Purpose of the study: The sural flap with a distal pedicle is a commonly used flap for ankle or foot cover; it has been described as easy to achieve, versatile and reliable. Following several personal failures, we attempted to analyse the principle factors of unfavourable outcome and to determine the precise role for this flap in distal cover of the lower limb.

Material and method: We retrospectively analysed a series of 25 sural flaps with a distal pedicle performed by one operator among a series of 55 ankle and foot flaps. Outcome was assessed as complete flap survival; even partial necrosis was noted. Factors examined included patient age, context, localization and surgical factors.

Results: Eight flaps necrosed (7 partial and 1 total) leading to amputation (32% complications). Flaps with partial necrosis nevertheless all healed after repair.

Discussion: This series had a high failure rate, like earlier reports in the literature. Most of the necrotic flaps were observed in older patients with vulnerable tissues. Conversely, the size of the flap or the localization of the recipient site did not appear to affect outcome; there was no apparent learning curve. The harvesting technique and the difficulties presented by anatomic variations are recalled. Treatment of the pedicle is important but cannot explain all of the failures. Why the distal sural flap should be chosen among the different flaps available for the lower limb depending on the site and situation is not clear. Technical elements, such as two-phase harvesting can be helpful, but for us do not appear to improve the survival of this flap whose outcome remains difficult to predict.

Purpose of the study: The thin soft tissue cover and the proximity of underlying structures of the ankle are factors favoring cutaneous necrosis which could rapidly expose the bone, joint or tendons. Flap cover is widely used. Several types of flap and donor sits have been described. We report a consecutive series to examine the different indications.

Material and methods: Between 2000 and 2005, we treated 22 cases of tissue defects involving the ankle. Most patients were trauma victims with damage involving the distal quarter of the leg to the forefoot. Mean size of tissue loss was 8 x 6 cm (range 2–13 x 2–9 cm). The localization was medial for nine, anterior for six, and lateral for seven. Several types of flaps were used: distally-based sural (n10), lateral supramaleolar (n=5), medial arch (n=2), pediculated soleus (n=4), island latissimus dorsi (n=1).

Results: The success rate was 72%. There was one total failure (medial arch). The six cases of partial failure (27%), which involved partial distal necrosis of three lateral supramaleolar flaps and three sural flaps, were revised by re-advancement of the pedicle or aspirative dressings.

Discussion: When possible, we prefer pediculated flaps considered to be more reliable. The rate of partial necrosis was high but all of the failure cases involved serious general problems. The sural flap is especially useful for anterior and lateral tissue defects. Its deep pedicle is often intact, improving chances of survival. It can also be used for transverse anteriomedial injuries. Large longitudinal medial defects would be a good indication for free flaps or, in the event of a contraindication and also, in our experience, for pediculated soleus flaps. Supramalleolar flaps can be a problem in this localization: we reserve these flaps for non-traumatic medial or anterior defects. We have found that the risk of failure it too great for the medial supramalleolar flap.

Purpose of the study: Osteitis with loss of distal soft tissue on the medial aspect of the leg raises a problem of cutanous cover, particularly in the event of longitudinal injury. Free flaps are frequently used with variable success in older patients with more risk factors. Four our more frail patients, we have used a retrograde soleus flap pediculated on the posterior tibial artery. We present here the possibilities offered by this flap and assess the different indications.

Material and methods: Six patients, mean age 55 years (range 44–68 years) were treated for cutaneous tissue loss measuring 9.5 x 6.5 cm on average. One patient was diabetic and two were smokers. The decision to use the soleus flap was made because of the presence of cutaneous lesions on the leg contraindicating a local falp. Arteriography revealed the persistence of the three vascular routes with satisfactory distal anastomoses, allowing high ligature of the posterior tibial arery intraopeartiely after a clamprepermeabilization test. The soleus flap was modeled to size and rotated en bloc with the tibial artery which was released to the retromaleolar localization for the distal flap^s. Treatment of osteitis incluced resection, cement filling and antibiotics then bone graft.

Results: All flaps survived. One had to be revised because of partial necrosis. There were no distal vascular problems. At minimum follow-up of 18 months, all the cases of osteitis had healed.

Discussion: The soleus flap pediculated on the posterior tibial artery is a reliable and effective flap. The territory covered can be very distal, reaching the foot. The vascularization of the soleus muscle allows moving the entire muscle, providing a very powerful flap. Deliberate sacrifice of a vascular supply considered as dominant for the leg is certainly a difficult decision, but which must be weighed against the risk of failure of a free flap.

Purpose: Instability of the injured elbow early after repair can lead to recurrent dislocation or failed fixation. Complementary immobilisation increases the risk of stiffness. The purpose of this study was to assess the contribution of dynamic external fixation which allows protected mobilisation and controlled distraction. We wanted to determine feasibility and appropriate indications.

Material and methods: We used the Pennig articulated elbow fixator in twelve trauma victims. Most had complex injuries: five dislocations with lesions of the medial ligaments and fractures of the radial head, including two with early recurrent dislocation; five joint fractures (involving to various degrees the lateral condyle, the head of the radius, the olecranon, and the humeral surface). This fixation method was also used for old or sequelar lesions to achieve reconstruction of the humeral surface (n=3) or after extensive arthrolysis (n=2). Mobilisation was started on day five postop.

Results: For the fresh injuries, the humero-ulnar articulation was centred in all cases. In these patients, mean final flexion was 0.35.130° and pronation-supination was 0.10.155°. One purely lateral dislocation was observed. Radio-ulnar synostosis after fracture of the ulna (n=1) and osteoma (n=1) were also observed.

Discussion: This dynamic external fixation system is a simple and safe procedure if a rigorous technique is applied. This method enabled early rehabilitation without secondary displacement and also enabled reliable contention particularly important in these multiple injury patients. The patients experienced very little pain during rehabilitation exercises, probably due to the distraction which did not appear to provoke reflex dystrophy. For complex instability of the elbow, the reduction of stress forces during mobilisation movements enables an extension of the indications for preservation of the joint fragments. Less reliable results are obtained for stiff elbows with old lesions.