Modified Sural Flap vs Free Anterolateral Thigh Flap for Soft Tissue Reconstruction Around the Ankle: A Randomized Controlled Trial

Background: Soft tissue defects around the ankle are common for orthopaedic surgeons in clinical practice. This study aimed to compare the modified sural flaps and free anterolateral thigh (ALT) flaps in terms of their ability to cover soft tissue defects, patient satisfaction, infection rates, flap ischemia, and flap sensation. Methods: This comparative study included 40 patients (24 males and 16 females) aged 5-60 years with defects in the lower one-fifth of their leg or foot, and less than 15 cm × 15 cm in size. Group A (20 patients) underwent a modified sural flap, whereas group B (20 patients) underwent free ALT flap. The study was performed in our specialized hand and reconstructive microsurgery unit from 2021 to 2023. Results: The operation time was significantly longer for the free ALT flap group compared with the modified sural flap group ( P value < .01). Patient satisfaction was higher with the modified sural flap. There were no significant differences in flap ischemia or donor site complications between the 2 groups. The sensation of the flap after 1 year favored the free anterolateral thigh flaps due to sensory nerve anastomosis, but after 1.5 years, good sensation was present in both flaps. Conclusion: The modified sural flap demonstrated superior efficiency with shorter operative times and higher patient satisfaction, whereas the free ALT flap provided better short-term sensory outcomes because of nerve micro-anastomosis capability. Both techniques achieved equivalent sensation recovery at 18 months, suggesting the modified sural flap may be preferable for most small to medium-sized defects foot and ankle defects.