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Background Soft tissue defects over the foot and ankle region are most challenging in reconstructive surgery. Sural artery and supramalleolar flaps have been commonly used for the reconstruction of non-weight-bearing surfaces of the foot. This article aimed to evaluate the long-term outcome comparisons between a sural artery and Supramalleolar flap in the reconstruction of extensive defects of foot and ankle only. Methods Between 1996 and 2020, a retrospective analysis of 53 fasciocutaneous flaps (27 sural and 26 Supramalleolar) used for reconstruction of soft tissue defects of foot and ankle were reviewed in this study. The parameters included were demographics data, causes, site and size of the defect, flap size, hospital stay, complications, and outcomes in a pre-structured proforma. The clinical outcome was assessed by a Self-Designed Tool based on flap survival, coverage of defect, weight-bearing status, functional activities of daily living, and cosmetic appearance. Data were analyzed through SPSS version 25. Results Among 53 flaps, the major cause of the defect was Trauma (60.4%). The maximum flap size harvested was 25*10 for sural and 20*8 cm for supramalleolar. Complications were seen in 8 (15%) cases in both flaps. Flap tip necrosis and venous congestion were seen in 4 cases. 2 each in Supramalleolar whereas 1 partial necrosis, 1 venous congestion, and 2 infections were seen in the sural artery flap. The flap survival rate in both flaps was 96.2%. Based on the self-designed Tool, flaps were graded Excellent in 43, Good in 8, and Fair in 2 cases. There was no case of Poor in both flaps. Conclusion Compared with the sural artery flap, the lateral supramalleolar flap demonstrated higher rates of functional outcomes although flap tip necrosis was higher in Supramalleolar.

Background To determine the anatomical basis of supramalleolar flap; retrograde versus antegrade and its clinical outcome based on the vascular pattern. Methods This analytic cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan. Patients who underwent coverage of soft tissue defects around the foot and ankle with supramalleolar flaps were included. Data collection was through medical records including demographic parameters, mechanism of injury, per-operative findings of perforator origin, and patient interviewing for final assessment. Patients with peripheral vascular disease, unavailability of skin, and radiation injuries were excluded. All analysis was done using SPSS version 25.0. Results 49 patients were included in the study from May 1999 to December 2020. The male to female ratio was 37:12. The cause of soft tissue defects was trauma in 9 (38.7%) followed by Infection in 16 (32.6%) and Blast injury in 5 cases (10.2%). The maximum flap size harvested was 20 × 8 cm. In 19 cases the peroneal artery perforator was absent and the flap was based on the perforator of an anterolateral malleolar branch (antegrade) while the remaining 30 flaps were based on the perforator of the peroneal artery (retrograde ). Overall, the flap survival rate was 98%; as 1 case had partial necrosis and required skin grafting. However, there were 9 minor complications. In 8 patients, the flap was rotated as a ‘ delay flap’ . All patients had satisfactory functional outcomes without significant morbidity of the donor site. Conclusion The lateral supramalleolar flap provided coverage to almost all regions of the foot and ankle with a cosmetically acceptable donor and recipient site. There were no problems with shoe wear, as only 2 patients required defatting for cosmetic reasons. Microvascular expertise was required for a predictable outcome.

Globally, over 3.3 million people have contracted COVID-19 and > 230,000 have died. The outbreak has strangled the world economy and has tested the resilience of all health systems —robust or fragile. While all categories of the economy have been affected, pandemic has directly affected people and possession processing services the most. For all countries analyzed, an average economic impact of -4.5% of GDP is expected. We assessed the response to the COVID-19 pandemic by healthcare systems in terms of testing capability, surge capacity, and collaboration; focusing on United States, United Kingdom, Singapore, China, and Pakistan. Despite its success, the China model cannot be the go-to paradigm everywhere as level of compliance to local authorities, harsh lockdown measures, and ability to quickly complete labor-intensive projects may not be replicable in other countries. Therefore, a context-specific strategy is necessary to deal with pandemic. COVID-19 pandemic has exposed multiple fault lines in health systems in term of accessibility, adaptability, and preparedness. It has also become clear that a global economy centered on the principle of capital accumulation and not societal uplift is not sustainable through times of crises.