Distally Based Sural Flap in Children: Reliability Technique

The distally based sural flap often poses the problem of venous suffering that can lead to necrosis. We present a reconstruction of a loss of substance of the ankle in a 6 years old child, using a distal pedicle sural flap, made reliable by a racket like flap method, which reduces the risk of vascular complications and led to good integration of the flap, with a good functional result. Nevertheless, the aesthetic sequelae remain significant.

Arteriovenous supercharging: A novel approach to improve reliability of the distally based sural flap

Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used, but it has a high partial necrosis rate due to venous insufficiency. We addressed this issue with AV supercharging by dorsalis pedis artery with short saphenous vein. Eight patients (seven males, mean age 34.12 years) with post traumatic lower limb defects over heel and foot were included. All flaps survived and healed although four flaps developed superficial partial epidermolysis. Average healing time was 20.12 days. Closure of the AV fistula was not required in any of the patients. At mean follow-up of two months, all patients were ambulatory with well settled flap. Arteriovenous supercharging of distally based sural flap through short saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.

An Effective Technique for Managing the Calcaneus Osteomyelitis Combined with Soft-Tissue Defect

The treatment of the Cierny–Mader (C–M) type III–IV calcaneus osteomyelitis combining with the soft-tissue defect is sophisticated and difficult. The aim of this study is to introduce the application and availability of the modified distally based sural flap with an adipofascial extension to reconstruct these defects. We retrospectively reviewed the data of 37 patients with C–M type III–IV calcaneus osteomyelitis accompanied with soft-tissue defect between December 2004 and December 2019. A modified distally based sural flap with an adipofascial extension was conducted to reconstruct the defect. The patient's demographics, duration of the diseases, etiology, reconstruction outcomes, infection control rate, recurrence rate, amputation rate, and follow-up data were collected to evaluate the effectiveness and reliability of the modification. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale was applied to assess the function of the ankle and hindfoot. Thirty-four flaps survived uneventfully, 1 flap displayed marginal necrosis and 2 flaps (5.41%) developed partial necrosis. Using this modified flap alone or combining with some simple salvage methods reconstructed all of the defects successfully. The calcaneus osteomyelitis was cured successfully, and no recurrences were observed during the follow-up period. The AOFAS ankle and hindfoot scores were excellent in 27 patients and good in 8 patients. The distally based sural flap with an adipofacial extension is a simple and effective technique to reconstruct the calcaneus osteomyelitis combined with soft-tissue defect in 1 stage. Applications of the adipofacial extension to obliterate the dead space and the well-vascularized skin island to cover the defect are the guarantee of achieving good ankle and foot functions. However, this technique is not appropriate for the patients with calcaneum less than half weight-bearing area.

Reliability of distally based sural flap in elderly patients: comparison between elderly and young patients in a single center

Background Reconstructions the soft-tissue defects of the distal lower extremities in the elderly patients (≥ 60 years old) are full of challenges because of many comorbidities. The purpose of this study was to report the clinical application of the distally based sural flap in the elderly patients, and to verify the reliability of this flap in the elderly patients. Methods Between March of 2005 and December of 2019, 53 patients aged over 60-year-old and 55 patients aged 18 to 30-year-old who underwent the procedure have been included in this study. The reconstruction outcomes, medical-related complications, flap viability-related complications and potential risk factors are compared between the group A (≥ 60 years old) and group B (ranging from 18 to 30 years old). Results The partial necrosis rate in group A (9.43%) is higher than group B (9.09%), but the difference is not significant (P > 0.05). The constitute ratio of the defects that were successfully covered using the sural flap alone or combining with simple salvage method (i.e., skin grafting) is 96.22% and 98.18% in group A and B, respectively (P > 0.05). The differences of the risk flaps factors that affected the survival of distally based sural flap were not significant between group A and B (P > 0.05). Conclusions The distally based sural flap can be effectively used to repair the soft-tissue defect of the lower extremity in the elderly patients. It is safe and reliable to harvest and transfer the flap in one stage, and the delay surgery is not necessary.

Distally Based Perforator-Plus Sural Neurocutaneous Flap with High or Low Pivot Point: Anatomical Basis and a Retrospectively Study of 378 Flap Clinical Series

Background This study is to describe the distribution of natural true anastomoses associated with the distally based perforator-plus sural neurocutaneous flap (sural flap), summarize our experience in the flap with high pivot point, and compare the outcomes between the flaps with high and low pivot points. Methods Five amputated lower limbs were perfused, and the integuments were radiographed. We retrospectively analyzed 378 flaps, which were divided into two groups: pivot points located ≤8.0 cm (low pivot point group) and >8.0 cm (high pivot point group) proximal to the tip of the lateral malleolus. Partial necrosis rates were compared between two groups. Results The arterial chain surrounding the sural nerve was linked by true anastomoses from the intermalleolar line to popliteal crease. True anastomoses existed among peroneal perforators and between these perforators and the arterial chain. There were 93 flaps with high pivot point and 285 flaps with low pivot point. Partial necrosis rates were 16 and 9.1% in the high and low pivot point group (p = 0.059), respectively. Conclusion True anastomosis connections among peroneal perforators and the whole arterial chain around sural nerve enable the sural flap to survive with a greater length. The sural flap with high pivot point is a good option for reconstructing soft-tissue defects in the middle and distal leg, ankle, and foot, particularly when the lowest peroneal perforator presents damage, greater distance to the defects, discontinuity with the donor site, or anatomical variation.