SLR - July 2021 - Clint Jiroux

Concurrent Internal Fixation and Soft Tissue Reconstruction by Distally Based Sural Flap: A Practicable Scheme for Complex Distal Tibial Fractures

Reference: 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. Eur J Orthop Surg Traumatol. 2021 May;31(4):711-718. doi: 10.1007/s00590-020-02827-8. Epub 2020 Nov 5. PMID: 33151483.

Level of Evidence: IV, Retrospective case series

Scientific Literature Review

Reviewed By: Clint Jiroux, DPM, MS
Residency Program: Mount Auburn Hospital – Cambridge, MA

Podiatry Relevance: A large defect/wound on the lower extremity that is elicited by either trauma or complication from surgery can be a challenge for a podiatric surgeon.  The use of a local fasciocutaneous flap would allow a robust treatment for a defect in the lower extremity. The authors set to utilize a sural fasciocutaneous flap to cover a large defect brought upon by an open Gustilo IIIB tibial fracture on the anterior aspect of the ankle. A local flap has the advantage to a free flap as it can be less technically demanding and high survival rate to its counterpart. The flap can be utilized for distal tibia, ankle and foot wounds that have a size larger than 100 square centimeters and would supply a well perfused flap for adequate healing.

Methods: Patients (n=17) presenting with Gustilo type IIIB open fractures of the distal tibia. The treatment algorithm consisted of three respective operations. First operation consisted of external fixation and debridement to achieve a regular shape (oval or ellipse) of the traumatized skin defect. Second operation was carried out 7-10 days after injury the fracture was reduced and fixed with a pre-contoured plate. A distal based sural flap was created on the posterior leg with the pivot point made 8-10 cm above the tip of the lateral malleolus with pedicle length was 1-1.5 centimeters longer from the pedicle to the defect. The skin pedicle measured 4-5 centimeters wide and transposed over the defect. Third operation involved skin grafter of the donor site. Measured outcomes include radiographic observation of fracture union (three to four cortices observed A/P and lateral view), flap viability, postop complications, and Puno functional score (pain, activities of daily living, range of motion, residual deformity, radiological changes, muscle strength and sensation).

Results: Out of the 17 patients with distal based sural flap, all the flaps had survived without total necrosis. One patient experienced partial flap necrosis managed by debridement and skin graft. Bone graft was need in nine of 17 patients. All fractures united at a mean duration of 22.6 weeks. No surgical site infection was present. The Puno functional score showed that 2 patient had excellent functional outcomes and 15 patients had good functional outcome. 

Conclusions: The authors concluded that this was the first study to utilize a local flap to cover an open fracture ORIF of this nature with 100 percent flap survival and 100 percent union of all fractures. They emphasized the flap can be utilized in hospitals with an orthopedic facility and defects greater than 50 square centimeters. Regarding my own practice, I find this to be another option when treating large defects on the anterior leg or foot. I believe this flap can be utilized in certain situations that would warrant it’s use. A better assessment of donor site morbidity and healing would have been helpful to discuss in the article. If the posterior soft tissue is intact and viable this flab could be another option for the podiatric surgeon. 

Educational Opportunities