Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap.

Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.

Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint.

The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.

Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction.

INTRODUCTION: Soft tissue defects of foot and ankle are challenging due to the susceptibility of the area to trauma and the complexity of the region. Several flaps have been described for wound coverage after surgical debridement at this location. The purpose of this study is to present the reverse sural flap for covering soft tissue defects at the ankle and foot. MATERIALS AND METHODS: From July 2014 to November 2017, ten patients with soft tissue defect at the ankle and foot were retrospectively reviewed. There were nine men and one woman with a mean age of 40.5 years (range 17-71 years). Seven patients were smokers and five were diabetics. The mean size of the defect was 50.5 cm2. All operations were performed by the same microsurgical team. At a mean follow-up of 21 months (range, 18 to 24 months), we evaluated wound healing and complications. RESULTS: In nine patients, the soft tissue defect was successfully covered. In four patients, venous congestion was noticed, whereas in one patient, there was total necrosis of the flap. In all cases, the donor site was healed uneventfully. CONCLUSION: The reverse sural artery flap is a reliable alternative for wound coverage at the ankle and foot, with low complication and morbidity rate. Nevertheless, it is a demanding microsurgical operation that requires knowledge of the anatomy and surgeons' experience.

The reverse sural artery flap for the reconstruction of distal third of the leg and foot.

Soft tissue defects around the distal third of the leg and the foot present a major reconstructive challenge. There is limited expertise with free tissue transfers in many developing countries, necessitating consideration of other options for the closure of such defects. The versatility and reliability of sural artery flap have made it an emerging popular option for the reconstruction of such defects. Twenty patients comprising of 13 males and 7 females with soft tissue defects of the lower third of the leg and foot requiring soft tissue cover were treated between January 2006 and December 2010. The age range was 7-58 years with a mean age of 30 years. Nineteen (95%) of the defects were post-traumatic while one (5%) was post-infective. All the defects were covered with reversed sural artery flaps, which were raised on the posterior aspect of the junction of the upper and middle third of the leg. The smallest flap was 4 × 4 cm(2) while the largest measured 20 × 12 cm(2). The donor defect was closed directly in 7 (35%) patients, while split skin graft was applied in the remaining 13 (65%) patients. There was satisfactory flap healing in 17 patients (85%), while 3 patients (15%) had complete flap necrosis. Two of these patients had significant comorbidities of haemoglobinopathy and poorly controlled diabetes mellitus. Sural artery flap remains a viable option for the reconstruction of soft tissue defects of the distal third of the leg and foot. Caution should, however, be exercised in patients with some significant systemic diseases.

Sural flap reconstruction of lateral malleolus following undifferentiated pleomorphic sarcoma resection with 1-year follow-up.

We report a case of a 54-year-old female who presents with a gradually expanding mass at the right lateral malleolus. The diagnosis of undifferentiated pleomorphic sarcoma was made after a histopathological examination of the mass following a wide tumor excision. The defected soft tissue area was reconstructed using a local flap, reverse sural artery flap. Following the surgical management, multiple radiotherapy sessions were completed. The patient's follow-up result showed no signs of local recurrence or metastasis, and the wound was well-healed with no complications other than paresthesia in a small area at the posterolateral aspect of the ankle under the lateral malleolus. This case represents a rare form of malignant neoplasm and emphasizes the effectiveness and safety of the reverse sural artery flap reconstruction technique, especially in places where microsurgery is unavailable or when the patient's status does not allow for prolonged anesthesia.

Post-traumatic Aeromonas hydrophila Osteomyelitis caused by an Infected Gustilo-Anderson Grade 3B Tibial Fracture: A Case Report with a 7-year Follow-up.

Introduction: Post-traumatic osteomyelitis (OM) is often caused by Staphylococcus aureus. However, occasionally, it is caused by an infection with a rare bacterium. A case of OM caused by Aeromonas hydrophila was first reported in 1975. Since then, only nine cases have been reported, making it a rare disease. Here, we report a case of rare A. hydrophila OM that developed following open tibial fracture (classified as Gustilo-Anderson 3B) caused by an injury in a river. Case Report: The patient was a 50-year-old male who got injured in a river and was diagnosed with open tibial fracture. Debridement in the first surgery happened at a leisurely pace. Purulent discharge from the wound persisted despite external fixation; however, no bacterium was detected in the bacterial culture. The patient underwent multiple debridement procedures; A. hydrophila was detected in the bone marrow. Despite the appropriate administration of antibacterial drugs and debridement, infection persisted until radical bone resection and tissue reconstruction were performed. In the present case, OM following an open fracture caused by an injury in a river was suspected, which was caused by the rare bacterium A. hydrophila. Conclusion: In cases of OM occurring after underwater trauma, A. hydrophila should be considered as a causative pathogen. In addition, in cases of post-traumatic OM accompanied by bone and soft-tissue defects, the orthoplastic approach is required.

Reconstruction of the weight-bearing heel with nonsensate reverse sural artery flaps.

BACKGROUND: The reverse sural artery flap (RSAF) is widely used to reconstruct foot and ankle defects. Although it is commonly used in a nonsensate type, there has been controversy as to whether it provides sufficient stability and durability when applied to weight-bearing heels. The aim of this study was to evaluate patient outcomes after weight-bearing heel coverage using a nonsensate RSAF. METHODS: Twenty-three patients who underwent reconstruction surgery of the weight-bearing heel with RSAF from 2004 to 2018 in a tertiary hospital were retrospectively reviewed. All surgeries were performed without a sensate procedure. The patients' experience of pressure sore on the flap area and the ability to use normal footwear were investigated. Light touch, Semmes-Weinstein test (SWT), and two-point discrimination tests were assessed, along with postoperative wound complications. RESULTS: Heel damage etiologies included malignant tumors in 14 (61%), trauma-related in 7 (30%) and diabetic ulcers in 2 (9%) patients. Patient mean age was 58 years (range, 18-93 years) and the mean follow-up period was 57 months (range, 12-185 months). The mean size of the flap was 64.1 cm2 (range, 20-169 cm2). All flaps healed without major complications. All returned to daily living activities and 20 (86%) patients were able to use normal footwear. Of the 11 patients who had available measurement records, 8 (73%) showed a light touch sense. The mean SWT value was 4.31 (range, 3.61- 4.56). Two-point discrimination was not observed in any of the patients. Two patients had experienced superficial ulcers on the flap within a one-year postoperative period, which spontaneously healed and did not recur. No full-thickness ulcers were observed during the follow-up period. CONCLUSIONS: The results of this study suggest that patients who underwent nonsensate RSAF for the reconstruction of the heel could expect to maintain the property for stable weight-bearing without pressure sore.

Resurfacing the donor sites of reverse sural artery flaps using thoracodorsal artery perforator flaps.

BACKGROUND: The reverse sural artery (RSA) flap is widely used for lower extremity reconstruction. However, patients sometimes suffer from donor site complications such as scar contracture and paresthesia, resulting in dissatisfaction with the aesthetic outcomes. This study investigated the characteristics of donor site morbidity associated with RSA flaps and described our experiences of dealing with complications by performing resurfacing surgery using thoracodorsal artery perforator (TDAP) flaps. METHODS: From April 2008 to August 2018, a total of 11 patients underwent contracture release and resurfacing surgery using TDAP flaps due to donor morbidity associated with RSA flaps. All affected donor sites were covered with a skin graft, the most common of which was a meshed split-thickness skin graft (six cases). RESULTS: Eight of the 11 patients (72.7%) suffered from pain and discomfort due to scar contracture, and seven (63.6%) complained of a depression scar. The donor sites were located 6.3±4.1 cm below the knee joint, and their average size was 140.1 cm². After resurfacing using TDAP flaps, significant improvements were found in the Lower Extremity Functional Scale (LEFS) scores and the active and passive ranges of motion (AROM and PROM) of the knee joint. The LEFS scores increased from 45.1 to 56.7 postoperatively (P=0.003), AROM increased from 108.2° to 118.6° (P=0.003), and PROM from 121.4° to 126.4° (P=0.021). CONCLUSIONS: Planning of RSA flaps should take into account donor site morbidity. If complications occur at the donor site, resurfacing surgery using TDAP flaps achieves aesthetic and functional improvements.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience.

BACKGROUND: Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area. METHODS: In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel. RESULTS: Out of 40 patients' medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group. CONCLUSION: Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

The reverse sural artery flap- How do modifications boost its reliability? A systematic analysis of the literature.

The reverse sural artery flap (RSAF) was first described approximately four decades ago and has since been used frequently for reconstruction of soft tissue defects in the distal part of the leg. Although the popularity of this flap never reached the extent of that of free perforator flaps, it still serves as a reliable alternative. This has been demonstrated by the increased rate of publication on the technique in recent years. The number of authors reporting data has risen up to 20 reports a year. During this time, several new modifications of the flap were inaugurated in order to boost the efficiency and reliability of the flap. The goal of this systematic analysis of the literature was to gain information on the influences of the modifications of the RSAF with regard to consistency and complication rates. An overall survival rate of 95% and a rate of complications of 14% were reported in all the analyzed cases. Some modifications were able to improve flap viability but not at a statistically significant extent. Venous supercharging and the adipofascial variant of the RSAF provided the best results. The RSAF is still a remarkable flap design, especially as a backup solution or in circumstances without a microsurgical skilled surgeon. Further investigation with controlled randomized prospective trials is vital to confirm this finding with more evidence.

Effectiveness of Reverse Sural Artery Flap in the Management of Wheel Spoke Injuries of the Heel.

OBJECTIVE: Soft tissue injuries at the level of lower extremities, plantar, and dorsal foot pose a surgical challenge for reconstructive surgeons. This kind of injury commonly occurs when lower limbs get stuck in between the spokes of the wheel. Reverse sural artery flap has been proven to be an effective option to cover such defects. The aim of this study is to analyze the demographic variables of affected individuals, technical aspects of reverse sural artery flap, quantify the effectiveness of reverse sural artery flap among various treatment options available, and to study the outcome of injury. METHODS: A total of 49 patients who presented during a period of six years from January 2010 to January 2016 were included in the study. The data was collected using patient's charts, by interviewing the patients, and from hospital records. The patients' wounds were prepared, examined, and the injury was graded depending upon the extent of tissue damage. Tendon and bone defects were repaired, and wounds were closed by either split thickness skin graft or reverse sural artery flaps. RESULTS: Children were the most commonly affected with no conclusive gender trend. The posterolateral part of the heel of the right foot was the most frequently injured part (69%). Surgical interventions together with proper postoperative care and follow-up produced very good results overall. CONCLUSION: Wheel spoke injuries of the heel can be managed without significant morbidity if the patient presents early, the wound is assessed properly, suitable surgical technique is utilized, and good postoperative care is provided.