Session III - Polytrauma

The Reverse-Flow Sural Artery Flap for Soft Tissue Injuries of the Lower Third of the Leg

David A. Volgas, MD; Brian M. Scholl, MD; James P. Stannard MD; Jorge E. Alonso, MD; University of Alabama at Birmingham, Birmingham, Alabama, USA

Purpose: Soft tissue injuries associated with fractures are common and are usually treated by a plastic surgeon and covered by a free flap. Problems can arise when the availability of the plastic surgeon does not coincide with the need for immediate coverage of these injuries. Furthermore, free flaps frequently require 8 to10 hours of operative time, which may not be possible early in the hospitalization of the multiply-injured patient. Free flaps are associated with donor-site complications in as many as 30% of cases and significant impairment in as many as 15%. An alternative to free muscle transfer is a fasciocutaneous flap. The purpose of this study was to report a series of 47 consecutive patients treated with a reverse-flow sural artery flap for soft tissue defects in the lower one-third of the leg by an orthopaedic traumatologist.

Methods: Forty-seven consecutive patients with soft tissue defects of the lower one-third of the leg requiring coverage were enrolled in an Institutional Review Board-approved prospective study. Each patient underwent coverage with a fasciocutaneous flap based on the sural artery by a single orthopaedic traumatologist. Patients were followed prospectively for wound healing problems, further surgery, infections, and outcomes.

Results: There were 30 male and 17 female patients with an average age of 41 years (range, 19 to 76). The mechanism of injury was a motor vehicle crash, 19; falls, 13; pedestrian versus auto, 4; shotgun wound, 2; unknown, 2; chronic osteomyelitis, 2; and single cases of necrotizing fasciitis, assault, crush, diabetic ulcer, kicked by a horse, and soft tissue tumor excision. There were 27 open fractures, 10 calcaneus fractures, and 18 distal tibia fractures. The average follow-up was 6.7 months (range, 1 to 29). Most cases involved wound dehiscence after operative treatment of the fracture (30 patients), but there were 13 cases of early wound coverage with a flap. Sixteen patients had preoperative deep infections prior to flap coverage. There were three flap failures (6.4%), two in patients who failed to return to the clinic for postoperative follow-up, and the third in an elderly diabetic patient with renal failure and chronic osteomyelitis of the calcaneus. Four patients, who had pre-existing deep infections, had transtibial amputation even though the flap healed. Tourniquet time was reduced from 90 minutes early in the series to less than 45 minutes currently, and blood loss was routinely under 100 cc. No patient who had a negative preoperative culture developed a post-flap infection.

Discussion/Conclusions: Fasciocutaneous flap coverage can be successful in the treatment of soft tissue injury of the distal third of the leg. It can be learned by the orthopaedic traumatologist and does not require microsurgical skills. It should be used with caution in patients with preoperative deep infection.