Circular external fixation for reverse sural flap protection after partial calcanectomy in a diabetic heel with distal tip necrosis

Ahmed Al-Aufi; Ali Kashoob; Ahmed Al-Barwani; Adel Al-Rawe; Ruqaiya Al-Weshahi; Rafal Aljadder

doi:10.18203/issn.2455-4510.IntJResOrthop20263948

Authors

Ahmed Al-Aufi Department of Vascular Surgery, Khoula Hospital, Muscat, Oman
Ali Kashoob Department of Orthopaedic Surgery, Khoula Hospital, Muscat, Oman
Ahmed Al-Barwani Department of Orthopaedic Surgery, Khoula Hospital, Muscat, Oman
Adel Al-Rawe Department of Vascular Surgery, Khoula Hospital, Muscat, Oman
Ruqaiya Al-Weshahi Department of Radiology, Oman Medical Specialty Board, Muscat, Oman
Rafal Aljadder Department of General Surgery, Khoula Hospital, Muscat, Oman

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20263948

Keywords:

Calcaneus, Diabetic foot, External fixators, Heel, Osteomyelitis, Surgical flaps, Sural artery, Wound healing

Abstract

Reverse sural artery flaps are susceptible to venous congestion, while posterior heel coverage requires strict protection from pressure. A 48-year-old woman with poorly controlled type 2 diabetes, anaemia and chronic calcaneal osteomyelitis had a persistent 4×5 cm left heel defect. Magnetic resonance imaging showed acute-on-subacute osteomyelitis with an intraosseous abscess. After multidisciplinary preparation, partial calcanectomy and a pedicled reverse sural flap with split-thickness skin grafting were performed. A circular external fixator was configured to suspend the heel, protect the pedicle and permit wound surveillance. The flap remained viable, but repeated supine positioning was followed by congestion and, at one month, 1 cm distal tip necrosis that was debrided and resutured. At 10 weeks, the flap was well settled with a residual 2×4 cm healing distal wound. Circular fixation can provide contact offloading and access, but does not replace positioning, congestion surveillance, metabolic optimisation and structured follow-up.

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