The distally based sural fasciomusculocutaneous flap for foot reconstruction

Outpatient regenerative therapy of a chronic diabetic foot ulcer with exposed bone surface

BACKGROUND: Treatment of deep chronic wounds with the bone tissue involvement against the background of lower limb atherosclerosis and diabetic foot syndrome does not fit any reasonable hospital stay duration and at the same time has no effective outpatient methods. Therapy with conditioned medium derived from human mesenchymal stem cells (CM-MSC) may be a solution for this problem. CLINICAL CASE DESCRIPTION: Patient F., 77-year-old, arrived for an outpatient treatment of local necrosis in the area of the 1st toe of the left foot in April, 2022. The main diagnosis: Peripheral arterial disease of the lower extremities. Multifocal atherosclerosis. Occlusion of the superficial femoral and popliteal arteries, diffuse lesions of the lower leg arteries on the left. Chronic arterial insufficiency of the 4th degree. Attempts of revascularisation of the left lower limb. Limited gangrene (Wagner IV) of the 1st toe of the left foot. Associated diseases: insulin-dependent type 2 diabetes mellitus (for more than 30 years). Diabetic polyneuropathy. Diabetic foot syndrome, neurotrophic form. Local treatment was performed by the microsurgical debridement of the affected surface in combination with the method of multilayered dressings, according to the previously patented technology. The microsurgical treatment of the bone surface in the wound area was carried out with the use of CM-MSC. Positive dynamics in the form of a partial closure of the bone fragment with soft tissue was observed on the sixth month of therapy. The complete closure of the open bone fragment was observed in 12 months from the beginning of the outpatient treatment. CONCLUSION: The developed method of treatment using CM-MSC can be effective for chronic wounds with open bone surfaces.

Reconstruction of lower limb defect with a variant sural neuro-fasciocutaneous flap: A case report

INTRODUCTION

The sural neuro-fasciocutaneous flap is widely used for reconstructing skin defects in the lower calf. Variations of the sural nerve in the calf are infrequent, which may require a variation in the traditional surgical procedure.

CASE PRESENTATION

A 76-year-old male patient had soft tissue defect of the right lateral ankle and lower leg caused by an accident 18 years ago. He had exposed bones and had osteomyelitis. He underwent two primary operations, and finally, we used a sural neuro-fasciocutaneous flap to effectively cover the defect. We observed that the course of the sural nerve was atypical during the surgery, and we adjusted the flap axis laterally to bring the lateral sural cutaneous nerve inside the flap to improve the success rate of the surgery. The flap entirely survived, and there was no sensory impairment in the calf. The patient was discharged from the hospital after 10 days.

CLINICAL DISCUSSION

Some type of variant of the sural nerve makes the flap harvest without the neurovascular component of the sural nerve and the cutaneous chain, which might decrease flap survival. Moving the flap axis laterally and bringing in the lateral sural nerve or peroneal communicating nerve offers an adequate blood supply to the vascular territory and the flap region.

CONCLUSION

In patients with sural nerve variants, the procedure does not have to follow the traditional theory of the sural neuro-fasciocutaneous flap. Preoperative and intraoperative protection of the sural nerve variant should also be considered.

Effectiveness of the Reverse Sural Flap in Covering Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis

Background: The reverse sural fasciocutaneous flap (RSFCF) has been used with success to cover noncomplicated foot and ankle soft tissue defects. However, there are some controversies when it is used in patients having chronic diabetic foot ulcers. This aim of this meta-analysis was to evaluate the efficacy of RSFCF in covering diabetic foot and ankle ulcers. Methods: A systematic review was undertaken from MEDLINE, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Only diabetic foot and ankle ulcers were accepted for inclusion and all study designs were included. Proximally based flaps, nondiabetic ulcers, and assisted negative pressure therapy were excluded. Suitability for inclusion was assessed by 2 reviewers. The random-effect estimate was reported for the set outcomes whenever high heterogeneity was present. Metaregression analysis was performed to identify independent risk factors for failure. Results: The search identified 33 relevant studies comprising 187 patients and flap interventions; all but 1 were case-series. The weighted outcomes were as follows: (1) the flap healing rate was 93.3% while 6.6% resulted in total necrosis, (2) the rate of partial flap necrosis was 12%, (3) venous congestion was reported in 6.6% of cases, (4) the infection rate was 8.3%, and (5) the donor site morbidity was 4.6%. No association was found between pedicle width or presence of a subcutaneous pedicle tunnel and the primary outcome of total loss. Conclusions: This review demonstrated excellent results of the flap when covering complicated or large diabetic foot and ankle ulcers. When compared to those published in the literature, our results found RSFCF to be relatively less successful in diabetic wounds than in trauma patients but more successful than in those having associated osteomyelitis and those who were treated with random local flaps.

How Safe Is Reverse Sural Flap?: A Systematic Review

BACKGROUND

Soft tissue reconstruction of the lower third of the leg, the ankle, and the foot is challenging for reconstructive surgeons. The options for reconstruction are limited. Reverse sural flap is relatively easy to perform and considered a good option for reconstruction. The complication rates are variable in studies. This study aims to systemically review all available articles based on reverse sural flap focusing on complications of the flap. The overall complication of the flap helps to better understand the reliability of the flap.

METHODS

A comprehensive literature search was performed using MEDLINE, EMBASE, and Google Scholar to identify cases of reverse sural artery flap.

RESULTS

A pooled analysis of 89 articles was performed, which yielded 2575 patients (2592 flaps) over a period of 19 years. Most of the cases were performed in Asian countries (1540 flaps, 59.4%) with the majority being performed in China (746 flaps, 28.8%). The most common cause for reverse sural flap surgery was trauma/postsurgical (1785/2592) followed by burn/scarring. Flap complications were recorded in 653 of 2592 flaps (25.20%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.85%) followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 participants (2.5% of all the flaps performed).

CONCLUSIONS

Reverse sural flap is reliable flap for the reconstruction of lower leg, ankle, and foot. It can give a comparable outcome as free flap when meticulously performed and, in many cases, a better result.

Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial

BACKGROUND

Distally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used for reconstructing soft-tissue defects of the lower extremity. However, reports on the reconstruction of the defects over the distal forefoot using the DPAPF flaps are scarce. Herein, we describe our experience on the reconstruction of these defects using DPAPF flaps in a considerable sample size.

METHODS

Between February 2005 and August 2019, a total of 56 DPAPF flaps in 56 patients were used to reconstruct soft-tissue defects in the forefoot. In order to reduce the length of fascial pedicle and the total length of the DPAPF flaps, the ankles were fixed in dorsiflexion using a Kirschner wire before designing the flaps. The flaps were elevated by the anterograde-retrograde approach. Patient factors and flap factors were compared between the "survival" and "partial necrosis" groups.

RESULTS

Overall, 47 flaps had survived completely in one stage. Partial necrosis developed in nine flaps, with only one remnant defect covered using a local flap. By fixing the ankles in dorsiflexion, the length of the fascial pedicle was reduced approximately 2.35 ± 0.58 cm, the total length of the flap was simultaneously shortened by the same amount as the length of the fascial pedicle. The width of the fascia pedicle varied from 3.0 cm to 6.0 cm. The fascial pedicle width > 4 cm was found in 21 flaps. The partial necrosis rate of the DPAPF flaps with the top edge located in the 8th zone was significantly lower than that in the 9th zone (p < 0.05).

CONCLUSIONS

The DPAPF flaps can be effectively used to reconstruct the defects over the distal forefoot because of convenient harvest and reliability. By fixing the ankle in dorsiflexion with Kirschner wire and widening the fascial pedicle appropriately, the top edge and LWR of the flaps will be decreased, and thus the procedures are helpful for the flaps survival.

Application of acellular human dermis and skin grafts for lower extremity reconstruction

OBJECTIVE

To use both acellular human dermis and skin grafting simultaneously for improved skin grafting without contracture. The study also aims to address the lack of research on the application of an acellular human dermis in diverse clinical cases.

METHOD

The study examined patients who had received acellular human dermis (CGDerm, CGBio, Seoul, Korea) and split-thickness skin grafting (STSG) simultaneously for lower limb, full-thickness skin defects between September 2012 and June 2014. The researchers performed chart reviews retrospectively and examined the patients based on the following factors: gender, age, injury mechanism, size, exposed structure, pre-coverage dressing method, coverage method, post-operational engraftment and total healing period, contracture development, elasticity, and infection development.

RESULTS

A sample of 27 patients with a total of 30 wounds took part in the study. Of these wounds, 29 showed successful engraftment without infection or contracture. In one case, continued seroma was observed and, following new coverage of both the acellular human dermis and STSG, engraftment was successful.

CONCLUSION

Human dermis can play an important role in securing the availability of surrounding tissue and in contracture prevention, both of which are key to lower limb reconstruction. Of the types available, acellular human dermis showed lower infection rates than other human dermis types, and its engraftment rate was higher than in STSG-only cases. These findings suggest that acellular human dermis use in STSG is effective and safe in lower limb reconstruction.

A Perifascial Areolar Tissue Graft With Topical Administration of Basic Fibroblast Growth Factor for Treatment of Complex Wounds With Exposed Tendons and/or Bones

The management of wounds with tendon and/or bone exposure is challenging because of the insufficient blood supply to the wound bed. We describe our experience with 19 patients using a perifascial areolar tissue (PAT) graft with topical administration of basic fibroblast growth factor (bFGF) in the treatment of complex wounds with exposed tendons and/or bones in the extremities. Using a PAT graft is minimally invasive and technically easy, and the donor site is relatively preserved. However, PAT grafts for the treatment of a complex wound with large areas of exposed tendons and/or bones have sometimes failed to survive because of insufficient vascularization of the wound bed. Therefore, topical administration of bFGF, which promotes angiogenesis, was added to the graft. All grafts showed good graft survival and successfully covered the tendons and bones. Topical administration of bFGF accelerated vascularization in the PAT graft and facilitated wound healing by increasing the blood supply to the wound bed and achieved success with the PAT graft. In conclusion, using a PAT graft with topical administration of bFGF is a suitable option for the treatment of complex wounds with a large proportion of exposed tendons and/or bones. With minimal damage to the tissues near the wound, the PAT graft can be a useful option for limb salvage and could become a valuable tool for reconstructive surgeons.

Distally Based Sural Artery Peroneus Flap (DBSPF) for Foot and Ankle Reconstruction

BACKGROUND

Reconstruction of soft-tissue defects in lower third of leg, ankle, and foot has been a challenge and reconstructive surgeons have been trying to innovate different flaps. To solve this issue, we propose a distally based sural artery peroneus flap (DBSPF) in which we include superficial portion of the peroneus brevis muscle and its blood supply with the peroneal artery distally. The aim of this study was to evaluate the functional outcome and its usefulness over conventional distal sural artery flap or other local options available.

METHODS

This is a case series of 20 patients that include a DBSPF that was done for defects around ankle, distal leg, and foot caused by trauma or tumor ablation within the period of June 2013 to March 2015 in Kasralainy Hospital, Cairo. All cases were evaluated according to flap vascularity, distal reach of flap, aesthetic outcome, and donor-site morbidity.

RESULTS

All flaps survived. One flap developed venous congestion that subsided spontaneously with limb elevation. The flap dimension ranged from 42 cm to 442 cm2, and it reached the midfoot easily. The pivot point was kept as low as 2-6 cm from lateral malleolus according to location of perforators. The ankle stability was maintained, and the desired aesthetic outcome was achieved.

CONCLUSIONS

The DBSPF is an addition to the armamentarium in plastic surgery for defects around ankle, distal leg, and foot. It is an easy and swift procedure as compared with complex microsurgical reconstruction.

Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis

The distally based sural fasciocutaneous flap is one of the few options available for local flap reconstruction of soft-tissue defects in the lower one-third of the leg. Few studies have assessed risk factors associated with poor outcomes in this flap. A literature search was performed of MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles evaluating the use of sural artery fasciocutaneous flaps for soft-tissue reconstruction of the leg. Data were pooled and a univariate analysis was performed to identify characteristics associated with increased morbidity. A logistic regression model was created, and odds ratios and p values associated with the development of complications were calculated. Sixty-one papers were identified which included data on 907 patients. The majority of sural flaps were used to cover defects of the heel (28.2%), foot (14.4%) or ankle (25.8%). Trauma was the most common indication, followed by ulcers and open fractures. Flap complications were recorded in 26.4% of cases with a flap loss rate of 3.2%. With multivariate analysis, venous insufficiency and increasing age were independent risk factors for complications. Patients with venous insufficiency had nine times the risk of developing a complication compared to patients without venous insufficiency.

Versatility of the distally-based sural artery fasciocutaneous flap on the lower leg and foot in patients with chronic disease

Background

A recent advancement in microsurgery, the free flap is widely used in the reconstruction of the lower leg and foot. The simple and effective methods of local flaps, including transposition and advancement flaps, have been considered for patients with chronic debilitation who are unable to endure long surgical procedures or general anesthesia. However, the location and size of the wound may restrict the clinical application of a local flap. Under these circumstances, a sural flap can be an excellent alternative, rendering satisfying clinical outcomes in chronically debilitated patients.

Methods

Between 2008 and 2012, 39 patients underwent soft tissue defect treatment by sural artery flap as a final method. All of the patients had at least one chronic disease or more (diabetes, hypertension, vascular disease, etc.). Also, all of the patients had a history of chronic lower extremity ulceration, which revealed no response to several months of conservative treatment.

Results

The results of the 39 cases had a success rate of 100% with 39 complete recoveries. Nine cases suffered complications: partial necrosis (n=4), wound dehiscence without necrosis (n=3), hematoma (n=1), and infection (n=1).

Conclusions

The sural artery flap is not only useful for the lower leg but also for the heel, and other various parts. Furthermore, it is a relatively simple surgical technique for reconstructing the defect area for patients with various chronic conditions with a high surgical risk or contraindications to surgery.

Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7-cm-wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot.

The reverse sural artery flap for the reconstruction of distal third of the leg and foot

Soft tissue defects around the distal third of the leg and the foot present a major reconstructive challenge. There is limited expertise with free tissue transfers in many developing countries, necessitating consideration of other options for the closure of such defects. The versatility and reliability of sural artery flap have made it an emerging popular option for the reconstruction of such defects. Twenty patients comprising of 13 males and 7 females with soft tissue defects of the lower third of the leg and foot requiring soft tissue cover were treated between January 2006 and December 2010. The age range was 7-58 years with a mean age of 30 years. Nineteen (95%) of the defects were post-traumatic while one (5%) was post-infective. All the defects were covered with reversed sural artery flaps, which were raised on the posterior aspect of the junction of the upper and middle third of the leg. The smallest flap was 4 × 4 cm(2) while the largest measured 20 × 12 cm(2). The donor defect was closed directly in 7 (35%) patients, while split skin graft was applied in the remaining 13 (65%) patients. There was satisfactory flap healing in 17 patients (85%), while 3 patients (15%) had complete flap necrosis. Two of these patients had significant comorbidities of haemoglobinopathy and poorly controlled diabetes mellitus. Sural artery flap remains a viable option for the reconstruction of soft tissue defects of the distal third of the leg and foot. Caution should, however, be exercised in patients with some significant systemic diseases.

Flap reconstruction of distal lower extremity wounds in diabetic patients

Lower extremity diabetic wounds have been a challenge to clinical surgeons because of the higher risk of limb ischemia, soft-tissue infection, and soft-tissue loss caused by the pathology of the disease. In the published data, the most commonly used reconstruction techniques include pedicled flaps, microsurgical muscle or musculocutaneous flaps, and microsurgical fasciocutaneous or perforator flaps. However, there is still no consensus about which type of flap should be preferred among various reconstructive options. It is therefore the aim of this study to review current articles describing distal lower extremity flap reconstruction in patients with diabetes to survey reported results from the literature.

Distally based dorsal pedal neurocutaneous flap for forefoot coverage

The authors describe their experience with the use of the distally based dorsal pedal neurocutaneous flap for distal foot coverage. Ten patients underwent reconstruction with 13 flaps between 2004 and 2008. One patient suffered from a traffic accident and 9 from electrical injury. All of the soft tissue defects resulted in metatarsophalangeal joint and phalanx bone exposure. The size of the flaps ranged from 6 × 2 cm to 11 × 6 cm. The flaps were elevated based on intermediate or medial dorsal pedal nerves. Nine flaps were harvested in first stage to repair the distal foot. Among them, 3 showed partial necrosis in the distal region because of venous insufficiency. Four flaps underwent a surgical delay procedure in the first stage and were then transferred to reconstruct phalanx wounds in the second stage, surviving completely. All patients were satisfied with their reconstruction and donor site contour. The distally based dorsal pedal neurocutaneous flap can be used to repair the distal foot soft tissue defects, providing sufficient skin territory and excellent aesthetic and functional recovery. Surgical delay effectively enhances the distally based dorsal pedal neurocutaneous flap survival, particularly for the large size flaps.

Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel

The reconstruction of the distal third leg and weight-bearing heel, especially when complicated with infection and/or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. In this report, we present the results of the anatomical study on vascular communication between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle and a modified technique in clinical applications for reconstruction of the soft tissue defects in the distal lower leg and heel. Six lower limbs of fresh cadavers were injected with red gelatin and dissected. A constant vascular connection with average four musculo-fasciocutaneous perforators with diameter 0.2-0.5 mm was identified in the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Based on these findings, a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only. The average size of the fasciocutaneous flap was 51 cm(2), and the muscle component 17.7 cm(2). All flaps survived uneventfully. Our results suggest that this technical modification could provide wider range for applications of the distally based sural neurofasciomyocutaneous flap in repair of the soft tissue defects of the lower extremity and heel.

Prefabricated flap to repair heel defect of child

The coverage of large soft tissue defects in heel is a problem for surgical reconstruction. Various reconstructive materials are available depending on the location, size and depth of heel defect, but unique function of heel skin cannot be restored easily by means of reconstruction. We used prefabricated flap of the foot heel to cover heel defect in a child and obtained satisfactory clinical results.