{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T07:16:23Z","timestamp":1788419783609,"version":"build-2803163510"},"reference-count":16,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:p>Lower extremity reconstruction in elderly patients with post-traumatic osteomyelitis presents a formidable challenge. We report a 70-year-old female with hypertension, dyslipidaemia, and bilateral knee osteoarthritis who sustained a Gustilo-Anderson type IIIB open right ankle fracture with exposed calcaneus following a fall. The course was complicated by chronic osteomyelitis, managed with partial talectomy and total calcanectomy, antibiotic-impregnated cement spacer placement, cement exchange and prolonged culture-directed intravenous antibiotics. Following infection eradication, definitive hindfoot fusion using a structural femoral head allograft fixed with a retrograde tibiotalocalcaneal arthrodesis nail and compression screws was performed. However, a persistent soft-tissue defect with exposed bone precluded primary closure. Given her age, comorbidities and compromised local vascularity, free tissue transfer was deemed high-risk. Therefore, a 2-stage delayed reverse sural artery flap (RSAF) was selected. The first stage involved flap elevation with ischaemic preconditioning over 2 weeks via stepwise incremental incisional delay, followed by definitive transposition and inset. The donor site was managed with an ovine tendon collagen (OTC) matrix and split-thickness skin grafts (STSGs), supported by intermittent negative-pressure wound therapy (NPWT). At 6-months of follow-up, the flap remained viable and had fully survived, and the patient achieved partial weight-bearing ambulation. This case illustrates the decision-making framework for complex lower limb salvage, highlighting a staged reconstructive strategy integrating the delay phenomenon and adjunctive wound technologies to achieve durable limb salvage when microsurgical reconstruction is contraindicated.<\/jats:p>","DOI":"10.3389\/fsurg.2026.1894777","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T06:43:03Z","timestamp":1788417783000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["When microsurgery is not an option: staged delayed reverse sural artery flap with ischaemic preconditioning for limb salvage in an elderly patient with chronic post-traumatic osteomyelitis\u2014a case report"],"prefix":"10.3389","volume":"13","author":[{"given":"Zhun Shen","family":"Tan","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Universiti Kebangsaan Malaysia","place":["Kuala Lumpur, Malaysia"]},{"name":"Plastic Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia","place":["Kuala Lumpur, Malaysia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adzim","family":"Poh Yuen Wen","sequence":"additional","affiliation":[{"name":"Plastic Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia","place":["Kuala Lumpur, Malaysia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Farzana","family":"Ansarutheen","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universiti Kebangsaan Malaysia","place":["Kuala Lumpur, Malaysia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohd Yazid","family":"Bajuri","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia","place":["Kuala Lumpur, 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