Rev. bras. ortop. vol.49 número2

w w w . r b o . o r g . b r

Original

Article

Fasciocutaneous

flaps

for

covering

foot

and

ankle

injuries

夽,夽夽

Alexandre

Carvalho

Quirino

,

Karen

Cristina

Viegas

b_{UniversidadeFederaldeSãoJoãoDelRei,SãoJoãoDelRei,MG,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received18January2012

Accepted27May2013

Availableonline18March2014

Keywords:

Surgicalflaps

Lowerextremity

Leginjuries/surgery

Reconstructivesurgicalprocedures

a

b

s

t

r

a

c

t

Objective:to presentsomecasesfromourserviceandtoconfirm thatsural andlateral

supramalleolarflapsaregoodoptionsforcoveringthesofttissuesofthefootandankle.

Methods:twenty-twoflapswereconstructedin21patientsofagesrangingfrom15to72

years.Malepatientspredominated(66.6%)andin47.6%ofthecasestheinjuryresulted

fromaccidentsinvolvingmotorcycles.

Results:amongthe22flaps,12weresuraland10werelateralsupramalleolar;inonecase,

twoflapswereused.Inallthecases,theinjuriesweresuccessfullycoveredandthepatients

recoveredwell.Duringthepostoperativefollow-up,thecommonestcomplicationwas

epi-dermolysis,occurringineightcases(threeinasuralflapandfiveinasupramalleolarflap),

amongwhichtwocasesprogressedtodistalnecrosisoftheflap(onesuralandtheother

supramalleolar).Onepatientwantedtheflapreviewedforestheticreasons.

Conclusions: suralandsupramalleolarflapsareveryreliable.Theypreservethemaintrunk

arteries,arequicklydissected,havelowhospitalcost,enablecoverageofextensiveareas,

presentestheticallyacceptabledamagetothedonorareaanddonotimpairmotorfunction.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.Allrightsreserved.

Retalhos

fasciocutâneos

para

cobertura

de

lesões

no

pé

e

tornozelo

Palavras-chave:

Retalhoscirúrgicos

Extremidadeinferior

Traumatismosdaperna/cirurgia

Procedimentoscirúrgicos

reconstrutivos

r

e

s

u

m

o

Objetivo:mostraralgunscasosdonossoservic¸o,alémdeconfirmarcomoboasopc¸õesos

retalhossuralesupramaleolarlateralnacoberturadepartesmolesdopéetornozelo.

Métodos:foramfeitos22retalhosem21pacientes,entre15e72anos.Houvepredomínio

dosexomasculino,com66,6%,eem47,6%aslesõesforamdecorrentesdeacidentesque

envolverammotocicletas.

Resultados: dos22retalhos,12foramdotiposurale10,supramaleolarlateral.Emumcaso

usaram-seosdoisretalhos.Emtodososcasoshouvesucessonacoberturadaslesões,com

boarecuperac¸ãodospacientes.Noseguimentopós-operatórioacomplicac¸ãomaiscomum

夽

Pleasecitethisarticleas:QuirinoAC,ViegasKC.Retalhosfasciocutâneosparacoberturadelesõesnopéetornozelo.RevBrasOrtop.

2014;49:183–188.

夽夽

WorkperformedatHospitalSãoJoãodeDeusandatHospitalSantaLúcia,Divinópolis,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:alexandrequirino@uol.com.br(A.C.Quirino).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

184

foi aepidermólise, comoitocasos, trêsnoretalhosural ecinconosupramaleolar, dos

quaisdoisprogrediramparapequenanecrosedistaldoretalho,umdelessuraleooutro

supramaleolar.Umpacientedesejoureveroretalhoporquestãoestética.

Conclusões: osretalhossuralesupramaleolarsãobastanteconfiáveis,preservamostroncos

arteriaisprincipais,sãoderápidadissecc¸ão,têmbaixocustohospitalar,permitem

cober-turadeáreasextensaseapresentamdanoestéticoaceitávelnaáreadoadorasemprejuízo

funcionalmotor.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier

EditoraLtda.Todososdireitosreservados.

Introduction

Beforebeginningthisstudy,weobtainedapprovalfromthe

BrazilPlatform, anonline toolforregisteringresearchthat

involveshumanbeings,whichisaimedtowardthegeneral

publicandtowardaidingtheworkoftheResearch

Commit-teesystemandtheNationalResearchEthicsCommitteeofthe

NationalHealthCouncil(CEP/CONEP/CNS).

Today,withthesignificantlyincreasednumberofcarand

motorcycleaccidents,tissuelossesfrom thefootandankle

regionarebecomingincreasinglyfrequent.1_{Theseinjuriesare}

dealtwithroutinelyatreferralservices,wherelabor,surgical

techniquesandspecializedtrainingareabundantlyavailable,

withthecapabilitytoresolvesuchlossesusingfreeflaps.

Ontheotherhand,manysuchservices,oftendistantfrom

themetropolises,alsoreceivesignificantnumbersofcasesof

theseinjuriesbutdonothavethesameconditionsasthe

refer-ral services. Thus, onevery reasonablechoicefor covering

these tissue losses in feet and ankles is sural

fasciocuta-neousandlateralsupramalleolarflaps.Thesetwoflapswere

describedbyMasqueletetal.in1992,2,3_{andtheyhavebecome}

oneofthefewoptionsforcoveringtheseregions,whichhave

asparsevascularbed4_{inwhichbonesandtendonsareoften}

foundtobeexposedinadditiontovesselsandnerves.

Suralandlateralsupramalleolarflapsareveryreliable5,6_:

theypreservethemaintrunkarteries,canbedissectedrapidly

and,differentlyfromfreeflaps,havealowhospitalcost.They

makeit possibletocover largeareas,havealargerangeof

rotation,5,7_{presentedacceptableestheticdamageinthedonor}

area without functional damageand are therefore a good

choiceforcoveringfootandankleinjuries.8

Thepresentstudyhadtheaimofshowingsomecasesfrom

ourservice,aswellasconfirmingthatsuralandlateral

supra-malleolarflapsaregoodoptionsforcoveringsofttissuesofthe

footandankle.Italsoconfirmsthatmanyinjuriesthat

for-merlywereonlycoveredwithfreeflapscanalsoberesolved

using fasciocutaneous flaps, withfaster and simpler

tech-niques,atservicesthatdonothavethehumanand/orsurgical

resourcesformicrosurgicalflapsofgreatersophistication.In

thismanner,freeflapsareleftasthelastoptionand/orfor

casesinwhichtherereallyisnootherchoice.

Materials

and

methods

Twenty-onepatients(22flaps)attendedatHospitalSãoJoão

deDeusandHospitalSantaLúciainDivinópolis,MinasGerais,

between2007 and 2012, were evaluated. Fourteen patients

Table1–Detailsofthepopulationstudied.

Variables N %

Sex

Male 14 66.67

Female 7 33.33

Causeofinjury

Motorcycleaccidents 10 47.62

Othertypes 11 52.38

Comorbidities

Yes 3(SAHa_:2/DMb_{:1) 14.28}

No 18 85.72

a _{Systemicarterialhypertension.}

b _{Diabetesmellitus.}

weremaleandsevenwerefemale,withameanageof37years

andarangefrom15to72.Thesideaffectedanddominantside

wereevenlybalancedamongthepatients.

In10patients(47.6%),theinjuriesresultedfrommotorcycle

accidents.Theinjurieswereobservedindifferentregionsof

thefootandankle,withninecasesintheankle,seveninthe

hindfoot(includingtheheel)andsixbetweenthemidfootand

forefoot.Thetimethathadelapsedbetweentheinjuryandthe

surgerytoprovidecoveragerangedfromtwoto264days,with

ameanof40.3.Therewerefourcontaminatedcases,which

weretheoneswiththelongestdelayinprovisionofcoverage,

withameanof116.5days.

Threepatientspresentedcomorbidities:twowithsystemic

arterialhypertension (SAH)andonewithdiabetes mellitus

(DM)(Table1andFig.1).

Thesurgical optionsforcovering thetissue losses were

chosenbetweensuralflaps(constructedin12patients)and

Hindfoot/heel 32%

Ankle - 9

Hindfoot/heel - 7

Midfoot/forefoot - 6 Ankle

41% Midfoot/forefoot

27%

Fig.2–Case1,rightfoot.(a)Lossofskinandbonetissueattheleveloftheheel;contaminatedwound;(b)markingforthe suralflapwithstartofthedissectionandapivotpoint5cmabovethelateralmalleolus;(c)finalresultafter18monthsof evolution,withoutinfection.

lateralsupramalleolarflaps(in10patients).Bothflapswere

usedinonepatient.

Bothofthesearefasciocutaneousflaps,composedofskin,

subcutaneoustissueandfascia.Suralflapscontainthesural

nerveand,forthisreason,theyarealsoneurocutaneousflaps

withirrigationthroughabranchofthefibularartery,thesural

artery.9,10_{Meanwhile,supramalleolarflapsaresuppliedbyan}

anastomoticnetworkfromtheankle.11

Theflapisonlyconstructedafterrigorousdebridementin

oneormoresurgicalprocedures,depending onthetypeof

woundandthe degreeofcontamination.Thepositionwas

chosenaccordingtothechoiceofflap:ventraldecubitusfor

thesuralflapandlateraldecubitusof50◦_forthe

supramalle-olarflap.Bothofthesewereconstructedusingapneumatic

tourniquet.

Sural flaps were marked out starting at a point 5cm

abovethelateralmalleolus,atthesitewherethesuralartery

emerges,whichwasthepivotpoint.Alinewastracedout

lon-gitudinallyintheproximaldirection,betweenthispointand

theAchillestendon.Followingthis,amoldoftheinjurywas

madeusingacompress andmethyleneblue, soastothen

projectthemoldcorrespondingtotheareaoftheinjury,from

thepivotpointtothelocationforraisingtheflap,onthe

pos-teriorfaceofthelowerleg.Raisingtheflapbeganproximally,

withtheaidofamagnifyingglassof3.5×magnification,and

thesuralnerveandarterywerelocatedsoastoformpartofthe

flap.Theflapwascarefullyliftedfromasubfasciallayerand

thebranchesofthesuralarterytotheadjacentmuscleswere

cauterized.Thepedicleoftheflapshouldalwaysbe

accom-paniedbyabout2–3cmoffattytissuesurroundingit,sothat

thereisnoriskofdistressandtominimizecongestionofthe

flap(Fig.2a–c).

In the supramalleolar flap, a point was marked in the

depressionofthelower part ofthelocaltibiofibular space,

wheretheperforatingbranchofthefibulararterypenetrates

theinterosseousmembrane,around5cmfromthetipofthe

lateralmalleolus.Thisbranchisanastomosedwiththe

ante-riorlateralmalleolararteryandthenwiththelateraltarsal

arteryinthelateraledgeofthefoot.Theflapcanbe

peninsu-larorpedunculate,inanislandwithadistalbase,depending

ontheareaofcoverage.

Thesuralflapneededtobedesignedtobelocated2–3cm

distally tothe abovementionedpoint and,asdescribed for

suralflaps,thesupramalleolarflapwasalsodesigned

start-ing from the pivotpoint, with the mold ofthe injury, and

wasraisedwithabroadpedicleforsecurity.Thedissection

wasstartedontheanteriorfaceofthedesignandproceeded

proximally.Atthislocation,thesuperficialfibularnervewas

encountered andwas cauterized.Theflapwas raisedfrom

a subfascialplaneand was extendedto the periosteumof

thefibula.Iftherewasaneedforverydistalcoverageofthe

foot,thedissectionbecameslightlymorelaboriousandthere

was aneed todissect thepedicle beyondthe tarsal canal.

Atthislocation,thepediclewassubdermalandtherewasa

greaterriskofinjurytothepedicleandalsoofflapdistress

(Fig.3a–d).

Amongthesuralflapcases,flaprotationpassingthrougha

tunnelwasperformedinfivepatientsandtheskinwasopened

fortheflaptopassbyinsevenpatients.Elevenpatientsfirstly

underwentgraftinginthedonorarea.

Amongthesupramalleolarcases,theflapwasrotatedand

theskinwasopened(withoutatunnel)infivepatients,while

theflappassedthroughatunnelinfourpatientsandtheflap

waspeninsularinonepatient.Inallthesetenpatients,the

donorareafirstlyunderwentgrafting.

Outofthe21patients,thewoundswerecleanin17cases

and contaminated in four cases: three with osteomyelitis

and onewith pyoarthritis.Thirteenpatients camethrough

SUS,seventhroughcontractedservicesandoneasaprivate

patient.

All the patients were operatedunder spinalanesthesia.

Dopplerultrasoundwasnotusedinanyofthecases.

Sutur-ingwasperformedusingmononylon4.0and5.0andwasleft

quite slackwhen above the pedicle. Long gauze was used

extensively forthe dressings,withcareregarding

186

Fig.3–Case2,leftfoot.(a)Lossofskinandbonematerialattheleveloftheforefoot,withexposureofthephalanxboneand thesesamoidsofthehallux;(b)markingofthelateralsupramalleolarflapwiththepivotpointinthedepressioninthelower partofthetibiofibularspace,thelocationwheretheperforatingbranchofthefibulararterypenetratestheinterosseous membranearound5cmfromthetipofthelateralmalleolus;(c)7thpostoperativeday,showinggraftedareaaroundtheflap, andflapwithepidermolysis;(d)finalresultafter10monthsofevolution,showinggoodcoverageoftheinjury.

Results

Inallcases,theinjuriesweresuccessfullycovered,withgood

recoveryamongthepatients.However,somecomplications

wereobserved.Thecommonestofthesewasepidermolysis,

ineightcases(36.3%):threeinsuralflapsandfivein

supra-malleolarflaps.Ofthesepatients,two(onesuralandtheother

supramalleolar)progressedtoslightdistalnecrosisoftheflap.

Thesupramalleolarcaserequiredanewintervention, with

subsequentskingraftingatthesite.Inonepatientwhohad

alreadyundergonereconstructionwithasuralflap,theburn

injuryprogressed,withnewboneexposure.Itwasdecidedto

constructanewflap,choosingthelateralsupramalleolartype

(Fig.4a–c).

Amongthe four contaminated cases, oneof them

pre-sented recurrence of secretion drainage, even with the

treatment. Another two interventions were needed, with

debridementandcurettage.

Out ofthe21 patients operated,20 were notconcerned

regardingtheissueofestheticsandonlyonewishedtoreview

theflap.Fateliminationwasperformedoneyearafterthefirst

surgicalapproach.

Noneuromaswereobservedintheflapdonorareas,

nei-therinthesuralnorinthefibularnerve.Noneofthepatients

suffered gaitalterations consequenttoundergoingthe flap

surgery.Whenasked,allthepatientsreportedparesthesiaon

thelateralfaceofthefootincasesofsuralflapsorthemedial

andintermediatefacesofthemidfootandforefootincasesof

lateralsupramalleolarflaps.However,theydidnotplaceany

importanceonthissymptom.

Discussion

Flapsforprovidingskincoverageforfeetandankleshavebeen

described.6,12–17 _{However,inmost injuriesinvolvinglossof}

tissue,itisnotpossibletoachievecoverageusingonlythe

sur-roundingtissue.Distantflapshavetobechosen,whichcould

befasciocutaneousorfreeflaps.6,13–17

Becausethesearepoorly vascularizedregions4 _thatalso

Fig.4–Case3,rightfoot:suralandlateralsupramalleolarflaps.(a)Lossofskintissuewithboneexposureinthemidfoot andhindfootandpartoftheankle,secondarytoburnsafteranaccidentinvolvingamotorcycleexhaust;(b)suralflap integratedinthehindfootandlateralsupramalleolarflapwithepidermolysisinthemidfoot;(c)finalresultaftertwoyears ofevolution.

tendons,arteries,veins,nervesand,justbelow,bones,

cover-ageusingskingraftsisnotachievedinmostoftheseinjuries.

Thesesegmentsrequirestablecoveragesoastoenable

bet-terjointmobilityandmakeitpossibleforthetendonstoslide

well,forgaittooccurwithaminimumofclaudicationandfor

theretobeasfewfunctionalsequelaeaspossible.

Suraland lateral supramalleolarflapsare reliable, allow

coverage of extensive areas and have a large arc of

rotation.5,6,18,19_{Thus,theyareanexcellentchoiceforcoverage}

ofinjuriestofeetandankles.6,20–22_{Eventhoughtheseflapsare}

differentregardingtheirdissection,suchthatsupramalleolar

flapstakelonger,withgreatertechnicaldifficulty,wedidnot

observeanysignificantdifferencesregardingcomplications.

OurexperiencedifferedfromthatofTouametal.,whofound

agreaternumberofcomplications,suchasflapnecrosis,when

lateralsupramalleolarflapswerechosen.23

Thefirst-choiceflapwasthesuralflap,becauseitisthe

simplerofthetwo.Whatmattersisnotthesizeoftheinjury

but,rather,itslocation.Incasesofverydistalinjuriestothe

forefootandmidfoot,andinpatientswithscarsinthearea

wherethesuralflapwouldberaised,thelateral

supramalle-olarflapwaschosen.Inoursample,wecould seethatthe

greater timerequiredand thedifficulty citedin relationto

lateralsupramalleolarflapsonlyoccurredwhentherewasa

needtoextendthe flapbeyondthe pointcorresponding to

thedepressioninthelowerpartofthetibiofibularspace,the

locationwheretheperforatingbranchofthefibularartery

pen-etratestheinterosseousmembrane.Webelievethattheseare

thecasesinwhichtherearemorefailuresinraisingthisflap.

Withregardtotunnelconstruction,thereisdivergencein

theliteratureanditisbelievedthatthisincreasestheriskof

flapdistress,duetovesselcompression,24_{aswellastheriskof}

distressduetotraction.Inthepresentstudy,wedonothave

sufficientcomparativedatatodecidebetweenopenor

tun-neledapproaches.However,incasesinwhichthetunnelwas

long,suchasinforefootinjuries,andinthoseinwhichthe

flapwasextensive,wepreferredtoopentheskinand

subcu-taneoustissue,ratherthanrunningtheriskofcompression

andtractionofthepedicle.

Conclusion

Suralandsupramalleolarflapsareverysafe,withreliable

pedi-cles, agood cost/benefitrelationship and acceptabletissue

damageintheregion.Theydonotcausefunctionaldamage,

thedurationofthesurgeryisshort,theyareeasytodissect,

importantvesselsintheregionarepreservedandthereisa

lowcomplicationrate.

They are options for providing coverage for extensive

injuries to the hindfoot, midfoot, forefoot and ankle; they

canbeperformedatmediumandhigh-complexityservices,

andcanbeconsideredtobeoneofthefirstchoicesforthese

injuries.

Conflicts

of

interest

188

Acknowledgement

Theauthors are gratefultoProf.Dr.ArlindoGomesPardini

Júnior.

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