Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : PC05 - PC09 Full Version

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


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49735.15166
Neeraj Kant Agrawal

1. Associate Professor, Department of Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.

Correspondence Address :
Dr. Neeraj Kant Agrawal,
04, Rudra Samriddhi Bhagwanpur, Varanasi, Uttar Pradesh, India.
E-mail: drneerajplasticsurgery@gmail.com

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

Reconstruction of heel is a tough proposition as it bears 60% of the body weight (1). Flaps used in reconstruction of the weight bearing heel should have protective sensation and should have minimum shearing between the flap and the recipient bed. The size of the soft tissue defect of the heel determines the flap chosen for reconstruction. Local fasciocutaneous flaps are often not available while medial plantar island flap can resurface only small defects (2) often measuring 2.5×2.5 cm to 5.5×9.5 cm (3). Some muscles reach the heel but the bulk of the muscle permits it to cover only small defects (4).

Medium (>5×5 cm) to large (>10×10 cm) defects of heel can be resurfaced by free flaps or pedicled flaps. Free flaps are preferred by many surgeons but the technical complexity, long surgical duration and immense experience are the limiting factors. Pedicled flaps are standard, more feasible and invaluable in heel reconstruction. Among these flaps posterior tibial, peroneal and sural neurocutaneous flaps have evolved as extremely useful flaps in reconstructive surgery of lower limbs. The advantages of using distally based sural neurocutaneous flap (aka revere sural flap) for heel reconstruction are that they provide adequately durable tissue that can easily be contoured to fit the defect. This flap was first described by Masquelet AC et al., in 1994 (5) and hence it became widely used. Reverse sural flaps can be further modified to make it safer like exteriorising the pedicle and a wider than usual base (6). This axial flap has a consistent blood supply with an added advantage of sparing the major lower limb vessels (7).

The flap is an axial flap perfused by the superficial sural artery which originates from the popliteal artery or from a sural artery and travels with the lesser saphenous vein and sural nerve giving branches to the medial/lateral sural nerve, deep fascia and upper calf. The artery descends to anastomose with 3-5 distal perforators of the peroneal artery which vascularises a distally based sural neurocutaneous flap (5),(8). Venous return is ensured by the lesser saphenous vein (9) but Chang SM proposed that lesser saphenous vein may congest and compromise flap survival (10). This may be prevented by ligation of large distal superficial veins.

The flap can safely be proposed to have reliable vascularity and acceptable complication rates as evidenced by studies that describe less than 80% of flap related complications (11).

Functional and aesthetic evaluation of the reconstructed heel is extremely vital to establish the usefulness and rationality of distally based sural flap to resurface such tricky defects. It was described by Kitaoka HB et al., as the AOFAS clinical ratings scale (12) and has also been validated by various scientists across the globe (13). A few studies do not find it very useful but the researchers have not entirely refuted it (14). The rating scale combined subjective and objective criteria to provide a profound outcome.

The present study was undertaken with the prime objective of understanding the usefulness and demonstrating the versatility of reverse sural flap in reconstruction of heel with appropriate follow-up. Functional outcome of foot using AOFAS scoring system (12) was vividly evaluated.

Material and Methods

This prospective descriptive study was carried out on 15 patients with soft tissue defects of the heel presenting to the Department of Plastic Surgery at a tertiary care centre in Eastern Uttar Pradesh, India, between April 2018 and March 2020. Medium size defects over weight-bearing heel (Table/Fig 1) varying from 35 cm2 to 91 cm2 were decisive in selecting the study population. The standard sampling methods were not applicable but the well-defined inclusion and exclusion criteria further helped in sample selection. The study was undertaken after approval from the Institute Ethics Committee and following consent from the subjects.

Inclusion criteria:

• Only soft tissue defects over the weight bearing heel including those associated with skeletal or Achilles tendon injury.
• Good active or passive movements of the ankle joints to facilitate aggressive postoperative physiotherapy.

Exclusion criteria:

• Vascular injury.
• Purulent discharge from the wound.
• Chronic smoking which can jeopardise flap vascularity.
• Extensive scarring on the calf and adjoining area precluding the use of reverse sural flaps.
• Patients with major systemic illness and uncontrolled diabetes mellitus.
• Anticoagulants, if any, were discontinued a week prior to surgery.

Preoperative Assessment

1. Heel wound characteristics.
2. Skin condition and scarring adjacent to the heel defect.
3. Dimensions of the defect.
4. Availability of calf tissue.
5. Dimensions of the tentative reverse sural flap and the incision site.
6. Planning of a backup flap in case the reverse sural flap necrosed.

Surgical Procedure

The patients were placed in prone position. A line was drawn from the midpoint of the popliteal fossa to the lateral malleolus that indicated the vascular axis of the sural neurocutaneous flap. Hand-held audio Doppler was performed along this axis to identify perforators from the peroneal artery that were marked. 2-3 perforators were found at an average distance of 5-10 cm proximal to the lateral malleolus. A template of the defect was used to position the flap along this axis, such that the distance from the chosen pivot point to the proximal end of the flap was just greater than the distance from the pivot point to the distal edge of the heel defect. It was of utmost importance to delineate the proximal limit of the reverse sural flap 10 cm down this line of vascular axis. The perforators were marked using a hand-held audio doppler. The dimensions of the flap were carefully planned to avoid small and inadequate flap. The flap to be harvested was marked and dissection was performed from proximal to distal under tourniquet control. The initial proximal horizontal incision was used to identify the saphenous vein and sural nerve. In an exsanguinated limb, vein was found collapsed and, the sural nerve helped in identification of the lesser saphenous vein. Manoeuvres to overcome shearing of the flap over the loose subcutaneous tissue were bevelling the proximal incision to include more of deep fascia and tucking the deep fascia to the dermis at regular intervals. Dissection was performed in between the deep fascia and epimysium. The distal dissection limit of the pedicle was 6-8 cm above the lateral malleolus between the fibula and Achilles tendon. The flap was narrowed distally keeping a 5-6 cm wide base to incorporate the perforators. This resulted in smooth transfer of the flap without torsion on the pedicle. Tourniquet was deflated and the proximal edge of the flap was inspected for bleeding once the vasospasm settled. The flap was wrapped in warm saline also soaked in 2% lignocaine or papaverine to relieve the spasm. After ascertaining satisfactory vascularity, the flap was transferred to the defect and sutured (Table/Fig 2). The limb was immobilised in an anterior plaster slab avoiding compression on the flap and the pedicle in supine position. This was extremely vital as even a trivial compression could compromise the vascularity. The pedicle was detached at three weeks for final flap inset into the heel defect (Table/Fig 3). Thereafter, partial weight bearing was initiated whereas full weight bearing was allowed only after about six weeks of surgery. Regular follow-up visits were advised to detect the complications at the earliest.

After 12 weeks, or when the stabilised skeletal injury had healed, functional assessment of the reconstructed weight bearing heel was done using AOFAS clinical ratings scale (12). The parameters studied were a combination of patient’s complains of pain and surgeon’s assessment of ulceration, gait and details of ambulation (Table/Fig 4).

Statistical Analysis

For interpretation of the quantitative variables mean, Standard Deviation (SD), minimum and maximum values were used.

Results

Mean age of the 15 patients was 38.33±13.48 years (range 18-60 years) including 13 males and 2 females. Patients presented for plastic surgical consultation after 44.73±21.26 days but not later than 72 days (Table/Fig 5). The mean size of heel defects was 57.75±17.08 cm2 (35-91 cm2). The largest defect was 13 cm long and 7 cm wide. The dimensions of the reverse sural flap to resurface defects were 147.46±20.87 cm2 (112-180 cm2). Non-healing ulcers of different aetiologies were the cause in seven patients, major road traffic accidents resulting in avulsion of heel pad were seen in five patients and iatrogenic heel defects due to various aetiologies were found in three patients (Table/Fig 5). Three flaps demonstrated distal necrosis and were 19-22 cm long while the width was narrowed to 5-7 cm at the base resulting in length: width ratio >3:1. This resulted in necrosis of the excess length beyond the safe dimensions of 3:1 and varied from 3 to 6 cm. The width of the flap in (Table/Fig 5) demonstrated the effective width of the proximal part of flap which, when transferred, is inset into the widest part of the heel defect. Other complications were persistent discharge and ulceration. Calcaneum, distal part of Achilles tendon or both structures were exposed in nine patients (Table/Fig 5).

Functional outcome and symptomatology of the reconstructed heel were studied in detail as defined by AOFAS Ankle-Hindfoot Rating System. The weightage given to various parameters were evaluated and analysed (Table/Fig 4). Out of maximum score of 60, the average score of the 15 patients were 50.2±7.39 (31-58).

Discussion

Resurfacing of heel should take into consideration the peculiar contour of the heel as well as sensibility and durability. The heel skin is thick and robust due to the presence of stratum lucidum and, therefore, can easily withstand stress and friction (15). The flap used for reconstruction of such weight bearing region should resist shearing forces during standing, walking and other forms of locomotion (16). Lack of an ideal donor complicates the issue further (17). Fasciocutaneous flaps have emerged as a viable option and alternative to muscle flaps and free tissue transfer in heel reconstruction. The enhanced reach of reverse sural flaps to resurface heel defects is largely due to proximity of the pedicle based between the Achilles tendon and lateral malleolus (Table/Fig 2). However, the distal limit of dissection should be kept at 5 cm proximal to lateral malleolus (18). Even more distal defect can be resurfaced by delaying the flap converting it to a three staged procedure (19).

The pedicle of the flap should be kept wide 5-6 cm to ascertain the inclusion of perforators as well as prevent venous congestion. The surgeon should learn to rely on audio doppler for localising the perforators to avoid unnecessary intraoperative dissection of perforators lest they get traumatised (20). The sural neurocutaneous flap relies on the vascular plexus around the sural nerve with the short saphenous vein accompanying it. Therefore, precise identification and inclusion of these structures in the initial horizontal incision assures the vascularity of the flap (21). Anaesthesia in distribution of sural nerve usually resolves with time but neuroma could be a concern. The sural nerve should be pulled distally prior to division using a scalpel to allow proximal retraction of the nerve.

Ponten’s revolutionary work on fasciocutaneous flaps demonstrated length-to-width ratio of 3:1 in the lower extremity (22). In the present study flaps that necrosed exceeded the ratio of 3:1. The length of the flap that necrosed was the part that exceeded the safe ratio and varied from 3-6 cm along the long axis. The subsequent loss of the effective flap fails to resurface the heel. Small defects were covered by advancement of the redundant flap or by alternative local flaps. Ulceration was seen in one patient with flap cover for diabetic ulcer that necessitated shaving of the calcaneal irregularity and local flap cover.

Flap is usually detached at three weeks by this time the flap is expected to develop neovascularisation from the recipient bed as well as skin margins of the recipient site (Table/Fig 3). On the contrary, Tsur H et al., demonstrated, in experimental setting, that flaps can be divided as early as 10 days (23). The speed with which the flap can be harvested is an indirect measure of the complexity of the flap. Injury to vital anatomical structures and consequent functional deficit is an extremely important parameter to ascertain patient safety. It may also invite unnecessary litigations and legal hassles. Aesthetics of the secondary donor site also need quantitative evaluation as perception of patients may be biased, varied and unrealistic.

Characteristics and functional outcomes of the reconstructed heel were critically evaluated by the AOFAS Ankle-Hindfoot clinical ratings scale (Table/Fig 4). The validity of the scale in assessment of heel defects was a matter of great debate but newer studies have concluded adequate validity and reliability making it a suitable instrument for investigating functional outcome (24). 40% of patients complained of varying degrees of pain limiting their ambulation. This was extremely crippling and was attributed to complications such as flap necrosis and ulceration as well as due to exposed peripheral nerves. Ulceration in reconstructed heels was recorded in only one patient in the present research but studies have reported 33% ulceration in fasciocutaneous flaps (25). It usually results form a calcaneal sore or defective footwear. Protective deep sensation was regained in 66% reconstructed heels although the need of sensate flap for heel has been debated. The issue largely remains unsettled but importance of deep pressure sensation cannot be undermined (26). It has been pointed out that muscle flaps cannot be neurotised to provide protective sensation and results in recurrent ulcers. This further justifies the use of fasciocutaneous flaps.

The AOFAS rating scale evaluated the functional outcome of reconstructed heel. Most of the patients could manage their routine work without any support except two patients who had severe limitations in carrying out their daily activities. These patients sustained necrosis of distal part of the flap and, therefore, required support to move around. The average points for daily activities as calculated by AOFAS scale was 7.6/10 with 5/15 patients absolutely normal. The average distance covered by the patients was 600-900 metres with average points 4.2/5. The mean distance traversed was less owing to the fact that three subjects, who had flap complications, could walk <400 metres with strenuous exertion. Therefore, walking on irregular surfaces was simply impossible. The crippled locomotion due to flap loss or ulcerations was easily understood.

Extensive statistical analysis was not performed as it was not extremely useful in the current study. The emphasis was on the approach and technical aspects of dissection of reverse sural flaps. The discussion was meant for the readers to appreciate the utility of the flap in reconstruction of the weight bearing heel as well as understand the scoring system to evaluate the functions of the foot.

Limitation(s)

The present study has limitation of being a single centre and a single surgeon work. Thus, demography of only one region has been studied which may be a surgical constraint. It also lacks comparison with other regional or distant flaps.

Conclusion

In the present study, the success of reverse sural fasciocutaneous flap for heel reconstruction was achieved by proper selection of patients, locating the perforators of peroneal artery by hand held audio doppler and planning an effective flap in upper third of the leg to be able to reach the heel without tension or torsion. AOFAS clinical ratings scale, despite controversies, proves to be a useful tool for assessment of functions of the reconstructed foot.

Multicentric study could give regional variations and help us to evaluate the surgical technique related results better. The future work should compare free flaps (microvascular) and pedicle flaps for distal foot and heel reconstruction. This would establish the superiority of either of the surgical technique. The sample size should be higher to reach a definite conclusion.

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DOI and Others

10.7860/JCDR/2021/49735.15166

Date of Submission: Apr 03, 2021
Date of Peer Review: May 13, 2021
Date of Acceptance: Jun 12, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 04, 2021
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• iThenticate Software: Jun 30, 2021, (8%)

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