Objective: The distally based sural lesser saphenous NVAF flap has been used with increasing frequency at our institution for reconstructing wounds of the foot, ankle, and distal one-third of the lower leg. The objective of this study is to review our experience with this flap in a variety of clinical situations, assess the complications associated with its use, and finally judge the functional outcome of this type of reconstruction.

Methods: A retrospective review was conducted of all NVAF flaps performed over a period from October 2000 through January 2007. Data were collected in regards to patient demographics, associated comorbidities, mechanism of the lower extremity wound, technical details of the operation(s) performed, postoperative complications, length of follow-up, and clinical outcomes with respect to healing and ambulation.

Results: During the study period, the NVAF flap has been used by four surgeons in the reconstruction of lower extremity defects in 34 patients. The locations of the wounds were diverse (13 wounds of the distal 1/3 of the lower leg, 12 ankle wounds, 3 heel wounds, and 6 foot wounds), as were the ages of the patients at the time of surgery (mean age 40.5 years, range 4-89 years). Traumatic wounds were the primary indication for reconstruction in 22 patients. Six patients presented with chronic osteomyelitis requiring resection of diseased bone, removal of hardware when necessary, and soft tissue coverage with the NVAF flap. Five patients suffered from malignant neoplasms necessitating radical resection, and 1 patient had a non-healing wound with exposure of tibia in the face of severe peripheral vascular disease. Complications were frequent, occurring in 17 (50%) of our 34 patients. Nine major complications occurred in 5 (14.7 %) patients. A major complication was defined as leading to total flap loss or amputation. Overall, 3 (8.8%) patients with a major complication went on to amputation. Of these, 1 had total flap loss and infection acutely; 1 had infection, total flap loss and hematoma; and the third had chronic osteomyelitis requiring amputation 10 months after the NVAF flap. Two patients with major complications were salvaged. One patient had late flap loss secondary to radiation therapy 10 months after the index operation. He was salvaged with radial forearm free flap to the leg. One child with traumatic wounds with post operative total flap loss and infection was salvaged with skin grafts. Seventeen minor complications occurred in 12 (35.3%) patients, often with multiple complications occurring in the same patient. Six (17.6%) patients suffered from partial flap loss. Three (8.8%) hematomas requiring evacuation were noted. Skin graft loss occurred in 5 (14.7%) patients and 3 (8.8%) minor infections were seen. Mean follow-up was 10.2 months (range 0 days to 48 months). One patient expired from cardiac disease during the study period. There is inadequate follow-up data on 4 patients to judge the success in return of ambulation. One patient died from unrelated causes one month after surgery. Three patients underwent amputation. Of the remaining 26, 18 (69.2 %) patients had healed wounds and were ambulating without assistance at their last follow-up visit. An additional 6 (23.1 %) patients had healing wounds and were walking with either a cane or walker. Two (7.7 %) patients are currently non-ambulatory, one has severe arthritic pain and the other has significant bony loss of the tibia requiring bone grafting prior to any attempts at weight bearing.

Conclusion: The NVAF flap remains our local flap of choice in treating difficult wounds of the distal one-third of the lower leg, ankle, heel, and foot. Major complications are uncommon (14.7%). However, minor complications are seen fairly frequently (35.3%). Despite this, healed wounds may consistently be obtained, along with the return of ambulation in the majority of patients following salvage of the lower extremity.
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