A Realistic Complication Analysis of 70 Sural Artery Flaps in a Multimorbid Patient Group

Abstract

The popularity of the sural artery flap has increased markedly throughout the years, and favorable results are reported almost uniformly. Previous publications have mainly presented results of small groups and of predominantly younger patients with posttraumatic defects, or they have reported technical modifications of the sural artery flap. The authors have increasingly used the reversed sural artery flap in a high-risk, critically multimorbid, and older patient population, and in contrast to the results of other authors, a considerable necrosis rate of 36 percent was seen. For the first time, a detailed, critical, retrospective complication analysis of 70 sural artery flaps is presented. The results reveal the following risk factors, which can potentially impair successful defect coverage and thus contribute to flap complications: concomitant diseases, particularly diabetes mellitus; peripheral arterial disease or venous insufficiency, which increase the risk of flap necrosis five-fold to six-fold; and patient age of over 40 years, because of an increased rate of comorbidity, underlying osteomyelitis, and the use of a tight subcutaneous tunnel. However, age alone did not seem to represent a risk factor by itself. Given the results of the analysis, the operative procedure was altered, as follows. In cases in which a lesser saphenous vein cannot be found, a delay procedure is recommended, or the flap is not utilized. In addition, an external fixation device seems to facilitate postoperative care markedly without adding specific complications; it is recommended in most patients. This analysis emphasizes specific risk factors that result in higher complication rates of the sural artery flap, and it leads to more realistic and appropriate expectations for this flap.

An Algorithmic Approach for Managing Orthopaedic Surgical Wounds of the Foot and Ankle

“…This early (prophylactic) mode of intervention may provide patients with more stable soft tissue coverage before their planned orthopaedic procedure, although larger studies will be needed to show this more conclusively. As reported by Baumeister et al [3], Marco Godina, a pioneer in modern orthoplastic surgery, introduced the approach of immediate soft tissue coverage after complete resection of all nonviable tissue, similar to the method used in ablative tumor surgery. The concept of a one-stage procedure in which maximal skeletal and soft tissue reconstruction is performed in one operation is critical for optimizing functional outcome, regardless of the cause of threat to the limb [24,26].…”

“…During the past few decades, advancement of reconstructive techniques in plastic surgery and orthopaedic surgery has revolutionized the treatment of traumatic foot and ankle injuries [21,23,25] and enabled improved success in limb salvage [3,15,18,22,29]. Concerted efforts of the plastic surgeon and orthopaedic surgeon have improved treatment of complex foot and ankle wound problems that once may have been considered unsalvageable, particularly in the case of open fractures [7,11,13,14].…”

Versatility of Delayed Reverse Sural Flap for Reconstruction of the Distal Lower Extremity in High-Risk Patients

“…However, despite these advantages, the rate of complications such as venous congestion, partial flap necrosis, and complete flap necrosis were higher in patients with significant medical comorbidities than in those with no comorbidities. Baumeister et al 10 found that patients with comorbidities such as diabetes mellitus, peripheral arterial disease, and venous insufficiency had a five-fold to six-fold higher risk of flap necrosis than patients with no comorbidities. They recommended delay procedures as a way to improve flap stability in patients with vascular risk factors.…”

“…In 2003, Baumeister et al 10 announced that the reverse sural flap is associated with a higher rate of necrosis in high-risk, critically-ill patients with multiple comorbidities, as well as in older patients. As a result, a sural flap "delay" procedure was proposed by the authors to reduce flap failure 10,13 . Two different delay procedures have been published 18 .…”

“…For such patients, they suggested that a surgical delay procedure should be considered 9 . The advantage of the delay procedure is that it improves flap survivability in patients with significant medical comorbidities [9][10][11][12][13] . Accordingly, we treated seven high-risk patients with soft tissue defects of the lower extremity by using a delayed reverse sural flap, and the results were excellent.…”