Can Sural Fasciocutaneous Flaps Be Effective in Patients Older Than 65?

Background: Many studies have evaluated the reverse sural fasciocutaneous flap for coverage of wounds on the distal lower extremity, and many of these have focused on younger, healthy patients. However, to our knowledge, there has been no dedicated study focusing on older patients. We believe there is a generalized concern about performing these procedures in older patients because of microvascular changes associated with aging.

Questions/purposes: (1) What is the likelihood of flap survival in a small series of patients older than 64 years who underwent reverse sural artery fasciocutaneous flap for coverage of lower extremity wounds? (2) What additional procedures did patients undergo after treatment with this flap?

Methods: From 2009 to 2018, we identified 16 patients, 64 years or older, who underwent a retrograde sural fasciocutaneous flap. Patients were a mean (range) age of 71.5 years (64 to 87). The average size of the flaps was 30 cm (range 12 to 64 cm). The reverse sural artery flap was indicated when the skin could not be closed primarily and there was not a suitable vascularized bed of tissue for a split-thickness skin graft. All patients underwent a wide-based pedicle (3 cm to 4 cm), reverse sural artery fasciocutaneous flap with all but one completed in a "flap delay" manner, between 2 to 7 days, and without the use of microsurgery or doppler. Thirteen flaps were done to cover wounds that occurred over fractures while three were performed to cover chronic wounds. We performed a retrospective review of the electronic health record to ascertain patient comorbidities, age, timing of coverage, and size of the wound.

Results: In all, 94% of flaps (15 of 16) survived with 100% viability. One flap had 30% skin necrosis at the distal tip. The flap ultimately healed with in-office wound care, and epithelization occurred over the intact fascia. A total of five additional procedures were performed in five patients. Although the flap ultimately healed, an 87-year-old patient with partial flap necrosis ultimately elected for below-knee amputation for a persistent tibial infected nonunion. Another patient, despite a healed flap, eventually underwent a below-knee amputation 3 years later for a chronic osteomyelitis present before undergoing the reverse sural flap. One patient developed a pseudomonal infection of their Gustillo-Anderson IIIB open tibia fracture, resulting in a surgical procedure for débridement, after which the flap healed. Two patients underwent underlying hardware removal to relieve wound tension and allow for complete flap healing. No patients underwent further coverage procedures.

Conclusions: In this small series, we found fewer complications than have been observed in prior studies, despite our series consisting solely of higher-risk, older patients. We believe this may have been attributable to the period of delay before placing the flap, which has been previously associated with higher flap survival and which allows for an extra recipient-site débridement. We believe this procedure can be performed by appropriately trained orthopaedic surgeons because it does not need microsurgery.

Level Of Evidence: Level IV, therapeutic study.