SLR - April 2018 - Wesley Maurice Leong

Reverse Sural Flap for Ankle and Heel Soft-Tissues Reconstruction

Reference: Ciofu RN, Zamfirescu DG, Popescu SA, Lascar I, Reverse Sural Flap for Ankle and Heel Soft-Tissues Reconstruction. Journal of Medicine and Life Vol. 10, Issue 1, January–March 2017, pp.94–98.

Scientific Literature Review

Reviewed By: Wesley Maurice Leong, DPM
Residency Program: Carilion Clinic/Virginia Tech School of Medicine (Roanoke, VA)

Podiatric Relevance: Soft-tissue defects of the foot and ankle are subjected to stresses that make them refractory to split thickness skin grafting or healing by secondary intention. These wounds often have exposed bone or tendons that result in a friable, unstable or painful scar. There have been many reported successful results of using a distally based reverse sural flap when addressing medium to large soft-tissue defects of the foot and ankle. Advantages of the flap include the relative simplicity of the procedure, reliability of the flap and decreased operative time compared to other coverage methods. The authors of this study sought to demonstrate the viability of the reverse sural flap in a high-risk patient population.

Methods: Ten patients with soft-tissue defects around the foot and ankle underwent a distally based reverse sural flap. The etiopathogeny of defects included cancer excision, trauma, unstable scars and chronic osteomyelitis. Patient comorbidities included diabetes mellitus, peripheral vascular disease and venous insufficiency.  

Results: The authors reported a 30 percent complication rate in their study. Transient venous congestion was cited as the most common complication, but it cleared in all affected patients after two days. Two of the patients in the group required a delayed flap procedure. Lateral foot paresthesia resulting from the sacrifice of the sural nerve resolved within two months. Ultimately, all patients in the study had their soft-tissue defects successfully covered and healed without major complications. If any part of the flap failed, it was usually a minor margin of the tip, which resolved uneventfully via secondary intention.  

Conclusions: From their experience, the authors concluded that the reverse sural flap is a safe, reliable option for soft-tissue coverage of the foot and ankle region. The study’s relatively small size and lack of control for comorbidities, wound size and etiology make it less useful for establishing specific recommendations for surgical planning. The reported successful coverage rate of 100 percent and absence of major complications would suggest that the reverse sural flap should be regarded as an equally viable alternative to free flap transfer. Additionally, this construct has an average reported operative time that is much lower than that required of a free muscle flap and also does not require expensive microvascular equipment or additional personnel. From their experience, the authors suggested that that an ideal indication of the flap would be to cover a defect over an intact partially exposed Achilles tendon.  

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