Effectiveness of the Reverse Sural Flap in Covering Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis

Abstract

Background: The reverse sural fasciocutaneous flap (RSFCF) has been used with success to cover noncomplicated foot and ankle soft tissue defects. However, there are some controversies when it is used in patients having chronic diabetic foot ulcers. This aim of this meta-analysis was to evaluate the efficacy of RSFCF in covering diabetic foot and ankle ulcers. Methods: A systematic review was undertaken from MEDLINE, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Only diabetic foot and ankle ulcers were accepted for inclusion and all study designs were included. Proximally based flaps, nondiabetic ulcers, and assisted negative pressure therapy were excluded. Suitability for inclusion was assessed by 2 reviewers. The random-effect estimate was reported for the set outcomes whenever high heterogeneity was present. Metaregression analysis was performed to identify independent risk factors for failure. Results: The search identified 33 relevant studies comprising 187 patients and flap interventions; all but 1 were case-series. The weighted outcomes were as follows: (1) the flap healing rate was 93.3% while 6.6% resulted in total necrosis, (2) the rate of partial flap necrosis was 12%, (3) venous congestion was reported in 6.6% of cases, (4) the infection rate was 8.3%, and (5) the donor site morbidity was 4.6%. No association was found between pedicle width or presence of a subcutaneous pedicle tunnel and the primary outcome of total loss. Conclusions: This review demonstrated excellent results of the flap when covering complicated or large diabetic foot and ankle ulcers. When compared to those published in the literature, our results found RSFCF to be relatively less successful in diabetic wounds than in trauma patients but more successful than in those having associated osteomyelitis and those who were treated with random local flaps.

Evaluation of the ankle function after Achilles tendon resection: a retrospective clinical study

“…It offers abundant, thin tissue with effortless dissection. The donor site morbidity, lack of available vascularized tendon and the relatively high complication rate of 26.4%, especially in the elderly and in patients with venous insufficiency render it a backup solution in our practice [ 15 – 17 ].…”

Comparison of instep and non‐instep flap in the reconstruction of the weight‐bearing portion of the forefoot and heel

“…Skin grafting of the donor site may lead to complications, including infection, depression deformity, medial plantar contracture, and nerve irritation or sensory disturbance of the medial plantar nerve and its branches (Bibbo, 2012; Wan et al, 2011). Similarly, the donor site morbidity for RSF and ALTF, including infection, hematoma, and skin necrosis, is minimal, and these complications can be resolved with simple procedures such as antibiotics, debridement, and primary closure (Yammine et al, 2022). Nerve related complications such as hypoesthesia of the lateral aspect of the foot in RSF and lateral thigh paresthesia in ALTF can occur (Collins et al, 2012).…”

Hemodynamics in Distally Based Sural Flaps for Lower Leg Reconstruction: A Literature Review

“…The sural flap is a versatile and effective alternative to microsurgical reconstruction of soft tissue defects in the lower leg. 5,49 Improving the survival of these flaps is critically dependent on the preoperative assessment of distal circulation using advanced diagnostic imaging. 6,10,18 Surgeons should then be prepared to accommodate individual patient risk factors by utilizing evidence-based modifications similar to those discussed above.…”

“…48 A recent systematic review and meta-analysis of sural flaps in the coverage of diabetic ulcers reported no significant associations between tunnel width, presence of a tunnel or venous congestion, and total flap loss (p > 0.05). 49 While the literature is limited regarding the effectiveness of tunnels, it may be appropriate to make this decision intraoperatively based on the laxity of the skin, patient comorbidities, and wound qualities. 32…”