Modified Sural Flap vs Free Anterolateral Thigh Flap for Soft Tissue Reconstruction Around the Ankle: A Randomized Controlled Trial

Abstract

Background:

Soft tissue defects around the ankle are common for orthopaedic surgeons in clinical practice. This study aimed to compare the modified sural flaps and free anterolateral thigh (ALT) flaps in terms of their ability to cover soft tissue defects, patient satisfaction, infection rates, flap ischemia, and flap sensation.

Methods:

This comparative study included 40 patients (24 males and 16 females) aged 5-60 years with defects in the lower one-fifth of their leg or foot, and less than 15 cm × 15 cm in size. Group A (20 patients) underwent a modified sural flap, whereas group B (20 patients) underwent free ALT flap. The study was performed in our specialized hand and reconstructive microsurgery unit from 2021 to 2023.

Results:

The operation time was significantly longer for the free ALT flap group compared with the modified sural flap group (P value < .01). Patient satisfaction was higher with the modified sural flap. There were no significant differences in flap ischemia or donor site complications between the 2 groups. The sensation of the flap after 1 year favored the free anterolateral thigh flaps due to sensory nerve anastomosis, but after 1.5 years, good sensation was present in both flaps.

Conclusion:

The modified sural flap demonstrated superior efficiency with shorter operative times and higher patient satisfaction, whereas the free ALT flap provided better short-term sensory outcomes because of nerve micro-anastomosis capability. Both techniques achieved equivalent sensation recovery at 18 months, suggesting the modified sural flap may be preferable for most small to medium-sized defects foot and ankle defects.

Keywords

ankle free anterolateral thigh flap soft tissue reconstruction modified sural flap

Get full access to this article

View all access options for this article.

References

Vendramin

. Retalho sural de fluxo reverso: 10 anos de experiência clínica e modificações. Rev Bras Cir Plást. 2012;27:309-315.

Nelson

Watts

. Working in resource-challenged environments. In: Sabharwal

, ed. Pediatric Lower Limb Deformities: Principles and Techniques of Management. Springer International Publishing; 2016:215-228.

Dhamangaonkar

Patankar

. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Trauma. 2014;15:225-229. doi:10.1007/s10195-014-0304-0

Shoeib

. Cross-leg flap: its reliability and outcome. Mod Plast Surg. 2013;3:9-14.

Kececi

Sir

. Increasing versatility of the distally based sural flap. J Foot Ankle Surg. 2012;51:583-587. doi:10.1053/j.jfas.2012.05.018

Spyropoulou

Zampakos

Hapsas

Kalofonou

Vourtsis

Mandrekas

. The distally based sural flap: a useful tool in the coverage of complex wounds of the distal third of shin and proximal foot. Hell J Surg. 2011;83:245-251. doi:10.1007/s13126-011-0047-9.

Masquelet

Romana

Wolf

GJP

, et al. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconst Surg. 1992;89:1115-1121.

Abo Elhassan

Abulezz

Ali

Elsayed

. Comparison between free anterolateral thigh flap and free medial sural artery perforator flap in reconstruction of post traumatic soft tissue defects of dorsum of the foot. Austin J Surg. 2021;8:1276-1288.

Khan

Cheruvu

VPR

Krishna

Laitonjam

Minz

Joshi

. Post-traumatic wounds over the dorsum of the foot-our experience. Int J Burns Trauma. 2020;10:137-145.

10.

Samra

Bibbo

Levin

Kovach

. A practical guide to the use of the anterolateral thigh flap. JBJS Essent Surg Tech. 2017;7:e22.

11.

Donski

Fogdestam

. Distally based fasciocutaneous flap from the sural region. A preliminary report. Scand J Plast Reconstr Surg. 1983;17:191-196.

12.

Low

O-W

Sebastin

Cheah

AEJ

. A review of pedicled perforator flaps for reconstruction of the soft tissue defects of the leg and foot. Indian J Plast Surg. 2019;52:26-36.

13.

R-G

Wang

, et al Sequential therapy of vacuum sealing drainage and free-flap transplantation for children with extensive soft-tissue defects below the knee in the extremities. Injury. 2012;43:822-828.

14.

Song

Chen

Song

. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37:149-159.

15.

Wong

Wei

Chen

Lin

. Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery. Plast Reconstr Surg. 2009;123:571-577.

16.

Madsen

Sørensen

. Versatility of the pedicled anterolateral thigh flap for surgical reconstruction, a case series. JPRAS Open. 2020;25:52-61.

17.

Kidd

Platt

Kidd

Grobbelaar

. Short- and long-term complications of free anterolateral thigh flap reconstructions: a single-centre experience of 92 consecutive cases. Surg Res Pract. 2022;2022:2122956.

18.

Beecher

Cahill

Theopold

. Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review. Arch Plast Surg. 2021;48:410-416.

19.

Grandjean

Romana

Fitoussi

. Distally based sural flap for ankle and foot coverage in children. Orthop Traumatol Surg Res. 2016;102:111-116.

20.

Park

Choi

Hong

Kang

Park

. Reconstruction of the weight-bearing heel with nonsensate reverse sural artery flaps. Injury. 2021;52:1993-1998.

21.

Akdeniz Doğan

Çavuş Özkan

Tuncer

Saçak

Çelebiler

. A comparative clinical study of flap thickness: medial sural artery perforator flap versus anterolateral thigh flap. Ann Plast Surg. 2018;81:472-474.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

1.54 MB