Original article

Grünberger Nisha Mercedes1, Neurauter Urs2, Strub Benedikt2,3
1 Orthopädie und Sportchirurgie Balsberg, Praxis, Schweiz
2 Abteilung Orthopädie und Traumatologie, Kantonsspital Baden, Schweiz
3 Fineartsurgery, Praxis für Plastische, Rekonstruktive und Ästhetische Chirurgie, Handchirurgie Baden, Schweiz


A 58- year old male patient presented, after a workplace accident with a 1 tonne of a metal plate on the right lower leg and foot, an open midfoot fracture and big soft tissue defect (Gustilo Anderson grade IIIA). Because of the soft tissue situation an external fixator was used for initial treatment. During hospitalization, progressing skin necrosing areas were presented, with the result that surgical depridements and a VAC (Vacuum Assisted Closure) system was necessary to treat the soft tissue damage. On the basis of this situation the decision was taken to treat the fracture with an external fixator instead and waiting until swelling was regressive. After two months, the external fixator could be removed and a dorsalis-pedis- and suralis flap with split-skin graft was performed. Eight months after skin flap the patient presented an ulcer on the heel, which could be managed with an excision and regular wound control. The follow ups during 3 years after surgery showed an acceptable outcome regarding fracture healing with painless posttraumatic arthrosis and skin flap.


Ein 58-jähriger männlicher Patient präsentierte, nach einem Arbeitsunfall mit einer 1 Tonnen schweren Metallplatte auf seinen rechten Unterschenkel und Fuss, eine offene Mittelfussfraktur mit grossem Weichteildefekt (Gustilo Anderson Grad IIIA). Aufgrund der prikären Weichteilsituation wurde ein Fixateur externa als initiale Behandlung gewählt. Während der Hospitalisation zeigten sich zunehmende Nekroseareale, sodass ein Debridement und VAC Anlage (Vacuum Assisted Closure, Vakuumtherapie) als Therapie des Weichteildefektes notwendig wurde. Im Rahmen dieser Grundsituation wurde der Entschluss gefällt, die Fraktur im Fixateur externa ausheilen zu lassen und die Abnahme der Schwellung abzuwarten. Nach zwei Monaten konnte der ­Fixateur externa entfernt und ein Dorsalis pedis-, als auch Suralislappen mit Spalthauttransplantat durchgeführt werden. Acht Monate nach der Lappenplastik zeigte der Patient ein Ulcus an der Ferse, welcher mit einer Exzision und regelmässigen Wundkontrolle behandelt werden konnte. Das Follow up drei Jahre nach dem Eingriff zeigte ein akzeptables Outcome bezüglich der Fraktur mit schmerzloser posttraumatischer Arthrose sowie Lappenplastik.


Complex open foot and ankle fractures with larger soft tissue defects, classified with the Gustilo Anderson grade (see table below), are still challenging for a trauma team and an interdisciplinary cooperation is necessary to provide successfully solutions, such as suralis flap. To avoid amputation and to ensure a satisfying outcome with a high quality of life it is necessary to work close with plastic surgeons as a team and plan the further surgeries in advance. For soft tissue defects, reconstruction on the distal third of the lower leg the free-flap coverage is the gold standard [1-6], but also local flap plastic is a possible option, however the indication is the key for an successful outcome [7].

Case Report

In February 2018 a 58-year old male patient brought in by ambulance after a workplace accident occurred with a 1 ton metal plate, which collapsed on the patients distal third of the lower limb and foot. At emergency department an open midfoot fracture (Gustilo Anderson grade IIIA) was diagnosed (Figure 1).

Figure 1: Initial condition of the lower right extremity at the emergency department. (02/2018)

The X-Ray and CT scan (Figure 2) confirmed a dislocation of the first row to the medial and subluxation of the upper ankle joint. Further multiple fractures were seen of the cuboid bone, medial, intermediate and lateral cuneiform bone, as well fractures of the metatarsal basis II-IV. The patient was immediately taken to the operation theatre to stabilize the fractures. Because of the size of skin avulsion and unforeseeable soft tissue damage an external fixator was used for initial treatment.

Figure 2: X-Ray and CT-scan: dislocation of the first row, and multiple fracture of the midfoot (02/2018)

During the course of hospitalization progressing skin ­necrosis were seen (Figure 3), therefore further surgeries with depridements and VAC dressing were necessary.

Figure 3: Progressing skin necrosis needed further debridements and VAC dressing

To decide ton the proper flap and optimize the outcome of the reconstructive procedure, the patient underwent an Angio CT scan, which confirmed sufficient blood supply. Two months after initial treatment the external fixator was removed and a dorsal-pedis- and sural artery flap was successfully performed (Figure 4). Postoperative care included partial weight-bearing and regular consultations to check the healing process.

Figure 4: preoperative and during surgery

After 8 months, the patient presented an ulcer at the heel, highly probably caused by a constant pressure from the cast, which was used to prevent talipes equinus. The ulcera was managed with debridement and regular dressings. Cause of the ulcera was probably a constant pressure This treatment showed a positive effect and no further interventions were required (Figure 5).

Figure 5: after surgery, sural artery flab and Thiersch graft was successful

Almost a year after last surgery the patient was able to walk with orthopedic shoes inserts without pain and was back to work. Despite of posttraumatic changes at TMT I joint ­(Figure 6) no arthrodesis was necessary.

Figure 6: Painless posttraumatic changes are more than one year after accident (March 2019)


Complex lower extremity fractures are frequently associated with soft tissue injuries that are still challenging for the team and needs interdisciplinary cooperation because of the frequent involvement of muscle, tendon, and bone, which is caused by the thinness and poor circulation of the skin covering them and by the small quality of local tissue available for reconstruction [8,9]. The soft tissue defects in the distal third of the leg and ankle remains an especially difficult problem as mentioned above, therefore several reconstructive procedures have been proposed, for instance local cutaneous flaps, pedicled fasciocutaneous flaps, pedicled muscle flaps and free flaps [10]. All of them have their own limiting factors, which should be considered before surgery is done. To be precise, for example muscle flaps for distal lower limb reconstruction are limited due to lack of mobile muscle belly in this region. The soleus muscle flap has been useful in treating small to moderate sized defects but is limited by its small distal rotation arc [11]. Whether used for defects of the leg or ankle, the muscle, initially bulky, has the benefit of “autothinning” over time. As the muscle atrophies, it provides a better aesthetic result than local fasciocutaneous flaps, but irregular contour and color of skin graft over muscle can be a problem. The thinner flap has advantage particularly around the ankle as the reconstruction is less likely to interfere with footwear [10].
Furthermore, risk factors such as patient age over 40 years, peripheral artery disease, venous insufficiency, and diabetes mellitus must be considered, whereas tobacco use, chronic, and alcoholism are secondary risk factors for flap failure [12]. To maximize the successful outcome, indication in terms of patient selection is one of the most important aspects. However, the ideal flap should be technically easy to do, reliable and with less donor site morbidity [10]. Free flap is the gold standard for soft tissue defects of lower extremity and it solves the problem of donor site morbidity, but it is a demanding procedure for the surgeons with less microsurgical experience [1-6,10]. Before performing definitive reconstruction, surgeons must examine and determine the extent of the injury, this ensures the right flap size, and reevaluates the perfusion status of the affected limb [13]. Local fasciocutaneous flaps have a high complication rate and limiting radius, so it should be used for smaller soft tissue defects. Suralis flap can be used for lower third leg-, foot- and ankle defects of moderate size, as well as salvage surgery in an attempt to prevent amputation [7,10]. Major complication is partial or complete flap necrosis. Additionally, the postoperative care includes a regular check-up of the perfusion within the first 5-7 days, however, it is the udmost importance that any pressure on the flap is avoided, this can be done with the right position. Depening on the swelling and the perfusion, the patient is allowed to put half weight at the beginning [14].
Our patient presented a normal perfusion rate, no other secondary diagnosis or other limiting factors which could affected the outcome after preforming an artery suralis flap. However, major studies of clinical applications at the critical lower extremity have not been reported yet [15].

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Corresponding author

Nisha Mercedes Grünberger 
Farenweg 16
Tel: + 41 79 869 35 52
Email: nisha.gruenberger@gmx.at


  1. Jakubietz RG, Schmidt K, Holzapfel BM, Meffert RH, Rudert M, Jakubietz MG. Die 180º-Propellerlappenplastik zur Defektdeckung im Bereich des distalen Unterschenkels. Operative Orthopädie und Traumatologie. 2012;24(1):43-9.
  2. Jakubietz RG, Jakubietz MG, Gruenert JG, Kloss DF. The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap. Ann Plast Surg. 2007;59(6):667-71.
  3. J. Masia GP, M. Fernandez, J.M. Pons, P. Serret. Experience with Local Perforator Flaps in Lower Limb Reconstruction Using the “Propeller Principle”. J Reconstr Microsurg. 2006;22 – A050.
  4. Quaba O, Quaba,Awf. Pedicled Perforator Flaps for the Lower Limb. Semin Plast Surg. 2006; 20(2):103-111.
  5. Schaverien MV, Hamilton SA, Fairburn N, Rao P, Quaba AA. Lower limb reconstruction using the islanded posterior tibial artery perforator flap. Plast Reconstr Surg. 2010;125(6):1735-43.
  6. Teo TC. The propeller flap concept. Clin Plast Surg. 2010;37(4):615-26, vi.
  7. Jakubietz RG, Meffert RH, Jakubietz MG, Seyfried F, Schmidt K. [Local flaps as a last attempt to avoid lower extremity amputation: an overview]. Unfallchirurg. 2020;123(12):961-8.
  8. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg. 2006;14(10 Spec No.):S205-10.
  9. Fraccalvieri M, Verna G, Dolcet M, Fava R, Rivarossa A, Robotti E, et al. The distally based superficial sural flap: our experience in reconstructing the lower leg and foot. Ann Plast Surg. 2000;45(2):132-9.
  10. Thammannagowda RK, Ashish G, Mudukappa S, Pushkar D, Vijayakumar A. Comparison between Peroneus Brevis Flap and Reverse Sural Artery Flap for Coverage of Lower One-Third Leg Defects. ISRN Plastic Surgery. 2014;2014:969420.
  11. Le Fourn B, Caye N, Pannier M. Distally based sural fasciomuscular flap: anatomic study and application for filling leg or foot defects. Plast Reconstr Surg. 2001;107(1):67-72.
  12. Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plastic and reconstructive surgery. 2003;112(1):129-40.
  13. Aydogan E, Langer S, Josten C, Fakler JKM, Henkelmann R. Outcomes of tissue reconstruction in distal lower leg fractures: a retrospective cohort study. BMC Musculoskelet Disord. 2020;21(1):799.
  14. Zhong W, Lu S, Chai Y, Wen G, Wang C, Han P. One-stage reconstruction of complex lower extremity deformity combining Ilizarov external fixation and sural neurocutaneous flap. Ann Plast Surg. 2015;74(4):
  15. Schepler H, Sauerbier M, Germann G. [The distally pedicled suralis flap for the defect coverage of posttraumatic and chronic soft-tissue lesions in the “critical” lower leg]. Chirurg. 1997;68(11):1170-4.

Comments are closed.