Functional Outcome of Weight Bearing Heel following its Reconstruction by Distally Based Sural Flaps

Abstract

Introduction: Tissue defects of the heel require resurfacing by flaps that could bear a great proportion of body weight and assist in pain free locomotion with minimum morbidity. The distally based sural flaps, also known as reverse sural flaps, have found widespread applications including reconstruction of the weight bearing heel. The durability of the reverse sural flap and its ease of resurfacing peculiar contour of the heel have encouraged its use. The evaluation of the functional aspect of this flap with regards to the pain, ulceration and ambulation is vital to establish and authenticate its use in heel reconstruction. American Orthopaedic Foot and Ankle Society (AOFAS) clinical ratings scale is one of the assessment schemes for its evaluation. Aim: To evaluate the usefulness and versatility of reverse sural flap in reconstruction of heel as well as assessment of functional outcome of foot using AOFAS scoring system. Materials and Methods: In this prospective study, carried out in the Department of Plastic Surgery at a tertiary care centre in Eastern Uttar Pradesh, India, 15 patients with soft tissue defects of the weight bearing heel were found who fulfilled the inclusion criteria. Reconstruction was carried out using reverse sural flap and its surgical planning as operative details were discussed. AOFAS scale was used to measure functional outcome of the reconstructed heel. Results: Average age was 38.33±13.48 years and they presented earlier than 72 days. The dimensions of the reverse sural flap were 147.46±20.87 cm2 to resurface heel defects of 57.75±17.08 cm2 . The largest defect was 13 cm long and 7 cm wide. Three flaps demonstrated distal necrosis as the length: width ratio was more than the well described safe limit of 3:1. They were 19- 22 cm long while the width was narrowed to 5-7 cm at the base resulting in unfavourable dimensions and consequent necrosis. Other complications were persistent discharge and ulceration. AOFAS rating had a maximum score of 60, the average score being 50.2±7.39 (31-58). Conclusion: The AOFAS clinical rating is a reliable and valid quantitative tool which is used for evaluating functional outcome in patients with reconstruction of weight bearing heel. Reconstruction of such challenging defects by the distally based sural flap proves its versatility and relialibity. At the same time, the surgical technique of flap harvest is safe, of shorter duration and provides alternative to microsurgical reconstruction.

Keywords

• foot and ankle clinical scoring
• heel defect
• resurfacing
• reverse sural flap