Reverse sural artery flap for reconstruction of blast injuries of the foot and ankle

Background: The reverse sural artery fasciocutaneous flap is a versatile soft tissue coverage procedure for traumatic soft tissue defects of the distal tibia, ankle, and foot. War-related blast injuries represent a unique injury mechanism. There are no reports on use of this reconstructive flap in treating highly contaminated war-related musculoskeletal trauma of the foot and ankle. The current study presents results using this soft tissue coverage procedure in a subacute fashion to treat a population of war-related blast injuries. Materials and Methods: A retrospective chart study was performed to assess outcomes of ten consecutive patients with severe lower extremity musculoskeletal trauma requiring soft tissue coverage using reverse sural artery fasciocutaneous flaps. Average patient age was 27.2 years. All injuries occurred between 2003 and 2008 as a result of severe war-related blast injuries. Results: All ten patients sustained Gustilo Type IIIB open fractures within the zones of injuries secondary to high energy blasts. Average time to flap coverage was 37 (range, 18 to 112) days post-injury. All ten flaps were well-healed at 12 weeks postoperatively. Major complications included one nonunion, three deep infections with chronic osteomyelitis, and three late elective amputations unrelated to the viability of the flap. Conclusion: In appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle, the reverse sural artery fasciocutaneous flap should be considered as a viable first option for soft tissue coverage, even in cases of subacute coverage. Early coverage is preferable in cases of severe contamination and soft tissue destruction, but late coverage of distal lower extremity defects with a sural artery flap is possible with good outcomes.