Clinical study of modified technique to reduce partial necrosis rate of distally pedicled sural flap_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

PENG Ping , DONG Zhonggen ,  LIU Lihong , WEI Jianwei , LUO Zhaobiao , CAO Shu

Department of Orthopedics, the Second Xiangya Hospital, Central South University, Changsha Hunan, 410001, P.R.China;

Corresponding author：

LIU Lihong, Email: drliulh@csu.edu.cn

Keywords：

Distally pedicled sural flap; technical modification; partial necrosis of flap; soft tissue defect; complication

DOI：

10.7507/1002-1892.202101105

Video：

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Objective To investigate whether the technical modifications regarding the risk factors related to the partial necrosis of the distally pedicled sural flap could reduce the partial necrosis rate of the flap.Methods A clinical data of 254 patients (256 sites) (modified group), who used modified technique to design and cut distally pedicled sural flaps to repair the distal soft tissue defects of the lower limbs between April 2010 and December 2019, was retrospectively analyzed. Between April 2001 and March 2010, 175 patients (179 sites) (control group) who used the traditional method to design and cut the skin flap to repair the distal soft tissue defects of the lower limbs were compared. Various technical modifications were used to lower the top-edge of the flap, reduce the length-width ratio (LWR) of the flap and width of the skin island. There was no significant difference in gender, age, etiology, duration from injury to operation, site and area of the soft tissue defect between groups (P>0.05). The length and width of the skin island and adipofascial pedicle, the total length of the flap and LWR, and the pivot point position were measured and recorded. The top-edge of the flap was determined according to the division of 9 zones in the posterior aspect of the lower limb. The occurrence of partial necrosis of the flap and the success rate of defect reconstruction were observed postoperatively.Results There was no significant difference in the length and width of the skin island, the length of the adipofascial pedicle, total length and LWR of the flap, and pivot point position of the flap between groups (P>0.05). The width of the adipofasical pedicle in modified group was significant higher than that in control group (t=–2.019, P=0.044). The top-edge of 32 flaps (17.88%) in control group and 31 flaps (12.11%) in modified group were located at the 9th zone; the constituent ratio of the LWR more than 5∶1 in modified group (42.58%, 109/256) was higher than that in control group (42.46%, 76/179); and the constituent ratio of width of skin island more than 8 cm in control group (59.78%, 107/179) was higher than that in modified group (57.42%, 147/256). There was no significant difference in the above indicators between groups (P>0.05). In control group, 155 flaps (86.59%) survived completely, 24 flaps (13.41%) exhibited partial necrosis. Among them, 21 wounds healed after symptomatic treatments, 3 cases were amputated. The success rate of defects reconstruction was 98.32% (176/179). In modified group, 241 flaps (94.14%) survived completely, 15 flaps (5.86%) exhibited partial necrosis. Among them, 14 wounds healed after symptomatic treatments, 1 case was amputated. The success rate of defect reconstruction was 99.61% (255/256). The partial necrosis rate in modified group was significantly lower than that in control group (χ²=7.354, P=0.007). There was no significant difference in the success rate between the two groups (P=0.310). All patients in both groups were followed up 1 to 131 months (median, 9.5 months). All wounds in the donor and recipient sites healed well.Conclusion The partial necrosis rate of the distally based sural flap can be decreased effectively by applying personalized modified technical for specific patients.

Citation： PENG Ping, DONG Zhonggen, LIU Lihong, WEI Jianwei, LUO Zhaobiao, CAO Shu. Clinical study of modified technique to reduce partial necrosis rate of distally pedicled sural flap. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(6): 750-755. doi: 10.7507/1002-1892.202101105 Copy

1.	Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg, 1992, 89(6): 1115-1121.
2.	Bordianu A, Gheorghiu-Branaru M, Marinescu S. ALT flap and reverse sural flap for simultaneous soft tissue coverage of both medial and lateral calf wounds in a diabetic patient. Injury, 2020, 51 Suppl 4: S31-S33.
3.	Perumal R, Bhowmick K, Reka K, et al. Comparison of reverse sural artery flap healing for traumatic injuries above and below the ankle joint. J Foot Ankle Surg, 2019, 58(2): 306-311.
4.	Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Traumatol, 2014, 15(3): 225-229.
5.	Schmidt K, Jakubietz M, Djalek S, et al. The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population. Plast Reconstr Surg, 2012, 130(2): 360-368.
6.	Parrett BM, Pribaz JJ, Matros E, et al. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg, 2009, 123(5): 1499-1504.
7.	de Blacam C, Colakoglu S, Ogunleye AA, et al. Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis. J Plast Reconstr Aesthet Surg, 2014, 67(5): 607-616.
8.	Daar DA, Abdou SA, David JA, et al. Revisiting the reverse sural artery flap in distal lower extremity reconstruction: A systematic review and risk analysis. Ann Plast Surg, 2020, 84(4): 463-470.
9.	Wei JW, Dong ZG, Ni JD, et al. Influence of flap factors on partial necrosis of reverse sural artery flap: a study of 179 consecutive flaps. J Trauma Acute Care Surg, 2012, 72(3): 744-750.
10.	尹朝东, 董忠根, 魏建伟, 等. 高旋转带与低旋转点腓肠神经营养血管皮瓣的疗效比较. 中华显微外科杂志, 2019, 42(2): 173-176.
11.	Peng P, Luo ZB, Lv GH, et al. Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial. J Orthop Surg Res, 2020, 15(1): 487. doi: 10.1186/s13018-020-02019-4.
12.	董忠根, 刘玺, 刘立宏, 等. 皮岛倾斜设计的远端蒂腓肠神经筋膜皮瓣修复胫前纵向或跟踝部横向创面. 中国修复重建外科杂志, 2016, 30(11): 1391-1395.
13.	Dong ZG, Wei JW, Ni JD, et al. Anterograde-retrograde method for harvest of distally based sural fasciocutaneous flap: report of results from 154 patients. Microsurgery, 2012, 32(8): 611-616.
14.	Chang SM, Wang X, Huang YG, et al. Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique. Ann Plast Surg, 2014, 72(3): 340-345.
15.	Al-Qattan MM. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg: inclusion of a gastrocnemius muscle “cuff” around the sural pedicle. Ann Plast Surg, 2001, 47(3): 269-274.
16.	Tsai J, Liao HT, Wang PF, et al. Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement. Microsurgery, 2013, 33(5): 342-349.
17.	de Rezende MR, Saito M, Paulos RG, et al. Reduction of morbidity with a reverse-flow sural flap: A two-stage technique. J Foot Ankle Surg, 2018, 57(4): 821-825.
18.	Roberts HJ, DeSilva GL. Can sural fasciocutaneous flaps be effective in patients older than 65? Clin Orthop Relat Res, 2020, 478(4): 734-738.
19.	Xu H, Cao XX, Kiu-Huen S, et al. A Retrospective study of an updated and traditional surgical approach of the distally based sural flap. J Reconstr Microsurg, 2021, 37(3): 227-233.
20.	池征璘, 曹学新, 陈一衡, 等. 改良腓肠神经营养血管筋膜蒂穿支皮瓣切取方式的应用. 中华显微外科杂志, 2020, 43(3): 238-242.
21.	Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg, 2007, 119(2): 590-598.
22.	庄家正, 王开放, 刘敏敏, 等. 皮蒂在穿支筋膜蒂皮瓣中的作用探讨. 中国临床解剖学杂志, 2019, 37(1): 34-39.
23.	Lu TC, Lin CH, Lin CH, et al. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg, 2011, 64(3): 386-393.
24.	Gascoigne AC, Ian Taylor G, Corlett RJ, et al. The relationship of superficial cutaneous nerves and interperforator connections in the leg: a cadaveric anatomical study. Plast Reconstr Surg, 2017, 139(4): 994e-1002e.
25.	陶世斌, 董忠根, 魏建伟, 等. 腓肠神经营养血管皮瓣的真性吻合连接及修复前足创面的疗效. 中国临床解剖学杂志, 2020, 38(4): 450-454.

1. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg, 1992, 89(6): 1115-1121.
2. Bordianu A, Gheorghiu-Branaru M, Marinescu S. ALT flap and reverse sural flap for simultaneous soft tissue coverage of both medial and lateral calf wounds in a diabetic patient. Injury, 2020, 51 Suppl 4: S31-S33.
3. Perumal R, Bhowmick K, Reka K, et al. Comparison of reverse sural artery flap healing for traumatic injuries above and below the ankle joint. J Foot Ankle Surg, 2019, 58(2): 306-311.
4. Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Traumatol, 2014, 15(3): 225-229.
5. Schmidt K, Jakubietz M, Djalek S, et al. The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population. Plast Reconstr Surg, 2012, 130(2): 360-368.
6. Parrett BM, Pribaz JJ, Matros E, et al. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg, 2009, 123(5): 1499-1504.
7. de Blacam C, Colakoglu S, Ogunleye AA, et al. Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis. J Plast Reconstr Aesthet Surg, 2014, 67(5): 607-616.
8. Daar DA, Abdou SA, David JA, et al. Revisiting the reverse sural artery flap in distal lower extremity reconstruction: A systematic review and risk analysis. Ann Plast Surg, 2020, 84(4): 463-470.
9. Wei JW, Dong ZG, Ni JD, et al. Influence of flap factors on partial necrosis of reverse sural artery flap: a study of 179 consecutive flaps. J Trauma Acute Care Surg, 2012, 72(3): 744-750.
10. 尹朝东, 董忠根, 魏建伟, 等. 高旋转带与低旋转点腓肠神经营养血管皮瓣的疗效比较. 中华显微外科杂志, 2019, 42(2): 173-176.
11. Peng P, Luo ZB, Lv GH, et al. Distally based peroneal artery perforator-plus fasciocutaneous flap in the reconstruction of soft tissue defects over the distal forefoot: a retrospectively analyzed clinical trial. J Orthop Surg Res, 2020, 15(1): 487. doi: 10.1186/s13018-020-02019-4.
12. 董忠根, 刘玺, 刘立宏, 等. 皮岛倾斜设计的远端蒂腓肠神经筋膜皮瓣修复胫前纵向或跟踝部横向创面. 中国修复重建外科杂志, 2016, 30(11): 1391-1395.
13. Dong ZG, Wei JW, Ni JD, et al. Anterograde-retrograde method for harvest of distally based sural fasciocutaneous flap: report of results from 154 patients. Microsurgery, 2012, 32(8): 611-616.
14. Chang SM, Wang X, Huang YG, et al. Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique. Ann Plast Surg, 2014, 72(3): 340-345.
15. Al-Qattan MM. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg: inclusion of a gastrocnemius muscle “cuff” around the sural pedicle. Ann Plast Surg, 2001, 47(3): 269-274.
16. Tsai J, Liao HT, Wang PF, et al. Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement. Microsurgery, 2013, 33(5): 342-349.
17. de Rezende MR, Saito M, Paulos RG, et al. Reduction of morbidity with a reverse-flow sural flap: A two-stage technique. J Foot Ankle Surg, 2018, 57(4): 821-825.
18. Roberts HJ, DeSilva GL. Can sural fasciocutaneous flaps be effective in patients older than 65? Clin Orthop Relat Res, 2020, 478(4): 734-738.
19. Xu H, Cao XX, Kiu-Huen S, et al. A Retrospective study of an updated and traditional surgical approach of the distally based sural flap. J Reconstr Microsurg, 2021, 37(3): 227-233.
20. 池征璘, 曹学新, 陈一衡, 等. 改良腓肠神经营养血管筋膜蒂穿支皮瓣切取方式的应用. 中华显微外科杂志, 2020, 43(3): 238-242.
21. Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg, 2007, 119(2): 590-598.
22. 庄家正, 王开放, 刘敏敏, 等. 皮蒂在穿支筋膜蒂皮瓣中的作用探讨. 中国临床解剖学杂志, 2019, 37(1): 34-39.
23. Lu TC, Lin CH, Lin CH, et al. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg, 2011, 64(3): 386-393.
24. Gascoigne AC, Ian Taylor G, Corlett RJ, et al. The relationship of superficial cutaneous nerves and interperforator connections in the leg: a cadaveric anatomical study. Plast Reconstr Surg, 2017, 139(4): 994e-1002e.
25. 陶世斌, 董忠根, 魏建伟, 等. 腓肠神经营养血管皮瓣的真性吻合连接及修复前足创面的疗效. 中国临床解剖学杂志, 2020, 38(4): 450-454.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical study of modified technique to reduce partial necrosis rate of distally pedicled sural flap

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