Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 45-49

Outcome of proximally based sural artery flap for the coverage of defects around knee joint


Department of Burns and Plastic Surgery, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India

Date of Web Publication20-Apr-2018

Correspondence Address:
Dr. Sudhanshu Punia
2479, Sector 1, Rohtak, Haryana, 124001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_12_17

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  Abstract 

Introduction: Soft tissue defects around the knee occour commonly. Various flaps have been described for coverage of these defects around the knee, such as local flaps, cross-leg flap or free flaps etc, but, knee joint function and appearance frequently compromise the outcome.
Materials and Methods: A retrospective study comprising of eight patients was conducted in a tertiary level trauma center. Proximal based sural artery fasciocutaneuos flap was used to cover tissue defects.
Results: No morbidity of the donor site and no functional deficits of the knee or ankle were detected in any of the cases. All flaps survived without any major complications. Most of the patients were satisfied with this thin and sensate flap.
Conclusion: The proximally based sural artery flap is easy to raise and execute. It provides a thin, sensate and good gliding surface. This flap is easy to learn and cosmesis is excellent at the recipient site. Hence the authors recommend it to be ideal choice for the coverage of the defects mentioned in the study.

Keywords: Defects around knee joint, knee soft tissue defects, proximally based sural artery flap


How to cite this article:
Singh K, Punia S, Singh B, Pramod D. Outcome of proximally based sural artery flap for the coverage of defects around knee joint. Nigerian J Plast Surg 2017;13:45-9

How to cite this URL:
Singh K, Punia S, Singh B, Pramod D. Outcome of proximally based sural artery flap for the coverage of defects around knee joint. Nigerian J Plast Surg [serial online] 2017 [cited 2018 May 26];13:45-9. Available from: http://www.njps.org/text.asp?2017/13/2/45/230799


  Introduction Top


Injuries resulting in soft-tissue skin defects around the knee are common and are often caused by road traffic accidents. They can also be secondary to burns, surgical infections, and after tumor resection. The reconstruction of these defects is not that easy because of the requirement of thin, pliable skin with the restoration of knee functions.[1] Various flaps have been described for the coverage of these defects around the knee, such as local (muscle, fasciocutaneous, perforator) flaps, cross-leg flap, or free flaps. Though these flaps are very reliable, the outcome of reconstruction at this site often falls below satisfaction, frequently compromising knee joint functions and appearance.[1],[2] So, considering these factors, we have evaluated the clinical outcomes of using a proximally based sural fasciocutaneous flap for the reconstruction of traumatic soft-tissue defects around the knee, proximal leg, and distal thigh.

The proximally based sural artery flap is the flap which is harvested from the posterior calf region for the reconstruction of such defects and it provides thin, reliable, and sensate skin, and there is minimal donor site morbidity.[3]


  Materials and methods Top


The present retrospective study was conducted in a tertiary level trauma centre between September 2013 and October 2016. The study was approved by Institutional Review Board. Eight patients with soft tissue and associated bone defects of lower limb around knee joint especially on lateral aspect were included after taking informed written consent. Proximal-based sural artery fasciocutaneous flap was used to cover tissue defects [Table 1].
Table 1: Details of the patients

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Surgical technique

The following surgical technique[2],[3] was used. A standard lateral or prone position was used after giving spinal or general anesthesia. Tourniquet was applied after leg elevation, and the exsanguination of the limb was not performed so that a pedicle of the flap was easily identified. The proper debridement of the recipient site was performed to create the exact size of the defect. The axis of the flap was drawn along the line which passes from the midline of popliteal fossa to a point midway of lateral malleolus and tendoachilles [Figure 1]. Planning in reverse was performed with the help of a lint piece. The pivot point of the flap was kept about 2 cm from the midpoint of popliteal fossa along the axis described above. Duplex ultrasound for the assessment of flow in the sural artery was not performed in any of the cases in the present study, because a portable hand held device was not available. The skin and fascia were incised along the distal margin of the flap. The sural nerve, associated vascular plexus, and the short saphenous vein were identified and sharply divided. Dissection was performed in distal to proximal fashion without any difficulty. Deep fascia was included in the flap at distal, medial, and lateral sides and was tacked with skin to avoid shearing. In the proximal part of the flap, only skin incision was made. The flap was designed to keep the neurovascular bundle in the middle. In the upper portion, sural nerve and the median superficial sural artery were dissected carefully in between the two heads of gastrocnemius till the decided pivot point [Figure 4]. Then an adequate subcutaneous tunnel was constructed to allow the flap and pedicle to pass to the recipient site. In some cases, we had to incise the tunnel as well because of the suspected compression of the pedicle. Tourniquet was deflated to confirm flap viability. The inset of the flap was performed at the recipient site, and corrugated/glove drain was put under the flap which was removed on 3rd to 5th day. Donor area was covered with split skin graft in all the cases. The plaster of Paris slab was applied across the knee joint for immobilization in all the patients. Patients were nursed in prone or lateral position with the elevation of the operated limb. Weight bearing was allowed after 4–6 weeks. Patients were followed up for minimum 1–1.5 years.
Figure 1: Defect at the upper third of the leg with proximal based sural artery flap marking

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Figure 4: Dissected flap

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  Results Top


The average time taken to complete the procedure was around 1.5–2 h. No morbidity of the donor site and no functional deficits of the knee or ankle were detected in any of the cases. All flaps [Figure 5] survived without any major complications. The average hospital stay was 1 week, and the average healing time was 4 weeks. In all cases, the sensory loss of the dorsolateral aspect of the foot occurred but the patients did not report it to be a major complaint in the postoperative period. None of the patients reported any recovery of sensation during the review period; however, they were counseled that some sensation may recover from the surrounding dermatomes. Most of the patients were satisfied with this thin and sensate flap.
Figure 5: Well settled flap

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There were five male and three female patients. The average age of the patients was 40 years with the range being 12–58 years. The cause of the defect was due to road traffic accidents (n = 7) and electric burn (n = 1). The site of defect was on the lateral side of lower limb in and around knee joint as defect upper third leg-lateral aspect [Figure 2] in five patients, exposed knee joints in two patients, and exposed implant lower end of femur in one patient. The dimensions of the defect ranged from 4 to 10 cm in length and 3–10 cm in width. The duration of the defect was acute (<3 days from injury) in all cases except in two where it was 2–3 weeks. The flap was peninsular in design in seven patients and was interpolated in one [[Figure 3] and [Figure 5]].
Figure 2: Knee soft tissue defect-lateral aspect

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Figure 3: Peninsular Flap which will be transposed through an adequate tunnel

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  Discussion Top


To reconstruct the soft tissue defects around the knee is considered to be a challenge for the plastic surgeon because of the specific requirements needed for the reconstruction around the knee joint. The method used for reconstruction should be easy, reproducible, and reliable with minimal morbidities at the donor site. The donor tissue should have thin, pliable, stretchable, and sensate skin, and the undersurface should be nonadhesive so that the knee function of flexion and extension is not compromised.[1] Various flaps have been described for the coverage of these defects around the knee, such as local (muscle, fasciocutaneous, perforator) flaps, cross-leg flap, or free flap.[2] The most commonly used muscle for the coverage of the defects at this area is Gastrocnemius, which was first reported by Barfod et al. in 1970.[4] This muscle flap is very easy to execute and very reliable. The lack of innervation and unacceptable cosmetic result (bulky and contour deformity) are the unfavorable points against the use of muscle flaps.[4]

The results of the local fasciocutaneous flap are not always satisfactory, because they are usually random pattern flaps with compromised vascularity at the tip; so, many a times, distal necrosis occurs at the site where they are needed most. So, subsequent healing compromises the knee joint functions and appearance.[5]

Perforator flaps (medial sural artery perforator flap, anterior tibialis artery perforator flap, reversed anterolateral thigh perforator flap, the pedicled vastus medialis perforator) are also the popular reconstructing method for repairing the skin defects around the knee, because these flaps do provide thin, pliable skin and so meet most of the requirements of reconstruction in the knee area. Cosmesis after the application of these flaps is excellent, and the donor site morbidity is also very less. However, lack of sensations, requirement of Doppler to localize a suitable size perforator nearby the defect, and long, relatively tedious dissection are the main disadvantages of such flaps.[6],[7]

Microvascular reconstruction[8] of the defects around knee joint area is another good option. It is a single-stage procedure but the requirement of the special equipments, such as microscope, and expertise of the surgeon are the drawbacks. Moreover, the finding of the suitable recipient vessels at the site is also a challenge.

Cross-leg flaps are not used, because much better reconstructive options exist. Though this flap is very reliable, it has a lot of disadvantages. Because it is a staged procedure, it requires immobilization for at least 3 weeks which further predisposes the patient for joint stiffness and risk of deep vein thrombosis. Hence, this flap should only be used as a last resort or when other options are not feasible.[1]

The proximally based sural fasciocutaneous flap, which we have used in our study, has certain advantages, because its tissue is thin and pliable, and the undersurface of the flap allows easy gliding of the knee joint. It is very reliable flap and can be easily extended in to the mid third of the leg and has long pedicle with the good arc of rotation to increase its reach easily to distal thigh as well.[9]

Other advantages of the flap are that it is very easy to raise, takes little time to raise and execute it, and does not require microsurgical skills and tedious dissection of the pedicle. In addition, because this flap is thin and sensate, it provides good cosmetic appearance of the site and range of movements of the knee joint is also not affected.[2],[3],[9]

Like any other flap this flap also does have certain disadvantages like, its appearance, if skin graft has been used at the donor site. This cosmetic disadvantage is not seen if the donor site is primarily closed, that is, in cases of lesser width (<3 cm) of the flap. As sural nerve is harvested along with the flap, there is loss of sensation over the lateral side of the foot which tends to reduce with time as we see in a well-established, distally based sural artery flap.[3] None of the patients reported reduction in the area of numbness during the review period.

Cheon et al.[3] also used the same technique and the flap for the reconstruction around the knee joint in 10 cases, with follow-up for 1–2.5 years. The results were comparable with our study, because the flap was thin, sensate, and did not restrict the function of the knee joint. Similar to our study, Cheon et al.[3] also found that the loss of sensation over the lateral side of the foot as a major disadvantage.

Suri et al.[9] used proximally based sural artery flap for knee defects in 37 cases. They also found the results similar to Cheon et al.[3] and our studies. As Cheon reported, the disadvantage of this flap was the loss of sensation over the dorsolateral aspect of foot because of division of the sural nerve.[3]

Although the sample size for this study was small, it has still demonstrated the versatility and usefulness of this flap.


  Conclusion Top


The proximally based sural artery flap is easy to raise and execute. It has the advantages of providing thin, sensate, and good gliding surface. This flap is easy to learn, and cosmesis is excellent at the recipient site. Hence, the authors recommend it to be an ideal choice for the coverage of the defects mentioned in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Deng C, Wei Z, Wang B, Jin W, Zhang W, Tang X et al. The proximally based lateral superficial sural artery flap: A convenient and optimal technique for the reconstruction of soft-tissue defects around the knee. Int J Clin Exp Med 2016;9:15167-76.  Back to cited text no. 1
    
2.
Pan H, Zheng Q, Yang S. Utility of proximally based sural fasciocutaneous flap for knee and proximal lower leg defects. Wounds 2014;26:132-8.  Back to cited text no. 2
[PUBMED]    
3.
Cheon SJ, Kim IB, Park WR, Kim HT. The proximally-based sural artery flap for coverage of soft tissue defects around the knee and on the proximal third and middle third of the lower leg: 10 patients followed for 1–2.5 years. Acta Orthop 2008;79:370-5.  Back to cited text no. 3
[PUBMED]    
4.
Barfod B, Pers M. Gastrocnemius-plasty for primary closure of compound injuries of the knee. J Bone Joint Surg Br 1970;52:124-7.  Back to cited text no. 4
[PUBMED]    
5.
Satoh K, Fukuya F, Matsui A, Onizuka T. Lower leg reconstruction using a sural fasciocutaneous flap. Ann Plast Surg 1989;23:97-103.  Back to cited text no. 5
[PUBMED]    
6.
Rad AN, Christy MR, Rodriguez ED, Brazio P, Rosson GD. The anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: Clinical cases and anatomic study. Ann Plast Surg 2010;64:210-6.  Back to cited text no. 6
[PUBMED]    
7.
Zheng HP, Lin J, Zhuang YH, Zhang FH. Convenient coverage of soft-tissue defects around the knee by the pedicled vastus medialis perforator flap. J Plast Reconstr Aesthet Surg 2012;65:1151-7.  Back to cited text no. 7
[PUBMED]    
8.
Fisher J, Cooney WP 3rd. Designing the latissimus dorsi free flap for knee coverage. Ann Plast Surg 1983;11:554-62.  Back to cited text no. 8
[PUBMED]    
9.
Suri MP, Friji MT, Ahmad QG, Yadav PS. Utility of proximally based sural artery flap for lower thigh and knee defects. Ann Plast Surg 2010;64:462-5.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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