Exploring the Long-Term Efficacy and Surgical Outcomes of Sural Neurovascular Flap Applications in Distal Lower Limb Wound Reconstruction: A Single-Center Retrospective Study

Exploring the Long-Term Efficacy and Surgical Outcomes of Sural Neurovascular Flap Applications in Distal Lower Limb Wound Reconstruction: A Single-Center Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Long-Term Efficacy and Surgical Outcomes of Sural Neurovascular Flap Applications in Distal Lower Limb Wound Reconstruction: A Single-Center Retrospective Study Mohamed Bangura, Li An He, Tend Zeng, Tadiwa Chirima, Sy-Trung Tran, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4491584/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The sural neurovascular flap has been effectively used to reconstruct complex tibial and soft tissue defects caused by severe trauma, promoting successful wound repair and healing. Proactive management is essential in minimizing postoperative complications and achieving optimal outcomes. Methods Our institution's ethics committee approved this retrospective study which involved 47 participants. Informed consent was obtained from all subjects. Data collected included demographic details, injury mechanisms and sites, mode, and size of soft tissue defects, complications, cosmetic outcomes, and functional outcomes of the lower limb and ankle. All flaps were performed by a single surgeon, with follow-up from January 2012 to February 2018. Result The study observed minor complications, primarily superficial necrosis. Over 95% of flaps survived, and less than 5% required reoperations due to superficial necrosis. Patient satisfaction was high, with over 50% achieving excellent cosmetic results and over 40% good cosmetic results. Conclusion Sural neurovascular flap applications show significant promise in reconstructing distal lower limb wounds. Our findings highlight the procedure's efficacy, demonstrated by high patient satisfaction, excellent cosmetic outcomes, and favorable functional results. Critical factors for success include meticulous patient selection, thorough debridement, and careful planning to mitigate risks and optimize outcomes. Sural neurovascular flap Sural neurovascular flap application Sural artery flap Reconstructive surgical procedure Clinical healing time Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Reconstructing wounds in the distal lower limb presents substantial challenges due to its complex anatomy and limited vascularity [ 1 – 3 ]. Various surgical procedures have been investigated to overcome these issues, with the sural neurovascular flaps emerging as a potential option. 4–8 The sural neurovascular flap, encompassing the sural nerve and surrounding arteries, has emerged as a viable option, offering consistent vascularity and flexibility in flap design [ 2 , 9 – 11 ]. This flap provides robust soft tissue coverage while preserving functional integrity, making it ideal for reconstructive surgery in the ankle and foot areas [ 1 , 3 , 9 , 12 – 17 ]. Additionally, this technique's low donor site morbidity enhances its appeal. However, successful application requires a thorough understanding of anatomy and surgical proficiency [ 1 , 3 , 18 ]. Over time, the sural neurovascular flap has been used to treat complicated tibial and soft tissue anomalies caused by severe trauma, resulting in successful wound repair and healing [ 6 , 19 – 22 ] Proactive management efficiently controls postoperative complications, resulting in the best results. While complications such as partial necrosis, deep infection, and flap ischemia may occur, overall clinical results are favorable, with donor sites healing well and mild paresthesia reported. 6 Valuable insights into surgical technique and aftercare help to improve the procedure's effectiveness and reduce risks. While previous studies have focused on immediate surgical outcomes, more data on the long-term functional and patient-reported outcomes of sural neurovascular flap reconstruction for distal lower limb wounds must be collected. Evaluating parameters such as range of motion and patient satisfaction over extended periods can provide valuable insights. Furthermore, there is a need to investigate the impact of this reconstruction technique on patients' quality of life and aesthetic satisfaction. Does sural neurovascular flap application in reconstructive surgical procedures lead to favorable cosmetic outcomes and high patient satisfaction rates? What are the incidence and types of complications associated with sural neurovascular flap application in reconstructive surgical procedures, and how do they impact patient outcomes? This research aims to evaluate the efficacy and long-term outcomes of sural neurovascular flap applications in distal lower limb wound reconstruction, utilizing a single-center retrospective study design. We hope that at the end of this research, we will have a thorough understanding of the aesthetic and functional outcomes and the clinical and efficacy findings of using sural neurovascular flaps to reconstruct severe wounds in the distal lower limbs. Patients and Methods Study Design and Setting This retrospective single-center study was conducted at an urban central hospital's orthopedic trauma center. Patients The study included 47 participants, selected based on predetermined inclusion and exclusion criteria. A single surgeon performed all surgeries from January 2012 to February 2018. Data collected included demographic information, injury characteristics, defect size, complications, cosmetic outcomes, and functional outcomes of the lower limb and ankle. Statistical analysis was conducted using SPSS, with a p-value of 0.05 considered statistically significant. Patient Selection Patients are selected based on predetermined inclusion and exclusion criteria as illustrated in Fig. 1 . All patients are selected from our department’s database with a strict follow-up protocol as stipulated by our institution’s ethics committee. The inclusion criteria were as follows: (1) Patients with Distal Lower Limb Wounds include individuals with open wounds or soft tissue defects in the distal lower limb region. (2) Cases where the primary method of reconstruction involved using a Sural Neurovascular Flap. (3) Age Range: 18 years and above. Exclusion criteria were as follows: (1) Cases where Sural Neurovascular Flap was not the primary or sole reconstruction method. (2) Pediatric patients were excluded. (3) Cases with severe systemic conditions like diabetes that may significantly impact wound healing independently of the surgical procedure. (4) Previous Failed Flap Reconstruction cases where the patient had prior unsuccessful attempts at flap reconstruction to isolate the impact of the Sural Neurovascular Flap. (6) Non-Distal Lower Limb Injuries cases involving wounds or injuries outside the distal lower limb region. Surgical Techniques Following the successful administration of spinal anesthesia, a patient is carefully positioned in the appropriate position. Preparation ensued as the affected limb underwent thorough disinfection using 1% iodine, followed by applying sterile wipes. The thigh airbag tourniquet pressurized at 500 mmHg is applied to ensure proper circulation control. Upon assessment, a skin defect approximately 10cm 2 in size is identified on the lateral aspect of the left calcaneus, revealing the calcaneus with visible milky white inflammatory exudation. Surrounding soft tissues appeared healthy, with the fibular tendons securely in place. The surgical area undergoes meticulous cleansing with hydrogen peroxide, diluted iodine, and physiological saline. Subsequent procedures included debridement, wound margin trimming, and removal of compromised tissues, with intermittent rinsing of the surgical site using the solutions above. The ankle joint wound is closed using Johnson & Johnson Line 1 oblique sutures, followed by the application of vacuum sealing drainage (VSD) excipients to facilitate wound healing while maintaining negative pressure. The patient safely returns to the ward following the surgery. Flap design When performing traditional sural neurotrophic vascular flap surgery, we opt for the "retrograde method." For flap design, the focus is on positioning it at the upper 1/3 of the posterior midline of the calf, aligning with the axis formed by the sural nerve, superficial peroneal artery, and small saphenous vein. This alignment follows a body surface projection from the midpoint of the popliteal fossa to the midpoint of the lateral malleolus and Achilles tendon, ensuring that neither side extends beyond the lateral midline. The retrograde sural neurovascular flap's transfer point lies at the ankle, making it suitable for addressing soft tissue defects in the heel, ankle, and lower 1/3 of the calf. To determine the flap rotation point, we locate it 5-7cm posterior and superior to the lateral malleolus. Subsequently, we symmetrically drew the excision area of the flap on the flap axis, considering the required pedicle length for the recipient area as shown in Figs. 2 and 3 . The blood supply to the distal pedicle flap is primarily sourced from the lowermost intermuscular perforator of the peroneal artery, located approximately 5cm behind and above the lateral ankle, within a range of 4–7 cm. This crucial vascular pathway typically exhibits an outer diameter of approximately 1.2 mm as demonstrated in Fig. 3 . Postoperative management Following surgery, antibiotics were administered intravenously to patients for at least 48 hours. The wounds are always kept clean and dry as dressings are frequently changed to prevent infections. We constantly monitor the wound for signs of infection like increased redness, swelling, warmth, or drainage. We regularly monitor the flap for signs of ischemia or necrosis, such as changes in temperature, color, or capillary refill time. A Doppler ultrasound was used to evaluate lap perfusion. Functional exercise was initiated three to five days after the operation to avert muscle atrophy and joint stiffness. Patients were permitted to resume weight-bearing activities three to five weeks following surgery. Statistical analysis The software IBM SPSS 27.0.1 was used for the data analysis. We deemed a p-value of 0.05 to indicate statistical significance. Sample Characteristics A Shapiro-Wilk test determined the normality of distribution of both the age and follow-up time between males and females. It demonstrates that they are both approximately normally distributed, with a p -value greater than 0.05. Visual examination of their histograms, standard Q-Q plots, and box plots revealed that the age and follow-up duration was approximately normally distributed for males and females, as shown in Table 1 . Table 1 Test for normality Age Follow-up period Male Female Male Female Shapiro-Wilk p -values 0.082 0.222 0.008 0.088 Result Descriptive Data Data from 89 patients who underwent sural neurovascular flap applications in distal lower limb wound reconstruction were collected, but only 47 met the follow-up and inclusion criteria. Of the 47 analyzed patients, 31 were males and 16 were females, with a mean age of 50.66 ± 10.10 years. The wounds average an area of 96 cm 2 . The detailed patient characteristics can be found in Table 1 of the supplementary files. The major mechanism of injury of our participants is trauma followed by Tumor resection, Achilles tendon rupture, dog bite, and burns. The study found minor complications, the majority of which were superficial necrosis. The majority of the flap survived with less than 5% requiring reoperations due to superficial necrosis. The average clinical healing time is slightly above 16 days. After a follow-up period of over 67 months, the majority of the participants were highly satisfied as over 50% had excellent cosmetic appearance, and over 40% had good cosmetic appearances as shown in Table 2 . The cosmetic appearance was graded according to Dr. Pervaiz Hashmi's grading [ 25 ] from excellent to poor with scores of 5,4,3, and 2 as indicated in Table 3 . Table 2 Clinical outcomes of the participants Serial No. Variables Outcomes N = 47 Significance p -value 1 Gender Male 31 (66%) 0.077 Female 16 (34%) 2 Age Mean ± SD (years) 50.66 ± 10.10 0.665 3 Complications Had complication 14 (29.8%) 0.005 No complication 33 (70.2%) 4 Flap survival Survived 45 (95.7%) 0.051 Reoperated 2 (4.3%) 5 Cosmetic appearance Excellent 24 (51.1%) 0.444 Good 20 (42.6%) Fair 3 (6.4%) Poor 0 6 Flap size Mean ± SD 96.89 ± 68.51 < 0.001 7 Follow-up period Mean ± SD 67.78 ± 8.29 8 Mechanism of injury Trauma 39 (83.0%) Dog bite 1 (2.1%) Archilles tendon rupture 2 (4.3) Tumor resection 4 (8.5%) Burns 1 (2.1%) 9 10 Patient Satisfaction Clinical Healing Time Highly Satisfy Satisfy Fairly satisfy Days 24 (51.1%) 20 (42.6%) 3 (6.4%) 16.30 ± 3.84 0.091 < 0.001 Table 3 Cosmetic appearance grading Variable Excellent (5) Good (4) Fair (3) Poor (2) Coverage 100% 90–100% 80–90% 70% and below Cosmetic appearance Total Highly acceptable 15 Acceptable with slightly raised skin margin 12 Acceptable with raised skin margin 9 Not acceptable due to thick and hairy skin 6 Discussion The main objective of this study was to investigate factors influencing success rates, clinical healing timing, the impact of preoperative recipient site conditions, the choice of sural neurovascular flap, and their correlation with long-term functional outcomes. To contextualize our investigation, we meticulously reviewed previous research on superficial neurovascular flap applications in distal lower limb wound reconstruction [ 1 – 25 ]. Our findings revealed a remarkable flap survival rate exceeding 95%, with less than 5% necessitating reoperation. The overall results remained commendable despite complications such as partial superficial necrosis, infection, and occasional venous congestion. Korompilias et al. conducted a retrospective analysis of 10 participants, demonstrating over 90% flap success, notwithstanding challenges posed by diabetes and smoking [ 1 ]. However, the limited participant pool might impinge on the statistical reliability of their conclusions. Similarly, Cang ZQ et al. examined 29 patients undergoing medial plantar flap reconstruction for lower leg and foot soft tissues, yielding a success rate exceeding 96%. However, one flap succumbed to partial necrosis, potentially attributable to diabetes [ 23 ]. A retrospective study conducted by Burusapat C and colleagues showcased encouraging outcomes yet encountered venous congestion in over 37% of patients, contrasting our findings [ 24 ]. Al-Himdani S. et al. emphasized the significance of careful flap selection. However, venous congestion remains the most common complication, highlighting the crucial need for careful planning to reduce risks [ 3 ]. The low incidence of complications substantially influences the procedure's success. Notwithstanding variations in flap sizes, clinical healing times appear congruent (within 16 days), barring those necessitating reoperations. Our investigations evince those complications warranting reoperation and influencing healing times ( p < 0.001). Di Summa et al. reported a complete healing time of 19 days, aligning closely with our observations. In contrast, Korompilias et al. documented a protracted healing period averaging over three weeks, possibly attributable to challenges posed by diabetes and smoking, and excluding patients with comorbidities such as diabetes and hypertension yielded relatively favorable healing outcomes, underscored by the high flap survival rates. Although studies on preoperative recipient site condition effects on wound healing remain scarce, variations in wound healing between diabetic and non-diabetic patients have been delineated [ 1 , 5 ]. The recipient site's condition emerges as pivotal to procedural success, thus accentuating the indispensable role of thorough debridement in averting complications like infections. With a high flap survival rate, the flap exhibits impeccable healing, as evidenced by over 50% rated as excellent, over 42% as good, and less than 7% as fair in terms of cosmetic appearance. Encouragingly, over 51% of participants expressed high satisfaction, with over 42% reporting satisfaction. Al-Himdani et al. study showcased remarkable patient satisfaction and functional outcomes with the medial sural artery perforator flap [ 1 ]. Similarly, Hashmi et al. examined 89 patients, with over 92% reporting excellent cosmetic appearance and no instances of poor cosmetic outcomes [ 25 ]. The consistently high satisfaction rates across our study and others conducted over time attest to the procedure's reliability. Strengths and limitations Our single-center study has various strengths that could benefit surgical research. The single-center strategy provides consistency in surgical techniques, follow-up protocols, and data gathering, improving the dependability and repeatability of our findings. From five years and beyond, sural neurovascular flap treatments' efficacy and durability are well documented, providing vital insights into their long-term results. Excluding individuals with comorbidities like diabetes and hypertension isolates the surgical intervention's effect, lowering confounding variables and strengthening our conclusions. Our outcomes may be more reliable because the same surgeons conducted all procedures, reducing surgical technique variability. Despite these merits, our study design has drawbacks. The retrospective study and limited sample size of 47 patients may restrict its statistical power and generalizability to other patient populations. The exclusion of people with diabetes and hypertension may also limit our findings in clinical settings. Retrospective studies are also prone to biases, inadequate data, and causality issues, which may weaken our conclusions. Despite controlling for confounding variables, unmeasured factors may still affect outcomes, affecting our study's internal validity. We suggest many research avenues to address these limitations and improve sural neurovascular flap use. Prospective research with larger sample sizes allows for better confounding variable control and causal inferences. In addition, incorporating patients with various comorbidities and demographics would improve our external validity and reveal the procedure's efficacy in clinical practice. Comparing sural neurovascular flap applications to other surgical techniques or therapies would provide valuable data on efficacy, safety, and cost-effectiveness. Finally, multi-center collaboration would boost sample size, diversity, and generalizability, enabling validation and replication across settings. By addressing these recommendations, future research can build on our study's basis and improve our understanding of clinical sural neurovascular flap uses. Conclusion After a thorough study of the factors that affect success rates, clinical healing times, conditions at the recipient site before surgery, and the choice of sural neurovascular flaps, along with how they relate to long-term functional outcomes, it is clear that sural neurovascular flap applications hold much promise in reconstructing wounds in the distal lower limb. Our study, supported by various findings, underscores the procedure's efficacy, as demonstrated by remarkable patient satisfaction, excellent cosmetic outcomes, and favorable functional results. Despite complications and varying healing times, meticulous patient selection, thorough debridement, and careful planning are critical factors in mitigating risks and optimizing outcomes. The consistently high satisfaction rates across multiple studies affirm the reliability and effectiveness of supravascular neurovascular flap applications in improving patient outcomes and warrant further consideration and adoption in clinical practice. Abbreviations NV Neurovascular Declarations Acknowledgment Not applicable Author’s contribution MLB received the study, and MLB, HSL, TZ, WK, MW, and XW provided the materials and contributed to data collection. MLB, LAH, HSL, STT, and YLJ conducted the data analysis and interpretation of the results. MLB wrote the manuscript, and TCC Provided administrative support. All authors read and approved the final manuscript and consented to publish this manuscript. Mohamed Lamin Bangura and Li An He contributed equally to this work. Funding Not applicable Availability of data All data generated or analyzed during this study are attached as a supplementary file. Consent of publication Not applicable Competing interest All authors declared no potential conflict of interest. Ethical approval and consent to participate The ethical committee of the First Affiliated Hospital of Yangtze University approved this retrospective study and informed written consent was obtained from participants included in the study. All procedures were carried out according to the relevant guidelines and regulations. All authors declared no potential conflict of interest. References Korompilias A, Gkiatas I, Korompilia M, Kosmas D, Kostas-Agnantis I. Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction. Eur J Orthop Surg Traumatol . 2019;29(2):367-372. Luo Z, Lv G, Wei J, et al. Comparison between distally based peroneal and posterior tibial artery perforator-plus fasciocutaneous flap for reconstruction of the lower extremity. Burns . 2020;46(1):225-233. Al-Himdani S, Din A, Wright TC, Wheble G, Chapman TWL, Khan U. The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction. Injury . 2020;51(4):1077-1085. Di Summa PG, Sapino G, Cherubino M, et al. Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long-term recovery and functional outcomes. Microsurgery . 2019;39(5):405-415. Lin J, Zhou F, Sun YD, et al. Modified Anterior Tibial Artery Perforator-Pedicled Propeller Flap for Soft-Tissue Coverage of the Ankle and Heel. World J Surg . 2020;44(7):2237-2242. Jitprapaikulsarn S, Sukha K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Concurrent internal fixation and soft tissue reconstruction by distally based sural flap: a practicable scheme for complex distal tibial fractures. Eur J Orthop Surg Traumatol . 2021;31(4):711-718. Fitzgerald O'Connor E, Ruston J, Loh CYY, Tare M. Technical refinements of the free medial sural artery perforator (MSAP) flap in reconstruction of multifaceted ankle soft tissue defects. Foot Ankle Surg . 2020;26(2):233-238. Athanaselis, E. D., Fyllos, A., Zibis, A. H., Karachalios, T., Hantes, M., Dailiana, Z., Malizos, K., & Varitimidis, S. (2021). A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up. Cureus , 13 (7), e16574. Assi C, Samaha C, Chamoun Moussa M, Hayek T, Yammine K. A Comparative Study of the Reverse Sural Fascio-Cutaneous Flap Outcomes in the Management of Foot and Ankle Soft Tissue Defects in Diabetic and Trauma Patients. Foot Ankle Spec . 2019;12(5):432-438. Hasegawa H, Tsukamoto S, Honoki K, et al. Soft-tissue reconstruction after soft-tissue sarcoma resection: the clinical outcomes of 24 patients. Eur J Orthop Surg Traumatol . 2022;32(1):1-10. Kozusko SD, Liu X, Riccio CA, et al. Selecting a free flap for soft tissue coverage in lower extremity reconstruction. Injury . 2019;50 Suppl 5:S32-S39. Mb O, Aksan T, Ertekin C, Tezcan M. Coverage of exposed bone and hardware of the medial malleolus with tibialis posterior artery perforator flap after ankle fracture surgery complications. Int Wound J . 2020;17(2):429-435. Li P, Zhang H, Zhu J, et al. Foot and ankle reconstruction using the lateral supramalleolar flap versus the anterolateral thigh flap in the elderly: A comparative study. Int Wound J . 2022;19(6):1518-1527. Lee ZH, Abdou SA, Daar DA, et al. Comparing Outcomes for Fasciocutaneous versus Muscle Flaps in Foot and Ankle Free Flap Reconstruction. J Reconstr Microsurg . 2019;35(9):646-651. Li B, Chang SM, Du SC, Zhuang L, Hu SJ. Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region. Ann Plast Surg . 2020;84(5):580-587. Li X, Yan X, Xie Q, et al. Medial Soft tissue and medial malleolus loss-the posterior tibial artery perforator technique combined with iliac crest autograft to Stabilize the ankle and cover Soft tissue defect: A case Series. J Orthop Surg (Hong Kong) . 2022;30(2) Jaiswal KS, Gupta S, Goil P, Mohammad A, Gupta P. Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects. Indian J Plast Surg . 2023;56(2):159-165. Published 2023 Feb 21. Vazales R, Masadeh S. First Dorsal Metatarsal Artery Flap for Coverage of Soft Tissue Defects of the Distal Foot: Delayed Technique, Proximal and Distally Based Fasciocutaneous and Adipofascial Variants. Clin Podiatr Med Surg . 2020;37(4):765-773. Li R, Zeng C, Yuan S, Chen Y, Zhao S, Ren GH. Free flap transplantation combined with Ilizarov bone transport for the treatment of severe composite tibial and soft tissue defects. J Int Med Res . 2021;49(5):3000605211017618. Kozusko SD, Liu X, Riccio CA, et al. Selecting a free flap for soft tissue coverage in lower extremity reconstruction. Injury . 2019;50 Suppl 5:S32-S39. Lese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations. J Bone Joint Surg Am . 2020;102(6):510-518. Lee JY, Lee HJ, Yang SH, et al. Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap. Medicina (Kaunas) . 2023;59(10):1751. Published 2023 Sep 30. Cang ZQ, Ni XD, Xu Y, Wang M, Wang Q, Yuan SM. Reconstruction of the distal lower leg and foot sole with medial plantar flap: a retrospective study in one center. J Plast Surg Hand Surg . 2020;54(1):40-46. Burusapat C. Perforator Flap Reconstruction for the Distal Third of Lower Extremity Defects: Clinical Application and Guideline Recommendation. Int J Low Extrem Wounds . 2019;18(4):376-388. Hashmi, D. P. M., Musaddiq, A., Ali, D. M., Hashmi, A., Zahid, D. M., & Nawaz, D. Z. (2021). Long-Term Clinical and Functional Outcomes of Distally Based Sural Artery Flap: A Retrospective Case Series. JPRAS open , 30 , 61–73. Additional Declarations No competing interests reported. Supplementary Files Suppementarydocument.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4491584","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":309639668,"identity":"63f7cd79-a5c3-4eaa-9596-39302ab0f824","order_by":0,"name":"Mohamed Bangura","email":"","orcid":"","institution":"The First People’s Hospital of Jingzhou, The First Affiliated Hospital of Yangtze University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Bangura","suffix":""},{"id":309639669,"identity":"3936426b-15ce-44b1-95d5-9a60b0501e4d","order_by":1,"name":"Li An 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Centre","correspondingAuthor":false,"prefix":"","firstName":"Minglu","middleName":"","lastName":"Wang","suffix":""},{"id":309639676,"identity":"63b12fd4-5d8b-4718-a16b-d42e6db56ea1","order_by":8,"name":"Huasong Luo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBACPgYGNjjnQIKBDQ8/fwN+LWxIWhgffChIk5GccYB4LcyGMz4ctjFoSCCgRSL52GOemjo5c/4FbNI8Bud5DBgOMH74mINPS1q6Mc+xw8aWMx6AtNzmMWduYJacuQ2flhwzaR62A4kbbhyAaLFsOMDGzEtQy786mJZzPAYHEojQwtvGnLjhfAPQ+wYHiNDC8yxNcm7fYWODG6BANkjmkZxxsBmvX/jZk49JvPlWJ2dw/gAwKv/Y2fPzNx/88BGPFgSQyP8AZTE2EKMeZN8BIhWOglEwCkbBiAMAvJ9MWU4EjlUAAAAASUVORK5CYII=","orcid":"","institution":"The First People’s Hospital of Jingzhou, The First Affiliated Hospital of Yangtze University","correspondingAuthor":true,"prefix":"","firstName":"Huasong","middleName":"","lastName":"Luo","suffix":""}],"badges":[],"createdAt":"2024-05-28 14:24:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4491584/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4491584/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58314806,"identity":"e5f43e87-90f0-4f38-be2e-57f815325802","added_by":"auto","created_at":"2024-06-13 20:51:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18361,"visible":true,"origin":"","legend":"\u003cp\u003eThis chart shows the patient inclusion process for this study.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4491584/v1/53641bc03d0d0c1289e7e87f.png"},{"id":58315802,"identity":"8f8fc727-0b9b-4fa3-a06b-766ebb514bc4","added_by":"auto","created_at":"2024-06-13 20:59:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":648054,"visible":true,"origin":"","legend":"\u003cp\u003eA 33-year-old male patient with an Achilles tendon rupture from severe trauma. a: shows preoperative examination and planning, b: during the operation, c: shows the end of the operation, \u0026amp; d: three days post operation\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4491584/v1/0d9a37958687ec75b219c692.png"},{"id":58314810,"identity":"46f54992-08d2-4a2f-b5bd-056327a5d829","added_by":"auto","created_at":"2024-06-13 20:51:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":654707,"visible":true,"origin":"","legend":"\u003cp\u003eA 55 years old male patient with left ankle trauma resulting in severe soft tissue damage, A: Preoperative, B: 9 days post operative, C: 21 days post operation, \u0026amp; D: 8 weeks post operation\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4491584/v1/d60bb134defa9b589cc65150.png"},{"id":58314809,"identity":"f565eebb-cd2b-43e7-bb72-424fc35d2c53","added_by":"auto","created_at":"2024-06-13 20:51:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":91612,"visible":true,"origin":"","legend":"\u003cp\u003eA schematic drawing of blood supply of distal and proximal pedicle flap.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNV: Neurovascular, P1: Vascular puncture point1, P2: vascular puncture point2, F1: proximal flap, F2: distal flap\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4491584/v1/72cee0d98f177f0f90961ae1.png"},{"id":59446191,"identity":"583dc86f-563f-4a43-b352-42a1e177c43a","added_by":"auto","created_at":"2024-07-01 23:52:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1850438,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4491584/v1/5d8f8898-8c7d-44af-8c2f-4dfd55694018.pdf"},{"id":58314808,"identity":"89386ff2-7c02-4352-8197-06376d3fc0ab","added_by":"auto","created_at":"2024-06-13 20:51:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24199,"visible":true,"origin":"","legend":"","description":"","filename":"Suppementarydocument.docx","url":"https://assets-eu.researchsquare.com/files/rs-4491584/v1/a7ebb27693ec293e02cd2851.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Long-Term Efficacy and Surgical Outcomes of Sural Neurovascular Flap Applications in Distal Lower Limb Wound Reconstruction: A Single-Center Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eReconstructing wounds in the distal lower limb presents substantial challenges due to its complex anatomy and limited vascularity [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Various surgical procedures have been investigated to overcome these issues, with the sural neurovascular flaps emerging as a potential option.\u003csup\u003e4\u0026ndash;8\u003c/sup\u003e The sural neurovascular flap, encompassing the sural nerve and surrounding arteries, has emerged as a viable option, offering consistent vascularity and flexibility in flap design [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This flap provides robust soft tissue coverage while preserving functional integrity, making it ideal for reconstructive surgery in the ankle and foot areas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, this technique's low donor site morbidity enhances its appeal. However, successful application requires a thorough understanding of anatomy and surgical proficiency [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver time, the sural neurovascular flap has been used to treat complicated tibial and soft tissue anomalies caused by severe trauma, resulting in successful wound repair and healing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Proactive management efficiently controls postoperative complications, resulting in the best results. While complications such as partial necrosis, deep infection, and flap ischemia may occur, overall clinical results are favorable, with donor sites healing well and mild paresthesia reported.\u003csup\u003e6\u003c/sup\u003e Valuable insights into surgical technique and aftercare help to improve the procedure's effectiveness and reduce risks.\u003c/p\u003e \u003cp\u003eWhile previous studies have focused on immediate surgical outcomes, more data on the long-term functional and patient-reported outcomes of sural neurovascular flap reconstruction for distal lower limb wounds must be collected. Evaluating parameters such as range of motion and patient satisfaction over extended periods can provide valuable insights. Furthermore, there is a need to investigate the impact of this reconstruction technique on patients' quality of life and aesthetic satisfaction. Does sural neurovascular flap application in reconstructive surgical procedures lead to favorable cosmetic outcomes and high patient satisfaction rates? What are the incidence and types of complications associated with sural neurovascular flap application in reconstructive surgical procedures, and how do they impact patient outcomes?\u003c/p\u003e \u003cp\u003eThis research aims to evaluate the efficacy and long-term outcomes of sural neurovascular flap applications in distal lower limb wound reconstruction, utilizing a single-center retrospective study design. We hope that at the end of this research, we will have a thorough understanding of the aesthetic and functional outcomes and the clinical and efficacy findings of using sural neurovascular flaps to reconstruct severe wounds in the distal lower limbs.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis retrospective single-center study was conducted at an urban central hospital's orthopedic trauma center.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe study included 47 participants, selected based on predetermined inclusion and exclusion criteria. A single surgeon performed all surgeries from January 2012 to February 2018. Data collected included demographic information, injury characteristics, defect size, complications, cosmetic outcomes, and functional outcomes of the lower limb and ankle. Statistical analysis was conducted using SPSS, with a p-value of 0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePatient Selection\u003c/h2\u003e \u003cp\u003ePatients are selected based on predetermined inclusion and exclusion criteria as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All patients are selected from our department’s database with a strict follow-up protocol as stipulated by our institution’s ethics committee. The inclusion criteria were as follows: (1) Patients with Distal Lower Limb Wounds include individuals with open wounds or soft tissue defects in the distal lower limb region. (2) Cases where the primary method of reconstruction involved using a Sural Neurovascular Flap. (3) Age Range: 18 years and above.\u003c/p\u003e \u003cp\u003eExclusion criteria were as follows: (1) Cases where Sural Neurovascular Flap was not the primary or sole reconstruction method. (2) Pediatric patients were excluded. (3) Cases with severe systemic conditions like diabetes that may significantly impact wound healing independently of the surgical procedure. (4) Previous Failed Flap Reconstruction cases where the patient had prior unsuccessful attempts at flap reconstruction to isolate the impact of the Sural Neurovascular Flap. (6) Non-Distal Lower Limb Injuries cases involving wounds or injuries outside the distal lower limb region.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Techniques\u003c/h2\u003e \u003cp\u003eFollowing the successful administration of spinal anesthesia, a patient is carefully positioned in the appropriate position. Preparation ensued as the affected limb underwent thorough disinfection using 1% iodine, followed by applying sterile wipes. The thigh airbag tourniquet pressurized at 500 mmHg is applied to ensure proper circulation control.\u003c/p\u003e \u003cp\u003eUpon assessment, a skin defect approximately 10cm\u003csup\u003e2\u003c/sup\u003e in size is identified on the lateral aspect of the left calcaneus, revealing the calcaneus with visible milky white inflammatory exudation. Surrounding soft tissues appeared healthy, with the fibular tendons securely in place.\u003c/p\u003e \u003cp\u003eThe surgical area undergoes meticulous cleansing with hydrogen peroxide, diluted iodine, and physiological saline. Subsequent procedures included debridement, wound margin trimming, and removal of compromised tissues, with intermittent rinsing of the surgical site using the solutions above. The ankle joint wound is closed using Johnson \u0026amp; Johnson Line 1 oblique sutures, followed by the application of vacuum sealing drainage (VSD) excipients to facilitate wound healing while maintaining negative pressure. The patient safely returns to the ward following the surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFlap design\u003c/h2\u003e \u003cp\u003eWhen performing traditional sural neurotrophic vascular flap surgery, we opt for the \"retrograde method.\" For flap design, the focus is on positioning it at the upper 1/3 of the posterior midline of the calf, aligning with the axis formed by the sural nerve, superficial peroneal artery, and small saphenous vein. This alignment follows a body surface projection from the midpoint of the popliteal fossa to the midpoint of the lateral malleolus and Achilles tendon, ensuring that neither side extends beyond the lateral midline. The retrograde sural neurovascular flap's transfer point lies at the ankle, making it suitable for addressing soft tissue defects in the heel, ankle, and lower 1/3 of the calf. To determine the flap rotation point, we locate it 5-7cm posterior and superior to the lateral malleolus. Subsequently, we symmetrically drew the excision area of the flap on the flap axis, considering the required pedicle length for the recipient area as shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe blood supply to the distal pedicle flap is primarily sourced from the lowermost intermuscular perforator of the peroneal artery, located approximately 5cm behind and above the lateral ankle, within a range of 4–7 cm. This crucial vascular pathway typically exhibits an outer diameter of approximately 1.2 mm as demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative management\u003c/h2\u003e \u003cp\u003eFollowing surgery, antibiotics were administered intravenously to patients for at least 48 hours. The wounds are always kept clean and dry as dressings are frequently changed to prevent infections. We constantly monitor the wound for signs of infection like increased redness, swelling, warmth, or drainage. We regularly monitor the flap for signs of ischemia or necrosis, such as changes in temperature, color, or capillary refill time. A Doppler ultrasound was used to evaluate lap perfusion. Functional exercise was initiated three to five days after the operation to avert muscle atrophy and joint stiffness. Patients were permitted to resume weight-bearing activities three to five weeks following surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe software IBM SPSS 27.0.1 was used for the data analysis. We deemed a p-value of 0.05 to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSample Characteristics\u003c/h2\u003e \u003cp\u003eA Shapiro-Wilk test determined the normality of distribution of both the age and follow-up time between males and females. It demonstrates that they are both approximately normally distributed, with a \u003cem\u003ep\u003c/em\u003e-value greater than 0.05. Visual examination of their histograms, standard Q-Q plots, and box plots revealed that the age and follow-up duration was approximately normally distributed for males and females, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTest for normality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFollow-up period\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShapiro-Wilk\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-values\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e "},{"header":"Result","content":"\u003ch2\u003eDescriptive Data\u003c/h2\u003e\u003cp\u003eData from 89 patients who underwent sural neurovascular flap applications in distal lower limb wound reconstruction were collected, but only 47 met the follow-up and inclusion criteria. Of the 47 analyzed patients, 31 were males and 16 were females, with a mean age of 50.66 ± 10.10 years. The wounds average an area of 96 cm\u003csup\u003e2\u003c/sup\u003e. The detailed patient characteristics can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e of the supplementary files. The major mechanism of injury of our participants is trauma followed by Tumor resection, Achilles tendon rupture, dog bite, and burns.\u003c/p\u003e\u003cp\u003eThe study found minor complications, the majority of which were superficial necrosis. The majority of the flap survived with less than 5% requiring reoperations due to superficial necrosis. The average clinical healing time is slightly above 16 days. After a follow-up period of over 67 months, the majority of the participants were highly satisfied as over 50% had excellent cosmetic appearance, and over 40% had good cosmetic appearances as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The cosmetic appearance was graded according to Dr. Pervaiz Hashmi's grading [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] from excellent to poor with scores of 5,4,3, and 2 as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcomes of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerial No.\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003cp\u003eN = 47\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (66%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (34%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean ± SD (years)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.66 ± 10.10\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHad complication\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (29.8%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo complication\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (70.2%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlap survival\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvived\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (95.7%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReoperated\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCosmetic appearance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (51.1%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (42.6%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.4%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlap size\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean ± SD\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.89 ± 68.51\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow-up period\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean ± SD\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.78 ± 8.29\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMechanism of injury\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (83.0%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDog bite\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArchilles tendon rupture\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTumor resection\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8.5%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBurns\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Satisfaction\u003c/p\u003e \u003cp\u003eClinical Healing Time\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHighly Satisfy\u003c/p\u003e \u003cp\u003eSatisfy\u003c/p\u003e \u003cp\u003eFairly satisfy\u003c/p\u003e \u003cp\u003eDays\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (51.1%)\u003c/p\u003e \u003cp\u003e20 (42.6%)\u003c/p\u003e \u003cp\u003e3 (6.4%)\u003c/p\u003e \u003cp\u003e16.30 ± 3.84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCosmetic appearance grading\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcellent (5)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood (4)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair (3)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePoor (2)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoverage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90–100%\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80–90%\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70% and below\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCosmetic appearance\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHighly acceptable\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcceptable with slightly raised skin margin\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAcceptable with raised skin margin\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot acceptable due to thick and hairy skin\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main objective of this study was to investigate factors influencing success rates, clinical healing timing, the impact of preoperative recipient site conditions, the choice of sural neurovascular flap, and their correlation with long-term functional outcomes. To contextualize our investigation, we meticulously reviewed previous research on superficial neurovascular flap applications in distal lower limb wound reconstruction [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings revealed a remarkable flap survival rate exceeding 95%, with less than 5% necessitating reoperation. The overall results remained commendable despite complications such as partial superficial necrosis, infection, and occasional venous congestion. Korompilias et al. conducted a retrospective analysis of 10 participants, demonstrating over 90% flap success, notwithstanding challenges posed by diabetes and smoking [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the limited participant pool might impinge on the statistical reliability of their conclusions. Similarly, Cang ZQ et al. examined 29 patients undergoing medial plantar flap reconstruction for lower leg and foot soft tissues, yielding a success rate exceeding 96%. However, one flap succumbed to partial necrosis, potentially attributable to diabetes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A retrospective study conducted by Burusapat C and colleagues showcased encouraging outcomes yet encountered venous congestion in over 37% of patients, contrasting our findings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Al-Himdani S. et al. emphasized the significance of careful flap selection. However, venous congestion remains the most common complication, highlighting the crucial need for careful planning to reduce risks [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The low incidence of complications substantially influences the procedure's success.\u003c/p\u003e \u003cp\u003eNotwithstanding variations in flap sizes, clinical healing times appear congruent (within 16 days), barring those necessitating reoperations. Our investigations evince those complications warranting reoperation and influencing healing times (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Di Summa et al. reported a complete healing time of 19 days, aligning closely with our observations. In contrast, Korompilias et al. documented a protracted healing period averaging over three weeks, possibly attributable to challenges posed by diabetes and smoking, and excluding patients with comorbidities such as diabetes and hypertension yielded relatively favorable healing outcomes, underscored by the high flap survival rates. Although studies on preoperative recipient site condition effects on wound healing remain scarce, variations in wound healing between diabetic and non-diabetic patients have been delineated [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The recipient site's condition emerges as pivotal to procedural success, thus accentuating the indispensable role of thorough debridement in averting complications like infections.\u003c/p\u003e \u003cp\u003eWith a high flap survival rate, the flap exhibits impeccable healing, as evidenced by over 50% rated as excellent, over 42% as good, and less than 7% as fair in terms of cosmetic appearance. Encouragingly, over 51% of participants expressed high satisfaction, with over 42% reporting satisfaction. Al-Himdani et al. study showcased remarkable patient satisfaction and functional outcomes with the medial sural artery perforator flap [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Similarly, Hashmi et al. examined 89 patients, with over 92% reporting excellent cosmetic appearance and no instances of poor cosmetic outcomes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The consistently high satisfaction rates across our study and others conducted over time attest to the procedure's reliability.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOur single-center study has various strengths that could benefit surgical research. The single-center strategy provides consistency in surgical techniques, follow-up protocols, and data gathering, improving the dependability and repeatability of our findings. From five years and beyond, sural neurovascular flap treatments' efficacy and durability are well documented, providing vital insights into their long-term results. Excluding individuals with comorbidities like diabetes and hypertension isolates the surgical intervention's effect, lowering confounding variables and strengthening our conclusions. Our outcomes may be more reliable because the same surgeons conducted all procedures, reducing surgical technique variability.\u003c/p\u003e \u003cp\u003eDespite these merits, our study design has drawbacks. The retrospective study and limited sample size of 47 patients may restrict its statistical power and generalizability to other patient populations. The exclusion of people with diabetes and hypertension may also limit our findings in clinical settings. Retrospective studies are also prone to biases, inadequate data, and causality issues, which may weaken our conclusions. Despite controlling for confounding variables, unmeasured factors may still affect outcomes, affecting our study's internal validity.\u003c/p\u003e \u003cp\u003eWe suggest many research avenues to address these limitations and improve sural neurovascular flap use. Prospective research with larger sample sizes allows for better confounding variable control and causal inferences. In addition, incorporating patients with various comorbidities and demographics would improve our external validity and reveal the procedure's efficacy in clinical practice. Comparing sural neurovascular flap applications to other surgical techniques or therapies would provide valuable data on efficacy, safety, and cost-effectiveness. Finally, multi-center collaboration would boost sample size, diversity, and generalizability, enabling validation and replication across settings. By addressing these recommendations, future research can build on our study's basis and improve our understanding of clinical sural neurovascular flap uses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAfter a thorough study of the factors that affect success rates, clinical healing times, conditions at the recipient site before surgery, and the choice of sural neurovascular flaps, along with how they relate to long-term functional outcomes, it is clear that sural neurovascular flap applications hold much promise in reconstructing wounds in the distal lower limb. Our study, supported by various findings, underscores the procedure's efficacy, as demonstrated by remarkable patient satisfaction, excellent cosmetic outcomes, and favorable functional results. Despite complications and varying healing times, meticulous patient selection, thorough debridement, and careful planning are critical factors in mitigating risks and optimizing outcomes. The consistently high satisfaction rates across multiple studies affirm the reliability and effectiveness of supravascular neurovascular flap applications in improving patient outcomes and warrant further consideration and adoption in clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNeurovascular\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMLB received the study, and MLB, HSL, TZ, WK, MW, and XW provided the materials and contributed to data collection. MLB, LAH, HSL, STT, and YLJ conducted the data analysis and interpretation of the results. MLB wrote the manuscript, and TCC Provided administrative support. All authors read and approved the final manuscript and consented to publish this manuscript. Mohamed Lamin Bangura and Li An He contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are attached as a supplementary file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eNot applicable\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declared no potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical committee of the First Affiliated Hospital of Yangtze University approved this retrospective study and informed written consent was obtained from participants included in the study. \u0026nbsp;All procedures were carried out according to the relevant guidelines and regulations. \u0026nbsp;All authors declared no potential conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKorompilias A, Gkiatas I, Korompilia M, Kosmas D, Kostas-Agnantis I. Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction. \u003cem\u003eEur J Orthop Surg Traumatol\u003c/em\u003e. 2019;29(2):367-372. \u003c/li\u003e\n\u003cli\u003eLuo Z, Lv G, Wei J, et al. Comparison between distally based peroneal and posterior tibial artery perforator-plus fasciocutaneous flap for reconstruction of the lower extremity. \u003cem\u003eBurns\u003c/em\u003e. 2020;46(1):225-233. \u003c/li\u003e\n\u003cli\u003eAl-Himdani S, Din A, Wright TC, Wheble G, Chapman TWL, Khan U. The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction. \u003cem\u003eInjury\u003c/em\u003e. 2020;51(4):1077-1085. \u003c/li\u003e\n\u003cli\u003eDi Summa PG, Sapino G, Cherubino M, et al. Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long-term recovery and functional outcomes. \u003cem\u003eMicrosurgery\u003c/em\u003e. 2019;39(5):405-415. \u003c/li\u003e\n\u003cli\u003eLin J, Zhou F, Sun YD, et al. Modified Anterior Tibial Artery Perforator-Pedicled Propeller Flap for Soft-Tissue Coverage of the Ankle and Heel. \u003cem\u003eWorld J Surg\u003c/em\u003e. 2020;44(7):2237-2242. \u003c/li\u003e\n\u003cli\u003eJitprapaikulsarn S, Sukha K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Concurrent internal fixation and soft tissue reconstruction by distally based sural flap: a practicable scheme for complex distal tibial fractures. \u003cem\u003eEur J Orthop Surg Traumatol\u003c/em\u003e. 2021;31(4):711-718. \u003c/li\u003e\n\u003cli\u003eFitzgerald O\u0026apos;Connor E, Ruston J, Loh CYY, Tare M. Technical refinements of the free medial sural artery perforator (MSAP) flap in reconstruction of multifaceted ankle soft tissue defects. \u003cem\u003eFoot Ankle Surg\u003c/em\u003e. 2020;26(2):233-238. \u003c/li\u003e\n\u003cli\u003eAthanaselis, E. D., Fyllos, A., Zibis, A. H., Karachalios, T., Hantes, M., Dailiana, Z., Malizos, K., \u0026amp; Varitimidis, S. (2021). A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up. \u003cem\u003eCureus\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(7), e16574.\u003c/li\u003e\n\u003cli\u003eAssi C, Samaha C, Chamoun Moussa M, Hayek T, Yammine K. A Comparative Study of the Reverse Sural Fascio-Cutaneous Flap Outcomes in the Management of Foot and Ankle Soft Tissue Defects in Diabetic and Trauma Patients. \u003cem\u003eFoot Ankle Spec\u003c/em\u003e. 2019;12(5):432-438. \u003c/li\u003e\n\u003cli\u003eHasegawa H, Tsukamoto S, Honoki K, et al. Soft-tissue reconstruction after soft-tissue sarcoma resection: the clinical outcomes of 24 patients. \u003cem\u003eEur J Orthop Surg Traumatol\u003c/em\u003e. 2022;32(1):1-10. \u003c/li\u003e\n\u003cli\u003eKozusko SD, Liu X, Riccio CA, et al. Selecting a free flap for soft tissue coverage in lower extremity reconstruction. \u003cem\u003eInjury\u003c/em\u003e. 2019;50 Suppl 5:S32-S39. \u003c/li\u003e\n\u003cli\u003eMb O, Aksan T, Ertekin C, Tezcan M. Coverage of exposed bone and hardware of the medial malleolus with tibialis posterior artery perforator flap after ankle fracture surgery complications. \u003cem\u003eInt Wound J\u003c/em\u003e. 2020;17(2):429-435. \u003c/li\u003e\n\u003cli\u003eLi P, Zhang H, Zhu J, et al. Foot and ankle reconstruction using the lateral supramalleolar flap versus the anterolateral thigh flap in the elderly: A comparative study. \u003cem\u003eInt Wound J\u003c/em\u003e. 2022;19(6):1518-1527. \u003c/li\u003e\n\u003cli\u003eLee ZH, Abdou SA, Daar DA, et al. Comparing Outcomes for Fasciocutaneous versus Muscle Flaps in Foot and Ankle Free Flap Reconstruction. \u003cem\u003eJ Reconstr Microsurg\u003c/em\u003e. 2019;35(9):646-651. \u003c/li\u003e\n\u003cli\u003eLi B, Chang SM, Du SC, Zhuang L, Hu SJ. Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region. \u003cem\u003eAnn Plast Surg\u003c/em\u003e. 2020;84(5):580-587. \u003c/li\u003e\n\u003cli\u003eLi X, Yan X, Xie Q, et al. Medial Soft tissue and medial malleolus loss-the posterior tibial artery perforator technique combined with iliac crest autograft to Stabilize the ankle and cover Soft tissue defect: A case Series. \u003cem\u003eJ Orthop Surg (Hong Kong)\u003c/em\u003e. 2022;30(2)\u003c/li\u003e\n\u003cli\u003eJaiswal KS, Gupta S, Goil P, Mohammad A, Gupta P. Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects. \u003cem\u003eIndian J Plast Surg\u003c/em\u003e. 2023;56(2):159-165. Published 2023 Feb 21. \u003c/li\u003e\n\u003cli\u003eVazales R, Masadeh S. First Dorsal Metatarsal Artery Flap for Coverage of Soft Tissue Defects of the Distal Foot: Delayed Technique, Proximal and Distally Based Fasciocutaneous and Adipofascial Variants. \u003cem\u003eClin Podiatr Med Surg\u003c/em\u003e. 2020;37(4):765-773. \u003c/li\u003e\n\u003cli\u003eLi R, Zeng C, Yuan S, Chen Y, Zhao S, Ren GH. Free flap transplantation combined with Ilizarov bone transport for the treatment of severe composite tibial and soft tissue defects. \u003cem\u003eJ Int Med Res\u003c/em\u003e. 2021;49(5):3000605211017618. \u003c/li\u003e\n\u003cli\u003eKozusko SD, Liu X, Riccio CA, et al. Selecting a free flap for soft tissue coverage in lower extremity reconstruction. \u003cem\u003eInjury\u003c/em\u003e. 2019;50 Suppl 5:S32-S39. \u003c/li\u003e\n\u003cli\u003eLese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e. 2020;102(6):510-518. \u003c/li\u003e\n\u003cli\u003eLee JY, Lee HJ, Yang SH, et al. Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap. \u003cem\u003eMedicina (Kaunas)\u003c/em\u003e. 2023;59(10):1751. Published 2023 Sep 30. \u003c/li\u003e\n\u003cli\u003eCang ZQ, Ni XD, Xu Y, Wang M, Wang Q, Yuan SM. Reconstruction of the distal lower leg and foot sole with medial plantar flap: a retrospective study in one center. \u003cem\u003eJ Plast Surg Hand Surg\u003c/em\u003e. 2020;54(1):40-46. \u003c/li\u003e\n\u003cli\u003eBurusapat C. Perforator Flap Reconstruction for the Distal Third of Lower Extremity Defects: Clinical Application and Guideline Recommendation. \u003cem\u003eInt J Low Extrem Wounds\u003c/em\u003e. 2019;18(4):376-388. \u003c/li\u003e\n\u003cli\u003eHashmi, D. P. M., Musaddiq, A., Ali, D. M., Hashmi, A., Zahid, D. M., \u0026amp; Nawaz, D. Z. (2021). Long-Term Clinical and Functional Outcomes of Distally Based Sural Artery Flap: A Retrospective Case Series. \u003cem\u003eJPRAS open\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e, 61\u0026ndash;73. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sural neurovascular flap, Sural neurovascular flap application, Sural artery flap, Reconstructive surgical procedure, Clinical healing time","lastPublishedDoi":"10.21203/rs.3.rs-4491584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4491584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe sural neurovascular flap has been effectively used to reconstruct complex tibial and soft tissue defects caused by severe trauma, promoting successful wound repair and healing. Proactive management is essential in minimizing postoperative complications and achieving optimal outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Our institution's ethics committee approved this retrospective study which involved 47 participants. Informed consent was obtained from all subjects. Data collected included demographic details, injury mechanisms and sites, mode, and size of soft tissue defects, complications, cosmetic outcomes, and functional outcomes of the lower limb and ankle. All flaps were performed by a single surgeon, with follow-up from January 2012 to February 2018.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe study observed minor complications, primarily superficial necrosis. Over 95% of flaps survived, and less than 5% required reoperations due to superficial necrosis. Patient satisfaction was high, with over 50% achieving excellent cosmetic results and over 40% good cosmetic results.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSural neurovascular flap applications show significant promise in reconstructing distal lower limb wounds. Our findings highlight the procedure's efficacy, demonstrated by high patient satisfaction, excellent cosmetic outcomes, and favorable functional results. Critical factors for success include meticulous patient selection, thorough debridement, and careful planning to mitigate risks and optimize outcomes.\u003c/p\u003e","manuscriptTitle":"Exploring the Long-Term Efficacy and Surgical Outcomes of Sural Neurovascular Flap Applications in Distal Lower Limb Wound Reconstruction: A Single-Center Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-13 20:51:42","doi":"10.21203/rs.3.rs-4491584/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7ab4948-6f16-4a31-869b-1787ae043522","owner":[],"postedDate":"June 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-01T23:44:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-13 20:51:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4491584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4491584","identity":"rs-4491584","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}