Chronic calcaneal osteomyelitis is a difficult surgical problem, especially in diabetic patients. After aggressive surgical eradication of nonviable soft tissue and infected bone, there will be a large soft-tissue and bony defect. A distally based sural fasciomusculocutaneous flap including the sural nerve and a midline cuff of the gastrocnemius muscle can be useful for covering the defect. This flap is designed on the proximal half of the posterior calf and has an adequate blood supply derived from retrograde perfusion of the vascular axis of the sural nerve to the musculocutaneous perforators of the gastrocnemius muscle. The patency of the peroneal artery should be confirmed by Doppler ultrasound or angiography before surgery. If there are any vascular problems, this flap will not be used to avoid complications resulting from poor flap circulation. This approach has been used for 11 diabetic patients in the past 2 years. All flaps survived completely and all wounds healed uneventfully. The authors found that the flap was reliable and technically simple to design and execute. This 1-stage procedure not only preserves the major arteries of the injured leg but has also proved valuable for filling bony defect and treating bony infection because it provides a well-vascularized muscle fragment. Compared with other tissue transfers, this flap has special characteristics for use on diabetic patients with chronic calcaneal osteomyelitis.

Resurfacing shallow defects over the ankle and foot with an appropriately thin flap is a common but difficult task. This can be accomplished by harvesting the medial sural artery perforator flap from the medial aspect of the upper calf. Based on the musculocutaneous perforator of the medial sural artery, this flap preserves the medial gastrocnemius muscle and avoids unnecessary flap bulkiness. Between January 2002 and February 2004, we used 2 variants of the free medial sural artery perforator flap for ankle and foot reconstruction in 13 patients (10 fasciocutaneous flaps and 3 adipofascial flaps). In these patients, skin defects were combined with bone, joint, or tendon exposure. The main advantage of this flap is that it provides a thin and pliable coverage to achieve better accuracy in the reconstructive site. Other advantages include maintaining the function of the medial gastrocnemius muscle, providing a long vascular pedicle, and avoiding the need to sacrifice major arteries of the leg. The main disadvantages are the tedious process of intramuscular retrograde dissection of the perforator and the unsightly skin graft over the medial calf.

Finding an appropriate soft-tissue grafting material to close a wound located over the ankle and heel can be a difficult task. The distally based lesser saphenous venofasciocutaneous flap mobilized from the posterior aspect of the upper leg, used as an island pedicle skin flap, can be useful for this purpose. The vascular supply to the flap is derived from the retrograde perfusion of the accompanying arteries of the lesser saphenous vein. These arteries descend along both sides of the lesser saphenous vein to the distal third of the leg, either terminating or anastomosing with the septocutaneous perforators of the peroneal artery. Between February of 1999 and March of 2001, four variants of this flap were applied in 21 individuals, including 11 fasciocutaneous, five fascial, three sensory, and two fasciomyocutaneous flaps. Skin defects among all patients were combined with bone, joint, and/or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-stage procedure not only preserves the major arteries and the sural nerve of the injured leg, but it also has proved valuable for covering a weight-bearing heel and filling a deep defect, because it potentially provides protective sensation and a well-vascularized muscle fragment. When conventional local flaps are inadequate, this flap should be considered for its reliability and low associated morbidity.