SLR - November 2018 - Riley Rampton

The Coverage of Skin Defects Over the Foot and Ankle Using the Distally Based Sural Neurocutaneous Flaps: Experience of 21 Cases

Reference: Gong Xu, Lu Lai-Jin. The Coverage of Skin Defects Over the Foot and Ankle Using the Distally Based Sural Neurocutaneous Flaps: Experience of 21 Cases.Journal of Plastic, Reconstructive and Aesthetic Surgery. 2008; 61(5):575–7.

Scientific Literature Review

Reviewed By: Riley Rampton, DPM
Residency Program: North Colorado Medical Center Podiatric Medicine and Surgery, Greeley, CO

Podiatric Relevance: Skin defects of the foot and ankle are a challenge for not only lower extremity surgically trained physicians but also reconstructive plastic surgeons. When presented with complex defects of the lower extremity which leave tendons and bones exposed, coverage by flaps may be an option for closure and coverage. Options available include pedicled fasciocutaneous flaps and free flaps. Flaps that cover the foot and ankle must have skin adequate for a weightbearing surface, must be adequate in size for proper coverage and must spare large vessels supplying blood flow to the extremity. The sural neurocutaneous flap is ideal for coverage of the foot and ankle. This case report presents the results of 21 cases in which this flap was used for coverage of ankle, heel and forefoot wounds. If podiatric surgeons can use the techniques presented in this article, there may be better outcomes for patients who have high-energy trauma injuries of the foot and ankle.

Methods: In this series, there were 22 flaps in 21 male patients. The patient ages ranged from six to 58. Cause of injury included 12 cases of motor vehicle accidents, eight crush injuries and one case of frostbite. Recipient sites included the dorsum of the foot (nine), heel (three), medial and lateral malleoli (eight) and forefoot. The defects ranged from 20 x 10 cm to 6 x 4 cm.

Results: All flaps were taken from the distal sural neurocutaneous site. Twenty-one flaps survived without the need for further revision, and one flap failed intraoperatively. The flaps healed within two to three weeks. Weightbearing was permitted at four weeks, and the follow-up period was at least six months. The flaps matched the surrounding tissue when placed at the level of the ankle or the dorsum of the foot; however, the thickness of the graft on the plantar foot was too bulky and created recurrent ulcers. In addition, the flap was mobile, and patients reported discomfort due to graft sliding on the plantar aspect of their feet.

Conclusions: The sural neurocutaneous flap can be chosen to cover skin defects over the dorsum of the foot, heel, medial and lateral malleoli, and plantar foot. In the case of serious injury in the foot and ankle, the podiatric surgeon must be able to properly be evaluated the need for skin flaps for proper coverage of tendons and bone. It is also imperative that the surgeon understand the weight bearing surfaces of the foot. With proper technique, plantar skin flap survival is high but without proper shoe gear and adequate follow-up, plantar recipient sites have a higher risk of ulceration. 

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