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Soft tissue defects around the foot and ankle region often present an awkward problem for plastic surgeons. The medial plantar artery flap raised from the non-weightbearing instep of the plantar foot offers a thick, sensorial, durable, and glabrous skin. The reversed sural artery flap offers a reliable option for coverage with the advantages of a wide arc of rotation, adequate dimensions, and a reliable blood supply. The present study compared the outcomes of the medial plantar artery flap and the distally based sural artery flap in foot and ankle reconstruction. The present comparative cross-sectional study included 30 adult patients with soft tissue defects in the foot and around the ankle, who were divided into 2 equal groups. One group underwent reconstruction with the proximally based island medial plantar artery flap (MPAF). The second group underwent reconstruction with the reversed sural artery flap (RSAF). The operative time and complications were carefully recorded. The surgical outcomes in terms of flap survival, durability of coverage, and functional outcome were assessed for all patients. No significant differences were found between the 2 groups in age, sex, etiology, or site of the defect. The defect size was significantly smaller in the MPAF group than in the RSAF group (22 ± 2.7 cm2 versus 66.2 ± 7.7 cm2; p < .001). However, the operative time was significantly longer in the MPAF group than in the RSAF group (100 ± 2.9 minutes versus 80.5 ± 3.1 minutes; p < .001). The flap survived in all cases in the MPAF group, but total flap necrosis occurred in 1 patient in the RSAF group. The mean follow-up period was 13.2 months. Weightbearing was significantly earlier in the MPAF group than in the RSAF group (5.8 ± 0.26 weeks versus 6.9 ± 0.19 weeks; p = .003). None of the 30 patients developed recurrent ulceration. The incidence of complications (33.3% versus 80%) was significantly less in the MPAF group than in the RSAF group (p = .01). Significantly greater improvement was found in the functional outcomes in the MPAF group compared with the RSAF group (p = .004). In conclusion, the MPAF and distally based sural artery flap are the 2 flaps available for foot and ankle reconstruction. However, the MPAF offers better functional outcomes with a lower frequency of postoperative complications. Thus, the sensate MPAF is recommended for reconstruction of moderate-size defects of the foot and ankle region.