International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - vol 06 issue 01, January, 2014

Pages: 53-62

Date of Publication: 30-Nov--0001

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Author: Mohammed Lafi Al-Otaibi

Category: Healthcare

Abstract:Introduction: To present the experience of an Orthopaedic Surgeon, certified consultant with no microsurgery or plastic surgery qualification working at a level one trauma center in managing soft tissue coverage of lower one third of tibia, ankle and the heel. Patients and Methods: Four patients, three males and one female, with soft tissue defect of lower one third tibia, ankle and the Heel requiring soft tissue cover were treated from August 2008 to August 2010. The Distally based suralis fasciocutaneous flap was harvested from the posterior aspect of the calf. The pedicle pivot is at least 5 cm proximal to the lateral mallelous to allow anastomosis with the peroneal artery via the constant peroneal perforators. Skin incision was started along the mid line of the calf posteriorly stoping 5 cm at least proximal to lateral malleolus which the fascial pedicle would be taken. The subdermal layer dissected to expose the sural nerve, accompanying superficial sural vessels and short saphenous vein.1 The subcutaneous facial pedicle elevated, with a width of 3cm to include the nerve and these vessels will pivot. At the proximal margin of the flap, the nerve and the vessels were ligated and severed.2 The skin island was elevated with the deep fascia. The donor site defect was covered with a split thickness skin graft from epsilateral thigh. Results: Well tolerated procedure by all patients, no plastic surgery or reoperation was need for any of the four cases, Survival of all flaps, maintenance of orthopaedic fixation, one flap showed some venous engorgement which subsided gradually in a few days. Complete take of all split skin graft over donor site bed. Conclusion: Distally based Sural artery flap is a good choice for reconstruction of soft tissue defects of lower 1/3 tibia, ankle and foot. The procedure is easy and should be done by an Orthopaedic surgeon when needed.

Keywords: Soft tissue defects distally based sural artery flap, Lower 1/3 tibia, ankle & foot.

Full Text:


Defects in Soft tissue accompanying fractures of lower 1/3 tibia, ankle and foot are a challenging problem facing orthopaedic surgeon's world wide. Hospitals with no plastic surgery departments where these patients usually being treated put there orthopaedic surgeons at the challenge.3 Distal third of tibia is subcutaneous and not forgiving in terms of soft tissue problems usually arise in situations such as open fractures or pilon fracture. Wound problems of the hind foot complicating Calcaneus fracture or after its open reduction and internal fixation is another challenging site for soft tissue coverage. Different forms of soft tissue cover are available e.g., Random cutaneous, arterial cutaneous (axial), musculocutaneous, muscle, fasciocutaneousand free flaps with their own indications, advantages and disadvantages. The distally based Sural artery flap, first described as a distally based neuro cutaneous flap by Masquelet et al.,4 is skin island flap supplied by the vascular axis of sural nerve. He reported, using colored latex injection studies in 1992, the blood supply to the skin from the arteries accompanying the nerves and described the concept of neuro cutaneous island flap. The objective of this paper was to present our experience of soft tissue cover of lower 1/3 of tibia, ankle and foot treated by an Orthopedic surgeon without any special training, and also the reliability of this flap. 


Approved by the Ethical Committee in our center four patients, three males and one female, with soft tissue defect of lower 1/3 tibia ankle and foot requiring soft tissue cover were treated from May 2008 to may 2010. The patient’s age ranged from 14 to 36 Years (mean 25 Years). Two of the wounds were over the distal third of the tibia, one on the lateral malleolus and one on the lateral aspect of hind foot. All four cases underwent same surgical technique as shown Figures 1 to 12. Donor flaps sutured in place or stabled over a haemovac drain and with no tension at the edges. The limb is warped in enough cotton and immobilized in Ankle foot orthosis to prevent pressure on the flap Fig -12. The procedure is done without tourniquet and all patients were given prophylactic dose of antibiotics, wounds inspected second post operative day as the drain removed. Oxygenation via face mask to keep saturation above 95% and assuring enough oxygen tention at the wounds as they heel. All patients kept in hospital until wounds heal and sutures removed.


The mechanism of injury was road traffic accident in three patients with open fracture tibia Fig-13 in two patients one is skeletally immature with growth plate injury Fig-14 and open ankle fracturein the third patient, the fourth case after operative treatment of fracture of the calcaneum complicated by wound necrosis Fig-15. Reveres flow suralis flap used in all cases (Table 1). All flaps flap showed slight venous congestion which subsided within a few days. Complete take of split skin graft over the donor site. No loss of sensation persisted at two years post op.


Previously, mostly lower limb flaps were based on the concept of random skin flap design, thus were limited by a certain length-to-width ratio (usually 1:1 in the lower extremity). Ponten flaps had length-to-width ratios as great as 3:1. These flaps have been referred to as Ponten super flaps. The concept of a neuroskin island flap has been first developed and applied by Masquelet4 as he reported its use in six clinical cases for coverage of some specific areas of the lower limb and gained attention since 1992. Cormack and Lamberty classified fasciocutaneous flaps according to their vascular anatomy.5 Mathes and Nahai also discussed the classification of fasciocutaneous flaps.6 Tolhurst, Haeseker, and Zeeman demonstrated a 15% greater survival length in flaps that included fascia.7 Cormack and Lamberty classified fasciocutaneous flaps based on vascular anatomy.Circulation to a fasciocutaneous flap is based on the prefascial and subfascial plexuses. There are also arterial plexuses at the subdermal and subcutaneous levels. These plexuses are supplied by regional arteries that may enter the deep fascia through an underlying muscle (musculocutaneous), through the septum between underlying muscles (septocutaneous), or through a direct cutaneous branch. Often, more than one source of blood supply to a particular area of skin or a particular muscle is present. If one of these arteries is ligated, the skin and fascia continue to receive blood supply from an alternative source. The arteries generally are accompanied by paired venae comitantes and are reasonably consistent in their location. In the extremities, many perforators pierce the septa between long slender muscles, while musculocutaneous perforators tend to supply the skin over the broad flat muscles of the trunk. Because of the directionality of the fascial plexus, particularly in the extremities, the orientation of the flap is important. Chan and colleagues8 in their study proved that early vascularized soft-tissue closure has long been recognized to be essential in achieving eventual infection-free union. The question of whether muscle or fasciocutaneous tissue is superior in terms of promoting fracture healing remains unresolved. In this article, the authors review the experimental and clinical evidence for the different tissue types and advocate that the biological role of flaps should be included as a key consideration during flap selection. Ebrahimi et al.9 concluded that reverse sural flap is a useful and versatile reconstructive method in patients with gunshot wounds of the lower leg and foot. Mukherjee et al.10 studied prospectively 20 cases and fined that Perforator flaps are a reliable option for closure of soft tissue defects of lower limb irrespective of size, location and depth. There is minimal donor site morbidity. It has the advantage of rapid dissection, flap elevation and reliable skin territory. As no special equipment is required it can be replicated in smaller centers also. Zayakova11 as other researchers proved the pedicle fascio cutaneous and muscle flaps are used in reconstructive surgery to treat large and deep defects of the lower leg. Full tissue coverage, functional recovery and good aesthetic results are achieved with minimum damage to the donor site. In addition, the surgical procedure is relatively short and easy to perform, and it doesn’t require microsurgical skills and instruments. Esezobor et al.12 mentioned in their study, though the loss of sensation on the area innervated by the sural nerve may resolve within some months after the use of reverse sural artery flap, preserving sensation on the foot is an advantage especially in patient with sensoneural problem. In some selected patients that require flap cover for the upper part of the distal 3rd and the mid 3rd on the ipsilateral leg, the sural nerve preserving sural artery flap is an option. Its area of coverage on the contralateral leg may extend to the whole of distal 3 rd. This is possible as long as the pivot of the flap is not more than 5cm distal to the level of the point where the sural nerve pierces the deep fascia and the arc of rotation is not more than 100°. Elsaftawy et al.13 reported 16 cases and find the reverse sural flap, technically easy, offers a viable, low-risk alternative to free and perforator-based flaps. Proving carrying the lowest risk of complication and failure. Chen Wang et al.14 concluded in a study involving 16 consecutive cases that The distally based flap pedicled with the lateral sural nerve and lesser saphenous vein was a reliable source for repairing soft tissue defects in the lower leg and foot due to its advantages of infection control, high survival rate, and sufficient blood supply without the need to sacrifice a major blood vessel Chang et al.15 stated that the reconstruction of the distal third leg and weight-bearing heel, especially when complicated with infection and / or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only.


Distally based Sural artery flap is a good choice for reconstruction of soft tissue defects of lower 1/3 tibia, ankle and foot (Fig 17). The procedure is easy and should be done by an Orthopaedic surgeon when needed.




1. Motamed S, Yavari M, Mofrad HRH, Reza R, Shahraki FN. Distally based sural artery flap without sural nerve. Acta Medica Iranica 2010; 48(2): 127-9.

2. Ali MA, Chowdhury P, Ali M, Ifteker Ibne Zuha, Dev J. Distally-based sural island flap for soft tissue coverage of ankle and heel defects. J Coll Physicians Surg Pak. 2010; 20(7): 475-7.

3. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg. 1981; 34(2):215-20.

4. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg. 1992; 89(6):1115-21.

5. Cormack GC, Lamberty BG. A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg. 1984; 37(1):80-7.

6. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchill Livingstone; 1997.

7. Tolhurst DE, Haeseker B, Zeeman RJ. The development of the fasciocutaneous flap and its clinical applications. Plast Reconstr Surg. 1983; 71(5):597-606.

8. Chan JK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps Plast Reconstr Surg. 2012; 130 (2): 284e-295e.

9. Ebrahimi A, Nejadsarvari N, Koushki ES. Experience With Reverse Sural Flap to Cover Defects of the Lower Leg and Foot. Trauma 2012; 16(4): 178-81.

10. Mukherjee MK, Parwaz MA, Chakravarty B, Langer B. Perforator flap: A novel method for providing skin cover to lower limb defects. Medical Journal Armed Forces India 2012; 68: 328-34.

11. Zayakova YK. Application of pedicle flaps for wound coverage of lower leg. J IMAB 2013, 19(1):382-386; DOI: 10.5272/jimab.2013191.382.

12. Esezobor EE, Nwokike OC, Aranmolate S, Onuminya JE, Abikoye FO. Sural nerve preservation in reverse sural artery fasciocutaneous flap-a case report. Ann Surg Innov Res. 2012; 6(1):10. doi: 10.1186/1750- 1164-6-10.

13. Elsaftawy A, Jab?ecki J, Domanasiewicz A, Paruzel M, Kaczmarzyk J, Kaczmarzyk L. Treatment possibilities of reverse-flow sural flap in covering the defects of lower extremities. Pol Przegl Chir. 2013; 85(4):192- 7. doi: 10.2478/pjs-2013-0029.

14. Wang C, Xiong Z, Xu J, Huang H, Li G. The distally based lateral sural neuro-lesser saphenous veno-fasciocutaneous flap: anatomical basis and clinical applications J Orthopaed Traumatol. DOI 10.1007/s10195- 012-0202-2.

15. Chang SM, Zhang K, Li HF, Huang YG, Zhou JQ, Yuan F, Yu GR. Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel. Microsurgery. 2009; 29(3): 205-13. doi: 10.1002/micr.20595.


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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to for more details.

Best Article Award

A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Leow Jun Xian and Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh et al. entitled "Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
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List of Awardees

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19

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