OTA 2002 - Session 3 Session III - Polytrauma Fri., 10/11/02 Polytrauma, Paper #13, 3:38 PM 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