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Multicenter Study
. 2025 Aug 12;26(1):53.
doi: 10.1186/s10195-025-00860-z.

Reverse sural artery flap for lower extremity reconstruction: a multicenter retrospective analysis of success and failure patterns

Saleh Abualhaj  1   2   3 , Mosleh M Abualhaj  4 , Mohd Said Dawod  5 , Maher Alkhateeb  6 , Eyad Alqarqaz  7 , Mohammed Jaber  8 , Rasha Al-Ebbini  9 , Mohammad Alananzh  10 , Lina Alshadfan  11
Affiliations
Multicenter Study

Reverse sural artery flap for lower extremity reconstruction: a multicenter retrospective analysis of success and failure patterns

Saleh Abualhaj et al. J Orthop Traumatol. .

Abstract

Background: The reverse sural artery flap (RSAF) has emerged as a versatile option for soft tissue reconstruction in the distal lower extremity, particularly when microsurgical expertise or resources are limited. Despite its increasing use, comprehensive multicenter data on its survival outcomes and anatomical site-specific performance remain limited.

Methods: This retrospective multicenter case series included all patients who underwent RSAF for distal lower extremity defects between 2015 and 2024 across military, governmental, private, and academic institutions. Data on patient demographics, defect characteristics, surgical technique, and postoperative outcomes were collected and analyzed using Jamovi. Kaplan-Meier survival analysis was used to assess flap survival over time, with subgroup comparisons based on defect site.

Results: A total of 60 patients were included. The overall flap survival rate was 96.7%, with a mean wound healing time of 21.5 days. Venous congestion occurred in 83.3% of cases. Persistent venous congestion occurred in 10% of cases, leading to partial flap necrosis. Flap width, pedicle length, prolonged operative time, and patient-specific factors such as body mass index (BMI) and smoking status were significantly associated with adverse outcomes. Site-specific analysis revealed that RSAFs used for ankle and lower leg defects had a 100% survival rate at 60 months, while heel-based flaps showed a decline in survival to 70.8% at 60 months.

Conclusions: RSAF is a highly successful and reliable option for lower extremity reconstruction, especially in resource-variable settings. However, anatomical site, flap design parameters, and modifiable patient risk factors significantly impact outcomes. Long-term surveillance highlights excellent durability in ankle and lower leg reconstructions, while heel-based reconstructions require closer follow-up. Level of Evidence Level III (Retrospective Comparative Study).

Keywords: Flap survival; Lower extremity reconstruction; RSAF; Reverse sural artery flap; Soft tissue defects.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was performed in accordance with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Al-Balqa Applied University. The requirement for written informed consent was waived for this study due to its retrospective design and the use of anonymized data. This waiver was approved by the institutional review boards of all participating centers, in accordance with ethical guidelines and regulations. Consent for publication: As this study involves retrospective data and does not include individual data or images that could identify participants, consent for publication was not required. Competing interests: The authors declare they have no financial nor nonfinancial interests related to this work to disclose.

Figures

Fig. 1
Fig. 1
Alluvial diagram: the flow of categorical variables related to RSAF success
Fig. 2
Fig. 2
Kaplan–Meier survival analysis—RSAF viability
Fig. 3
Fig. 3
Flap viability by anatomical site: a Kaplan–Meier survival analysis
See this image and copyright information in PMC

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