Purpose of the study: The purpose of this retrospective study was to evaluate the reliability of the sural flap with a distal pedicle for covering tissue loss of the posterior aspect of the heal and the malleolar region in diabetic patients.

Material and methods: We present a retrospective consecutive series with 28 month follow-up. Thirteen flaps in 13 patients (10 men, 3 women), mean age 64 years. A homolateral flap was used in all cases, covering on average 48 cm². Substance loss involved the hind foot in ten cases and the malleolar region in three. Three patients had recent bone trauma, four had chronic osteitis and six a pressure wound involving the heel. All patients had non-insulin dependent diabetes mellitus.

Results: The flap head in 24 days on average (range 18–45), the donor site in 15 days. Eleven patients were able to wear normal shoes. At last follow-up all patients were free of infectious recurrence. There was one flap necrosis, three necrotic borders (one skin graft), two cases of venous insufficiency, and ten cases of hypoesthesia of the lateral border of the foot.

Discussion: There have not been any reports in the literature of the neurocutaneous sural flap with a distal pedicle for diabetic patients. In our series, this flap was found to be a reproducible solution for covering substance loss of the heel and malleolar region in the diabetic.

Conclusion: This flap with a long pedicle does not require microvascular qualification. It is easy to perform, induces few functional sequelae. For diabetic patients, it is an alternative to amputation, without compromising future options since the vascular and muscle stock are preserved.

Purpose: Osteosynthesis of complex subtrochanteric fractures is a difficult task. Complications are frequent and results are uncertain. Cemented fixation of pathological metastatic fractures requires a major intervention. The functional prognosis remains uncertain. Our objective was to evaluate the contribution of the long gamma nail (50 nails) in this type of situation and to determine its advantages and disadvantages.

Material and methods: The 50 long gamma nails were inserted in 23 women and 26 men who were followed eight months (4–16). We implanted 39 long gamma nails for complex subtrochanteric fractures (AO classification) in patients aged 59 years on average (19–93) and eleven nails for metastatic femur fractures in patients aged 59 years on average (19–93) with a trochanterodiaphyseal localisation. For the non-metastatic fractures, closed nailing was used in 28 patients and minimum opening for eleven. For the metastatic fractures, the primary tumour was known in eleven cases. The nailing was a preventive measure in six and performed after fracture in five. Three patients had plurifocal fractures. We analysed 43 parameters (position of the cervical screw in the four quadrants of the femoral neck and clinical and radiological features).

Results: For the 39 fractures, reduction was anatomic in 24 and with a gap in 15. The position of the cervical nail was correct in 34 cases. It was in the anterosuperior quadrant in three, the posterosuperior quadrant in one and the posteroinferior quadrant in one. Weight bearing was resumed at 1.5 months on average. Healing with total weight bearing was achieved at four months on average (maximum 8 months). Mechanical complications were: migration of the cephalic screw (n=4), rupture of the locking wings (n=9), nail fracture (n=1), non-union (n=2). Total pain relief was achieved for the eleven pathological fractures (maximum follow-up 16 months). Weight-bearing with crutches was possible in seven patients and not possible in four. There was no dismounting. Outcome was comparable with cemented osteosyntheses.

Discussion: For pathological fractures, this less aggressive osteosynthesis provides very effective pain relief. For other complex subtrochanteric fractures, complete closed nailing was not always possible.