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Objective: The objective of the study was to determine the versatility of reverse sural artery flap in terms of its reliability and efficacy for reconstruction of soft-tissue defects of heel and proximal foot in children. Material and Methods: A total of 30 patients aged 5-13 years with ankle and foot defects admitted to the Plastic Surgery and Burn department at the Sheikh Zayed Hospital, Rahim Yar Khan from January 2018 to July 2020 were studied by designing a retrospective cross-sectional case series study. Results: Out of 30 flaps, 26 (86.7%) healed fully, whereas 4 (13.3%) complicated by partial necrosis requiring a secondary procedure. Nineteen (63.3%) patients had wheel spoke injuries, eight (26.6%) sustained degloving injury after a road traffic accident, and three (0.1%) patients were having a history of electric burn. In 22 patients an interpolated flap was used and in 8 cases an islanded flap. Donor sites were skin grafted in all patients. Two patients developed hypertrophic scarring at donor area. All patients showed good functional results, however flap remained insensate throughout the follow-up period that was minimum for 6 months. Conclusion: The reverse sural artery flap is versatile, reliable and a method of choice in reconstructing soft-tissue defects of the hind foot in children. This flap is easy to dissect, has robust blood supply and does not sacrifice any major blood vessel of the leg. Key Words: Reverse Sural Artery Flap, children, Ankle and Foot, Soft-tissue Defects, Wheel Spook Injury

Background Reconstruction of soft tissue defects around the lower leg, foot and ankle is a challenge for orthopedic surgeons. These defects commonly occur as a result of trauma, infection and tumor excision. Sural artery neurovascular island flap is a relatively thin, pliable and insensate flap with minimum donor-site morbidity and acceptable aesthetic outcome. Methods A retrospective analysis of a case series was conducted, all operated by a single surgeon over a period of 25 years from July 1996 to February 2020. Data were collected through a structured proforma; the variables included were as follows: demographic data, mechanism of injury, defect site and size, size of flap, hospital stay, complications, outcome of flap and functional status of limb. Data analysis was performed by using SPSS version 25.0. Results We included 89 patients out of 106, with 92 distally based sural artery flaps. The flap coverage was divided in two groups: group I for leg (n=41) and group II for foot (n=51). The mean flap dimension in leg was 9.98 ± 2.2 cm and 12.15 ± 3 cm in foot. Postoperatively functional outcomes were assessed using a self-designed tool and graded as excellent in 79 cases (leg=38; foot=41), good in 10 cases (leg=2; foot=8), fair in 3 cases (leg=1; foot=2) and poor in zero cases. All flaps survived uneventfully. Conclusion The reverse sural artery flap is versatile and reliable, and can be performed easily with good knowledge and using a microsurgical technique. It is useful for the reconstruction of soft tissue defects around the lower third of the leg, dorsum of the foot, malleoli and hind foot. The functional range of motion of the ankle is not compromised because of the flap's supple and pliable nature. The reverse sural artery flap is ideal for the coverage of the foot, ankle and lower one third of the leg. This flap is insensate and not suitable for the weight-bearing area of the heel.

Background: Wounds around the lower 1/3rd of leg and foot are difficult to manage. Treatment options like skin grafting, healing by secondary intention can result in an unstable scar. Free tissue transfers and Regional flaps has its own disadvantages. To circumvent these difficulties a fasciocutaneous flap harvested from sural angiosome was proposed. In this study, we have made an attempt to find out different scenarios in which this flap can be used as a management option and ways to minimize the complications associated with this flap. Methods: A retrospective observational study was conducted over 2 years. 30 patients were studied. Patient details was obtained from the case record, operative notes and postoperative follow-up.Results: Patients between the age of 10 years to 65 years were studied. RSA flap with adipofascial pedicle and fasciocutaneous pedicle was done in 21 and 9 patients respectively. Delaying of flap was done in 9 patients, with most common indication as distal defect. Common site of defect which were reconstructed was on the Tendoachilles region, Heel region. Various complications were loss of graft used to cover adipofascial pedicle, Venous congestion, hematoma formation and partial skin necrosis of the flap. None of the patients complained of any effect on routine activity during postoperative follow up.Conclusion: It is a versatile flap and different scenario can be managed with customization in plan. With proper selection of patients, it can be judiciously used to manage different leg defects.

Background Distal one – third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature. Material & methods In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months. Results The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment. Discussion Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity. Conclusion Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.

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.

The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.

Zusammenfassung Hintergrund Die Weichgewebsrekonstruktion bei alten Patienten stellt eine Herausforderung dar. Der freie Gewebetransfer kann bei gesunden Patienten trotz hohen Alters mit hoher Erfolgsrate durchgeführt werden. Bei multimorbiden Patienten, die für den freien Gewebetransfer nicht in Betracht kommen, werden häufig lokale Lappenplastiken eingesetzt, welche mit einer hohen Komplikationsrate assoziiert sind. Gerade solche Rettungseingriffe müssen so gewählt werden, dass eine Amputation durch die Wahl der Entnahmestelle nicht nachteilig beeinflusst wird oder gar unmöglich wird. Methode Drei distal basierte lokale Lappenplastiken wie Suralis‑, Peronaeus-brevis- und Propellerlappenplastik werden im Hinblick auf die Platzierung der Entnahmestelle sowie die Komplikationen der Wundheilungsstörung diskutiert. Ergebnisse Die Entnahmestelle der Suralislappenplastik ist nachteilig, da die proximale, dorsale Wadenregion betroffen ist, die im Falle einer Unterschenkelamputation die Weichteildeckung des Stumpfes ermöglicht. Schlussfolgerung Soll eine lokale Lappenplastik als „Rettungseingriff“ als Versuch der Vermeidung einer Unterschenkelamputation bei für einen freien Gewebetransfer nichtgeeigneten Patienten zum Einsatz kommen, gilt es, Lappenplastiken zu wählen, die die Entnahmestelle außerhalb der dorsalen, proximalen Wade platzieren, um die Weichteildeckung einer Stumpfbildung potenziell zu ermöglichen.

Background The reverse sural artery flap (RSAF) is a popular option for patients with distal lower extremity defects who are not ideal candidates for free flap reconstruction. This is the first systematic review and pooled analysis of surgical characteristics, risk factors, and outcomes of the RSAF. Methods A systematic literature review was conducted. All studies reporting on patients undergoing RSAF reconstruction and their outcomes were included. Outcomes were pooled and analyzed using Fisher exact or χ test. Results Forty-three studies (479 patients, 481 flaps) were analyzed. The majority of patients were male (70.3%), and average ± SD age was 46.9 ± 16.7 years. Rates of smoking, diabetes mellitus (DM), and peripheral vascular disease (PVD) were 34.6%, 35.4%, and 12.3%, respectively. Defect etiologies were largely traumatic (60.4%). The most common defect location was the heel (40.8%). Flap modifications were reported in 123 flaps (25.6%). The most common modification was adipofascial extension (20.3%).Overall, the partial and total flap loss rates were 15.4% and 3.1%, respectively. Partial flap loss was significantly increased in smokers (28.9% vs 12.2% in nonsmokers, P = 0.0195). Technical modifications decreased the odds of partial necrosis by almost 3-fold compared with traditional RSAF reconstruction (7.2% vs 17.9%; odds ratio, 2.8 [1.4-5.8]; P = 0.0035). Patient age, DM, and PVD were not significantly associated with flap loss. Conclusions The RSAF remains a safe salvage option for patients with DM or PVD but should be used with caution in smokers. Technical modifications to minimize pedicle compression significantly reduce rates of partial necrosis.

Aim: Small soft tissue defects of the distal tibia and hindfoot resulting from traumatic, operative, or neoplastic conditions and chronic ulcers can be successfully dealt with the use of the reverse sural artery flap (RSAF). This study aims to describe a single center’s results and familiarity with this technique over a 15-year period of time. Material and methods: We retrospectively reviewed the clinical files of patients who were consecutively treated with RSAF and regularly followed up between January 1, 2004 and December 31, 2018, with a minimum postoperative follow-up period of two years. Patient demographics and comorbidities, location of the defect, performing surgeon, mean operation time, flap pedicle width, mean size of the defect, days of hospitalization following the operation, healing flap rate, and complications were recorded. Results: The sample consisted of 30 adult patients (25 men, 5 women), with a mean age of 51.07 years (16-80 years, SD 18.61). The mean operation time was 99.03 min (range 83-131, SD 10.57), and the mean size of the defect was 11.11 cm2 (range 6.1-19.4, SD 3.22). Successful flap rate (complete healing and coverage of the defect, with or without additional minor intervention) was 83.3% (25/30). Among successfully healed flaps, six patients with partial necrosis of the dermis were treated by an additional split-thickness skin graft. Five flaps failed to heal. Deep infection was present in two patients, leading to flap failure and reoperation. Serious venous congestion resulting in flap ischemia occurred in three cases. Circumferential keloid formation (not affecting successful outcome) was present in seven cases. Flap thickness approximated to normal within six months. All donor sites healed well (either by a split-thickness cutaneous flap or by immediate wound closure). Light paresthesia on the lateral border of the leg and foot disappeared within six months. Conclusions: A single-center experience with the RSAF has yielded satisfactory clinical outcomes, and the long-term tackle with the difficult reconstruction conditions around the ankle, has led to valuable advice on surgical technique and postoperative protocol, based on an anatomical basis.

Cross-leg flaps are a useful reconstructive option for complex lower limb defects when free flaps cannot be performed owing to vessel damage. We describe the use of the extended distally based sural artery flap in a cross-leg fashion for lower extremity coverage in three patients. To maximise the viability of these extended flaps, a delay was performed by raising them in a bipedicled fashion before gradual division of the tip over 5 to 7 days for cross-leg transfer. Rigid coupling of the lower limbs with external fixators was critical in preventing flap avulsion and to promote neovascular takeover. The pedicle was gradually divided over the ensuing 7 to 14 days before full flap inset and removal of the external fixators. In all three patients, the flaps survived with no complications and successful coverage of the critical defect was achieved. One patient developed a grade 2 pressure injury on his heel that resolved with conservative dressings. The donor sites and external fixator pin wounds healed well, with no functional morbidity. The cross-leg extended distally based sural artery flap is a reliable reconstructive option in challenging scenarios. Adequate flap delay, manoeuvres to reduce congestion, and postoperative rigid immobilization are key to a successful outcome.

ZusammenfassungDieser Artikel beleuchtet den Stellenwert von gestielten Lappenplastiken an der unteren Extremität im Rahmen der regionalen Weichteilrekonstruktion nach Trauma. Die typischen Fallstricke dieser Verfahren sowie Tipps und Tricks zu 5 gängigen gestielten Lappenplastiken werden detailliert dargestellt.

Locoregional flaps play an important role in soft tissue reconstruction of the lower extremity and should be considered an effective option in soft tissue reconstruction. The medial hemisoleus muscle flap and the distally based sural artery flap can be elevated because of unique vascular anatomy and more advanced surgical techniques in flap dissection. Each flap can replace free tissue transfer as the first choice for soft tissue reconstruction of a less extensive wound in the distal third of the leg. Patient selection and detailed knowledge of the flap and its advanced technique for flap dissection are keys to success.

The medial sural artery flap was first described by Cavadas in 2001. It is a newer flap that combines the benefits of the anterolateral thigh flap and the radial forearm free flap: It is a thin flap that makes it ideal for more distal soft tissue reconstruction of the extremity, while it has minimal donor site morbidity. It can often be closed primarily, resulting in a cosmetically acceptable scar. The blood supply to the flap runs parallel to the muscle fibers, resulting in muscle preservation during dissection, and it makes it ideal for patient desiring no muscle sacrifice (Fig. 29.1). Its dissection is based on the same principles as the gastrocnemius muscle flap. Its skin territory is the skin overlying the medial gastrocnemius. It needs to be noted that an analogous lateral sural perforator artery flap can be designed based on the lateral sural artery in the same fashion. We usually include the superficial venous system if possible (greater saphenous vein – GSV) for drainage. Although a good flap, it should be noted that the MSAP flap is not as reliable as other more commonly used flaps (e.g., the ALT flap) and has a steep learning curve due to its highly random vascular territory. Sometimes, during dissection, a reliable perforator is not encountered and the MSAP flap cannot be used. The medial sural artery has many muscular branches that need to be identified and ligated, making the dissection tedious and time consuming.

Hintergrund Die Weichgewebsrekonstruktion bei alten Patienten stellt eine Herausforderung dar. Der freie Gewebetransfer kann bei gesunden Patienten trotz hohen Alters mit hoher Erfolgsrate durchgeführt werden. Bei multimorbiden Patienten, die für den freien Gewebetransfer nicht in Betracht kommen, werden häufig lokale Lappenplastiken eingesetzt, welche mit einer hohen Komplikationsrate assoziiert sind. Gerade solche Rettungseingriffe müssen so gewählt werden, dass eine Amputation durch die Wahl der Entnahmestelle nicht nachteilig beeinflusst wird oder gar unmöglich wird. Methode Drei distal basierte lokale Lappenplastiken wie Suralis‑, Peronaeus-brevis- und Propellerlappenplastik werden im Hinblick auf die Platzierung der Entnahmestelle sowie die Komplikationen der Wundheilungsstörung diskutiert. Ergebnisse Die Entnahmestelle der Suralislappenplastik ist nachteilig, da die proximale, dorsale Wadenregion betroffen ist, die im Falle einer Unterschenkelamputation die Weichteildeckung des Stumpfes ermöglicht. Schlussfolgerung Soll eine lokale Lappenplastik als „Rettungseingriff“ als Versuch der Vermeidung einer Unterschenkelamputation bei für einen freien Gewebetransfer nichtgeeigneten Patienten zum Einsatz kommen, gilt es, Lappenplastiken zu wählen, die die Entnahmestelle außerhalb der dorsalen, proximalen Wade platzieren, um die Weichteildeckung einer Stumpfbildung potenziell zu ermöglichen.

Wounds in the distal third of the tibia can be considered the most challenging for reconstruction and lower extremity salvage. This “no man’s land” provides very limited local reconstructive options because of its paucity of soft tissue laxity and redundancy. To this end, most reconstructive surgeons view distal-third injuries as requiring free tissue transfer for adequate soft tissue reconstruction. In limited circumstances, however, there are several viable options for local, pedicled soft tissue reconstruction in the distal third. These include the reverse sural artery flap, bipedicled flaps, propeller perforator flaps, and keystone flaps.

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. 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. 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. 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.

Reconstruction for injuries around the ankle becomes a challenge due to limitation of available similar or near similar tissue. Tendons, bones and joints are frequently exposed after trauma because of the thinness of the subcutaneous tissue around the ankle. A durable flap with good texture, reliable vascularity, good arc of rotation and minimum donor site morbidity is always desired for coverage of such defect. Traditionally local flaps are used for resurfacing but their use is limited by their size and arc of rotation. This study was done in the dept. of Plastic Surgery, NITOR from Dec, 2012 to Feb, 2016. Total number of patients was 50 and their age varied from 7 years to 55 years. Among the 50 patients, 41 patients recovered uneventfully, 8 patients showed partial flap necrosis and complete flap necrosis in 1 patient. The distally based sural flap is a versatile and reliable flap for coverage of soft tissue defects around the ankle. Most of the cases were single stage procedure except extended reverse sural flap. The dissection is easy with short operative time and minimum morbidity. Thus the superficial sural artery flap can be used as a good alternative to microsurgical reconstruction.J Bangladesh Coll Phys Surg 2018; 36(3): 101-106

Introduction: Coverage of defects of the distal lower extremity and foot remains a challenging reconstructive prcedure. Free tissue transfer remains the standard for the management of these defects. However, there are some disadvantages like; longer operative times, bulky contour, and the need for highly skilled expertise. The reverse superficial sural artery flap (RSSAF) is a distally based fasciocutaneous or adipo-fascial flap that is used for coverage of defects that involve the distal third of the leg, ankle, and foot. A significant advantage of this flap is a constant blood supply that does not require sacrifice of a major artery. Methods: Twenty RSSAF flaps were harvested for reconstruction of different traumatic soft tissue defects of the lower third of leg, ankle and foot. Follow up for 6 months postoperative. Results: Twenty Patients; twelve males and eight females underwent reconstruction of different soft tissue defects over the foot and ankle using RSSAF. The overall complications occurred in 6 flaps; 4 minor and 2 major complications. The remaining 14 flaps passed an uneventful follow up. Conclusions: The reverse superficial sural artery flap RSSAF can be used as a reliable alternative to free tissue transfer in reconstruction of defects over the lower third of leg, ankle, and foot. Venous congestion is the major threat to the flap but its incidence can be minimized by wide pedicle, less kink of the flap, and keep the venae comitants around the artery.

BACKGROUND Due to shortage of local donor tissue and unreliable blood supply, free flaps were the mainstay of treatment for tissue defects in the lower leg and foot region, but it requires a qualified microvascular surgeon. Recently, attention has been paid to reverse superficial sural artery flap (RSSAF) and its modifications as a good alternative to pave the way to simple and friendly techniques. METHODS Excluding each patient with septic and severely ischemic foot, every patient with tissue defect in distal leg and proximal foot region were studied. Various methods were applied including spout technique with sufficient follow up. No imaging was used to evaluate the blood supply. RESULTS Five patients underwent spout technique with excellent results in four cases. Spout technique in one case failed due to narrow base. In five cases, RSSAF was performed with creating skin tunnel and very good results. CONCLUSION RSSAF is a good alternative for free flap to cover the leg and foot tissue defects. We also advise wide base pedicle (>4 cm) in every patient.

Purpose: Infected lateral malleolar bursitis occurring as a diabetic complication requires debridement and flap surgery because it cannot be treated by conservative methods. The most accessible flap is the reverse sural artery flap, which can be harvested as a fasciocutaneous flap or an adipofascial flap. The purpose of this study was to compare the two types of flap methods performed in patients with diabetic infected lateral malleolar bursitis. Methods: Twenty-nine cases of diabetic infected lateral malleolar bursitis treated with reverse sural artery flap between 2006 and 2017 were analyzed retrospectively. Fasciocutaneous flap methods were performed in 15 cases (group A), and adipofascial flap methods were performed in 14 cases (group B). Patients in the two groups did not differ in sex or age. The mean follow-up period was 16 months. Results: All flaps survived. Infection was controlled at a mean of 2.4 months in both groups. At final follow-up, infection recurred in one case of each group, which was treated with antibiotics. No case developed an ulcer in the flaps. The patients were able to ambulate in regular shoes. All but one of the patients (28 patients) expressed satisfaction with the aesthetic appearance following treatment. No case required a debulking operation. Conclusion: Both the fasciocutaneous and adipofascial methods for reverse sural artery flaps were shown to be viable options for the control of diabetic lateral infection. In addition, the two groups did not differ in terms of appearance or complication rate following treatment.

Ruptur tendon achilles adalah cedera yang paling sering terjadi pada tendon ekstremitas bawah, meskipun merupakan tendon yang terbesar dan terkuat. Penelitian ini bertujuan menjelaskan teknik operasi dengan modifikasi augmentation pada penatalaksanaan ruptur tendon Achilles yang disertai kerusakan pada jaringan lunak yang luas. Kasus pada penelitian ini adalah seorang pasien (usia 30 tahun) dengan ruptur terbuka tendon Achilles akut dan terinfeksi, serta hilangnya tendon sampai dengan 5 cm, kecacatan tendon yang tidak menempel di bagian distal dan hilangnya sebagian tulang calcaneus. Kerusakan kulit diukur setelah dilakukan debridemen dengan rentan antara 8 cmx5 cm sampai dengan 15 cmx10 cm. Ruptur pada tendon dijahit dengan gastrosoleus turn down flap ke tulang calcaneus . Reverse sural artery digunakan untuk menutupi kulit. Flap yang dibuat berhasil hidup. Pasien dapat berjalan normal, dapat berdiri dengan ujung kaki, fleksi plantar yang aktif, dan dapat kembali beraktivitas dalam 2 bulan setelah operasi. Pasien memiliki rentang gerak penuh ke segala arah. Simpulan, debridemen, rekonstruksi tendon dalam satu tahap, dan r everse flow sural artery flap memberikan hasil yang memuaskan pada kasus robekan luas tendon Achilles dan kerusakan jaringan lunak yang luas. [ MKB . 2016;48(1):58–62] Kata kunci: Gastrosoleus turn down flap, ruptur, sural artery flap, tendon Achilles Achilles Tendon Turndown Flap Reconstruction and Fasciocutanous Sural Flap in Severe Tendon Achilles Loss with Massive Tissue Defect: a Case Report Abstract Achilles tendon rupture is the most common ruptur of tendon in the lower limb despite being one of the toughest tendons. This rupture presents a complex problem to the treating surgeon especially if it is associated with tendon and soft tissue loss. The case in this study is one patient (male, age 30-year old) with a spectrum of acute and infected open tendon-achilles rupture that includes loss of tendon of up to 5 cm, tendon defect with no distal attachment, and partial loss of the calcaneum. The skin defect measured after debridement ranged from 8 x 5 cm to 15 x 10 cm. The ruptured tendon was sutured using gastrocnemius-soleus turn down flap technic to calcaneus bone. A reverse sural artery was used to provide soft tissue cover. The flap survived. The patient had normal gait, were able to stand on tip toes, had active plantar flexion, and had returned to his original occupation 2 months after reconstruction. He had full range of movement at the ankle. Augmented repair of Achilles tendon rupture with large soft tissue defect using gastrocnemius- soleus turn down flap and sural artery flap are stable enough to allow early weight-bearing with favorable clinical result for this patient. Conclusions is single stage tendon reconstruction and reverse flow sural artery flap give good functional outcome in complex Achilles tendon rupture with tendon and soft tissue loss. [ MKB . 2016;48(1):58–62] Key words: Achilles tendon, gastrocnemius-soleus turn down flap, rupture, sural artery flap

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 fasciocutaneous flap has become a workhorse for the reconstruction of distal leg soft tissue defects. When its use is not feasible, perforator‑based propeller flap offers a better, easier, faster, and cheaper alternative to free flap. We present our experience with two men both aged 34 years who sustained Gustilo 3B injuries from gunshot. The donor area for reversed sural artery flap was involved in the injuries. They had early debridement, external fixation, and wound coverage with perforator‑based propeller flaps. The donor sites were covered with skin graft. All flaps survived. There were minor wound edge ulcers due to the pressure of positioning that did not affect flap survival and the ulcers healed with conservative management. Perforator‑based propeller flap is a versatile armamentarium for reconstruction of soft tissue defects of the distal leg in resource‑constrained settings, especially when the donor area for a reverse flow sural flap artery is involved in the injury.Key words: Flap, perforator flap, propeller flap, reconstruction

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.

Background Reconstruction of soft-tissue defects in lower third of leg, ankle, and foot has been a challenge and reconstructive surgeons have been trying to innovate different flaps. To solve this issue, we propose a distally based sural artery peroneus flap (DBSPF) in which we include superficial portion of the peroneus brevis muscle and its blood supply with the peroneal artery distally. The aim of this study was to evaluate the functional outcome and its usefulness over conventional distal sural artery flap or other local options available. Methods This is a case series of 20 patients that include a DBSPF that was done for defects around ankle, distal leg, and foot caused by trauma or tumor ablation within the period of June 2013 to March 2015 in Kasralainy Hospital, Cairo. All cases were evaluated according to flap vascularity, distal reach of flap, aesthetic outcome, and donor-site morbidity. Results All flaps survived. One flap developed venous congestion that subsided spontaneously with limb elevation. The flap dimension ranged from 42 cm to 442 cm2, and it reached the midfoot easily. The pivot point was kept as low as 2-6 cm from lateral malleolus according to location of perforators. The ankle stability was maintained, and the desired aesthetic outcome was achieved. Conclusions The DBSPF is an addition to the armamentarium in plastic surgery for defects around ankle, distal leg, and foot. It is an easy and swift procedure as compared with complex microsurgical reconstruction.

Introduction: The islanded reverse sural artery flap is a versatile, relatively simple procedure, useful in reconstruction of lower third leg, heel, tendo achilles region, malleoli and hind foot defects because of the long vascular pedicle. The surgical technique is safe, of short duration and provides alternative to microsurgical reconstruction. Aim: To study the versatility and applications of islanded reverse sural artery flaps in the reconstruction of distal third leg, heel and foot defects. Materials and Methods: A prospective study was conducted between October 2007 to March 2010, 26 patients with moderate sized skin and soft tissue defects in the distal third of leg and foot were treated with Islanded Reverse Sural Artery Flap at Government Chengalpattu Medical College, Tamil Nadu, India. The flap was planned in reverse, after marking with Doppler and procedure was performed. Factors like size of defect, length and width of pedicle, comorbid factors and complications were taken into account for the study. Results: Most of the flaps were done on post traumatic defects. Around 80% of the flaps had settled well with no or minimal donor site morbidity. Increasing age, co-morbid factors, narrow pedicle and arc of rotation of about 180 degrees all caused an increased complication rate which varied from 10 to 38%. Conclusion: Islanded reverse sural artery flap with its wide arc of rotation can provide cover to lower third of leg, heel and foot defects, thereby, reducing the need for staged cross leg flap and other flaps. It is a reliable and versatile flap in the hands of reconstructive surgeon to provide good quality skin cover for defects of the leg and foot with acceptable donor site morbidity in a single stage.

We describe the use of a free medial sural artery perforator flap to reconstruct a complex composite defect to the dorsum of the right index finger following a low voltage electrical injury. The resulting defect was a 3.5 × 5 cm full thickness wound, with segmental tendon loss and loss of underlying periosteum. Due to both size and local vascular injury related to the mechanism, free tissue transfer was felt to be the most reliable option to resurface the composite defect in a single stage. The medial sural artery perforator flap, for reasons outlined below, was felt to be the best option: 1. Thin profile. 2. Vascularised fascia can be taken as a tongue, adjacent to the skin paddle: a gliding surface to prevent the tendon graft sticking to exposed bone. 3. Long pedicle: micro-anastomosis away from zone of injury. 4. Little donor site morbidity: can be closed directly (if

Posttraumatic wounds and soft tissue defects in the distal third of the leg and ankle remain a challenge. Defects at this site will often require flap cover. Free flap is ideal for these defects and gives good results but with its own limitations. The reverse sural artery flap (RSAF) and distal peroneus brevis flap (DPBF) have gained popularity for lower third leg defects among surgeons. We did a retrospective study on 64 patients admitted between 2011 and 2013 with posttraumatic moderate size defects of lower one-third leg who underwent RSAFs and DPBFs. These patients were followed up in the immediate and late postoperative period for complications and outcome assessment. The average surface area covered by DPBF was 27 cm2 and by RSAF was 38 cm2. Both flaps gave a good functional outcome. DPBF has better aesthetic appearance at donor site and recipient site, with the advantages of ease of surgery, speedy recovery, less hospital stay, and no donor site morbidity; DPBFs appear to be a preferred choice for moderate size lower third leg defects. RSAFs should be chosen over DPBFs for defects in medial malleolus and larger size defects.