Clinical and Functional Outcomes Following Reverse Sural Flap of Lower Extremity Defects: A Comparative Retrospective Study.

Abstract

Background: The reverse sural artery flap (RSAF) is widely used for soft-tissue reconstruction of distal lower extremity defects. However, outcomes may vary based on the defect site. This study aimed to compare clinical, functional, and aesthetic outcomes of RSAF performed at the ankle, heel, and lower leg, and to identify predictors of postoperative complications.

Methods: A retrospective analysis was conducted on 60 patients who underwent RSAF for soft-tissue reconstruction in the lower extremity. Patients were stratified by defect location: ankle, heel, or lower leg. Clinical data, complication rates, functional outcomes (Foot and Ankle Ability Measure [FAAM]), aesthetic outcomes (Vancouver Scar Scale), and predictors of complications were analyzed.

Results: The heel group exhibited the highest complication rate (50%) compared to the ankle (33.3%) and lower leg (6.2%) (p = 0.019). Functional outcomes were poorest in the heel group, with a mean FAAM score of 76.8, while the lower leg group had the best outcomes (mean FAAM, 91.2). Aesthetic satisfaction was also lowest in heel reconstructions. Smoking, elevated body mass index (BMI), longer pedicle length, and heel defect location were significantly associated with higher complication rates in univariable analysis. However, in multivariable analysis, smoking (odds ratio [OR], 5.29; p < 0.001), increased BMI (OR, 1.653; p = 0.001), and pedicle length (OR, 1.241; p = 0.030) remained independent predictors, whereas the defect site did not reach statistical significance (p = 0.083, p = 0.155).

Conclusions: While heel reconstructions demonstrated the highest raw complication rates and poorest functional outcomes, multivariable analysis suggests that patient factors-particularly smoking, obesity, and longer pedicle length-are stronger independent predictors of adverse outcomes than defect location itself. These findings underscore the importance of preoperative optimization and careful patient selection and highlight the need to interpret the influence of heel location with caution due to confounding factors such as the high prevalence of smoking in this subgroup.