High-energy trauma to the lower extremities is frequently associated with soft tissue defects, and their reconstruction can present a significant challenge. Historically, for extensive defects in the distal third of the leg, ankle, and heel, microvascular free flaps were almost always required. These procedures involved complex decision-making, specialized instrumentation, and advanced microsurgical training.

In recent years, perforator flaps of the leg have gained importance due to several advantages: they avoid sacrificing major vessels, are performed on the same limb without creating morbidity at a distant donor site, provide tissue characteristics similar to the defect site, improve local aesthetics, and can be performed by orthopedic surgeons without microsurgical training [[1], [2], [3], [4]].

This approach allows for an orthoplastic strategy, combining orthopedic and reconstructive techniques to address both skeletal stabilization and adequate soft tissue coverage, thereby restoring function and positioning the orthopedic surgeon as a key player in management [[5], [6], [7]].

Among the available soft tissue coverage options, the reverse sural fasciocutaneous flap has become increasingly popular for defects in the distal third of the leg and foot. However, its viability can be compromised when used for coverage beyond the ankle joint, requiring a longer pedicle due to anatomical limitations of the peroneal artery perforators, which are located within the last 6 cm proximal to the lateral malleolus [8]. This raises the question of whether pedicle length itself increases the risk of ischemic complications and whether specific strategies are needed to optimize outcomes for defects distal to the ankle.

Hypothesis: Reverse sural flaps with long pedicles (distal to the ankle joint) have a higher rate of vascular complications than those with short pedicles (proximal to the ankle joint).

General objective: Determine whether pedicle length influences the occurrence of vascular complications in reverse sural fasciocutaneous flaps.

Assess whether vascular comorbidities affect flap viability.

Compare the effect of pedicle rotation angle on viability.

Determine whether skin paddle size affects viability.

Identify and classify vascular complications.