Versatility of Reverse Sural Artery Flap for Heel Reconstruction

Introduction: The heel has two parts, weight bearing and non-weight bearing part. Soft tissue heel reconstruction has been a challenge due to its complex nature of anatomy, weight bearing part of foot and the mechanism of injury requiring reconstruction. The pattern of injury includes from simple laceration to a complex wound with loss of soft tissue and fracture involving various degrees of calcaneus. Most common pattern of heel injury is due to road traffic accidents especially the foot caught in the moving motor bike wheel. The resultant soft tissue defect may be large or small. The treatment option for complex large soft tissue defect of weight bearing part of the heel reconstruction has been invariably flaps containing thick skin, pliable subcutaneous tissue with strong fascia planes REF. Historically, most commonly used flaps for large soft tissue defect are radial forearm flap, deltoid flap, lateral arm flap, scapular/parascapular flaps, sural artery flaps either as free tissue transfer or pedicle flaps REF. For small defect of the heel; local pedicle options are medial plantar flap, abductor digiti minimi muscle, abductor halluces brevis muscle, flexor digitorum brevis muscle, lateral calcaneal flap; a muscle free flap gracilis, serratus, or rectus abdominus muscle. The retergrade sural artery fasciocutaneous flap depends on the minusculate sural artery that nourishes the sural nerve (1). The artery originates from a peroneal perforator 5 cm above the lateral malleolus and courses with the sural nerve. The flap can cover any ankle or rear foot defect. Material and Methods: This study includes 25 total number of patients with traumatic heel injury and Seven cases of traumatic soft tissue heel reconstruction performed with reverse sural artery flap and one patient out of seven required fracture fixation for calcaneus with screw by the single author between July 2011 and June 2016. The age range from 9 years to 36 years. Four patients required split thickness skin graft for donor site closure in the calf while in three patients donor defect was closed primarily. Results: All patients wound managed with the reconstruction of heel by using reverse sural artery fasciocutaneous flap healed within a month post operatively and on three month follow up have normal gait with full weight bearing and no recurrent ulceration or wound breakdown. Conclusion: The use of reverse sural artery flap for weight bearing large tissue defect of the heel remained versatile for its near similar anatomy. It can provide coverage as large as 8X12 cm, has sensibility, and has a wide arc of rotation due to long pedicle. It is excellent for heel defects and medial/lateral ankle, lower leg, and hindfoot defects.