Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination. The treatment of these lesions usually consists of substitution of the internal hardware with external fixation devices and further flap coverage. We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained. Four patients were retrospectively analyzed. Soft tissue reconstruction was achieved in all cases. In one case hardware removal was necessary for complete healing. The sural fasciomusculocutaneous flap is a safe alternative to other pedicled and free flaps. Moreover, it allows direct coverage of internal fixators, thus completing the reconstruction in less time. This flap fits best to the morphology of the wound and internal hardware, leaving the main vascular trunk of the leg intact and at the same time providing a reliable vascular supply.

Prosthetic exposure is a severe complication of total knee arthroplasty. Many factors are responsible for failed wound healing, and successful salvage of total knee arthroplasty requires early identification of infection, antecedent events related with wound healing failure, aggressive surgical debridement and early appropriate soft-tissue coverage with local skin, fasciocutaneous, muscle, neurocutaneous or perforator flaps. In this report, we present 15 cases of exposed knee prosthesis treated with island sural neurocutaneous flap. Follow-up showed favorable clinical outcomes: all flaps survived and only two cases of hematoma and one of aseptic phystula occurred. According to our results, the island neurofasciocutaneous sural flap represents a sensate reconstructive alternative for providing fine and dependable soft tissue for covering skin defects around the knee.

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