Purpose of the study: The sural flap with a distal pedicle is a commonly used flap for ankle or foot cover; it has been described as easy to achieve, versatile and reliable. Following several personal failures, we attempted to analyse the principle factors of unfavourable outcome and to determine the precise role for this flap in distal cover of the lower limb.

Material and method: We retrospectively analysed a series of 25 sural flaps with a distal pedicle performed by one operator among a series of 55 ankle and foot flaps. Outcome was assessed as complete flap survival; even partial necrosis was noted. Factors examined included patient age, context, localization and surgical factors.

Results: Eight flaps necrosed (7 partial and 1 total) leading to amputation (32% complications). Flaps with partial necrosis nevertheless all healed after repair.

Discussion: This series had a high failure rate, like earlier reports in the literature. Most of the necrotic flaps were observed in older patients with vulnerable tissues. Conversely, the size of the flap or the localization of the recipient site did not appear to affect outcome; there was no apparent learning curve. The harvesting technique and the difficulties presented by anatomic variations are recalled. Treatment of the pedicle is important but cannot explain all of the failures. Why the distal sural flap should be chosen among the different flaps available for the lower limb depending on the site and situation is not clear. Technical elements, such as two-phase harvesting can be helpful, but for us do not appear to improve the survival of this flap whose outcome remains difficult to predict.