs
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - Mamtha S Raj
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - Frank G Lee
- University of South Florida Morsani College of Medicine, 2049 Street Wood Street, Allentown, PA 18103, USA
| | - Weston Terrasse
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
| | - Sean J Wallace
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 3701 Corriere Road, Suite 15, Easton, PA 18045, USA
| | - Nathan F Miller
- Division of Plastic and Reconstructive Surgery, Lehigh Valley Health Network, 1250 South Cedar Crest Boulevard, Allentown, PA 18103, USA
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11
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Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects. Plast Reconstr Surg Glob Open 2022; 10:e4131. [PMID: 35198355 PMCID: PMC8856593 DOI: 10.1097/gox.0000000000004131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
Due to the wide spectrum of lower extremity defect presentation, various reconstructive techniques are available. Classic adipofascial flaps are still a second choice. The authors described a new multistage reconstructive approach with perforator-based pedicled adipofascial flap.
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12
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Dai J, Zhou Y, Mei S, Chen H. Application of the distally based sural neurocutaneous flaps in the management of foot and ankle defects in patients with diabetic foot. Front Endocrinol (Lausanne) 2022; 13:1009714. [PMID: 36213287 PMCID: PMC9537483 DOI: 10.3389/fendo.2022.1009714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We report our experience on the use of a distally based sural flap for soft tissue reconstruction of foot and ankle defects in patients with diabetic foot. METHODS The actual study is a retrospective, open, non-controlled, and clinical study of 25 patients treated with diabetic foot on whom reconstruction with distally based sural neurocutaneous flaps was performed from May 2019 to December 2021. RESULTS The mean age was 64.9 years, and there were 15 male and 10 female patients. The mean follow-up was 9.8 months, which ranged from 6 to 12 months. The size of the flaps ranged from 6 × 5 to 15 × 9 cm2. Twenty-two of the 25 flaps survived intact with sufficient blood supply. Two cases had a small superficial necrosis, which was resolved after a change of daily dressing and was heeled eventually. In one case, partial necrosis was observed that was managed with minor revision and the use of split-thickness skin graft. CONCLUSIONS The distally based sural flap is considered to be useful for reconstruction of foot and ankle defects in patients with diabetic foot.
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Affiliation(s)
- Jiezhi Dai
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yu Zhou
- Department of Orthopedic Surgery, Civil Aviation Hospital of Shanghai, Shanghai, China
| | - Shasha Mei
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- *Correspondence: Hua Chen, ; Shasha Mei,
| | - Hua Chen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- *Correspondence: Hua Chen, ; Shasha Mei,
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13
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CLIVATTI GUSTAVOMOREIRA, NASCIMENTO BRUNOBAPTISTADO, RIBEIRO RENANDIEGOAMÉRICO, MILCHESKI DIMASANDRÉ, AYRES ARALDOMONTEIRO, GEMPERLI ROLF. REVERSE SURAL FLAP FOR LOWER LIMB RECONSTRUCTION. ACTA ORTOPÉDICA BRASILEIRA 2022; 30:e248774. [PMID: 36092178 PMCID: PMC9425924 DOI: 10.1590/1413-785220223004e248774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/12/2021] [Indexed: 11/22/2022]
Abstract
ABSTRACT Introduction: Reconstruction of distal wounds in lower extremities can be challenging due to the lack of tissue to perform local flaps. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap. Objective: To present an 18-month experience on ankle, calcaneus, and foot reconstruction using the reverse-flow sural flap, performed by the Complex Wounds Group of the Plastic Surgery Department of the University of São Paulo Medical School. Methods: An observational, retrospective and descriptive study was performed through data survey on medical records of all patients treated between November 2018 and June 2020. Results: Nine reverse-flow fasciocutaneous sural flaps were performed. All patients were men. The mean age was 38 years old. Five patients had acute wounds for traffic collision, one electrical trauma and three chronic post-traumatic injuries. The ankle was the most common injury site (6), followed by foot (2) and calcaneus (1). Four patients had complications, three of which were partial necrosis and one distal epitheliosis. No case of total necrosis was recorded. The average hospital stay was 30.1 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a viable, reproducible, and reliable option for distal lower limb reconstruction. Level of Evidence IV, Case Series.
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Thuau F, Lancien U, Crenn V, Perrot P, Duteille F. [The de-epidermized sural flap: An original technique to increase the reliability of the neurocutaneous sural flap]. ANN CHIR PLAST ESTH 2021; 67:93-100. [PMID: 34583875 DOI: 10.1016/j.anplas.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/03/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The neurocutaneous sural flap is useful to cover defects of the distal quarter of the lower limb. Nevertheless, severe complications occur in 14% of the cases, and venous congestion is reported in 75% of these cases. This congestion can lead to total necrosis of the flap and a failure of the procedure. We describe a new surgical method aiming to reduce the risk of venous congestion occurrence and failure of the defect coverage. PATIENTS AND METHODS We realized a retrospective study of patients who undergone a de-epidermized distally based neurocutaneous sural flap in our surgery department from 2015 to 2020. The following data were collected: sex, age, vascular risk factors, size of the wound, defect area, etiology, delay between the surgery of the flap and the split-thickness skin graft and complications. RESULTS The cohort is composed of 5 cases. We reported no failure of the coverage of the defect. There were no cases of venous congestion. CONCLUSION The de-epidermized distally based neurocutaneous sural flap could increase the reliability of these flaps by reducing the risk of venous congestion. A larger study comparing the classic technique to the de-epidermized sural flap could confirm these data on a greater number of cases and position this technique in the therapeutic arsenal.
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Affiliation(s)
- F Thuau
- Service de chirurgie plastique et reconstructrice, centre de traitement des brûlés adultes et enfants, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
| | - U Lancien
- Service de chirurgie plastique et reconstructrice, centre de traitement des brûlés adultes et enfants, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - V Crenn
- Service de chirurgie orthopédique et traumatologique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; Laboratoire PhyOS Inserm UMR 1238, faculté de médecine, 1 rue Gaston-Veil, 44000 Nantes, France
| | - P Perrot
- Service de chirurgie plastique et reconstructrice, centre de traitement des brûlés adultes et enfants, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - F Duteille
- Service de chirurgie plastique et reconstructrice, centre de traitement des brûlés adultes et enfants, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Jeng SF, Shih HS, Papadakis M. Plantar forefoot reconstruction: A proposal of a management algorithm based on a case series analysis: Plantar forefoot reconstruction. J Plast Reconstr Aesthet Surg 2021; 75:173-182. [PMID: 34649830 DOI: 10.1016/j.bjps.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 05/06/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Several loco-regional flaps have been described for plantar forefoot coverage. We, herein, report our single-centre experience in plantar forefoot reconstruction and propose a decision-making process based on the defect's size. METHODS This is a retrospective case series study of all patients who underwent plantar forefoot reconstruction in a 10-year period. We propose a treatment algorithm, based on the defect size. Defects are classified into small, moderate and large. Small defects (<10cm2) can be covered with the hemi-pulp toe flap. Patients with moderate defects (10-25cm2) can be treated with the reverse medial plantar artery flap (MPAF) from the instep area. For large defects (>25cm2), we recommend regional flaps, that is the distally based sural flap (DBSF) from the ipsilateral calf, or free flaps, such as the anterolateral thigh flap (ALT) or the skin-grafted gracilis flap. RESULTS The data of 51 patients were collected and analysed. The median age was 58 years (range 19-84). Nine patients had small defects and underwent hemi-pulp toe flap reconstruction. Three patients presented with moderate defects that were covered with reverse MPFs. The vast majority of the patients (39 patients) had large defects. Of these, eight cases were treated with DBSF and 31 cases with free flaps. Free flap transfers were successful in 97% of the cases. Overall complication rate was 25%. CONCLUSION We conclude that local flaps should be preferred in plantar forefoot reconstruction as they provide like-tissue for small to moderate defects, for large defects regional flaps or free flaps were indicated. A defect-based approach can facilitate the decision-making process.
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Affiliation(s)
- Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, I-Shou University Kaohsiung, Taiwan
| | - Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, I-Shou University Kaohsiung, Taiwan
| | - Marios Papadakis
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, I-Shou University Kaohsiung, Taiwan.
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Athanaselis ED, Fyllos A, Zibis AH, Karachalios T, Hantes M, Dailiana Z, Malizos K, Varitimidis S. A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up. Cureus 2021; 13:e16574. [PMID: 34434674 PMCID: PMC8380273 DOI: 10.7759/cureus.16574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/05/2022] Open
Abstract
AIM Small soft tissue defects of the distal tibia and hindfoot resulting from traumatic, operative, or neoplastic conditions and chronic ulcers can be successfully dealt with the use of the reverse sural artery flap (RSAF). This study aims to describe a single center's results and familiarity with this technique over a 15-year period of time. MATERIAL AND METHODS We retrospectively reviewed the clinical files of patients who were consecutively treated with RSAF and regularly followed up between January 1, 2004 and December 31, 2018, with a minimum postoperative follow-up period of two years. Patient demographics and comorbidities, location of the defect, performing surgeon, mean operation time, flap pedicle width, mean size of the defect, days of hospitalization following the operation, healing flap rate, and complications were recorded. RESULTS The sample consisted of 30 adult patients (25 men, 5 women), with a mean age of 51.07 years (16-80 years, SD 18.61). The mean operation time was 99.03 min (range 83-131, SD 10.57), and the mean size of the defect was 11.11 cm2 (range 6.1-19.4, SD 3.22). Successful flap rate (complete healing and coverage of the defect, with or without additional minor intervention) was 83.3% (25/30). Among successfully healed flaps, six patients with partial necrosis of the dermis were treated by an additional split-thickness skin graft. Five flaps failed to heal. Deep infection was present in two patients, leading to flap failure and reoperation. Serious venous congestion resulting in flap ischemia occurred in three cases. Circumferential keloid formation (not affecting successful outcome) was present in seven cases. Flap thickness approximated to normal within six months. All donor sites healed well (either by a split-thickness cutaneous flap or by immediate wound closure). Light paresthesia on the lateral border of the leg and foot disappeared within six months. CONCLUSIONS A single-center experience with the RSAF has yielded satisfactory clinical outcomes, and the long-term tackle with the difficult reconstruction conditions around the ankle, has led to valuable advice on surgical technique and postoperative protocol, based on an anatomical basis.
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Affiliation(s)
| | - Apostolos Fyllos
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Aristeidis H Zibis
- Anatomy, School of Health Sciences, University of Thessaly, Larissa, GRC
| | - Theofilos Karachalios
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Michael Hantes
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Zoe Dailiana
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Konstantinos Malizos
- Orthopedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Sokratis Varitimidis
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
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Zeiderman MR, Pu LLQ. Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma. BURNS & TRAUMA 2021; 9:tkab024. [PMID: 34345630 PMCID: PMC8324213 DOI: 10.1093/burnst/tkab024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/22/2021] [Indexed: 11/29/2022]
Abstract
The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon’s armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.
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Affiliation(s)
- Matthew R Zeiderman
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Lee L Q Pu
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
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Peng P, Dong Z, Wei J, Liu L, Luo Z, Cao S, Zheng L. Revisit of flap factors relating to partial necrosis of distally based sural flaps: an analysis of 435 cases in a single center. Eur J Trauma Emerg Surg 2021; 48:2359-2368. [PMID: 34184108 DOI: 10.1007/s00068-021-01737-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Partial necrosis is an ongoing topic in regard to flap complications of the distally based sural (DBS) flap However, the factors influencing partial necrosis of the flap remain in debate. The aim of the present study is to further illuminate the flap-related risk factors and the effects of several technical improvements. METHODS We retrospectively reviewed the data of 429 patients who underwent 435 DBS flaps between April 2001 and December 2019. The reconstruction outcomes, flap viability-related complications, and potential risk factors were compared between the survival group and partial necrosis group, as well as between group A (the procedures performed from April 2001 to March 2010) and group B (those from April 2010 to December 2019). RESULTS Among the 435 flaps, 39 flaps (8.97%) exhibited partial necrosis. With the increase of the top edge of the flap, the partial necrosis rate increased significantly (P < 0.05). When the length-to-width ratio [LWR] of the flap was more than 5:1 or the total length of the flap (the length of the skin island plus the length of the adipofascial pedicle) was more than 20 cm, the partial necrosis rate increased significantly (P < 0.05). The partial necrosis rate in group B (5.86%, 15/256) was significantly lower than that in group A (13.41%, 24/179) (P = 0.007). CONCLUSIONS The top edge of the flap is an essential indicator for predicting the prognosis of the DBS flap. When the total length of the flap is more than 20 cm or the LWR of the flap more than 5:1, the partial necrosis rate will increase significantly. Various technical modifications can lower the top edge of the flap and reduce the LWR of the flap and width of the skin island, and thus improve the flap survival effectively.
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Affiliation(s)
- Ping Peng
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China
| | - Zhonggen Dong
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China
| | - Jianwei Wei
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China.
| | - Lihong Liu
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China
| | - Zhaobiao Luo
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China
| | - Shu Cao
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China
| | - Lei Zheng
- Department of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, 450003, Henan, People's Republic of China
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Agarwal P, Sharma D, Kukrele R. Arteriovenous supercharging: A novel approach to improve reliability of the distally based sural flap. Trop Doct 2021; 51:339-344. [PMID: 34058929 DOI: 10.1177/00494755211020854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used, but it has a high partial necrosis rate due to venous insufficiency. We addressed this issue with AV supercharging by dorsalis pedis artery with short saphenous vein. Eight patients (seven males, mean age 34.12 years) with post traumatic lower limb defects over heel and foot were included. All flaps survived and healed although four flaps developed superficial partial epidermolysis. Average healing time was 20.12 days. Closure of the AV fistula was not required in any of the patients. At mean follow-up of two months, all patients were ambulatory with well settled flap. Arteriovenous supercharging of distally based sural flap through short saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.
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Affiliation(s)
- Pawan Agarwal
- Professor and In Charge, Department of Surgery, NSCB Government Medical College, Jabalpur, Madhya Pradesh, India
| | - Dhananjaya Sharma
- Professor and Head, Department of Surgery, NSCB Government Medical College, Jabalpur, Madhya Pradesh, India
| | - Rajeev Kukrele
- Assistant Professor, Department of Surgery, NSCB Government Medical College, Jabalpur, Madhya Pradesh, India
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Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region. Ann Plast Surg 2021; 84:580-587. [PMID: 31663937 DOI: 10.1097/sap.0000000000002069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUNDS Distally based perforator propeller flap from the lower leg region is a versatile local reconstructive technique for the foot and ankle defects. However, flap venous congestion remains a tough nut to crack. We hypothesize that raising an adipofascial flap with turnover mode of transposition can improve venous drainage and enhance flap safety. METHODS Based on the 2 rows of septocutaneous perforators in the posterior distal third of the lower leg, distally based adipofascial flap was raised from medial sural region nourished by 1 perforator bundle from the posterior tibial artery or from the lateral sural region from the peroneal artery. The superficial dissection was performed in subdermal plane and deep in to the subfascial space. The flap was nourished by perforator-plus-adipofascial pedicle and turned over 180 degrees upside down to reach the distal wounds. One week later, a split-skin graft was used to cover the exposed fascial flap. Postoperatively, flap survival, complications, and patient functional recovery were evaluated. RESULTS Distally based sural turnover adipofascial flaps were used in 12 cases with complicated wounds of the distal third lower leg, foot, and ankle region. All wounds were caused by trauma and experienced fracture implants fixation and 5 with osteomyelitis. The comorbidities include diabetes in 9 cases and smoking in 7. There were 8 medial ural flaps and 4 lateral sural flaps. The adipofiscial flaps measured from 6.0 cm × 5.0 cm to 17.0 cm × 6.0 cm (mean, 61.3 cm). Postoperatively, all flaps survived uneventfully without any complication such as flap ischemia and/or necrosis. Two minor donor site complications were encountered, one was postoperative hematoma, and another was hyperproliferative scar. After a mean of 14.6 months of follow-up, the adipofascial flap plus skin graft showed a durable esthetic coverage, with normal shoe wearing and walking. CONCLUSIONS Distally based sural adipofascial turnover flap is a simple and reliable wound coverage technique. It avoids venous congestion as usually seen in distally based fasciocutaneous flaps.
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21
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Zhou LL, Wei JW, Peng P, Liu LH, Yin CD, Luo ZB, Tao SB, Dong ZG. Distally Based Perforator-Plus Sural Neurocutaneous Flap with High or Low Pivot Point: Anatomical Considerations and a Retrospective Study of a Clinical Series of 378 Flaps. J Reconstr Microsurg 2021; 37:580-588. [PMID: 33592636 DOI: 10.1055/s-0041-1723817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study is to describe the distribution of natural true anastomoses associated with the distally based perforator-plus sural neurocutaneous flap (sural flap), summarize our experience in the flap with high pivot point, and compare the outcomes between the flaps with high and low pivot points. METHODS Five amputated lower limbs were perfused, and the integuments were radiographed. We retrospectively analyzed 378 flaps, which were divided into two groups: pivot points located ≤8.0 cm (low pivot point group) and >8.0 cm (high pivot point group) proximal to the tip of the lateral malleolus. Partial necrosis rates were compared between two groups. RESULTS The arterial chain surrounding the sural nerve was linked by true anastomoses from the intermalleolar line to popliteal crease. True anastomoses existed among peroneal perforators and between these perforators and the arterial chain. There were 93 flaps with high pivot point and 285 flaps with low pivot point. Partial necrosis rates were 16 and 9.1% in the high and low pivot point group (p = 0.059), respectively. CONCLUSION True anastomosis connections among peroneal perforators and the whole arterial chain around sural nerve enable the sural flap to survive with a greater length. The sural flap with high pivot point is a good option for reconstructing soft-tissue defects in the middle and distal leg, ankle, and foot, particularly when the lowest peroneal perforator presents damage, greater distance to the defects, discontinuity with the donor site, or anatomical variation.
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Affiliation(s)
- Ling-Li Zhou
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jian-Wei Wei
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Ping Peng
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Li-Hong Liu
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Chao-Dong Yin
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhao-Biao Luo
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Shi-Bin Tao
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhong-Gen Dong
- Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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Abstract
Locoregional flaps play an important role in soft tissue reconstruction of the lower extremity and should be considered an effective option in soft tissue reconstruction. The medial hemisoleus muscle flap and the distally based sural artery flap can be elevated because of unique vascular anatomy and more advanced surgical techniques in flap dissection. Each flap can replace free tissue transfer as the first choice for soft tissue reconstruction of a less extensive wound in the distal third of the leg. Patient selection and detailed knowledge of the flap and its advanced technique for flap dissection are keys to success.
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Affiliation(s)
- Lee L Q Pu
- Division of Plastic Surgery, University of California, Davis, 2335 Stockton Boulevard, Room 6008, Sacramento, CA 95817, USA.
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Luo Z, Ni J, Lv G, Wei J, Liu L, Peng P, Dong Z. Utilisation of distally based sural fasciocutaneous flaps in lower extremity reconstruction: a single-centre experience with 88 paediatric patients. J Orthop Surg Res 2021; 16:52. [PMID: 33441179 PMCID: PMC7805089 DOI: 10.1186/s13018-021-02206-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND No large series have analysed distally based sural fasciocutaneous (DBSF) flaps in paediatric patients. The aims of this study were to assess the reliability and analyse the potential risk factors for these flaps and to describe complications in the donor site and the functional follow-up results. METHODS Between June 2002 and November 2017, 88 DBSF flaps were used to reconstruct soft tissue defects in paediatric patients. Potential risk factors, reconstruction outcomes, and complications in the donor site of the flaps were analysed. RESULTS Among the 88 flaps, partial necrosis developed in 8 flaps (9.1%). The partial necrosis rate was significantly higher in flaps with the top edge located in the 9th zone (26.1%), with a length-width ratio (LWR) ≥ 5:1 (28.6%), and with a dimension of the skin island ≥ 100 cm2 (22.7%). Partial necrosis did not occur in flaps with a dimension of the skin island < 80.0 cm2 or with a skin-island width < 7.0 cm. The reconstruction outcomes in most paediatric patients were evaluated as "excellent" or "good". The incidence of obvious scarring was higher in the donor site. CONCLUSIONS Partial necrosis of DBSF flaps will significantly increase when the top edge of the flap is located in the 9th zone, when the LWR of the flap is ≥ 5:1, or when the dimension of the skin island is ≥ 100.0 cm2. Flaps with a skin-island width < 7.0 cm or with a dimension of the skin island < 80 cm2 are relatively safe and reliable.
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Affiliation(s)
- Zhaobiao Luo
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Jiangdong Ni
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Guohua Lv
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Jianwei Wei
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Lihong Liu
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Ping Peng
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
| | - Zhonggen Dong
- Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China.
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Jitprapaikulsarn S, Sukha K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Concurrent internal fixation and soft tissue reconstruction by distally based sural flap: a practicable scheme for complex distal tibial fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:711-718. [PMID: 33151483 DOI: 10.1007/s00590-020-02827-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND It is difficult to establish both fracture union and wound healing of open fractures complicated with soft tissue defects of the distal tibia. We describe the simultaneous use of internal fixation and soft tissue coverage by a distally based sural flap (DBSF) for these complex injuries. METHODS Seventeen patients with Gustilo IIIB open fractures of the distal tibia were operated on by internal fixation and DBSF coverage. Data were collected on the size of the defect, time to fixation and soft tissue coverage or 'fix & flap', types of implant, time to union, postoperative complications and objective clinical measurement. RESULTS The average size of the soft tissue defect after debridement was 6.4 × 8.4 cm2 (range 4.0-9.0 × 6.0-12.0). The mean time to fix & flap was 8.1 days (range 7-10). A medial precontoured plate was used in 8 patients and an anterolateral precontoured plate in 9. All fractures were united in a mean duration of 22.6 weeks (range 20-28). One patient had partial flap necrosis. Using the Puno functional score, 2 patients had excellent functional outcomes and 15 patients had good functional outcomes. CONCLUSION Concurrent Internal fixation and soft tissue reconstruction by DBSF is effective and reproducible for Gustilo type III open fractures of the distal tibia even in cases of more than 50 cm2 soft tissue defects.
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Affiliation(s)
- Surasak Jitprapaikulsarn
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand.
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Chawanan Patamamongkonchai
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Witoon Thremthakanpon
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
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Yang W, Wen G, Zhang F, Lineaweaver WC, Wang C, Jones K, Chai Y. Free neurosensory flap based on the accompanying vessels of lateral sural cutaneous nerve: anatomic study and preliminary clinical applications. J Plast Surg Hand Surg 2020; 55:111-117. [PMID: 33107362 DOI: 10.1080/2000656x.2020.1838294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The posterior aspect of the leg is an ideal donor site for flap surgery. In this study, the anatomy was investigated of the lateral sural cutaneous nerve (LSCN) and its accompanying artery, superficial lateral sural artery (SLSA), and a lateral sural neurocutaneous flap was designed. METHODS Five fresh adult cadaver legs perfused with red latex were dissected to observe the course and relationship between LSCN and SLSA. The outer diameter of SLSA at its origin was measured. Then a lateral sural neurocutaneous flap was designed and used to repair soft tissue defects in six patients. RESULTS The anatomic results showed that the SLSA gave rise to branches that followed the LSCN and ramified into terminals at the ramification of the nerve. It originated directly from the popliteal artery 4.2 ± 0.2 mm above the fibular head, where its outer diameter was 0.96 ± 0.23 mm. Several perforators penetrated from the crural fascia and anastomosed to the SLSA, creating a fine anastomotic network. The clinical results showed that the size of the flap ranged from 12 × 6 cm to 25 × 8 cm. All six flaps survived completely without complications. Follow-up ranged from 6 to 18 months with 11 months on average. The overall contour and sensory recovery of the flap were satisfied. CONCLUSION A free innervated flap may be elevated safely based on the LSCN and its accompanying vessels. It provides an alternative in reconstruction of soft tissue defects where sensory recovery is important.
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Affiliation(s)
- Weichao Yang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Gen Wen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Feng Zhang
- Joseph M. Still Burn and Reconstruction Center, Jackson, MS, USA
| | | | - Chunyang Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Joseph M. Still Burn and Reconstruction Center, Jackson, MS, USA
| | - Kyler Jones
- Joseph M. Still Burn and Reconstruction Center, Jackson, MS, USA
| | - Yimin Chai
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Johnson L, Liette MD, Green C, Rodriguez P, Masadeh S. The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot. Clin Podiatr Med Surg 2020; 37:699-726. [PMID: 32919599 DOI: 10.1016/j.cpm.2020.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.
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Affiliation(s)
- Lance Johnson
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Michael D Liette
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Chris Green
- American College of Foot and Ankle Surgeons, Integris Limb Salvage Center, Oklahoma City, OK, USA
| | - Pedro Rodriguez
- Plastic and Reconstructive Surgery, OSF Saint Anthony Medical Center, University of Illinois, 698 Featherstone Road, Rockford, IL 61107, USA
| | - Suhail Masadeh
- University of Cincinnati Medical Center, Cincinnati Veteran Affairs Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
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Xu H, Cao X, Kiu-Huen S, Zhu Z, Chen J, Chi Z, Zhang Y. A Retrospective Study of an Updated and Traditional Surgical Approach of the Distally Based Sural Flap. J Reconstr Microsurg 2020; 37:227-233. [PMID: 32942310 DOI: 10.1055/s-0040-1716744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The distally based sural flap (DBSF) is one of the armamentarium in the lower limb reconstruction. However, the flap has not gained popularity due to concerns about its reliability and donor site morbidity. Based on the anatomy characterization, we combined and developed five modifications to improve the vascular supply and reduce donor site morbidity. PATIENTS AND METHODS The authors performed a comparison of retrospective study that included patients who underwent either traditional distally based sural flap (tDBSF) or modified distally based sural flap (mDBSF) surgery approach for ankle, heel, and dorsal foot coverage between January 2007 and May, 2019. The five modifications developed to improve the reliability of the flap include: 1. shift the pivot point more proximally 7.0 cm above the lateral malleolus, 2. preserve the lesser saphenous vein and include branches that communicates with the flap, 3. harvest thinner fascial pedicle, 4. change the skin incision to "S" shape, 5. closure of the donor site with a propeller flap. RESULTS Thirty-one patients underwent mDBSF, and 23 received tDBSF. There were no significant differences in the size of the DBSF. Mean pedicle width was significantly narrower in mDBSF (1.63 ± 0.52 cm vs. 3.81 ± 0.70 in tDBSF). The pivot point was also found to be higher in mDBSF (8.01 ± 0.63 cm vs. 5.46 ± 0.56 cm) above the lateral malleolus. In mDBSF, the size of the propeller flap required for donor site closure was 53.45 ± 19.06 cm2 (range 33-80 cm2). The rate of partial necrosis between mDBSF and tDBSF was significantly different (9.68 vs. 34.78%). While the other complications had no difference. CONCLUSION The modifications applied to the harvesting of the DBSF have achieved higher survival rate, lower dehiscence rate, and shorter hospital stay time in comparison with traditional approach in our retrospective study.
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Affiliation(s)
- Heng Xu
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xuexin Cao
- Department of Orthopedics, Center of Reconstructive and Microsurgery, Suqian Third Hospital, Anhui, People's Republic of China
| | - Sally Kiu-Huen
- Department of Plastic Surgery, Austin Health, Melbourne, Australia
| | - Zhu Zhu
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jun Chen
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhenglin Chi
- Department of Orthopedics, Center of Reconstructive and Microsurgery, Suqian Third Hospital, Anhui, People's Republic of China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Goil P, Sharma AK, Gupta P, Srivastava S. Comparison of the outcomes of adipofascial and two-staged fasciocutaneous reverse sural flap in patients with lower leg trauma. J Clin Orthop Trauma 2020; 14:113-120. [PMID: 33680817 PMCID: PMC7919930 DOI: 10.1016/j.jcot.2020.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/18/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Distal one - third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature. MATERIAL & METHODS In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months. RESULTS The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment. DISCUSSION Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity. CONCLUSION Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.
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Revisiting the Reverse Sural Artery Flap in Distal Lower Extremity Reconstruction. Ann Plast Surg 2020; 84:463-470. [DOI: 10.1097/sap.0000000000002041] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Roberts HJ, DeSilva GL. Can Sural Fasciocutaneous Flaps Be Effective in Patients Older Than 65? Clin Orthop Relat Res 2020; 478:734-738. [PMID: 32229743 PMCID: PMC7282575 DOI: 10.1097/corr.0000000000000963] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 08/28/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many studies have evaluated the reverse sural fasciocutaneous flap for coverage of wounds on the distal lower extremity, and many of these have focused on younger, healthy patients. However, to our knowledge, there has been no dedicated study focusing on older patients. We believe there is a generalized concern about performing these procedures in older patients because of microvascular changes associated with aging. QUESTIONS/PURPOSES (1) What is the likelihood of flap survival in a small series of patients older than 64 years who underwent reverse sural artery fasciocutaneous flap for coverage of lower extremity wounds? (2) What additional procedures did patients undergo after treatment with this flap? METHODS From 2009 to 2018, we identified 16 patients, 64 years or older, who underwent a retrograde sural fasciocutaneous flap. Patients were a mean (range) age of 71.5 years (64 to 87). The average size of the flaps was 30 cm (range 12 to 64 cm). The reverse sural artery flap was indicated when the skin could not be closed primarily and there was not a suitable vascularized bed of tissue for a split-thickness skin graft. All patients underwent a wide-based pedicle (3 cm to 4 cm), reverse sural artery fasciocutaneous flap with all but one completed in a "flap delay" manner, between 2 to 7 days, and without the use of microsurgery or doppler. Thirteen flaps were done to cover wounds that occurred over fractures while three were performed to cover chronic wounds. We performed a retrospective review of the electronic health record to ascertain patient comorbidities, age, timing of coverage, and size of the wound. RESULTS In all, 94% of flaps (15 of 16) survived with 100% viability. One flap had 30% skin necrosis at the distal tip. The flap ultimately healed with in-office wound care, and epithelization occurred over the intact fascia. A total of five additional procedures were performed in five patients. Although the flap ultimately healed, an 87-year-old patient with partial flap necrosis ultimately elected for below-knee amputation for a persistent tibial infected nonunion. Another patient, despite a healed flap, eventually underwent a below-knee amputation 3 years later for a chronic osteomyelitis present before undergoing the reverse sural flap. One patient developed a pseudomonal infection of their Gustillo-Anderson IIIB open tibia fracture, resulting in a surgical procedure for débridement, after which the flap healed. Two patients underwent underlying hardware removal to relieve wound tension and allow for complete flap healing. No patients underwent further coverage procedures. CONCLUSIONS In this small series, we found fewer complications than have been observed in prior studies, despite our series consisting solely of higher-risk, older patients. We believe this may have been attributable to the period of delay before placing the flap, which has been previously associated with higher flap survival and which allows for an extra recipient-site débridement. We believe this procedure can be performed by appropriately trained orthopaedic surgeons because it does not need microsurgery. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Haydn J Roberts
- H. Roberts, G. DeSilva, Department of Orthopaedics, University of Arizona-Tucson, Tucson, AZ, USA
| | - Gregory L DeSilva
- H. Roberts, G. DeSilva, Department of Orthopaedics, University of Arizona-Tucson, Tucson, AZ, USA
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Kim KJ, Ahn JT, Yoon KT, Lee JH. A comparison of fasciocutaneous and adipofascial methods in the reverse sural artery flap for treatment of diabetic infected lateral malleolar bursitis. J Orthop Surg (Hong Kong) 2020; 27:2309499019828546. [PMID: 30776959 DOI: 10.1177/2309499019828546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Infected lateral malleolar bursitis occurring as a diabetic complication requires debridement and flap surgery because it cannot be treated by conservative methods. The most accessible flap is the reverse sural artery flap, which can be harvested as a fasciocutaneous flap or an adipofascial flap. The purpose of this study was to compare the two types of flap methods performed in patients with diabetic infected lateral malleolar bursitis. METHODS Twenty-nine cases of diabetic infected lateral malleolar bursitis treated with reverse sural artery flap between 2006 and 2017 were analyzed retrospectively. Fasciocutaneous flap methods were performed in 15 cases (group A), and adipofascial flap methods were performed in 14 cases (group B). Patients in the two groups did not differ in sex or age. The mean follow-up period was 16 months. RESULTS All flaps survived. Infection was controlled at a mean of 2.4 months in both groups. At final follow-up, infection recurred in one case of each group, which was treated with antibiotics. No case developed an ulcer in the flaps. The patients were able to ambulate in regular shoes. All but one of the patients (28 patients) expressed satisfaction with the aesthetic appearance following treatment. No case required a debulking operation. CONCLUSION Both the fasciocutaneous and adipofascial methods for reverse sural artery flaps were shown to be viable options for the control of diabetic lateral infection. In addition, the two groups did not differ in terms of appearance or complication rate following treatment.
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Affiliation(s)
- Kyu Jin Kim
- 1 Department of Orthopedic Surgery, Gachon University Gil Hospital, School of Medicine, Gachon University, Incheon, Korea
| | - Jung Tae Ahn
- 2 Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Kyung Tack Yoon
- 2 Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Jae Hoon Lee
- 2 Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
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Talukdar A, Yadav J, Purkayastha J, Pegu N, Singh PR, Kodali RK, Kalita D, Bannoth S. Reverse sural flap - A feasible option for oncological defects of the lower extremity, ankle, and foot: Our experience from Northeast India. South Asian J Cancer 2019; 8:255-257. [PMID: 31807492 PMCID: PMC6852637 DOI: 10.4103/sajc.sajc_11_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Soft-tissue management around the lower third of the leg and foot presents a challenge to the surgeon. To achieve local control of tumor, additional surgical margins are required, thus creating large soft-tissue defects. The reverse sural artery flap (RSAF) is a popular option for many of these defects. Materials and Methods: This is a retrospective study of 26 patients who underwent resection of tumor around the lower leg, ankle, and foot, and reconstruction with RSAF was performed at our institute from 2012 to 2018. Results: Among the 26 studied patients, aged between 22 and 71 (mean age: 50.8) years, 5 were female and rest were male. The most common site of involvement by tumor was heel (42.3%), followed by sole (26.9%). The most common histopathological diagnosis was melanoma (61.5%), followed by squamous cell carcinoma (26.9%) and soft-tissue sarcoma (11.5%). Conclusion: The distally based sural flap is a reliable flap for the coverage of soft-tissue defects following oncological defects of the distal lower extremity and foot.
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Affiliation(s)
- Abhijit Talukdar
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Jitin Yadav
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Joydeep Purkayastha
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Niju Pegu
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Pritesh R Singh
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Revanth K Kodali
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Dwipen Kalita
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
| | - Srinivas Bannoth
- Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
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Assi C, Samaha C, Chamoun Moussa M, Hayek T, Yammine K. A Comparative Study of the Reverse Sural Fascio-Cutaneous Flap Outcomes in the Management of Foot and Ankle Soft Tissue Defects in Diabetic and Trauma Patients. Foot Ankle Spec 2019; 12:432-438. [PMID: 30526038 DOI: 10.1177/1938640018816378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. Soft tissue defects in the distal leg and foot are challenging conditions for reconstruction. The widely used reverse sural fascio-cutaneous flap (RSFCF) has been reported with large variation in complication frequency. Some authors reported higher complications in the diabetic population when compared with trauma patients. We compared the reliability of the RSFCF in treating such defects among both populations. Methods. This is a retrospective series with a prospective data collection of 24 patients (11 with type 2 diabetes and 13 in trauma settings) treated with an ipsilateral RSFCF for soft tissue defects of the distal leg and the rear foot. Healing events and complications were recorded and compared for both groups. The mean follow-up was 32 months. Results. Diabetic group versus trauma group showed the following results; mean flap healing time of 24 versus 22 days, donor site healing time of 14 versus 16 days, 1 total flap necrosis in both groups, 3 versus 2 cases of skin edge necrosis, 2 cases of temporary venous congestion in both groups, and 8 versus 10 cases of transient hypoesthesia of the lateral border of the foot. No infection was encountered in both groups and no recurrence of infection in the primary infected diabetic patients. Conclusions. We found the RSFCF to be useful, reproducible, and reliable in treating soft tissue defects with a very low frequency of serious complications. Diabetic patients were found to have similar outcomes when compared with trauma patients. Therefore, diabetes might not be a major factor of flap failure. Levels of Evidence: Level III: Therapeutic.
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Affiliation(s)
- Chahine Assi
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Camille Samaha
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Moussa Chamoun Moussa
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Tony Hayek
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
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Sahu RK, Kala PC, Midya M. Two-staged reverse sural flap: a versatile flap with consistent results in the soft tissue reconstruction of distal leg and heel defects-an institutional experience. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:337-341. [PMID: 31473822 DOI: 10.1007/s00590-019-02544-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Reverse sural flap (RSF) is commonly used for soft tissue reconstruction of distal leg and heel defects. The classic method of flap transfer is the single-staged cutaneous islanded reverse sural flap (SS-RSF). This method is associated with variable flap complications notably the venous congestion. The other form of flap transfer is the two-stage reverse sural flap (TS-RSF), in which the pedicle of the flap is exteriorized in the first stage. Flap division and re-inset are done in the second stage. The aim of this paper is to review the flap outcomes and complications among the SS-RSF and TS-RSF reconstruction of soft tissue defects in the distal leg and heel. METHODS This is a retrospective chart review of RSF being operated in a tertiary care hospital. The duration of study was 1.5 years. Twelve RSFs (6 SS-RSF, 6 TS-RSF) were done for soft tissue defects in the distal leg and heel. Wounds of various etiologies (traumatic, chronic, non-healing ulcers) were reviewed. Trauma was the most common etiology with 8 out of 12 (66.7%) patients. Large wounds, donor site damage and patients with peripheral vascular disease were excluded from the study. RESULTS Five out of six (83.3%) of TS-RSF healed uneventfully. However, 3 out of 6 (50%) of SS-RSF had partial flap necrosis. All complicated flaps healed well subsequently. No donor site complication was found in any of our patients. CONCLUSION Pedicle exteriorization in TS-RSF eliminates the element of venous congestion and eventually flaps necrosis. Less technical expertise and minimal morbidity are additional advantages of TS-RSF. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Ranjit Kumar Sahu
- Department of Burns and Plastic Surgery, Room No. 403, OPD Block, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, 342005, India
| | - Prakash Chandra Kala
- Department of Burns and Plastic Surgery, Room No. 403, OPD Block, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, 342005, India
| | - Manojit Midya
- Department of Burns and Plastic Surgery, Room No. 403, OPD Block, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, 342005, India.
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Abstract
There is a significant burden of disease associated with infected fractures, and their management is challenging. Prevention of infection after musculoskeletal trauma is essential because treatment of an established infection continues to be a major obstacle. Despite the need for evidence-based decision making, there is a lack of consensus around strategies for prevention and surgical management of the infected fracture. The current evidence for the prevention of the infected fracture is reviewed here with a focus on evidence for antibiotic therapy and debridement, the induced membrane technique, management of soft-tissue defects, patient optimization, and adjuncts to prevent infection.
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Reconstruction of Defects in the Weight-Bearing Plantar Area Using the Innervated Free Medial Plantar (Instep) Flap. Ann Plast Surg 2019; 80:245-251. [PMID: 29406384 DOI: 10.1097/sap.0000000000001274] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Defects in the weight-bearing heel or forefoot are commonly derived from chronic wounds, acute trauma, or tumor excision. Reconstruction of such defects pose a significant challenge to provide a flap that is stable, durable, and sensate. Several flaps have been described for reconstruction of plantar defects, but recurrent ulcerations and/or the need of additional procedures are common. This article provides the approach and outcomes of innervated free medial plantar flap for weight-bearing plantar defects reconstruction. METHODS Chart review was performed of 17 consecutive patients with defects in the weight-bearing heel and/or forefoot who were treated with innervated free medial plantar flaps between the years 1999 and 2016. Eleven patients were male, and 6 patients were female. The mean age was 29.5 years (range, 4-52 years). One case was combined heel/forefoot defect, 7 were heel defects, and 9 were forefoot defects. Indications were acute trauma, secondary reconstruction after trauma, and tumor excision. RESULTS The mean defect size was 8.0 ± 5.4 cm × 5.1 ± 2.1 cm, and mean flap size was 9.7 ± 1.4 cm × 6.4 ± 0.9 cm. One flap suffered from arterial thrombosis, which necessitated reoperation, and was salvaged. For the remaining cases, the postoperative course was uneventful. The mean follow-up time was 59.3 (±51.3.6) months. Two patients received minor flap corrections due to hyperkeratosis and hypertrophic scar, and 2 patients required donor site correction owing to partial loss of skin graft. One patient succumbed within 1 year owing to metastatic disease. All patients that were followed more than 1 year (n = 15) could sense blunt touch of the flap. Ten patients underwent 2-point discrimination test. No patient had recurrence of ulceration. CONCLUSIONS The innervated medial plantar flap is an excellent solution for treatment of medium-to-large defects in the weight-bearing heel or forefoot. It provides glabrous skin that is stable, durable, and sensate. The long-term results are good, with no patient afflicted by recurrent ulceration during the follow-up time.
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Perumal R, Bhowmick K, Reka K, Livingston A, Boopalan PRJVC, Jepegnanam TS. Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint. J Foot Ankle Surg 2019; 58:306-311. [PMID: 30850100 DOI: 10.1053/j.jfas.2018.08.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 02/03/2023]
Abstract
The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.
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Affiliation(s)
- Rajamani Perumal
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
| | - Kaushik Bhowmick
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India.
| | - Karuppusami Reka
- Senior Demonstrator, Department of Biostatistics, Christian Medical College, Vellore, India
| | - Abel Livingston
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
| | - P R J V C Boopalan
- Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
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Donegan R, Blume PA. Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report. J Foot Ankle Surg 2018; 57:833-837. [PMID: 29631969 DOI: 10.1053/j.jfas.2017.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Indexed: 02/03/2023]
Abstract
Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.
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Affiliation(s)
- Ryan Donegan
- Resident Surgeon, Yale New Haven Hospital, New Haven, CT.
| | - Peter A Blume
- Assistant Professor, Department of Surgery, Anesthesia and Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Mikami T, Kaida E, Yabuki Y, Kitamura S, Kokubo K, Maegawa J. Negative Pressure Wound Therapy Followed by Basic Fibroblast Growth Factor Spray as a Recovery Technique in Partial Necrosis of Distally Based Sural Flap for Calcaneal Osteomyelitis: A Case Report. J Foot Ankle Surg 2018; 57:816-820. [PMID: 29605553 DOI: 10.1053/j.jfas.2017.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Indexed: 02/03/2023]
Abstract
The distally based sural flap is regarded as the first choice for reconstruction in the distal part of the lower leg because the flap is easy to raise, reliable in its blood supply, and prone to only a few complications. Limited data have investigated the details of treatment in cases of failure of distally based sural flaps. We report a case of calcaneal osteomyelitis in which a successful outcome was finally obtained with a partially necrosed, distally based sural flap using negative pressure wound therapy with basic fibroblast growth factor spray. The 2-year follow-up examination was uneventful. Moreover, the patient was able to walk freely with an ankle-foot orthosis in her house. This technique can be considered as a useful and effective option to recover unfavorable results of distally based sural flaps.
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Affiliation(s)
- Taro Mikami
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan; Associate Professor and Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa-ken, Japan.
| | - Eriko Kaida
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan
| | - Yuichiro Yabuki
- Assistant Professor and Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa-ken, Japan
| | - Sho Kitamura
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan
| | - Ken'ichi Kokubo
- Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Fujisawa Shounandi Hospital, Fujisawa, Kanagawa-ken, Japan
| | - Jiro Maegawa
- Professor and Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa-ken, Japan
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Rezende RBM, Macedo JLSD, Rosa SC, Galli FS. Epidemiological profile and treatment of substance losses by trauma to the lower limbs. ACTA ACUST UNITED AC 2018; 44:444-451. [PMID: 29019572 DOI: 10.1590/0100-69912017005004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/20/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES to evaluate the epidemiological profile, the surgical treatment and the postoperative results of patients with complex traumatic injuries to the lower limbs. METHODS we conducted a retrospective study of patients with traumatic complex injuries treated by the Plastic Surgery Service of a regional hospital in Brasília. We analyzed clinical-epidemiological data, type of surgical procedure and functional recovery of the limb after six months of treatment. RESULTS 119 patients were treated, with a mean age of 29 years, predominantly men (76.4%). Motorcycle accident was responsible for most of the injuries, in 37.8% of cases. The most frequent surgical treatment was skin grafting (62.1%), followed by the fasciocutaneous flap (21.9%), muscular flap (12.6%) and microsurgical flap (3.4%). Six months after completion of the surgical treatment, 35.3% of the patients needed crutches to move, characterizing a delay in limb functional recovery that, however, was significantly related to the presence of fractures, external fixation or bone exposure in the preoperative period. CONCLUSION the profile of the patient with complex traumatic lower limb injury was a male, motorcycle accident victim, and grafting was the most used treatment. Orthopedic trauma with bone fracture, bone exposure and the presence of external fixator were significantly associated with a higher risk of limb functional impairment, requiring locomotion crutches after six months of treatment.
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Affiliation(s)
| | | | - Simone Corrêa Rosa
- - North Wing Regional Hospital, Plastic Surgery Service, Brasília, DF, Brazil
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Reply: Sural Nerve Splitting in Reverse Sural Artery Perforator Flap: Anatomical Study in 40 Cadaver Legs. Plast Reconstr Surg 2018; 141:789e-790e. [PMID: 29659448 DOI: 10.1097/prs.0000000000004310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Early Reconstruction of Distal Leg and Foot in Acute High-Voltage Electrical Burn: Does Location of Pedicle in the Zone of Injury Affect the Outcome of Distally Based Sural Flap? Ann Plast Surg 2017; 78:41-45. [PMID: 26808748 DOI: 10.1097/sap.0000000000000719] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Distally based fasciocutaneous sural flap is popular in the reconstruction of distal leg and foot burns. However, utilization of this technique in high-voltage electrical injury has been challenging. AIMS The present study aimed to compare the outcome of early aggressive debridement and coverage of contact point of acute high-voltage electrical injury using distally based fasciocutaneous sural flap between high-risk and low-risk patients defined by the anatomic proximity of the flap pedicle to the zone of injury. METHODS A total of 51 patients with contact point of high-voltage electrical burn (HVEB) in distal leg and foot undergoing distally based fasciocutaneous sural flap were included in this prospective clinical study. In 28 patients, the flap pedicle was not involved in the contact point of high-voltage electrical injury (low risk/control group), whereas in 21 patients, it was located inside the zone of injury (high-risk/case group). Patients were followed up for a median of 21 months (range, 12-44 months). RESULTS Wound dimensions to be covered were relatively similar between the 2 groups. Complications of flap survival (primary outcome) and other minor early and late complications (secondary outcome) did not significantly differ between the 2 groups (P > 0.05). CONCLUSIONS Provided that early and completed debridements of contact points of HVEB were achieved, distally based sural flap is feasible and there is reliable coverage in HVEB even in patients with flap pedicle located in vicinity of the zone of injury.
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Avashia YJ, Shammas RL, Mithani SK, Parekh SG. Soft Tissue Reconstruction After Total Ankle Arthroplasty. Foot Ankle Clin 2017; 22:391-404. [PMID: 28502354 DOI: 10.1016/j.fcl.2017.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement.
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Affiliation(s)
- Yash J Avashia
- Division of Plastic Surgery, Duke University, Room 135, Brown Zone, Duke South, Durham, NC 27710, USA
| | - Ronnie L Shammas
- Division of Plastic Surgery, Duke University, Room 135, Brown Zone, Duke South, Durham, NC 27710, USA
| | - Suhail K Mithani
- Division of Plastic Surgery, Department of Orthopaedic Surgery, Duke University, 3609 Southwest Durham Drive, Durham, NC 27707, USA
| | - Selene G Parekh
- North Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery, Fuqua Business School, Duke University, 3609 Southwest Durham Drive, Durham, NC 27707, USA.
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Ebrahiem AA, Manas RK, Vinagre G. Distally Based Sural Artery Peroneus Flap (DBSPF) for Foot and Ankle Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1276. [PMID: 28507850 PMCID: PMC5426869 DOI: 10.1097/gox.0000000000001276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/01/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reconstruction of soft-tissue defects in lower third of leg, ankle, and foot has been a challenge and reconstructive surgeons have been trying to innovate different flaps. To solve this issue, we propose a distally based sural artery peroneus flap (DBSPF) in which we include superficial portion of the peroneus brevis muscle and its blood supply with the peroneal artery distally. The aim of this study was to evaluate the functional outcome and its usefulness over conventional distal sural artery flap or other local options available. METHODS This is a case series of 20 patients that include a DBSPF that was done for defects around ankle, distal leg, and foot caused by trauma or tumor ablation within the period of June 2013 to March 2015 in Kasralainy Hospital, Cairo. All cases were evaluated according to flap vascularity, distal reach of flap, aesthetic outcome, and donor-site morbidity. RESULTS All flaps survived. One flap developed venous congestion that subsided spontaneously with limb elevation. The flap dimension ranged from 42 cm to 442 cm2, and it reached the midfoot easily. The pivot point was kept as low as 2-6 cm from lateral malleolus according to location of perforators. The ankle stability was maintained, and the desired aesthetic outcome was achieved. CONCLUSIONS The DBSPF is an addition to the armamentarium in plastic surgery for defects around ankle, distal leg, and foot. It is an easy and swift procedure as compared with complex microsurgical reconstruction.
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Affiliation(s)
- Ahmed Ali Ebrahiem
- From the Department of General Surgery, Plastic and Reconstructive Surgery Division, Cairo University, Egypt; Department of Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India; and Department of Orthopaedic Surgery and Traumatology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Raj Kumar Manas
- From the Department of General Surgery, Plastic and Reconstructive Surgery Division, Cairo University, Egypt; Department of Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India; and Department of Orthopaedic Surgery and Traumatology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Gustavo Vinagre
- From the Department of General Surgery, Plastic and Reconstructive Surgery Division, Cairo University, Egypt; Department of Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India; and Department of Orthopaedic Surgery and Traumatology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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MACEDO JEFFERSONLESSASOARES, ROSA SIMONECORRÊA, BOTELHO DANIELLOBO, SANTOS CLENDESPEREIRADOS, QUEIROZ MURILONEVESDE, GOMES TABATHAGONÇALVESANDRADECASTELOBRANCO. Lower extremity reconstruction: epidemiology, management and outcomes of patients of the Federal District North Wing Regional Hospital. Rev Col Bras Cir 2017; 44:9-16. [DOI: 10.1590/0100-69912017001003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/03/2016] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to evaluate the management of lower limbs complex traumatic injuries by analyzing their characteristics, types, conduct and evolution, with emphasis on surgical treatment. Methods: we conducted a prospective study of patients treated by Plastic Surgery at a regional hospital of the Federal District during a one-year period. We collected data through serial evaluations and telephone contact records. Results: we studied 40 patients, with a mean age of 25.6 years, predominantly male (62.5%). The most frequent wounds were of the distal third of the lower limb (37.5%). Bone or tendon exposures occurred in 55% had and there was a 35% rate of exposed lower limb fractures. The treatments employed were skin grafting (57.5%), local fasciocutaneous flap (15%), muscle flap (12.5%), cross-leg fasciocutaneous flap, reverse sural flap (12.5%) and microsurgical flap (2.5%). Short-term evaluation showed that 35 patients had excellent or good results (87.5%), four had a regular result (10%), and one had an unsatisfactory result (2.5%). In the long term, of the 18 patients who answered the questionnaire, ten resumed walking, even with support, in the first three months after surgery (55.6%). Conclusion: young men involved in motorcycle accidents during leisure time represented the profile of patients with lower limb trauma requiring surgical reconstruction; the distal third of the leg was the most affected region. Grafting was the most used technique for reconstruction and postoperative functional evaluation showed that, despite complex lesions, most patients evolved with a favorable healing process and successful functional evolution.
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Abstract
Management of defects on the hand and foot with exposed tendons remains a major challenge for plastic surgeons. Here, we present a case of hand reconstruction with a totally laparoscopic peritoneal flap. The anterior rectus sheath was preserved in situ. The peritoneal free flap supplied by peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover the soft tissue defect of the hand. The defect of the dorsal hand was 17 cm ×12 cm. The peritoneal flap measuring 22 cm × 15 cm survived completely without any complications. A following split-thickness skin graft offered the suc- cessful wound closure. Motor and sensory function improved gradually within the first year follow-up. The totally laparoscopic peritoneal free flap is a good choice for reconstruction of the soft tissue de- fects accompanied by exposed tendons on the hand and foot.
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Affiliation(s)
- En-Qi Guo
- Corresponding author. Tel.: +86 13116730078.
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Wei JW, Ni JD, Dong ZG, Liu LH, Yang Y. A Modified Technique to Improve Reliability of Distally Based Sural Fasciocutaneous Flap for Reconstruction of Soft Tissue Defects Longitudinal in Distal Pretibial Region or Transverse in Heel and Ankle. J Foot Ankle Surg 2016; 55:753-8. [PMID: 27066868 DOI: 10.1053/j.jfas.2016.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Indexed: 02/03/2023]
Abstract
Partial flap loss is a common complication of the distally based sural fasciocutaneous flap. We present a modified technique of a sloped skin island design to improve the reliability of the flap when used to reconstruct a longitudinal distal pretibial defect or transverse heel and ankle defect. Thirty-one flaps with the slope-designed skin island were used to reconstruct such defects in 30 patients. In the modified technique, the skin island was rotated toward the vascular axis of the flap. The defects were located in the distal pretibial region in 7 cases and the ankle and heel region in 24. The horizontal dimension of the skin island decreased by an average of 5.6 (range 2.5 to 14.8) cm with the sloped design, and the rotation angle varied from 42° to 90° (mean 69°). Of the 31 flaps, 29 survived, 1 developed marginal necrosis, and 1 developed lateral partial necrosis. The sloped design of the skin island is applicable to reconstruction of longitudinal distal pretibial or transverse heel and ankle defects. The modified technique can decrease the horizontal dimension and increase perfusion of the skin island, thus improving the reliability of the flap.
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Affiliation(s)
- Jian-Wei Wei
- Department of Orthopaedics, Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Jiang-Dong Ni
- Department of Orthopaedics, Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Zhong-Gen Dong
- Department of Orthopaedics, Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.
| | - Li-Hong Liu
- Department of Orthopaedics, Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Ying Yang
- Department of Orthopaedics, Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
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A convenient flap for repairing the donor area of a distally based sural flap: Gastrocnemius perforator island flap. J Plast Reconstr Aesthet Surg 2016; 69:1109-15. [PMID: 26944233 DOI: 10.1016/j.bjps.2016.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 11/09/2015] [Accepted: 01/25/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The reconstruction of complex lower leg and foot defects is difficult for plastic surgeons. The distally based sural flap (DBSF) is an option for non-free flap lower leg reconstruction. However, one of the major drawbacks of the DBSF is its aesthetically non-acceptable donor area scarring. MATERIALS AND METHODS Eight patients (six men and two women) who had lower leg or foot defects were evaluated in this study. We used an ipsilateral or cross-leg DBSF to repair the defect. A medial or lateral gastrocnemius perforator island flap (average size 8.1 × 6.1 cm) was used to cover the donor area of the DBSF in a two-stage operative procedure. RESULTS We did not observe any complications with the gastrocnemius perforator island flap. Two patients had local infections under the DBSF and were treated with bacteria-specific antibiotherapy. All patients were followed up for 1 year postoperatively. The donor areas of the distally based sural flaps were aesthetically acceptable. Patients gained ambulatory status during the follow-up period. CONCLUSIONS Reconstruction of the donor area of a DBSF with a gastrocnemius perforator island flap allows for more acceptable aesthetics and functional results than do other reconstructive procedures.
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Distally based sural flap for ankle and foot coverage in children. Orthop Traumatol Surg Res 2016; 102:111-6. [PMID: 26726097 DOI: 10.1016/j.otsr.2015.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 10/01/2015] [Accepted: 10/14/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Coverage of soft-tissue defects of the ankle and foot is often challenging. The distally based sural fascio-cutaneous flap is useful for reconstructing the lower leg, ankle, heel, and foot but has rarely been evaluated in paediatric patients. The objectives of this study were to assess the reliability of this flap in paediatric patients, to describe the complications associated with its use, and to define its indications in paediatric patients with soft-tissue defects of the ankle and foot. HYPOTHESIS We hypothesised that the sural flap was reliable for covering soft-tissue defects at the ankle and foot in paediatric patients. MATERIAL AND METHODS A distally based sural fascio-cutaneous flap was used to cover soft-tissue defects of the ankle and foot in 20 paediatric patients between 1997 and 2013. The evaluation at last follow-up included a physical examination and determination of the modified functional Kitaoka score. Mean follow-up was 50.6 months (range, 10-192 months) and mean patient age at surgery was 8.8 years (range, 1.5-17 years). Trauma was the most common cause of soft-tissue defect (n=12); other causes were surgical-site infections (n=2), tumours (n=3), chronic ulcer (n=1), burn injury (n=1), and infusion fluid extravasation (n=1). RESULTS Of the 20 flaps, 16 (80%) remained fully viable, whereas 4 developed partial necrosis requiring excision and skin grafting, which consistently ensured a good outcome. Other complications consisted of marginal necrosis (n=4), unsightly donor-site scars (n=5), and infection (n=2). Abnormal flap sensation was noted in 11 patients. The mean modified Kitaoka score was 65/80 (range, 0-80), and the score value indicated that function was excellent in 9 (45%) patients, good in 9 (45%) patients, and poor in 2 (10%) patients. DISCUSSION The distally based sural fascio-cutaneous flap is a method of choice for covering soft-tissue defects of the ankle and foot in paediatric patients. This reliable flap spares the major blood vessels and has a strong blood supply. Its best indication is coverage of an acute traumatic soft-tissue defect with exposure of a vital structure. In patients requiring late reconstruction, caution is in order when considering the use of a distally based sural fascio-cutaneous flap, which can induce delayed complications, most notably at the donor site. LEVEL OF EVIDENCE IV, retrospective case-series study.
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An Algorithm for Forefoot Reconstruction With the Innervated Free Medial Plantar Flap. Ann Plast Surg 2016; 76:221-6. [DOI: 10.1097/sap.0000000000000564] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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