INTRODUCTION
High energy leg injuries usually result in soft
tissue losses and skin defects and are usually
accompanied with bony fractures or even bony
defects. These injuries may be severe enough to
be associated with major leg vessel injuries rendering
reconstructive options limited. The lower
one third skin defects of leg usually represents a
reconstructive challenge and the role of local skin
flaps and distally based fasciocutaneous flaps may
be limited especially if their vascular pedicles fall
within the zone of injury. Free flaps are the golden
operation in reconstruction [1] of these defects but
it may not be applicable in vascular compromised
limbs as those suffering injury of one or two large
291
vessels from the three major vessels supplying the
lower limb (Posterior tibial, Anterior tibial and
Peroneal vessels). Perforator flaps [2,3] based on
either direct or indirect perforator may be useful
especially in small defects but has tedious dissection
and partial flap loss rate at 11.3%. Cross leg flaps
are another option but it may render impossible if
the patient has another proximal femur or pelvic
fractures or even if they have external fixator to
leg bones with difficult flap inset, with local flap
necrosis of 40% [4]. Distally based neuro-vascular
sural flap is used with local flap necrosis rate of
21% [5]. The reversed flow hemi-soleus flap with
sacrifice of the posterior tibial artery to be included
within the flap was described by Guyron [6]. However
the flap did not gain much popularity because
it has the great disadvantage of sacrificing major
leg blood vessel [6,7,8]. The distally based Soleus
muscle flap based on the distal perforators of the
posterior tibial was introduced by Townsend [9]
and later on by Fayman et al., [10], is a good option
in reconstruction of lower one third leg defects in
vascular compromised leg (one or two vessels
injury) owing to the following advantages; no
disruption of major blood vessels, stable coverage
and profound circulation that is able to supply the
underlying bone with blood especially bone grafts
or osteomyelic bone after less than radical excision.
So our aim in this study is to re-evaluate the
reliability of the distally based hemi-soleus muscle
flap in the reconstruction of lower third leg defects
in vascular compromised cases where only the
posterior tibial artery is always preserved.
PATIENTS AND METHODS
The study was compiled from a retrospective
chart review of sixteen patients in a two year period
(September 2014 till July 2016) at the Plastic and
Reconstructive Surgical Departments in Ain Shams
University and Alzayton Hospitals. These patients
suffered from lower one third skin defects of leg
with injury of one or more leg vessels sparing the
posterior tibial vessels. The defects were due to
one of the following causes; post traumatic, post
tumour excision or osteomyelitis and unstable scar.
The injured vessels in these patients were either
the anterior tibial alone, peroneal alone or both the
anterior tibial and the peroneal vessels. All patients
underwent reconstruction of the skin defects by
distally based medial hemi-soleus muscle flaps
based on distal posterior tibial perforators arising
from the posterior tibial artery distally and directly
entering the medial side of the soleus muscle.
These perforators were identified intraoperatively
and preserved. Patients had early debridement and
careful assessment of the injured leg vascular tree.
That was done routinely using Duplex ultrasound
and in case of confirmed vascular injury by the
duplex, CT angiography is done to confirm the
findings and confirm the level of vessel interruption.
The integrity of the posterior tibial vessels till
distal leg was confirmed before proceeding to the
flap coverage.
Operative procedure:
The technique described by Townsend [9] then
Fayman [10] was done. Incision was done 2cm
posterior to the medial border of the tibia then the
gastrocnemius muscle was encountered and bluntly
dissected from the underlying soleus muscle owing
to the natural plane between them except at the
beginning of the tendo-achillis where sharp dissection
is the role. The vascular pedicle of the soleus
muscle is explored to confirm adequacy and location
of the distal perforators of the posterior tibial
artery, also preservation of the blood supply to the
lateral portion of the muscle coming through the
proximal vascular pedicles that shared to a limited
part in the supply to the muscle distally as the
medial and lateral portions of the muscle are proven
to be not a watershed level concerning its vascularity
[10]. After pedicle adequacy confirmation,
the flap is dissected from the deep muscles of the
292 Vol. 42, No. 2 / Reconstruction of Lower One Third Leg Defects
back of the leg and splitting of the soleus muscle
ensue along its natural plain if available, harvesting
the medial hemi-soleus as needed to reach the
defect safely without tension. Extreme care during
dissection was taken to avoid injury of the major
vessels as the legs were already suffering one or
two vessel injury.
RESULTS
Sixteen patients shared in this study; fourteen
males and two female with ages ranging from 12
to 54 years, suffering from skin defects in the lower
one third of the leg (pretibial in fourteen cases and
tendoachilis in two cases). They suffered also from
major leg vessel disruption either anterior tibial
or peroneal or both as detected by the pre-operative
duplex and proven by CT lower limb arterial angiography.
Ten patients suffer from anterior tibial
vessels injury alone, four patients suffered from
peroneal vessels injury and two patient suffered
from both anterior tibial and peroneal vessels injury.
The causes of the skin defects were due to trauma
in most of cases (14 cases), osteomyelitis and
unstable scar (one case) or post tumour excision
(one case). The average presentation of patients
ranged from 4 to 183 days.
In all patients distally based medial hemi-soleus
muscle flap based were used without sacrifice of
the posterior tibial vessels. Twelve flaps healed
well (75%) (Figs. 1,2), one flap suffered total loss
due to ischemia (6%) (Fig. 3), three flaps suffered
venous congestion and partial loss (distal one
centimetre) (19%) (Fig. 4). One of the three flaps
that suffered venous congestion; local recurrence
from the tumour excised before occurred with
partial loss of the flap. All surviving flaps underwent
grafting on the seventh day except for flaps
that suffered congestion and partial loss, underwent
grafting after 21 days. All patients had excellent
take of the skin graft. Two patients needed further
operation in the form of bone grafting to the tibia
after one month. Table (1) summarizes the data of
the patients.
Fig. (1): 43 years old male with post
traumatic defect of the distal one third of the
tibia that resulted after a period of negligence
in osteomyelitis. A- After radical debridement
of the chronic osteomyelitis, B- The resultant
defect was reconstructed using distally based
medial hemi-soleus muscle flap, C- after one
week. D- Followed by skin grafting.
(A) (B) (C) (D)
Egypt, J. Plast. Reconstr. Surg., July 2018 293
Fig. (2): 37 years old male A- with post traumatic unstable scar over the tendoachilis that was presented 50
days following the trauma. B- He underwent excision of the scar and resurfacing by distally based
medial hemi-soleus muscle flap. C- Followed by its skin grafting.
Fig. (3): 55 years old, heavy smoker male with A- Post traumatic pretibial skin defect with injury to the anterior
tibial vessels, first free rectus muscle flap was done to cover the whole defect, but total loss of the
free flap occurred so another option was done. B- That was reconstructed by distally based medial
soleus suffering ischemia and eventually total loss.
(A) (B) (C)
Fig. (4): 12 years old male with. A- Sarcoma of the lower tibia with local invasion of the skin. B- The patient underwent radical
excision of the bone and external freezing followed by its reinsertion as a bone graft fixed by k wires. C- The resultant
defect was reconstructed by distally based medial hemi-soleus that suffered congestion and partial loss about less than
one centimetre. D- Two months later the flap was infiltrated with local recurrence of the tumour.
(A) (B) (C) (D)
(A) (B)
294
1
2
3
4
5
Defect
Location
and size
Distal one third
of tibia, total
surface area of
the defect
87cm2
Distal one third
of tibia. total
surface area of
the defect
98cm2
Tendo-achilis.
total surface
area of the
defect 46 cm2
Distal one third
of tibia. total
surface area of
the defect
54cm2
Distal one third
of tibia. total
surface area of
the defect
43cm2
Case
number Age
12
43
37
33
15
Gender
Male
Male
Male
Male
Male
Cause
Post sarcoma excision
of the tibia
with bone freezing
and application
as bone
graft then fixation
by k wires
Osteomyelitis following
internal
fixation of fracture
tibia with
skin necrosis
Post-traumatic unstable
scar with
tendo-achilis exposure
Post traumatic
skin loss over
the distal tibia
Post traumatic defect
pretibial
lower one third
Duration
(days)
21
183
50
7
150
Associated
conditions
Sarcoma
metastasis in the
lung
Seavy smoker
No
Heavy smoker
No
Both the anterior
tibial and
peroneal
vessels were
ligated in the
procedure of
sarcoma
excision
Anterior tibial
Anterior tibial
Peroneal vessels
Anterior tibial
Vessel
affected Result
The flap healed
well but venous
congestion with
partial flap loss
about one cm
followed by
local recurrence
occurred in the
distal part of the
tibia
Flap healed well
Flap healed well
Partial loss
followed by
dressings
Flap healed well
18
8
7
21
7
Period before
graft (days)
Need for
another
procedures
No
No
No
No
Needed bone
grafting after
one month
Excellent
Excellent
Excellent
Excellent
Excellent
Graft
healing
Disruption of the
distal part of the
flap due to
venous
congestion
followed
bylocal
recurrence of
sarcoma in the
distal part of the
flap and general
metastasis in
the lungs,the
patient died five
months later
No
Haematoma
underneath the
flap that was
evacuated with
no further
sequel
Partial loss of the
flap
No
Complication
(s)
Table (1): Data of patients in the study.
Vol. 42, No. 2 / Reconstruction of Lower One Third Leg Defects
Egypt, J. Plast. Reconstr. Surg., July 2018 295
Defect
Location
and size
Distal one third
of tibia.total
surface area of
the defect
33cm2
Distal one third
of tibia.total
surface area of
the defect
87cm2
Distal one third
of tibia, free
rectus flap was
donefollowed
by complete
loss. total
surface area of
the efect
120cm2
Tendoachilis total
surface area of
the defect
40cm2
Distal one third
of tibia. total
surface area of
the defect
34cm2
Distal one third
of tibia. total
surface area
ofthe defect
56cm2
6
7
8
9
10
11
Case
number Age
54
19
55
42
33
27
Gender
Female
Male
Male
Female
Male
Male
Cause
Post traumatic defect
pretibial
lower one third
Post traumatic
skin loss over
the distal tibia
Post traumatic
skin loss over
the distal tibia
Post traumatic
skin loss over
the tendo achilis
Post traumatic defect
pretibial
lower one third
Post traumatic defect
pretibial
lower one third
Duration
(days)
100
4
4
21
2
10
Associated
conditions
NO
Smoker
Diabe tic,
heavy smoker
No
No
No
Anterior tibial
Peroneal vessels
Anterior tibial
vessels
Peroneal vessels
Anterior tibial
vessels
Both the anterior
tibialand
peroneal
vessels injury
Vessel
affected Result
Flap healed well
Flap healed well
Flap suffered
severe ischemia
and loss of the
whole flap
Flap suffered
venous
congestion and
partial loss
about one cm
Flap healed well
Flap healed well
7
7
No
17
9
7
Period before
graft (days)
Need for
another
procedures
No
No
Coverage by
cross leg flap
No
Another skin
grafting
operation
No
Excellent
Excellent
No
Good with partial
loss of the skin
graft that left to
heal by
secondary
intention
Infection
occurred with
more than 70%
loss of the skin
graft followed
by re-grafting
Excellent graft
take
Graft
healing
No
No
Total loss of the
flap
Flap congestion
with partial loss
of the flap
Loss of the skin
graft
No
Complication
(s)
Table (1): Continued
Defect
Location
and size
Distal one third
of tibia. total
surface area of
the defect
72cm2
Distal one third
of tibia. total
surface area of
the defect
64cm2
Distal one third
of tibia.total
surface area of
the efect 54cm2
Distal one third
of tibia. total
surface area of
the defect
52cm2
Distal one third
of tibia. total
surface area of
the defect
70cm2
12
13
14
15
16
Case
number Age
14
23
52
54
22
Gender
Male
Male
Male
Male
Male
Cause
Post traumatic defect
pretibial
lower one third
Post traumatic defect
pretibial
lower one third
Post traumatic defect
pretibial
lower one third
Post traumatic defect
pretibial
lower one third
Post traumatic defect
pretibial
lower one third
Duration
(days)
11
2
4
3
12
Associated
conditions
No
Heavy smoker
No
No
No
Anterior tibial
vessels
Peroneal vessels
Anterior ti bial
vessels
Anterior tibial
vessels
Anterior tibial
vessels
Vessel
affected Result
Flap healed well
Flap healed well
Flap healed well
Flap healed well
Flap healed well
7
8
8
7
8
Period before
graft (days)
Need for
another
procedures
No
No
No
No
No
Excellent graft
take
Partial loss of the
skin graft then
left to heal by
secondary
intention
Excellent graft
take
Excellent graft
take
Excellent graft
take
Graft
healing
No
No
No
No
No
Complication
(s)
Table (1): Continued
296 Vol. 42, No. 2 / Reconstruction of Lower One Third Leg Defects
DISCUSSION
The skin defects of the lower one third of the
leg are considered one of the challenging defects
due to skin tightness and subcutaneous nature of
the bones and tendons. An added problem is injury
of one or more of the major vessels of the leg, as
this makes the free flaps option more difficult. So
here comes the necessity of coverage by regional
flap without sacrificing a major blood supply of
the leg.
The distally based hemi-soleus muscle flap has
these criteriae and also the advantage of neither
major function loss occurs after flap harvest, nor
donor site morbidity. Also it has the advantage of
increasing the blood supply to the underlying bone;
promoting bone salvage in chronic osteomyelitis
[11,12,13] attributing to its robust blood supply from
the feeding perforators of the distal posterior tibial
artery, the venous plexus [9], and also keeping the
lateral part of the flap preserved allowing for its
additional blood supply from the proximal pedicles
through the significant vascular communications
between the medial and lateral portions of the
muscle [10].
In our study sixteen cases with skin defects of
the lower one third of the leg were reconstructed
by distally based medial hemi-soleus muscle flaps
where 75% healed completely.
Conclusion:
The distally based medial hemisoleus is a reliable
flap for reconstruction of problematic lower
one third defects in vascular compromised lower
limbs as those suffering from injury to the anterior
tibial and/or peroneal vessels; provided that the
posterior tibial vessels are preserved. It provides
reliable coverage concerning the vascularity and
even can treat conditions as osteomyelitis in tibia
by its robust blood supply.
