Effectiveness of the Reverse Sural Flap in Covering Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis

Background: The reverse sural fasciocutaneous flap (RSFCF) has been used with success to cover noncomplicated foot and ankle soft tissue defects. However, there are some controversies when it is used in patients having chronic diabetic foot ulcers. This aim of this meta-analysis was to evaluate the efficacy of RSFCF in covering diabetic foot and ankle ulcers. Methods: A systematic review was undertaken from MEDLINE, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Only diabetic foot and ankle ulcers were accepted for inclusion and all study designs were included. Proximally based flaps, nondiabetic ulcers, and assisted negative pressure therapy were excluded. Suitability for inclusion was assessed by 2 reviewers. The random-effect estimate was reported for the set outcomes whenever high heterogeneity was present. Metaregression analysis was performed to identify independent risk factors for failure. Results: The search identified 33 relevant studies comprising 187 patients and flap interventions; all but 1 were case-series. The weighted outcomes were as follows: (1) the flap healing rate was 93.3% while 6.6% resulted in total necrosis, (2) the rate of partial flap necrosis was 12%, (3) venous congestion was reported in 6.6% of cases, (4) the infection rate was 8.3%, and (5) the donor site morbidity was 4.6%. No association was found between pedicle width or presence of a subcutaneous pedicle tunnel and the primary outcome of total loss. Conclusions: This review demonstrated excellent results of the flap when covering complicated or large diabetic foot and ankle ulcers. When compared to those published in the literature, our results found RSFCF to be relatively less successful in diabetic wounds than in trauma patients but more successful than in those having associated osteomyelitis and those who were treated with random local flaps.