• Users Online: 74
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 108-111

Sural flap effectiveness in exposed lower extremity fractures

1 Department of Traumatology and Orthopedic Surgery, Reconstructive Microsurgery Unit, Hospital Roosevelt, Guatemala, Guatemala
2 Department of Traumatology and Orthopedic Surgery, Hospital Roosevelt, Guatemala, Guatemala
3 Medical Research, Francisco Marroquin University, Guatemala, Guatemala

Date of Submission21-Apr-2020
Date of Acceptance04-Nov-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Fernando Romero
Department of Traumatology and Orthopedic Surgery, Reconstructive Microsurgery Unit, Hospital Roosevelt, Guatemala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_26_20

Rights and Permissions

Background: In a Guatemalan public hospital, 3710 fractures were diagnosed in 2016, of which 723 corresponded to the tibia. Of these tibial fractures, approximately 15% were exposed. Skin coverage in exposed fractures has always been a challenge for the attending physician. In the case of the lower limb, there is the option of making a sural flap. Objectives: To determine the effectiveness of the sural flaps when utilizing this technique as a treatment for exposed fractures in the lower limb in adult patients. Methods: A prospective observational descriptive study, the evaluated patients and patient files as primary and secondary sources, respectively, and control with observational variables. The sample consisted of 24 patients who got 3 follow-up appointments at 5 days, 2 weeks, and a year. Results: The results manifested effectiveness of 95.8%. The area most affected was the lateral malleolus. Additionally, comorbidities, schooling, and gender showed no influence on the effectiveness of the flap. Conclusion: The effectiveness of the sural flap technique in exposed fractures was 95.8%. Recommendations: Physicians ought to consider using the sural flap as the treatment of choice for skin coverage defects localized in the distal and middle third regardless of the leg and cause of the defect.

Keywords: Effectiveness, exposed fracture, lower extremity, procedure, sural flap

How to cite this article:
Romero F, Gonzalez JC, Reyes CR, Ardebol J. Sural flap effectiveness in exposed lower extremity fractures. J Orthop Traumatol Rehabil 2021;13:108-11

How to cite this URL:
Romero F, Gonzalez JC, Reyes CR, Ardebol J. Sural flap effectiveness in exposed lower extremity fractures. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Nov 27];13:108-11. Available from: https://www.jotr.in/text.asp?2021/13/2/108/333557

  Introduction Top

Due to a large number of car accidents, firearm wounds and falls, the incidence of exposed fractures has increased continually. Since the past decades, both infections and hemorrhage are the most frequent causes of death or limb loss. In Guatemala from July 2015 to July 2016, there were 4707 road accidents.[1] Evidently, a large fraction of the population remains at risk of suffering an exposed fracture.

An exposed fracture is a loss of continuity of a bone segment that deviates from its natural course and contacts the external environment, whether the fracture ends are visible or not. In these lesions, the wound is in communication with the fracture site. Therefore, the treatment of the wound and the coverage of the bone is one of the fundamental pillars for the treatment of this type of fracture.[2]

The management of fractures with loss of skin coverage can be a real challenge, especially in the lower limb due to size, irrigation, and the compulsory need of the limb for walking. In 1992, Masquelet et al. introduced the concept of a neurocutaneous flap and described the sural flap, named after the sural nerve. This Masquelet flap opens a new treatment option for exposed fractures in the lower limb.[1],[2],[3],[4],[5]

However, with the aforementioned, we showed that lower limb fractures are the most common and the nature of exposure increases the complexity of the treatment. This is why it remains a challenge for the treating traumatologist and one of the determinants for a correct treatment outcome is the amount of time the patient spends with the fracture and exposure. Therefore, if the treatment result of the patient depends on the time the patient spends after the moment of the fracture, a knowledgeable traumatologist who provides an adequate diagnosis, at the opportune moment, to give the correct treatment is also compulsory. However, clinicians may justify the treatment provided with evidence-based medical treatment investigations. The lack of information regarding this type of management justifies the necessity to evaluate the effectiveness of the flaps at the hospital to aid the orthopedic surgeon in providing another treatment option. Moreover, gathering information concerning patient follow-up and length of hospital stay.

The following clinical parameters will be evaluated accordingly: achievement of bone covering without dehiscence, infection, an optimal capillary filling in the part of the flap, and the presence or not of underlying hematoma.

Nonetheless, comorbidities, degree of education, location of the fracture, and the patient's gender were evaluated and analyzed to determine which parameters influence the effectiveness of the flap.

Surgical technique

The patient is placed in a prone position to elaborate an ideal flap design and placing a tourniquet in the patient's thigh with a pressure of 350 mmHg to avoid bleeding when the flap is dissected. The two heads of the gastrocnemius muscle are released, and the flap size drawn proportionally to cover the desired defect. Later descending on the path of the artery, vein, and sural nerve and extending up to 5 cm from the vertex of the peroneal malleolus, where the pivot point of the flap is discovered (site of anastomosis between the sural artery and the perforating peroneal septocutaneous artery). An incision is performed on the skin (island of the flap) extending from the fascia and pedicle fat to the muscular epimysium. The vein and sural nerve are elevated and sectioned, respectively. Seemingly, the sural nerve proximally deepens into the muscular bellies of gastrocnemius to bury the neuroma. Once the path of the sural nerve and external saphenous vein is identified, the adipofascial border will be resected with a length of 2-4 cm. The pedicle including the fascia is dissected all the way to the pivot point. Posteriorly, an arc of rotation is made, which allows the coverage of the defect. Once raised, the point of rotation will be 5 cm above the external malleolus and the arc of rotation will be wide (up to 180°) reaching cover lesions of the middle and distal third of the leg, internal and external malleolus, Achilles' tendon, and heel. If the donor area is ≤4 cm it is closed directly, otherwise it will be necessary to utilize free partial-thickness graft taken from the contralateral thigh. Finally, a drainage device is recommended to eliminate collections that predispose a pressure increase on the pedicle or the fasciocutaneous island. Large flaps (10 cm × 13 cm) may be elevated nevertheless are subject to venous congestion.[6],[7]

  Methods Top

The investigation is an interventional study that consisted of a homogeneous sample size of 24 adult patients. The study lasted for 1 year and the patients were followed on three occasions after the surgery; 5 days, 2 weeks, and 1 year. Patients selected to take part in the investigation were chosen once they arrived at the emergency department following a vehicular accident. The most important requirement for each patient was to have an exposed fracture in either lower limb. The sural flap technique utilized was performed in each patient regardless of comorbidities. After acquiring data, analysis was elaborated in the Microsoft Excel software.

  Results Top

Data analysis was performed using an online archive where access to general patient information and relevant variables was granted to determine the effectiveness of flap placement and discover reasons for failure.

Of the 24 patients evaluated, 23 had completely effective flaps and 1 patient had a 2 cm wide by 2.5 cm long flap dehiscence and thereby did not meet the objective of complete viability and was recognized as a noneffective flap.

These results display an effectiveness percentage of 95.8% and failure of 4.2% representing 23 patients and 1 patient respectively.

The patient who presented dehiscence was a 25-year-old male patient, with low socioeconomic status and no relevant medical history. The flap was elaborated on the medial malleolus region.

The age interval ranged from 18 to 74 years old, and the average age was 32 years old [Table 1].
Table 1: Patient Age

Click here to view

In total, the surgical technique was elaborated in six areas. These areas showed no difference when evaluating the effectiveness of the flap. This observation is consistent with scientific evidence, and the location justified using irrigation and the mechanism of survival of the flap. In all these flaps, the neurovascular complex was the same and only the place of coverage varied [Table 2].
Table 2: Location of the flap

Click here to view

Comorbidities, such as diabetes mellitus, arterial hypertension, vasculitis, and obesity are known predisposing factors for failure using the sural flap in other studies. For this reason, the patient's comorbidities were taken into account. However, in this study, no comorbidity negatively impacted the outcome of the flap.

In this investigation, eight patients had at least 1 comorbidity, which represents 33% of the sample size. From the sample studied, 6 patients had 1 comorbidity (25%), 1 patient presented 2 comorbidities (4.16%) and 1 patient had 3 comorbidities (4.16%) [Table 3]. All of these patients with comorbidities had an effective flap. This supports the notion that comorbidities are not a contraindication to perform sural flap surgery.
Table 3: Population with comorbidity (n=24)

Click here to view

Along with comorbidities, previous reports have shown that the size of the flap correlates with effectiveness, explaining that the larger the flap the more prone to suffer a degree of necrosis. However, in our study flaps were average in size and did not contribute to failure.

One of the discoveries we made with this study is that there is no proof that the degree of education affects flap outcome. Nonetheless, due to public health knowledge, it is evident that most health problems are found in habitants of low socioeconomic status.

In Guatemala, only 23% of the population receives a high school level of education and people without prior education are more prone to developing unhealthy lifestyles and preventable health issues.

Therefore, based on this premise, the level of education of the patients was investigated, to show its effect on flap effectiveness. Of the 24 patients evaluated, 4 (16.5%) had only gone to elementary school, 8 (33.3%) went to high school, 9 (37.5%) with high school and a diploma in computer or writing, and 3 (12.5%) had a college-level education. The patient with dehiscence had only reached 3rd grade in elementary school [Table 4].
Table 4: Level of education (n=24)

Click here to view

A difference in gender impact was observed with 17 men (71%) and 7 women (29%) of the total sample [Table 5].
Table 5: Distribution by sex (n=24)

Click here to view

  Discussion Top

During this investigation, the results obtained were consistent with other studies regarding the effectiveness of sural flaps. In two studies, the researchers reported effectiveness of 100% and 91.2% with a sample size of 10 and 110 respectively.[8],[9] In this study, sural flap treatment effectiveness was 95.8% which approached the results demonstrated in previous studies. The area of coverage did not influence flap effectiveness due to the aforementioned principle that the flap will use the same plexus for irrigation and drainage. However, it is worth emphasizing that the most affected area was the lateral malleolus and the least affected area was the plantar region of the foot.

Evidently, comorbidities worsen any situation regarding health and wound repair. However, sural flaps for skin coverage remain the best option despite patient comorbidities since other wound management options such as VAC system or gauzes for second intention closure in patients with diabetic foot or bone exposure (osteomyelitis, tumor, exposed fracture, etc) take much longer time to heal and tend to generate more hospital-related expenses due to longer hospital stay.[8],[9],[10] The present study manifested a 100% effectiveness when treating patients with comorbidities implying an optimal management method in patients with lower limb defects.

A section of the evaluation emphasized on patient education to address whether the degree of schooling would negatively impact the survival of the flap in view of the fact that people with lower levels of education are often linked to participate in unhygienic habits thereby providing inadequate wound care.[10] In this investigation, 17 (72%) patients were male and 7 (29%) were female. The majority of the sample was male which was compatible with other studies. This can be explained by the simple fact that men are most commonly associated with accidents and fractures.

Postoperative care is fundamental, and efforts must be made to ensure appropriate healing such as elevation of the limb to reduce edema, not using an oppressive bandage, cleaning the flap, and rest. In this study, it is noteworthy to mention that all the postoperated patients were transferred to the wards, where the flap was decontaminated and cleansed daily, and anti-inflammatory and antibiotic treatment was provided. When caring for flaps on the upper limb, the arm is elevated to 30°. Subsequently, the gauze-covered area where the flap is placed is revealed after 6 days, and the graft is monitored through a visible segment on the bandage.

Patient follow-up was provided on 3 occasions. The first evaluation was 5 days after surgery before being discharged from the hospital, the second check-up in the outpatient clinic, and the third follow-up was verified through telephone communication. There are 3 distinct phases of graft adherence. The first phase of plasma imbalance occurs between 24 and 72 h after the procedure. This initial phase consists of edema in the localized to the grafted region and the presence of fibrin which confers stability. Therefore, the grafted part is not uncovered until the 5th postoperative day. Prolonged best red rest and minimizing patient mobility are the most important methods to avoid graft failure due to factors, such as premature mobility, in early stages.[11] Nevertheless, graft shifting is reduced by limiting extremity movement, as a result, graft adherence is enabled. Capillary formation commences from the 6th day onward.

  Conclusion Top

The effectiveness of the sural flap procedure was satisfactory. Several areas were covered and proved a shorter hospitalization stay and lower costs than other treatment modalities. For these reasons, sural flaps are a valuable option to treat patients with lower limb defects. Complications are infrequent and most cases are due to patient nonadherence to proposed flap care, such as reduced mobility and bed rest. In this study, one patient suffered from dehiscence and the cause was investigated. This patient did not attend the initial follow-up appointments in the outpatient clinic due to long travel distance. However, the patient sought medical attention and the dehiscence was treated accordingly with the appropriate medical care and resolved completely. This investigation revealed effectiveness of 95.8% regarding sural flap surgery for the treatment of exposed fractures in the lower limb.


  1. onsider using the sural flap as the treatment of choice for lower limb coverage defects regardless of the cause of the defect or patient comorbidities
  2. Increase awareness of the importance of learning this procedure to students in training to provide better care and better treatment to the patients cared for
  3. Provide adequate postoperative follow-up to patients to achieve satisfactory effectiveness when performing a sural flap.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cuque J. Traffic Accidents, Second Place of Deaths in Guatemala, Guatemala. Daily journal; 2016. from: http://diariodigital.gt/2016/09/los-accidentes-transito-segundo-lugar-muertes-guatemala/. [Last accessed on 2017 Mar 05].  Back to cited text no. 1
Di Nunzio L, García M, González M, Guilligan T, Lagos F, Montani M. Fractures Exposed. Salamanca: University of Salamanca, Faculty of Medicine; Available from: http://medi.usal.edu.ar/archivos/medi/otros/fracturasexpuestas.pdf. [Last accessed on 2017 Mar 05].  Back to cited text no. 2
Iglesias S, Allende C, Gutiérrez N, Núñez J, Ruchelli L. Inverse fasciocutaneous sural flap to cover soft tissue defects in the leg, ankle and foot. Rev Asoc Argent Ortop Traumatol 2017;79:204-9.  Back to cited text no. 3
Dhamangaonkar AC, and Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. Journal of orthopaedics and traumatology: official journal of the Italian Society of Orthopaedics and Traumatology, 2014;15:225-9. https://doi.org/10.1007/s10195-014-0304-0.  Back to cited text no. 4
Muñoz J, Vivesa P. Caba Doussouxb, D. Martí i Garín. Open Fractures. Rev Esp Cir Ortop Traumatol 2010;54:399-410.  Back to cited text no. 5
Contedini F, Negosanti L, Fabbri E, Pinto V, Tavaniello B, Sgarzani R, et al. Cross-leg as salvage procedure after free flaps transfer failure: a case report. Case reports in orthopedics, 2012, 205029. https://doi.org/10.1155/2012/205029.  Back to cited text no. 6
Andrades P, Sepúlveda S. Essential Plastic Surgery. 1st ed. Santiago: University of Chile; 2005.  Back to cited text no. 7
Ciofu RN, Zamfirescu DG, Popescu SA, Lascar I. Reverse sural flap for ankle and heel soft tissues reconstruction. J Med Life 2017;10:94-8.  Back to cited text no. 8
Faizal A, Hanafiah H, Khandasamy Y. Delayed reverse sural flap for cover of heel defect in a patient with associated vascular injury. A case report. Indian J Surg 2013;75:Suppl 1:148-9.  Back to cited text no. 9
López E. Reconstruction of Lower Extremities with Sural Flap. Guatemala: San Carlos University of Guatemala; 2015.  Back to cited text no. 10
Persaud S, Chesser A, Pereira R, Ross A. Sural Flap use for the treatment of wounds with underlying osteomyelitis: Graft size a predictor in outcome, a systematic review. Foot Ankle Spec 2017;10:560-6.  Back to cited text no. 11


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Tables

 Article Access Statistics
    PDF Downloaded60    
    Comments [Add]    

Recommend this journal