CONTRIBUTION OF THE DISTALLY-BASED NEUROCUTANEOUS SURAL FLAP FOR RECONSTRUCTION OF TISSUE DEFECTS OF THE LOWER THIRD OF THE LEG: 16 CASES

Abstract

Purpose of the study: The difficulty of achieving successful reconstruction after tissue loss involving the lower third of the leg, particularly the malleolar region in septic cases, is well known. We report our experience with sequential surgery to treat open fractures of the lower leg and examine the contribution of the distally-based neurocutaneous sural flap.

Material and methods: The following protocol was used for the treatment of tissue defects involving the lower third of the leg and the ankle in 16 patients: repeated wound debridement, change in fixation system for 13 cases, rapid cover of the posterior segment of the leg with an island-dissected distally based neurocutaneous sural flap. Ten nonunions were treated later with a bone graft. Mean age in this series of 14 men and 2 women was 34 years (range 21–70 years). Thirteen patients were secondary hospitalization patients. The Gustilo classification after debridement was class IIIb. Time to cover ranged from one to eight months.

Results: Healing was achieved in three weeks. For three cases, revision was necessary due to re-activation of an infectious focus. All fractures healed (with tibiotalar fusion in two cases).

Discussion: The distally-based pediculated neurocutaneous sural flap is an interesting alternative to microanastomosis flaps for reconstruction of tissue defects of the lower third of the leg. Harvested from the posterior aspect of the calf which is generally spared, this flap must be carefully planned since there is no potential for augmenting the covering capacity. Great care must be taken to protect the pedicle; in our experience tunnelisation must be avoided. This flap also allows cover of a sterile osteosynthesis plate and resists local infection well. It can be raised easily if a bone graft is later necessary. In trauma victims, the esthetic and sensorial prejudice can be considered minor.

Conclusion: The distally-based neurocutaneous sural flap greatly contributes to our strategy for the management of tissue defects involving the lower third of the leg. Its main limitation is its size which can rarely exceed 80 cm2 in our experience.