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Reconstruction of the distal lower extremity (LE) is challenging due to limited local flap options and poor blood supply. The reverse sural artery flap (RSAF) is a popular salvage option for patients who are not ideal candidates for free tissue transfer. However, high rates of partial flap necrosis and venous congestion have been reported. This is the first systematic review on RSAF and pooled analysis of surgical characteristics, risk factors, and outcomes.
Methods
A systematic literature review was conducted according to PRISMA guidelines. Three electronic databases (PubMed, MEDLINE Ovid, and Cochrane Library) were queried. All patients who underwent reconstruction with the RSAF with reported outcomes were included. No study was excluded based on surgical technique. Pediatric cases (≤18 years) and those in which individual outcomes were not reported were excluded from pooled analysis. Categorical data were analyzed with Fischer’s exact or Chi-square test, and continuous variables were analyzed via ROC curve. A p-value of <0.05 was considered statistically significant.
Results
A total of 68 studies encompassing 1,525 flaps published between 1997-2018 were included in this systematic review. All studies were case series (Level IV evidence), and the majority (77.9%) were not U.S-based. Twenty-five studies (36.8%) reported on surgical technique modifications. Eleven studies (148 flaps) reported on delayed reconstruction.
Forty-three studies (479 patients, 481 flaps) were analyzed. The majority of patients were male (70.3%), and average age was 46.9 ±16.7 years old. Rates of smoking, diabetes mellitus (DM), and peripheral vascular disease (PVD) were 34.6%, 35.4%, and 12.3% respectively. Defect etiologies were largely traumatic (60.4%). The most common defect location was the heel (40.8%). Flap modifications were reported in 123 (25.6%) flaps. The most common modification was adipofascial extension (20.3%).
Overall, the partial and total flap loss rates were 15.4% and 3.1%, respectively. Partial flap loss was significantly increased in smokers (28.9% versus 12.2% in non-smokers, p=0.0195). Technical modifications decreased the odds of partial necrosis by almost 3-fold compared to traditional RSAF reconstruction (7.2% versus 17.9%, OR=2.8 [1.4-5.8], p=0.0035). Patient age, DM, and PVD were not significantly associated with flap loss.
Conclusions
Despite its reliance on a healthy vascular supply, the RSAF remains a safe salvage option for LE defects in patients with co-morbidities such as DM or PVD, but should be utilized with caution in smokers. Furthermore, employing technical modifications to minimize pedicle compression significantly reduces rates of partial necrosis.