Commentary on "Distally based sural neuro-fasciocutaneous island flap to cover tissue loss in the distal third of the leg" by Parodi et al.

Excerpt

Covering of soft tissue defects, in particular when compound, in the distal one-third of the lower leg, over the malleoli, and in the calcaneal region remains a challenge for all surgeons (general, trauma, orthopedic, plastic) dealing with this difficult problem. In the last three decades of the twentieth century the conservative approach (plaster of Paris cast immobilization, traction or external fixation, and daily changing of dressings until granulation tissue covered the exposed fracture and other structures followed by skin grafting, a tube pedicle or a cross leg flap) was replaced by a more active philosophy of treatment derived from better knowledge of vascular anatomy of muscle, skin, fascia, and bone. Earlier coverage of open fractures by well vascularized tissues dramatically decreased the incidence of chronic osteomyelitis. Pedicled muscle flaps (gastrocnemius and soleus) solved the problem of open fractures in the proximal and middle third of the lower leg. Free flaps were advocated for the same indication in the distal one-third where soft tissues were not available, and the number of capillary nets per gram of tissue was the lowest in the body. Later the fasciocutaneous flaps gained popularity. Their advantage was that they brought into the defect local soft tissues from adjacent areas based on a circulation derived from perforators from the three major arteries of the lower leg. These procedures did not require any microvascular anastomosis. However, they did require knowledge of microsurgery since, on many occasions, the perforators had to be followed to the main vessel in a compartment and dissected free to allow the flap to be turned without "kinking" and avoiding arterial insufficiency or venous stasis. …