SLR - July 2022 - Alyse Acciani, DPM, MPH
Reference: Hashmi, P.M., Musaddiq, A., Ali, M., Hashmi, A., Zahid, M., & Nawaz, Z. Journal of Surgical Reconstruction, Open Access. 2021 July 31; 30, 61-73.Level of evidence: IV
Scientific Literature Review
Reviewed by: Alyse Acciani, DPM, MPH
Residency Program: Hennepin Healthcare, Minneapolis MN
Podiatric Relevance: Podiatric surgeons are increasingly performing soft tissue reconstruction procedures, including skin flaps. This article reviews 25 years of cases, primarily traumatic, and provides a statistical analysis of functional outcomes and patient satisfaction with their flap. Podiatric surgeons are often an integral part of the care team for patients after foot and ankle trauma. The ability to offer such a procedure to patients is extremely beneficial for continuity of care after initial management of such a trauma. Often these types of cases are complex, with various complications.
Methods: A single surgeon’s 25-year history of cases were collected and analyzed. Only sural flaps were included, thus other flaps such as free flaps, perforator flaps and others were not included. The research team reviewed general patient demographics, mechanism of injury, defect site and size, size of flap, hospital stay, complications, outcome of flap, and functional status of limb. Cases from July 1996 to February 2020 were included in the case series review. This timeline allowed for 89 patients with 92 distally based sural artery flaps for review. Statistical analysis was performed using SPSS software, which is primarily used for quantitative analysis. The team also used a self-designed grading system for functional outcome that included excellent, good, fair, and poor functional outcomes.
Results: The patient group of 89, included 92 flaps, was divided in groups I for leg flap and group II for foot flap; group I was 41 legs, group II was 51 feet. Group I age range was 37.4 + 17, and group II was 33.3 + 20 years. The team reviewed mean flap size, post operative functional outcomes, and flap survival. The team designed a grading system that assessed the functional outcomes. The system reported 79 excellent outcomes, 10 good, 3 fair, and 0 poor. Flap survival rate was 96.8% among both groups; the failure flaps were due to partial necrosis that required skin flaps of necrosed area.
Conclusions: Data did support using the sural artery flap for defects in the lower one-third of the leg including malleoli, dorsal foot, and the non-weightbearing aspect of the hind foot. Further, data confirmed function and range of motion of the leg, ankle, and foot was not compromised in either group. It should be mentioned, however this flap is insensate and must be a consideration when assessing and choosing patients for such a procedure. Of note, the injuries chosen were primarily trauma, with others for blast injury, infection, contracture release, and TA coverage after repair. Though these were generally young healthy persons, the eldest patient being 78, it is unclear what other comorbidities were present in the groups and which ages experienced complications. Among the complications of flap necrosis, it was determined the most common cause was venous congestion secondary to poor placement of the short saphenous vein, however ligation of SSV was recommended reduce this complication. The self-designed grading system was not validated, thus weakening the reported grading outcomes.