SLR - March 2016 - Ryan Goldfine

Title: Sural Versus Perforator Flaps for Distal Medial Leg Wounds

Reference: Schannen AP, Truchan L, Goshima K, Bentley R, DeSilva GL. Sural Versus Perforator Flaps for Distal Medial Leg Wounds. Orthopedics. 2015 Dec 1; 38(12).
Scientific Literature Review

Reviewed By: Ryan Goldfine, DPM
Residency Program: Beaumont Farmington Hills (Botsford Campus)
Podiatric Relevance: Soft tissue coverage of the distal medial ankle wounds is difficult because of limited local tissue. Based on the reconstructive ladder, a local flap is preferable to a free flap. Free flaps may not have as great a healing potential as rotational flaps. Free flaps require microsurgery, anticoagulation, and usually ICU monitoring. The authors cite a study that shows a 13 percent failure rate of free flaps. Since sural artery flaps have been shown to have such a high success rate, the authors wanted to compare it to a propeller flap (posterior artery-based flap).

Methods: The authors conducted a retrospective study of fourteen patients within a 40 month period, that underwent either a sural or propeller flap for a distal medial leg wound. The same orthopaedic surgeon performed all of the surgeries. Patients had to be at least eighteen years old, have a distal medial leg wound from acute trauma or sub-acute breakdown, and have no active infection. The surgeon chose which flap to perform based on Doppler ultrasound findings and viability of each pedicle. Most of the sural flaps were performed in a two-staged procedure, while the propeller flaps were performed in one-stage procedures. Flap healing, underlying fracture healing, flap size, return to normal shoe-gear, and need for further interventions were measured.

Results: All seven sural flaps healed without incident, with underlying fracture healing. Six out of seven perforator flaps healed without incident, with underlying fracture healing. One had superficial tip necrosis, but healed later on with local wound care. The average size of the defect covered was 23 cm2. The average time between fracture fixation and flap coverage in the sural flap group was 4.7 weeks, while the average time was 13.7 weeks in the propeller flap group. All patients returned to normal shoe-gear.

Conclusions: Both sural artery rotational flaps and posterior tibial artery-based rotational flaps are viable options for distal medial leg soft tissue coverage. All patients healed at the distal medial leg, regardless of comorbidities or underlying fracture. While free flaps are commonly used to cover large defects, the use of local flaps can provide great coverage. Local flaps have great healing potential, as long as the donor site is assessed clinically and with ultrasound. While the authors concluded that both types of flaps have great healing potential, the sural artery flap allowed for coverage of the defect in a shorter period of time.

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