DFA 2000-625X Diabetic Foot & Ankle Vol. 2, No. 0, January 2011, pp. 1–7 sici xxx PUBMED Abbreviation Ioannis A. Ignatiadis MD, PhD

*Ioannis A. Ignatiadis Hand Surgery-Upper Limb and Microsurgery Department KAT General Hospital Athens Greece

Vassiliki A. Tsiampa MD Spyridon P. Galanakos MD Georgios D. Georgakopoulos MD Nicolaos E. Gerostathopoulos MD, PhD Mihai Ionac MD, PhD Lucian P. Jiga MD, PhD Vasilios D. Polyzois MD, PhD Hand Surgery-Upper Limb and Microsurgery Department KAT General Hospital

Athens Greece

4th Orthopedic Department KAT General Hospital

Athens Greece

Vascular Surgery Department Timisoara University Hospital

Timisoara Romania

Diabetic Foot & Ankle CLINICAL RESEARCH ARTICLE Reverse sural fasciocutaneous flaps for treating infections The authors present their experience with the use of sural fasciocutaneous flaps for the treatment of various soft tissue defects in the lower limb. This paper is a review of these flaps carried out between 2003 and 2008. The series consists of 16 patients, 11 men and 5 women with an average age of 41 years (17-81) and with a follow-up period between 2 and 7 years. The etiology was major velocity accident in six cases, diabetes mellitus with osteomyelitis after ORIF for fractures (2), work accident in five, and another two cases with complications of lower limb injuries. The defect areas were located on calcaneus, malleolar area, tarsal area and lower tibia. Associated risk factors in the patients for the flap performance were diabetes (five patients) and cigarette smoking (ten patients). The technique is based on the use of a reverse-flow island sural flap combined with other flaps in three cases (cross-leg, peroneal, gastrocnemius). The anatomical structures which constituted the pedicle were the superficial and deep fascia, the sural nerve, the lesser saphenous vein and skin. The flap was viable in all 15 patients. On 8 cases was achieved direct closure, on three cases occurred a superficial necrosis and was skin grafted, on one case was observed partial necrosis which was treated with a second flap (posterior tibial perforator flap) and another one occurred delayed skin healing. The sural fasciocutaneous flap is useful for the treatment of severe and complex injuries and their complications in diabetic and non diabetic lower limbs. Its technical advantages are easy dissection, preservation of more important vascular structures in the limb and complete coverage of the soft tissue defects in just one operation without the need of microsurgical anastomosis. Thus this flap offers excellent donor sites for repairing soft tissue defects in foot and ankle. foot-ankle necrosis defects sural flap diabetic foot necrosis neuropathy wounds The management of soft-tissue defects in the lower limbs due to an increase of high energy trauma currently has become a very frequent procedure. The orthopedic surgeon should be capable of carrying out an integral treatment of these lesions, including not only open reduction and internal or external fixation of the fracture fragments, but also the management of possible complications such as local skin necrosis. In 1992, Masquelet et al. described the use of the neurocutaneous flap for reconstruction of soft-tissue defects of the distal third of the leg 1. Among the main indications for a sural fasciocutaneous flap are soft-tissue defects of the heel and the lateral or medial perimalleolar regions 2. This flap can also be combined with other flaps in cases with some special soft-tissue defects (e.g. cases with simultaneous osteomyelitis, bone defect, and dead space). This study is a retrospective review of the sural fasciocutaneous and neurocutaneous flaps carried out in 16 patients (Table 1): 12 men and 4 women with an average age of 41 years (ages 17–81) and a postoperative follow-up between 2 and 7 years. The soft-tissue defect in the lower limb in this study was located on the heel and calcaneal area in five cases, on the malleolar and paramalleolar area (Fig. 1a, b) in three cases, on the distal tibia in another three cases, dorsal tarsal area in four cases, and medial plantar area in one case. Five patients were diabetic and suffered from osteomyelitis (four pressure sores and one post-traumatic osteomyelitis). Eleven patients were smokers and only five were non-smokers.

(a) Case 1 (female) and (b) case 2 (male) young patients with external malleolar and lateral tarsal area necrosis.

Case Age, gender Type and location of defect Type of main flap Fractures-infection Aetiology mechanism of lesion Operation timing-previous surgery Complication second reconstructive operation Final result follow up 1 49, Male smoker Calcaneal diabetic Sural \reversed 5×8 Calcaneus + Infection Diabetic heel fistula unknown mechanism 12 months Direct closure Very good 8 years 2 26, Female smoker External malleolus > > 5×7 Soft-tissue necrosis MVA 2 weeks > >  Very good 7 years 3 56, Male smoke Lower anterior tibia >> 4,5 x8 Lower tibial postfracture osteomyelitis already treated by illizarof MVA Latent diabetic patient 2 months Delayed skin healing Good 1 year 4 26, Male Tarsal dorsal area Sural reversed 6×9 2nd, 3rd metatarsals Work 1 month Superficial necrosis split thickness skin graft Very good 4 years 5 31, Male smoker Dorsum of the ankle >> 6, 5×10 Tallus, bimalleolar old fracture arthrodesis ankle-infection Work accident 1 year > >  Good 3 years 6 51, Female smoker Presion sore of the heel diabetic >> 6, 5×16 Osteomyelitis calcaneus Diabetic backround-pressure sore 2 months Minior revision – Split skin grafting after 2 weeks Good 4.5 years 7 17, Male Medial plantar and tarsal area Cross leg and sural rev flap Calacanear fracture 5×8 Work accident At 3.5 weeks Direct closure Satisfactory (aesthetically moderate result) 4 years 8 35, Male Tibia anteromedial aspect inferior third Gastrocnemius and sural reversed flaps 4×6 Open tibia cominutive fracture MVA At 3 weeks postop Skin closure Good 3 years 9 33, Male Heel and achilles area Mixed – sural and peroneal perforator 7×10 Avulsive fracture of the calcaneus-failed ORIF Work At 1 month postop Partial necrosis second flap based on the tibial posterior artery perforator Satisfactory(aesthetically moderate result) 3.5 years 10 29, Female smoker Dorsum of the ankle Mixed – sural and peroneal perforator 7×9 Luxation chopart and Talo-calcaneal, extensor tendons laceration MVA Emergency Superficial necrosis split thickness skin graft Good 3 years 11 81, Male Heel-pressure sore Sural reversed 6×8 Osteomyelitis calcaneus Diabetic pressure sore 3 months Direct closure Good 3 years 12 40, Male smoker External paramaleoral area >> 5×7 Tibiocalcaneal arthrodesis. Pin track, soft-tissue necrosis MVA diabetic 1 month Direct closure Good 4 years 13 42, Male smoker Open fracture Gustillo 3-lower third Tibia-damage poster tibial artery Sural flap 5×7.5 Posteromedial tibial area open fracture tibia poster tibial artery grafting MVA 1 month postop (half gastrocnemius flap) Split thikness skin fraft Satisfactory 1.5 years 14 35, Male smoker External malleolus. Soft-tissue necrosis >> 4.5×7 Previously treated tibial fracture EXFIX osteomyelitis pin traction infection Postraumatic infection 2 month Direct closure Very good 2 years 15 65, female smoker Dorsal tarsal aspect >> 4.5×6 Previously treated tibiocalcaneal arthritis and total arthroplasty Postraumatic necrosis 2 month Direct closure Very good 4 years 16 24, Male smoker Achilles area heel defect and necrosis Calcaneus bone lost achille's tendon complete lost Debridement, sural flap and split thikness 1 week after the accident Work accident 2 month postop 2nd operation and another 2 month postop the 3rd operation Secondary medial plantaris neurovascular flap and 3rd operation tibiocalcaneal arthrodesis taylor frame Satisfactory (esthetically moderate result) ankle arthodesis 1 year In two cases where the fracture was treated with external fixation, the sural flap was performed to treat: The soft-tissue defect in combination with the external fixation. The post-traumatic infection due to pin track infection. In another case, the flap was performed in order to treat the remaining soft-tissue defect due to residual osteomyelitis from post-traumatic infection of a distal tibial fracture, which was treated with surgical debridement and distraction osteogenesis with the Ilizarov technique. In the cases where the sural flap was used to cover defects due to osteomyelitis infection, the patients were diabetic except one case where the infection was a complication from an ankle arthroplasty. Finally, on three cases the flap was combined with: Gastrocnemius flap (large defect – the sural flap was preceded by a partial failed gastrocnemius flap). Peroneal flap. Medial plantar flap (for gaining some sensibility). One sural flap in a case with big local hematoma was preceded by a cross-leg emergency flap. The majority of flaps were fasciocutaneous except two (patients with calcaneal osteomyelitis) that were neurofasciocutaneous. During surgery all patients were positioned prone and were anaesthetized with spinal anesthesia. A tourniquet was placed in the proximal lower limb. For the three diabetic patients with calcaneal osteomyelitis, the osteomyelitis was diagnosed with physical examinations and typical Radiographies. Intraoperative cultures and/or histological examinations confirmed the diagnosis for each of them. The dorsalis pedis and posterior tibial artery pulses were palpable in all patients. Broad spectrum antimicrobial therapy was administered to all patients. Postoperative antimicrobial treatments were adjusted according to the results of culture antibiograms for the microorganisms isolated from the deep-tissue specimens. The average therapy consisted of 3 to 4 weeks of intravenous treatment followed by 2–3 weeks of oral treatment in moderate infections and longer protocols of treatment in case of osteomyelitis. The duration of antibiotic therapy was determined on the basis of culture results and clinical assessments of the wound and soft tissues. The patients’ follow-up was between 1 and 8 years. The sural fasciocutaneous flap is made up of skin and subcutaneous fat, the superficial and deep fascia of the posterior part of the leg, sural nerve, the sural vein, and the superficial sural artery. The flap is based initially on the vascularization that runs with the sural nerve. Flap irrigation is accomplished by distal reverse flow of the superficial sural artery dependent on perforators of the peroneal arterial system. There are numerous anastomosis between the peroneal artery and the vascular axis of the flap. The most distal is usually found at a distance of 4–5 cm above the tip of lateral malleolus; thus, it consists of the pivot point of the flap. Flap harvesting techniques have been well described in the literature 3 4 5 6 . The flap was outlined according the size of the defect on a zigzag line drawn from the popliteal fossa to the Achilles tendon along the posterior middle one-third of the leg. The pedicle (4–5 cm in width) consists of subcutaneous tissue, deep fascia, the small saphenous vein, the sural nerve (in 2 cases), and accompanying arteries. The small saphenous vein and the sural nerve were ligated (proximally and distally) at the proximal border of the flap and then the lateral and medial border of the flap and pedicle were incised down to the muscle. Then the flap was rotated over its pedicle up to 180° (Fig. 2a, b) and adapted to the defect (Fig. 3a, b).

(a and b) Cases 1 and 2, sural flap harvesting.

(a and b) Cases 1 and 2, flap adjustment on the defects areas.

In two cases the pedicle of the flap included the distal peroneal perforator of the peroneal artery. Skin closure is achieved with sutures on the reapproximated tips of each triangle of the z incision, and free skin grafts cover the created defects. At the end of the procedure the tourniquet is deflated and adequate circulation of the flap verified. Numerous punctures of the flap using a 25 G needle are made to allow bleeding thus minimizing hyperemia and venous congestion. The limb is dressed with cotton and elastic bandages. Demographic information, complications, and results are presented in Table 1. All flaps survived completely (Fig. 4a, b). In one case a slight venous congestion was managed with the vasodilating agent Buflomedil Hydrochloride (600 mg×1/24 h) and oral micronized purified flavonoid fraction (MPFF) (Daflon) – a vasoprotector and venotonic agent. In four cases, a small superficial necrosis was observed that was managed with minor revision and the use of split skin graft. In another two complex cases, the sural flap was combined with the posterior tibial artery perforator flap for complete defect closure and with a medial plantar neurovascular flap in order to provide sensation and ankle arthrodesis (case with calcaneal bone defect and Achilles tendon complete loss).

(a and b) Cases 1 and 2: final results.

The average surgery time was 60–100 min (including flap dissection) and the average size of the flap 5×7 cm. The flaps provided a successful coverage in all cases. Between 1.5 months and 3 months postoperatively, all patients walked without crutches (Fig. 4a, b) or with frames (circular external fixator). There is a large variety of pedicled or muscular flaps for the reconstruction of post-traumatic soft-tissue defects of the lower limb. These techniques are not all familiar to orthopedic surgeons. The potential for flap failure and donor side morbidity are common risk factors. The main alternatives to sural flaps are free flaps, lateral supramalleolar skin flaps, and posterior tibial perforator flaps. Free flap reconstruction of defects requires lengthy and costly hospitalization, microsurgery training and experience, special instruments, and a two-team approach. The long operative time and functional donor-site morbidity are the major disadvantages of this method. Free flaps are advised for extensive skin defects 1. The lateral supramalleolar skin flap offers a range of coverage similar to that of the sural flap, but the dissection is more difficult than for a sural flap and offers no advantages, the remaining non-sensitive area in sural flaps is smaller than the one left after the transection of the superficial peroneal nerve. Theoretically, the sural flap doesn't cover as distal as the supramalleolar flap, but some authors stated that the distally based sural flap is more reliable than the lateral supramalleolar flap, especially regarding the venous congestion and have shown the usefulness of the sural flap for weight-bearing areas even when resensibilization is not performed. A lateral supramalleolar skin flap is not recommended for coverage in this areas. The global proportion of failures is almost four times as great for the supramalleolar skin flap 7. The posterior tibial perforator flap is another option 8. It is a very reliable lap and indicated in lower limb defects, especially in reconstruction of chronic Achilles tendon defects. A more difficult dissection and a larger learning curve are the main disadvantages. A medial distal septocutaneous flap 9 based on the intramuscular posterior tibial perforators is an alternative. The advantages of the sural flap compared to the above mentioned flaps are the simplicity of the design and dissection of the pedicle that can be carried out with a loop magnification and without the need of microsurgical instrumentation or anastomosis, the preservation of the principal vascularization of the lower limb, and the need for only one operation. It can also be combined with various osteosynthesis techniques as external fixation of comminuted fractures and Ilizarov, and also with other fasciocutaneous flaps (tibial, medial plantar), muscle flaps (gastrocnemius), or distant flaps (cross-leg). According to the treatment of calcaneal osteomyelitis (except the sural flap), various surgical methods have been used like debridement and coverage with local muscle or free muscle flaps 10 11 12 13 , partial calcaneal resection 14 15 16 17 , and total Calcanectomy 18.Below-the-knee amputation has been recommended for cases with extensive and/or progressive involvement of the os calcis 19. Useful local muscle flaps for calcaneal osteomyelitis treatment are the abductor digiti minimi and abductor hallucis muscles. The major disadvantage of these flaps is their small size especially when there is an extensive tissue loss. When local viable tissue is inadequate, free muscle transfers allow coverage. The rectus abdominis and gracilis muscle flaps are usually preferred for the treatment of calcaneal osteomyelitis 20. Coverage with the above mentioned flaps has demonstrated good functional results and adequate weight-bearing surfaces 11 12 13 . Muscle flaps have good vascularity for the treatment of infection, a positive effect on bone healing, and an obliteration effect because of their bulky tissue. However, free muscle flap reconstruction of calcaneal osteomyelitis associated defects requires lengthy and costly hospitalization, microsurgical training and experience, special instruments, and a two-team approach. The major disadvantages of this method are the long operative time and functional donor-site morbidity. The fasciocutaneous sural flaps that were successfully used in our series (Table 1) have many advantages for the treatment of calcaneal osteomyelitis including easy dissection, short operative time (45 min), wide rotation arc, and acceptable donor-site morbidity. There is no need to sacrifice the major artery of the leg. Unlike free flaps, there is no need for a vascular anastomosis; thus, there is no risk for the blood supply of the foot. They can be elevated in relatively large sizes, so that part of the flap can be deepithelialized and used for obliteration of a bone cavity. Diabetes mellitus doesn't compromise their vascularity. Except this study, other reports on the literature confirm that they can be used safely for soft-tissue reconstruction of diabetic patients 21. The sural flap constitutes a reliable and versatile technique that should form part of the therapeutic arsenal of all orthopedic surgeons, facilitating the integral treatment of complex lower limb injuries with exposed defects and infected calcaneal osteomyelitis in diabetic or non-diabetic patients. The authors have not received any funding or benefits from industry or elsewhere to conduct this study. 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