- Email: [email protected]
Heel Coverage Using a Distally Based Sural Artery Fasciocutaneous Cross-leg Flap: Report of a Small Series
Heel Coverage Using a Distally Based Sural Artery Fasciocutaneous Cross-leg Flap: Report of a Small Series Attilio Basile, MD,1 Marcello Stopponi, MD,1 Andrea Loreti, MD,2 and Angelo Ugo Minniti de Simeonibus, MD1 One of the goals in the management of severe open injuries of the foot is to obtain adequate soft tissue coverage. In extreme conditions of pedal soft tissue loss, in patients who are not satisfactory candidates for local or free-tissue transfer, the cross-leg flap remains an option for surgical reconstruction. We present the results of 7 patients with multiple lower limb open fractures associated with ipsilateral degloving injuries, and/or secondary pressure ulcers of the hindfoot with exposure of the calcaneus, in which a distally based sural artery island fasciocutaneous flap, elevated from the contralateral leg and crossed to the injured side, was used to repair the soft tissue defect of the recipient heel. All of the flaps survived and the soft tissues healed uneventfully, thereby providing satisfactory and stable coverage of the calcaneal tuberosity. To the best of our knowledge, this is the first report in which this technique has been used to repair hindfoot soft tissue defects associated with complex bone and vascular injuries of the lower limb in polytrauma patients. Level of Clinical Evidence: 4 ( The Journal of Foot & Ankle Surgery 47(2):112–117, 2008) Key Words: calcaneus, cross-leg flap, degloving, fasciocutaneous flap, heel ulcer, musculoskeletal trauma, soft tissue defect
I n the presence of an extensive hindfoot soft tissue defect,
without the ability to employ microsurgical free-tissue transfer or ipsilateral fasciocutaneous or local muscular flaps, very few solutions are available for attempting coverage of the calcaneus and other portions of the traumatized hindfoot. In such cases, cross-leg and cross-foot flaps can be employed, and use of the sural artery cross-leg flap for coverage of contralateral heel defects may be a useful option. One case of sural cross-leg flap has been previously mentioned in a report of 22 patients in which the ipsilateral distally based sural fasciocutaneous flap was used to reconstruct distal leg defects (1). The sural cross-leg flap has also been used successfully to reconstruct 2 cases of chronic and infected ulcers of the foot (2). The aim of the current report was to retrospectively assess the results of heel coverage using a distally based sural artery fasciocutaneous cross-leg flap in a series of patients that had sustained polytrauma with associated complex bone and soft tissue defects in-
Address correspondence to: Attilio Basile, MD, Via Nicola Pellati 45, 00149 Rome, Italy. E-mail: [email protected]. 1 Orthopaedic Surgeon, Department of Orthopaedic and Trauma Surgery, Ospedale San Giovanni-Addolorata, Rome, Italy. 2 Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Ospedale San Giovanni-Addolorata, Rome, Italy. Copyright © 2008 by the American College of Foot and Ankle Surgeons 1067-2516/08/4702-0006$34.00/0 doi:10.1053/j.jfas.2007.12.005
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volving the leg and hindfoot. To the best of our knowledge, this is the first report of the results of this sural artery cross-leg flap for coverage of the heel in polytrauma patients. Patients and Methods We retrospectively reviewed consecutive patients who were treated at our institution by means of a distally based sural artery fasciocutaneous cross-leg flap. To be included in the case series, the patients had to have been admitted for treatment of polytrauma that included leg and foot bone and soft tissue defects, and the aforementioned cross-leg flap had to have been employed for the coverage of a persistent heel wound. The review was undertaken by the authors, who also served as the managing surgeons for the patients described in this report. Review of the records revealed 7 patients who met our inclusion criteria (Table 1). All of the patients were motor vehicle accident victims and, in all of the cases, the contralateral limb was uninjured. Six of the patients suffered Gustilo-Anderson (G-A) grade III B open tibial fractures while 1 presented with a G-A grade III C injury (3). All of the injuries were associated with exposure of the ipsilateral heel by means of acute degloving that was sustained at the time of the initial trauma, or due to secondary nonhealing ulceration of the hindfoot with resultant exposure of the
TABLE 1
Clinical characteristics of the case series
Patient
Age (y)
1
26
Male
2
36
Male
3
30
Female
4
28
Male
5
29
Male
6
55
Male
7
33
Female
Gender
Injuries
Degloving injury (secondary bone exposition) Primary hindfoot soft tissue defect Degloving injury (secondary bone exposition) Pressure ulcer Primary hindfoot soft tissue defect Pressure ulcer Primary hindfoot soft tissue defect
Medical comorbidities
Heel wound defect (cm)
Wound preparation
None
6⫻6
External fixation
None
4⫻8
None
5⫻7
None (cigarette smoker) None
6⫻8 5⫻5
Vacuum-assisted closure Vacuum-assisted closure Vacuum-assisted closure Vacuum-assisted closure Wet to dry
None (cigarette smoker) None
4⫻7
Wet to dry
External fixation
5⫻8
Wet to dry
External fixation
posterior tuberosity of the calcaneus that developed over the course of the hospitalization. The patients were treated between December 2002 and March 2006, at our level I trauma center. The case series consisted of 5 males and 2 females with an average age of 33.9 years (range 26 to 55 years), and none of the patients were complicated with any systemic disease comorbidities at the time of admission. Two of the patients related that they smoked 10 to 15 cigarettes per day and were strongly advised to discontinue smoking during the recovery period, and both of these patients fully complied with this recommendation. Upon admission, all of the patients underwent assessment and resuscitation according to advanced trauma life support (ATLS, American College of Surgeons, Inc., Chicago, IL) guidelines (4). All of the patients, moreover, were administered intravenous antibiotics (cefotaxime 2 g every 8 hours for 5 days); and neurological, thoracic, and abdominal lifethreatening injuries were treated. Open fractures were managed with urgent debridement and irrigation, and external fixation was used in 5 patients while immediate intramedullary nailing was used in 2 patients. In 1 case, categorized as a G-A III C fracture, repair of the posterior tibial artery was performed with an interpositional vein graft. All open wounds were packed with tobramicin-impregnated polymethylmethacrylate beads. Within 24 to 48 hours, patients were taken back to the operative theater for repeat debridement and irrigation. The average tibial wound size after this debridement procedure was 13 cm ⫻ 7 cm (Figure 1). At 5 to 10 days after the initial trauma, when the soft tissues were considered stable, free latissimus dorsi muscle flaps were performed to cover the tibial defect in each patient. At 3 to 10 weeks following the traumatic event, all of the patients had been referred to our foot and ankle unit for treatment of open heel defects that resulted in exposure of the posterior tuberosity of the calcaneus. In each case, the heel defect had
Patients’ limb immobilization
External fixation Intramedullary nail External fixation Intramedullary nail
FIGURE 1 Distal leg and hindfoot soft tissue defect after multiple debridement procedures.
resulted from either the original trauma, or it had developed secondary to pressure ulceration during the course of their care. The average heel open wound size was 5 cm ⫻ 7 cm (Figure 2). Prior to presentation to the foot and ankle service, these polytrauma patients had undergone a mean average of 6 surgeries, including operations for either thoracic and/or abdominal, neurological, vascular, plastic reconstructive, or orthopedic interventions. Moreover, the hindfoot soft tissue defects had been treated with repeated irrigation and debridement procedures and wet-to-dry dressings, or, in 4 patients (beginning in 2004), vacuum-assisted wound closure (V.A.C. Therapy, Kinetic Concepts, Inc., San Antonio, TX). After consideration, the plastic surgeons treating these patients declared that these patients were not candidates for a potentially complicated free tissue transfer, for the folVOLUME 47, NUMBER 2, MARCH/APRIL 2008
113
FIGURE 3 Cross-leg flap coverage of the heel.
FIGURE 2 Faliure of the distal portion of the flap with resulting exposure of the posterior tuberosity of the calcaneus.
lowing reasons: (1) poor potential vascular supply to a free tissue transfer in 1 patient with a G-A grade III C open fracture and consequent single vessel limb after a previous revascularization used to treat the initial tibial defect; (2) relatively small heel defect with granulation tissue partially covering the calcaneal tuberosity in 4 cases; (3) previous failure of the distal part of the latissimus dorsi free flap used to cover the tibial and hindfoot defect in 1 case; and (4) the presence of trauma-related medical and metabolic comorbidities, namely pulmonary complications, coagulopathy, and fluid and electrolyte imbalances in 1 case. Moreover, in all 7 of these patients, a simpler local muscle flap or ipsilateral fasciocutaneous reconstruction was also contraindicated because of preexisting soft tissue damage and postsurgical scars. In 3 patients who were treated before 2004, when we did not have vacuum-assisted wound closure technology at our institution, the pursuit of secondary intention healing by means of ongoing, repetitive wet-to-dry dressing changes was deemed inadvisable due to the anticipated length of treatment that would have been necessary to achieve adequate coverage of the heel defects. In 4 of the patients, vacuum-assisted wound closure promoted granulation coverage of the heel defects; however, we considered 114
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the use of a split-thickness skin graft in this location to be inadvisable for reasons related to graft durability. Therefore, we decided to elevate a distally based sural artery fasciocutaneous island flap on the contralateral leg, and cross it to the opposite lower extremity to repair the exposed region of the heel. Two preoperative tests were performed on the donor site (uninjured limb) in all of the cases: (1) a simple clinical exam to confirm the presence of a normal sensation through the distribution of the sural nerve, and (2) a Doppler ultrasound evaluation of the vascular network to confirm normal blood flow in the peroneal and tibial vessels. Other reversed island flaps such as the peroneal artery flap, anterior tibial artery flap, and posterior tibial artery flap were considered but excluded because it was determined that sacrifice of a major artery constituted a potentially serious disadvantage. The instep fasciocutaneous flap raised from the plantarmedial region of the sole between the heel and the metatarsal heads was also considered, and is known to be useful for reconstruction of weight-bearing heel defects; however, because of the shortness of the pedicle, we considered it too difficult to successfully cross. For the patients in our series, the sural artery tissue transfer remained our first choice for reconstruction because the blood supply to the flap is reliable, elevation is relatively easy and quick, and major arteries are not sacrificed. Limb immobilization was obtained either by means of external fixation of both legs in a comfortable position, or by means of a circumferentially applied elastic wrap. Five of the patients underwent application of an external fixator (Figure 3), which was first applied to the uninjured leg, and then to the side with the tibial defect. In the 2 patients who had undergone tibial intramedullary nailing, an elastic bandage was used to maintain the extremities in apposition. In these 2 cases, moreover, the heels were off-loaded simply using pillows to keep the hindfoot lifted above the support-
the line of the fascial pedicle, and the subdermal layer was dissected to expose the sural nerve and the accompanying vessels. The subcutaneous fascial pedicle was elevated, with a width of at least 2 cm, inclusive of the neurovascular bundle. In all of the cases, procurement of the flap was readily undertaken without complication, and blood loss was minimal. A number of reports have discussed the potential benefits of trying to preserve the sural nerve in the donor limb, however these techniques are associated with markedly increased operative time (5, 6). As with all island flaps, particular care was required during flap rotation to prevent torsion, compression, or kinking of the vascular pedicle. The skin paddle was then sutured to the defect. The donor site defect was skin grafted with autogneous splitthickness skin. The overall mean operative time was 106 minutes (range 80 to 135 minutes). FIGURE 4 Appearance of the flap after pedicle division. Note the soft tissue padding of the weight-bearing area of the heel.
Results ing surface. In all of the cases, the patients were able to flex both knees and to abduct their hips together while changing position in bed, without pulling on the flap pedicle. No specific exercises were prescribed while the flap was crossed and the legs immobilized. In all cases, the pedicle was divided 21 days postoperative, since this period of time is generally considered enough for primary flap insetting and autonomization (Figure 4). The external fixation devices were subsequently removed from the uninjured legs uneventfully. In all of the cases, deep venous thrombosis (DVT) prophylaxis was instituted using 4000 international units of enoxaparin daily, until full weight bearing was resumed. Progressive weight bearing was allowed between 6 and 8 weeks after the division of the cross-leg pedicle, depending upon the degree of soft tissue and bone healing. All of the patients had resumed full weight bearing by 12 weeks postoperative. Thereafter, accommodative footwear was used to protect the remodeling graft sites. The mean follow-up time was 28 (range 13 to 50) months. In all of the cases, the surgical procedure for execution of the sural artery cross-leg fasciocutaneous island flap involved positioning the patient supine, with additional support placed beneath the contralateral buttock to effect a semi-lateral decubitus position. In no case was a tourniquet used. Careful soft tissue debridement and bone resection was performed at the receiving site, after which the sural nerve was marked from the midcalf between the 2 heads of the gastrocnemius to the midpoint between the Achilles tendon and the lateral malleolus from the contralateral limb. The appropriately sized flap was marked out on this line with the pivot point kept at least 7 cm above the lateral malleolus. The incision was initiated at the proximal margin of the flap, and the sural nerve and associated vessels were identified, dissected, and then appropriately ligated and severed. The skin incision was then elongated distally along
All the distally based sural fasciocutaneous cross-leg flaps survived totally and the soft tissues healed uneventfully, thereby providing satisfactory and stable coverage of the calcaneal tuberosity. In one patient we observed a minimal superficial rim necrosis that appeared before pedicle division and healed by secondary intention with local wound care. There were no cases of infection, hematoma, or graft loss at the donor site. The only inevitable morbidity was the lack of sensation in the territory of the sural nerve on the donor limb. In one patient (G-A grade III C), an early failure of the tibial free flap due to a deep infection was observed. We were not able to control the infection and a below-the-knee amputation was performed. Interestingly, the sural artery fasciocutaneous sural flap used to cover the heel had healed uneventfully even in this patient. At the time of final followup, substantial flap remodeling had occurred, and no patient experienced local wound drainage and/or recurrent ulcerations, and all of the patients were able to walk on the flap without pain (Figure 5). Interestingly, all of the patients developed a certain degree of protective deep touch sensation in the area of flap coverage of the recipient heel. Discussion One of the goals in the management of severe open injuries of the foot is to obtain adequate soft tissue coverage. Defects over the weight-bearing part of the heel require a well-vascularized reconstruction having the characteristics of stability, adequate padding and durability. Different forms of soft tissue coverage are available, including muscle, fasciocutaneous, and free flaps (7). However, in the presence of hindfoot soft tissue defects, particularly those involving exposure of the posterior tuberosity of the calcaVOLUME 47, NUMBER 2, MARCH/APRIL 2008
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FIGURE 5 Long-term clinical appearance of the heel at the latest follow-up visit. Good remodeling and padding of the heel have occurred.
neus, in patients who are not candidates for microsurgical free-tissue transfer, ipsilateral fasciocutaneous, or local muscle flaps, very few solutions are available in order to attempt limb salvage. In this difficult scenario, the cross-leg flap remains an option for surgical reconstruction of the heel. Classically, cross-leg flaps allow a limited amount of tissue transfer, as the pedicles are short, thick, and not capable of being stretched. Furthermore, cross-leg flaps traditionally convey a limited arch of rotation and an unreliable random blood supply. These limitations force the patient into uncomfortable cross-leg postures that must be maintained while the graft is taking at the recipient site. As a result of these shortcomings, traditional cross-leg flaps have been associated with complications, including an inability to adequately cover the recipient site wound (2, 7). In 1981, Potén (8) pointed out the significance of the fasciocutaneous circulation. Subsequently, the vascular anatomy of the skin was closely detailed and fasciocutaneous flaps were designed with predictable circulation (9 –11). In 1992, Masquelet et al (9) described skin island flaps supplied by the vascular axis of the sensitive superficial nerves of the leg. The vascular axis, which can be either a true artery (a named anatomical vessel) or an interlacing network, ensures the vascularization of the nerves, gives off several cutaneous branches in the suprafascial course of the nerve, and anastomoses with the septocutaneous arteries issuing from a deep main vessel. The superficial nerves that course the leg can therefore be considered as vascular relays owing to their neurocutaneous arteries (9). The vascular supply to the distally based sural fasciocutaneuos flap is derived from the retrograde perfusion of the arteries that accompany the lesser saphenous vein and sural nerve. These arteries descend along both sides of the lesser saphenous vein, either terminating or anastomosing with the septocu116
THE JOURNAL OF FOOT & ANKLE SURGERY
taneous perforators of the peroneal artery 5 to 10 cm above the lateral malleolus. The blood supply courses in a retrograde fashion from these perforators when the nerve and the arteries are cut proximally. The distally based lower-leg fasciocutaneous and adipofascial local flaps, described by Masquelet et al (9) offer an easy and reliable surgical option, to free flaps in presence of distal third soft tissues defects of the leg and foot of small and medium extension. Their use in acute and chronic traumatic soft tissue injuries, namely degloving, crush, and avulsion injuries with resultant loss of wound coverage, is well documented and is gaining widespread acceptance (1, 9, 11, 12). Compared to the traditional cross-leg technique, the cross-leg island flap with a subcutaneous pedicle based on the sural neurovascular bundle has provided a major improvement in flap mobility, with a longer and more pliable pedicle and a predictable blood supply. In the series of patients described in this report, the pedicles of the cross-leg flaps were divided 21 days postoperative, as this period of time is generally considered enough for primary flap insetting and autonomization. Much to our satisfaction, and that of the patients, all of the flaps described in this report survived completely. Acland (13) found regular flap necrosis when the pedicle vessels were ligated at 7 days. Similarly, Serafin and colleagues (14) noted a high correlation between the timing of vessel ligation and the percentage of flap survival. In our series, we also found vacuum-assisted wound closure to be a useful adjunct for hindfoot defects because of its ability to control exudate and edema, to increase vascularity and decrease wound size, and to decrease bacterial colonization; however, multimodal therapies including flap coverage are still often needed to facilitate closure after heel wounds have been prepared (15–18). Initially developed in the early 1990s for the management of large, chronically infected wounds that could not be closed in extremely debilitated patients, vacuum-assisted wound closure has, more recently, been used in the treatment of traumatic wounds (15, 16). Although the use over bone, tendon, or hardware was considered an early contraindication to the negative-pressure wound therapy (NPWT), there are now reports that support its use in the presence of exposed deep structures (15–17). In our hands, although we were able to obtain profuse granulation tissue covering bone, we still needed a regional flap to be rotated in order to obtain complete wound coverage about the heel. Our results using NPWT were in line with those noted in previously published reports, wherein Herscovici and colleagues (15) stated that the use of a free-tissue transfer was still required in 43% of their cases, and De Franzo and colleagues (16) described successful wound coverage in 71 of 75 cases with skin and or regional muscle transfer versus free-tissue transfer after the use of vacuum-assisted closure.
It is our opinion that the distally based sural fasciocutaneous cross-leg flap may still be required to obtain adequate coverage in very specific cases; even efforts to achieve closure using NPWT. Due to the weight-bearing requirements of the heel, and the precarious soft tissue padding offered by granulation tissue covering the posterior tuberosity of the calcaneus, we did not consider the use of a split-thickness skin graft to be a suitable option. This concern has also been expressed in the literature, where a number of authors have demonstrated the failure of efforts to resurface the weight-bearing area of the heel using splitthickness skin grafts (1, 19 –21). Moreover, NPWT, as well as the use of microvascular free flaps, require relatively expensive instrumentation and highly skilled surgeons, and these assets are not always readily available, particularly in underprivileged areas of the world. In such eventualities, we believe that the distally based sural artery fasciocutaneous cross-leg flap described in this report provides a useful option for reconstruction of the heel. Although we could not draw definitive conclusions because of the small size of our case series, the distally based sural cross-leg flap proved to be a valuable reconstructive option for our patients. In conclusion, we recommend that the sural fasciocutaneous cross-leg flap be considered as a “last chance” for limb salvage in a select cohort of patients with soft tissue defects over weight-bearing surfaces of the hindfoot in which no other reasonable solution is available.
6.
7.
8. 9.
10. 11.
12.
13. 14.
15.
16.
References 17. 1. de Almeida OM, Monteiro AA Jr, Neves RI, de Lemos RG, Braz JC, Brechtbuhl ER, Gemperli R, Ferreira MC. Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot. Ann Plast Surg 44:367–373, 2000. 2. Atiyeh BS, Al-Amm CA, El-Musa KA, Sawwaf AW, Musharafieh RS. Distally based sural fasciocutaneous cross-leg flap: a new application of an old procedure. Plast Reconst Surg 111:1470 –1474, 2003. 3. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of the long bones: retrospective and prospective analysis. J Bone Joint Surg 58-A:453– 458, 1976. 4. Advanced Trauma Life Support for Doctors, ed 7, p 1–391, American College of Surgeons, Chicago, IL, 2005. 5. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Fukui Y, Miyasaka T, Kodama T, Aiso S, Fujino T. Accompanying arteries of the lesser
18.
19. 20.
21.
saphenous vein and sural nerve: anatomic study and its clinical applications. Plast Reconst Surg 103:104 –120, 1999. Yilmaz M, Karatas Q, Barutca A. The distally based sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg 102: 2356 –2367, 1998. Chapman MV, Olson SA. Open fractures. In Rockwood and Green’s Fractures in Adults, ed 4pp 305–352, edited by RW., Bucholz JD., Heckman Court-Brown C., P., Tornetta KJ., Kova Lippincott-Raven, Philadelphia, 1996. Potén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 34:215–220, 1981. 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 89(6):1115–1121, 1992. Fix RJ, Vasconez LO. Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg 18:571–582, 1991. Louton RB, Harley RA, Hagerty RC. A fasciocutaneous transposition flap for coverage of defects of the lower extremity. J Bone Joint Surg 71-A:988 –994, 1989. Touam C, Rostoucher P, Bhatia A, Oberlin C. Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 107:383–392, 2001. Acland RD. In Skin Flaps, p 100 –105, edited by WC Grabb, B Myers B, Little Brown, Philadelphia, PA, 1975. Serafin D, Shearin JC, Georgiade NG. The vascularization of free flaps: clinical and experimental correlation. Plast Reconstr Surg 60: 233–237, 1977. Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 17(10):683– 688, 2003. DeFranzo AJ, Argenta LC, Marks MW, Molnar JA, David LR, Webb LX, Ward WG, Teasdall RG. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg 108:1184 –1191, 2001. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuumassisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 38(6):553–562, 1997. Argenta LC, Morykwas MJ. Vacuum-assisted closure. A new method for wound control and treatment. Clinical experience. Ann Plast Surg 38(6):563–577, 1997. S¸avk O, S¸avk E. Reverse sural artery flap for distal lower extremity defects. J Dermatol 33(10):700 –704, 2005. Ortak T, Ozdemir R, Ulusoy MG, Tiftikcioglu YO, Karaaslan O, Kocer U, Sensoz O. Reconstruction of heel defects with a proximally based abductor hallucis muscle flap. J Foot Ankle Surg 4(44):265–270, 2005. Suri MP, Patel AG, Vora HJ, Raibagkar SC, Mehta DR, Vyas UH. Post traumatic posterior heel soft defect reconstruction. Indian J Plastic Surgery 2(38):138 –143, 2005.
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I n the presence of an extensive hindfoot soft tissue defect,
without the ability to employ microsurgical free-tissue transfer or ipsilateral fasciocutaneous or local muscular flaps, very few solutions are available for attempting coverage of the calcaneus and other portions of the traumatized hindfoot. In such cases, cross-leg and cross-foot flaps can be employed, and use of the sural artery cross-leg flap for coverage of contralateral heel defects may be a useful option. One case of sural cross-leg flap has been previously mentioned in a report of 22 patients in which the ipsilateral distally based sural fasciocutaneous flap was used to reconstruct distal leg defects (1). The sural cross-leg flap has also been used successfully to reconstruct 2 cases of chronic and infected ulcers of the foot (2). The aim of the current report was to retrospectively assess the results of heel coverage using a distally based sural artery fasciocutaneous cross-leg flap in a series of patients that had sustained polytrauma with associated complex bone and soft tissue defects in-
Address correspondence to: Attilio Basile, MD, Via Nicola Pellati 45, 00149 Rome, Italy. E-mail: [email protected]. 1 Orthopaedic Surgeon, Department of Orthopaedic and Trauma Surgery, Ospedale San Giovanni-Addolorata, Rome, Italy. 2 Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Ospedale San Giovanni-Addolorata, Rome, Italy. Copyright © 2008 by the American College of Foot and Ankle Surgeons 1067-2516/08/4702-0006$34.00/0 doi:10.1053/j.jfas.2007.12.005
112
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volving the leg and hindfoot. To the best of our knowledge, this is the first report of the results of this sural artery cross-leg flap for coverage of the heel in polytrauma patients. Patients and Methods We retrospectively reviewed consecutive patients who were treated at our institution by means of a distally based sural artery fasciocutaneous cross-leg flap. To be included in the case series, the patients had to have been admitted for treatment of polytrauma that included leg and foot bone and soft tissue defects, and the aforementioned cross-leg flap had to have been employed for the coverage of a persistent heel wound. The review was undertaken by the authors, who also served as the managing surgeons for the patients described in this report. Review of the records revealed 7 patients who met our inclusion criteria (Table 1). All of the patients were motor vehicle accident victims and, in all of the cases, the contralateral limb was uninjured. Six of the patients suffered Gustilo-Anderson (G-A) grade III B open tibial fractures while 1 presented with a G-A grade III C injury (3). All of the injuries were associated with exposure of the ipsilateral heel by means of acute degloving that was sustained at the time of the initial trauma, or due to secondary nonhealing ulceration of the hindfoot with resultant exposure of the
TABLE 1
Clinical characteristics of the case series
Patient
Age (y)
1
26
Male
2
36
Male
3
30
Female
4
28
Male
5
29
Male
6
55
Male
7
33
Female
Gender
Injuries
Degloving injury (secondary bone exposition) Primary hindfoot soft tissue defect Degloving injury (secondary bone exposition) Pressure ulcer Primary hindfoot soft tissue defect Pressure ulcer Primary hindfoot soft tissue defect
Medical comorbidities
Heel wound defect (cm)
Wound preparation
None
6⫻6
External fixation
None
4⫻8
None
5⫻7
None (cigarette smoker) None
6⫻8 5⫻5
Vacuum-assisted closure Vacuum-assisted closure Vacuum-assisted closure Vacuum-assisted closure Wet to dry
None (cigarette smoker) None
4⫻7
Wet to dry
External fixation
5⫻8
Wet to dry
External fixation
posterior tuberosity of the calcaneus that developed over the course of the hospitalization. The patients were treated between December 2002 and March 2006, at our level I trauma center. The case series consisted of 5 males and 2 females with an average age of 33.9 years (range 26 to 55 years), and none of the patients were complicated with any systemic disease comorbidities at the time of admission. Two of the patients related that they smoked 10 to 15 cigarettes per day and were strongly advised to discontinue smoking during the recovery period, and both of these patients fully complied with this recommendation. Upon admission, all of the patients underwent assessment and resuscitation according to advanced trauma life support (ATLS, American College of Surgeons, Inc., Chicago, IL) guidelines (4). All of the patients, moreover, were administered intravenous antibiotics (cefotaxime 2 g every 8 hours for 5 days); and neurological, thoracic, and abdominal lifethreatening injuries were treated. Open fractures were managed with urgent debridement and irrigation, and external fixation was used in 5 patients while immediate intramedullary nailing was used in 2 patients. In 1 case, categorized as a G-A III C fracture, repair of the posterior tibial artery was performed with an interpositional vein graft. All open wounds were packed with tobramicin-impregnated polymethylmethacrylate beads. Within 24 to 48 hours, patients were taken back to the operative theater for repeat debridement and irrigation. The average tibial wound size after this debridement procedure was 13 cm ⫻ 7 cm (Figure 1). At 5 to 10 days after the initial trauma, when the soft tissues were considered stable, free latissimus dorsi muscle flaps were performed to cover the tibial defect in each patient. At 3 to 10 weeks following the traumatic event, all of the patients had been referred to our foot and ankle unit for treatment of open heel defects that resulted in exposure of the posterior tuberosity of the calcaneus. In each case, the heel defect had
Patients’ limb immobilization
External fixation Intramedullary nail External fixation Intramedullary nail
FIGURE 1 Distal leg and hindfoot soft tissue defect after multiple debridement procedures.
resulted from either the original trauma, or it had developed secondary to pressure ulceration during the course of their care. The average heel open wound size was 5 cm ⫻ 7 cm (Figure 2). Prior to presentation to the foot and ankle service, these polytrauma patients had undergone a mean average of 6 surgeries, including operations for either thoracic and/or abdominal, neurological, vascular, plastic reconstructive, or orthopedic interventions. Moreover, the hindfoot soft tissue defects had been treated with repeated irrigation and debridement procedures and wet-to-dry dressings, or, in 4 patients (beginning in 2004), vacuum-assisted wound closure (V.A.C. Therapy, Kinetic Concepts, Inc., San Antonio, TX). After consideration, the plastic surgeons treating these patients declared that these patients were not candidates for a potentially complicated free tissue transfer, for the folVOLUME 47, NUMBER 2, MARCH/APRIL 2008
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FIGURE 3 Cross-leg flap coverage of the heel.
FIGURE 2 Faliure of the distal portion of the flap with resulting exposure of the posterior tuberosity of the calcaneus.
lowing reasons: (1) poor potential vascular supply to a free tissue transfer in 1 patient with a G-A grade III C open fracture and consequent single vessel limb after a previous revascularization used to treat the initial tibial defect; (2) relatively small heel defect with granulation tissue partially covering the calcaneal tuberosity in 4 cases; (3) previous failure of the distal part of the latissimus dorsi free flap used to cover the tibial and hindfoot defect in 1 case; and (4) the presence of trauma-related medical and metabolic comorbidities, namely pulmonary complications, coagulopathy, and fluid and electrolyte imbalances in 1 case. Moreover, in all 7 of these patients, a simpler local muscle flap or ipsilateral fasciocutaneous reconstruction was also contraindicated because of preexisting soft tissue damage and postsurgical scars. In 3 patients who were treated before 2004, when we did not have vacuum-assisted wound closure technology at our institution, the pursuit of secondary intention healing by means of ongoing, repetitive wet-to-dry dressing changes was deemed inadvisable due to the anticipated length of treatment that would have been necessary to achieve adequate coverage of the heel defects. In 4 of the patients, vacuum-assisted wound closure promoted granulation coverage of the heel defects; however, we considered 114
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the use of a split-thickness skin graft in this location to be inadvisable for reasons related to graft durability. Therefore, we decided to elevate a distally based sural artery fasciocutaneous island flap on the contralateral leg, and cross it to the opposite lower extremity to repair the exposed region of the heel. Two preoperative tests were performed on the donor site (uninjured limb) in all of the cases: (1) a simple clinical exam to confirm the presence of a normal sensation through the distribution of the sural nerve, and (2) a Doppler ultrasound evaluation of the vascular network to confirm normal blood flow in the peroneal and tibial vessels. Other reversed island flaps such as the peroneal artery flap, anterior tibial artery flap, and posterior tibial artery flap were considered but excluded because it was determined that sacrifice of a major artery constituted a potentially serious disadvantage. The instep fasciocutaneous flap raised from the plantarmedial region of the sole between the heel and the metatarsal heads was also considered, and is known to be useful for reconstruction of weight-bearing heel defects; however, because of the shortness of the pedicle, we considered it too difficult to successfully cross. For the patients in our series, the sural artery tissue transfer remained our first choice for reconstruction because the blood supply to the flap is reliable, elevation is relatively easy and quick, and major arteries are not sacrificed. Limb immobilization was obtained either by means of external fixation of both legs in a comfortable position, or by means of a circumferentially applied elastic wrap. Five of the patients underwent application of an external fixator (Figure 3), which was first applied to the uninjured leg, and then to the side with the tibial defect. In the 2 patients who had undergone tibial intramedullary nailing, an elastic bandage was used to maintain the extremities in apposition. In these 2 cases, moreover, the heels were off-loaded simply using pillows to keep the hindfoot lifted above the support-
the line of the fascial pedicle, and the subdermal layer was dissected to expose the sural nerve and the accompanying vessels. The subcutaneous fascial pedicle was elevated, with a width of at least 2 cm, inclusive of the neurovascular bundle. In all of the cases, procurement of the flap was readily undertaken without complication, and blood loss was minimal. A number of reports have discussed the potential benefits of trying to preserve the sural nerve in the donor limb, however these techniques are associated with markedly increased operative time (5, 6). As with all island flaps, particular care was required during flap rotation to prevent torsion, compression, or kinking of the vascular pedicle. The skin paddle was then sutured to the defect. The donor site defect was skin grafted with autogneous splitthickness skin. The overall mean operative time was 106 minutes (range 80 to 135 minutes). FIGURE 4 Appearance of the flap after pedicle division. Note the soft tissue padding of the weight-bearing area of the heel.
Results ing surface. In all of the cases, the patients were able to flex both knees and to abduct their hips together while changing position in bed, without pulling on the flap pedicle. No specific exercises were prescribed while the flap was crossed and the legs immobilized. In all cases, the pedicle was divided 21 days postoperative, since this period of time is generally considered enough for primary flap insetting and autonomization (Figure 4). The external fixation devices were subsequently removed from the uninjured legs uneventfully. In all of the cases, deep venous thrombosis (DVT) prophylaxis was instituted using 4000 international units of enoxaparin daily, until full weight bearing was resumed. Progressive weight bearing was allowed between 6 and 8 weeks after the division of the cross-leg pedicle, depending upon the degree of soft tissue and bone healing. All of the patients had resumed full weight bearing by 12 weeks postoperative. Thereafter, accommodative footwear was used to protect the remodeling graft sites. The mean follow-up time was 28 (range 13 to 50) months. In all of the cases, the surgical procedure for execution of the sural artery cross-leg fasciocutaneous island flap involved positioning the patient supine, with additional support placed beneath the contralateral buttock to effect a semi-lateral decubitus position. In no case was a tourniquet used. Careful soft tissue debridement and bone resection was performed at the receiving site, after which the sural nerve was marked from the midcalf between the 2 heads of the gastrocnemius to the midpoint between the Achilles tendon and the lateral malleolus from the contralateral limb. The appropriately sized flap was marked out on this line with the pivot point kept at least 7 cm above the lateral malleolus. The incision was initiated at the proximal margin of the flap, and the sural nerve and associated vessels were identified, dissected, and then appropriately ligated and severed. The skin incision was then elongated distally along
All the distally based sural fasciocutaneous cross-leg flaps survived totally and the soft tissues healed uneventfully, thereby providing satisfactory and stable coverage of the calcaneal tuberosity. In one patient we observed a minimal superficial rim necrosis that appeared before pedicle division and healed by secondary intention with local wound care. There were no cases of infection, hematoma, or graft loss at the donor site. The only inevitable morbidity was the lack of sensation in the territory of the sural nerve on the donor limb. In one patient (G-A grade III C), an early failure of the tibial free flap due to a deep infection was observed. We were not able to control the infection and a below-the-knee amputation was performed. Interestingly, the sural artery fasciocutaneous sural flap used to cover the heel had healed uneventfully even in this patient. At the time of final followup, substantial flap remodeling had occurred, and no patient experienced local wound drainage and/or recurrent ulcerations, and all of the patients were able to walk on the flap without pain (Figure 5). Interestingly, all of the patients developed a certain degree of protective deep touch sensation in the area of flap coverage of the recipient heel. Discussion One of the goals in the management of severe open injuries of the foot is to obtain adequate soft tissue coverage. Defects over the weight-bearing part of the heel require a well-vascularized reconstruction having the characteristics of stability, adequate padding and durability. Different forms of soft tissue coverage are available, including muscle, fasciocutaneous, and free flaps (7). However, in the presence of hindfoot soft tissue defects, particularly those involving exposure of the posterior tuberosity of the calcaVOLUME 47, NUMBER 2, MARCH/APRIL 2008
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FIGURE 5 Long-term clinical appearance of the heel at the latest follow-up visit. Good remodeling and padding of the heel have occurred.
neus, in patients who are not candidates for microsurgical free-tissue transfer, ipsilateral fasciocutaneous, or local muscle flaps, very few solutions are available in order to attempt limb salvage. In this difficult scenario, the cross-leg flap remains an option for surgical reconstruction of the heel. Classically, cross-leg flaps allow a limited amount of tissue transfer, as the pedicles are short, thick, and not capable of being stretched. Furthermore, cross-leg flaps traditionally convey a limited arch of rotation and an unreliable random blood supply. These limitations force the patient into uncomfortable cross-leg postures that must be maintained while the graft is taking at the recipient site. As a result of these shortcomings, traditional cross-leg flaps have been associated with complications, including an inability to adequately cover the recipient site wound (2, 7). In 1981, Potén (8) pointed out the significance of the fasciocutaneous circulation. Subsequently, the vascular anatomy of the skin was closely detailed and fasciocutaneous flaps were designed with predictable circulation (9 –11). In 1992, Masquelet et al (9) described skin island flaps supplied by the vascular axis of the sensitive superficial nerves of the leg. The vascular axis, which can be either a true artery (a named anatomical vessel) or an interlacing network, ensures the vascularization of the nerves, gives off several cutaneous branches in the suprafascial course of the nerve, and anastomoses with the septocutaneous arteries issuing from a deep main vessel. The superficial nerves that course the leg can therefore be considered as vascular relays owing to their neurocutaneous arteries (9). The vascular supply to the distally based sural fasciocutaneuos flap is derived from the retrograde perfusion of the arteries that accompany the lesser saphenous vein and sural nerve. These arteries descend along both sides of the lesser saphenous vein, either terminating or anastomosing with the septocu116
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taneous perforators of the peroneal artery 5 to 10 cm above the lateral malleolus. The blood supply courses in a retrograde fashion from these perforators when the nerve and the arteries are cut proximally. The distally based lower-leg fasciocutaneous and adipofascial local flaps, described by Masquelet et al (9) offer an easy and reliable surgical option, to free flaps in presence of distal third soft tissues defects of the leg and foot of small and medium extension. Their use in acute and chronic traumatic soft tissue injuries, namely degloving, crush, and avulsion injuries with resultant loss of wound coverage, is well documented and is gaining widespread acceptance (1, 9, 11, 12). Compared to the traditional cross-leg technique, the cross-leg island flap with a subcutaneous pedicle based on the sural neurovascular bundle has provided a major improvement in flap mobility, with a longer and more pliable pedicle and a predictable blood supply. In the series of patients described in this report, the pedicles of the cross-leg flaps were divided 21 days postoperative, as this period of time is generally considered enough for primary flap insetting and autonomization. Much to our satisfaction, and that of the patients, all of the flaps described in this report survived completely. Acland (13) found regular flap necrosis when the pedicle vessels were ligated at 7 days. Similarly, Serafin and colleagues (14) noted a high correlation between the timing of vessel ligation and the percentage of flap survival. In our series, we also found vacuum-assisted wound closure to be a useful adjunct for hindfoot defects because of its ability to control exudate and edema, to increase vascularity and decrease wound size, and to decrease bacterial colonization; however, multimodal therapies including flap coverage are still often needed to facilitate closure after heel wounds have been prepared (15–18). Initially developed in the early 1990s for the management of large, chronically infected wounds that could not be closed in extremely debilitated patients, vacuum-assisted wound closure has, more recently, been used in the treatment of traumatic wounds (15, 16). Although the use over bone, tendon, or hardware was considered an early contraindication to the negative-pressure wound therapy (NPWT), there are now reports that support its use in the presence of exposed deep structures (15–17). In our hands, although we were able to obtain profuse granulation tissue covering bone, we still needed a regional flap to be rotated in order to obtain complete wound coverage about the heel. Our results using NPWT were in line with those noted in previously published reports, wherein Herscovici and colleagues (15) stated that the use of a free-tissue transfer was still required in 43% of their cases, and De Franzo and colleagues (16) described successful wound coverage in 71 of 75 cases with skin and or regional muscle transfer versus free-tissue transfer after the use of vacuum-assisted closure.
It is our opinion that the distally based sural fasciocutaneous cross-leg flap may still be required to obtain adequate coverage in very specific cases; even efforts to achieve closure using NPWT. Due to the weight-bearing requirements of the heel, and the precarious soft tissue padding offered by granulation tissue covering the posterior tuberosity of the calcaneus, we did not consider the use of a split-thickness skin graft to be a suitable option. This concern has also been expressed in the literature, where a number of authors have demonstrated the failure of efforts to resurface the weight-bearing area of the heel using splitthickness skin grafts (1, 19 –21). Moreover, NPWT, as well as the use of microvascular free flaps, require relatively expensive instrumentation and highly skilled surgeons, and these assets are not always readily available, particularly in underprivileged areas of the world. In such eventualities, we believe that the distally based sural artery fasciocutaneous cross-leg flap described in this report provides a useful option for reconstruction of the heel. Although we could not draw definitive conclusions because of the small size of our case series, the distally based sural cross-leg flap proved to be a valuable reconstructive option for our patients. In conclusion, we recommend that the sural fasciocutaneous cross-leg flap be considered as a “last chance” for limb salvage in a select cohort of patients with soft tissue defects over weight-bearing surfaces of the hindfoot in which no other reasonable solution is available.
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References 17. 1. de Almeida OM, Monteiro AA Jr, Neves RI, de Lemos RG, Braz JC, Brechtbuhl ER, Gemperli R, Ferreira MC. Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot. Ann Plast Surg 44:367–373, 2000. 2. Atiyeh BS, Al-Amm CA, El-Musa KA, Sawwaf AW, Musharafieh RS. Distally based sural fasciocutaneous cross-leg flap: a new application of an old procedure. Plast Reconst Surg 111:1470 –1474, 2003. 3. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of the long bones: retrospective and prospective analysis. J Bone Joint Surg 58-A:453– 458, 1976. 4. Advanced Trauma Life Support for Doctors, ed 7, p 1–391, American College of Surgeons, Chicago, IL, 2005. 5. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Fukui Y, Miyasaka T, Kodama T, Aiso S, Fujino T. Accompanying arteries of the lesser
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saphenous vein and sural nerve: anatomic study and its clinical applications. Plast Reconst Surg 103:104 –120, 1999. Yilmaz M, Karatas Q, Barutca A. The distally based sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg 102: 2356 –2367, 1998. Chapman MV, Olson SA. Open fractures. In Rockwood and Green’s Fractures in Adults, ed 4pp 305–352, edited by RW., Bucholz JD., Heckman Court-Brown C., P., Tornetta KJ., Kova Lippincott-Raven, Philadelphia, 1996. Potén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 34:215–220, 1981. 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 89(6):1115–1121, 1992. Fix RJ, Vasconez LO. Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg 18:571–582, 1991. Louton RB, Harley RA, Hagerty RC. A fasciocutaneous transposition flap for coverage of defects of the lower extremity. J Bone Joint Surg 71-A:988 –994, 1989. Touam C, Rostoucher P, Bhatia A, Oberlin C. Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 107:383–392, 2001. Acland RD. In Skin Flaps, p 100 –105, edited by WC Grabb, B Myers B, Little Brown, Philadelphia, PA, 1975. Serafin D, Shearin JC, Georgiade NG. The vascularization of free flaps: clinical and experimental correlation. Plast Reconstr Surg 60: 233–237, 1977. Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 17(10):683– 688, 2003. DeFranzo AJ, Argenta LC, Marks MW, Molnar JA, David LR, Webb LX, Ward WG, Teasdall RG. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg 108:1184 –1191, 2001. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuumassisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 38(6):553–562, 1997. Argenta LC, Morykwas MJ. Vacuum-assisted closure. A new method for wound control and treatment. Clinical experience. Ann Plast Surg 38(6):563–577, 1997. S¸avk O, S¸avk E. Reverse sural artery flap for distal lower extremity defects. J Dermatol 33(10):700 –704, 2005. Ortak T, Ozdemir R, Ulusoy MG, Tiftikcioglu YO, Karaaslan O, Kocer U, Sensoz O. Reconstruction of heel defects with a proximally based abductor hallucis muscle flap. J Foot Ankle Surg 4(44):265–270, 2005. Suri MP, Patel AG, Vora HJ, Raibagkar SC, Mehta DR, Vyas UH. Post traumatic posterior heel soft defect reconstruction. Indian J Plastic Surgery 2(38):138 –143, 2005.
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