Sural Artery Flap, Distally or Proximally Based

A soft tissue defect of the leg and foot, combined with open fracture or osteomyelitis, presents a challenging issue because of poor circulation and low healing potential. This study evaluated the usefulness and reliability of a distally or proximally based sural artery flap as an alternative to free flaps for soft tissue defects in the lower extremity.

From February 1998 to December 2004, 27 cases of soft tissue defects in the lower leg, foot, or around the ankle were treated with sural artery flaps. The mean patient age was 32.2 years (4–68 years), and there were 22 males and 5 females. The causes of the defect were trauma in 20 cases and osteomyelitis in 7 cases. Defects were located at the proximal third of the lower leg in 3 cases, middle third in 2, distal third or ankle in 13, hindfoot in 5, and dorsum of the foot in 5 cases. Proximally-based flaps were utilized in 3 cases and distally-based flaps in 24 cases.

Twenty-five flaps survived successfully and two flaps failed. The size of the defects ranged from 3 × 3 cm to 20 × 3 cm. Marginal necrosis was observed in 5 cases, of which 3 cases underwent skin graft and 2 cases received secondary suture. Complete failure was observed in 2 cases of 24 distally based flaps, one 20 × 3 cm in size and applied around an ankle soft tissue defect, and the other 12 × 5 cm in size and applied to a midfoot soft tissue defect, respectively, which were reoperated on with split-thickness skin grafts. The cause of failure might have been a technical problem in one case, that is, failure to elevate the pedicle with the deep fascia; the cause of the other failure was a preexisting poor soft tissue condition. One case had venous congestion in the early postoperative period, which resolved after conservative management. Among 7 cases of osteomyelitis with a mean duration of 19 months, 1 case with partial necrosis needed marginal resection, and 6 flaps survived without recurrence during the follow-up period.

The advantages of the sural artery flap are as follows: (1) reliable blood supply; (2) preservation of the major arteries; (3) less donor-site morbidity. Owing to the advantages of this flap, the authors consider it useful for soft tissue coverage of the lower leg, foot, and around the ankle.