The coverage defects in the lower limb, especially in the leg, are a difficult problem to face due to the specific characteristics of the anatomic area, bony prominences, the paucity of soft tissues and limited elasticity [9, 15].
Reconstruction solutions include the gastrocnemius and soleous flaps. Their use was limited to the proximal and middle third of the leg  and the reconstruction of the distal third of the leg being subject to complex options as a cross-leg flap or a microsurgical flap [9, 10]. With this approach a 15–20% complication and failure rate was repoted .
At the same time, it is important to highlight that the complexity of the coverage defects added to patient conditions make the reconstruction difficult to be carried out .
Different strategies of reconstruction have been developed, being the fasciocutaneous perforator flaps and mainly the sural flap the most frequently used nowadays. [2, 7]. The reverse sural flap has little local morbility, it does not affect principal vessels and does not require a high level experience to be performed. However, it cannot always be used to treat soft-tissue defects in the distal third of the leg either because the defect can be out of its coverage area or its vascular pedicle can be damaged . In that case a change of reconstructive surgical strategy of the soft tissue defects is needed such as the distal posterior tibial artery perforator flap (PTAPF). This flap meets the same indication criteria than the sural flap but the PTAPF allows the primary closure of the donor site as well as a better aesthetics results.
The aim of this case series is to present a therapeutic alternative and describe the surgical technique, the results and complications in the treatment of coverage defects in the lower limb.
For the purpose of this retrospective study, we reviewed medical records of patients whose leg had been treated with a PTAPF at a large tertiary academic hospital. All operations were performed by an orthopaedic surgeon specialized in lower limb surgery and microsurgery (GC). We included twelve patients with coverage defect on the anterior face of the leg, with bone or tendon exposure or skin defect in whom the surgical reconstruction had been specifically performed with a PTAPF.
We followed the PROCESS guideline to report this case series . Every patient gave their informed consent to be treated, understanding the risk and the objectives of the treatment.
We analysed preoperative, intra operative and postoperative variables.
The pre-operative variables analyzed were: body mass index, comorbilities, number of previous surgeries, cause, type of defect and indication for this flap. The intraoperative variables were: pedicle location, size of the skin paddle, rotation degrees of the flap, intraoperative complications as well as the need of a second surgical time. Furthermore we recorded complications defined as venous congestion, partial or total necrosis and the flap survival as postoperative variables.
The patients were preoperatively evaluated to determine the presence of perforators by Doppler sonography.
The procedure starts with the patient in supine position, with a slight external rotation of the limb that is being operated on. A cutaneous mapping is performed to identify the presence of perforators in the influence site of the posterior tibial artery and close to the defect to be covered.
We define the proximal or distal orientation of the flap to be rotated (from 45 to 180 degrees) depending on the location of the defect, the presence of previous scars and the location of the perforator vessels.
Subsequently, we define the skin to be elevated including the perforator/s in one of the extremes (Figure 1). The length of the skin paddle will be consistent with the distance between the distal edge of the defect and the perforator, adding 1–2 centimeters according to the perforator theoretical location at a skin level.
Afterwards the flap is elevated (Figure 2) under limb ischemia. It can be totally performed either far from the perforator territory or on its posterior face. Then we identify the perforator vessels. (Figure 3)
After having identified the perforator vessel/s (usually no more than 2) and depending on the necessary rotation to reach the defect area, one of those perforators may be sacrificed to obtain the desired rotation.
It is worth noting that, when a rotation higher to 90 degrees is needed, it is mandatory to free the perforator from the fascia until the posterior tibial artery in order to diminish the possibility of kinking the vessel and complications associated to the venous congestion.
Once the flap is raised, the ischemia is released to assess its adequate capillary filling and to perform the corresponding hemostasis. The flap rotation is performed reaching and covering the soft-tissue defect suturing with separate stitches in two layers and without tunneling (Figure 4). The primary closure is performed at the donor site level.
Depending on the bone underlying pathology and the procedure performed, the use of a half cast may be considered.
From March 2008 to 2018, we performed twelve PTAPF, all of them on male patients. The average age was 52 years old (range 29 to 77 years).
The average body mass index (BMI) was 31.4, more than half of the patients having an over-30-BMI. Five patients were cigarette smokers, three were diabetics Type II and one was hypothyroid. Four out of the twelve patients had no comorbilities.
The patients diagnosis was:
The type of soft-tissue defect suffered by the patients was:
There were no patients showing vascular soft tissue defects.
Regarding the specific medical indication in each patient, we took into account if they had undergone previous surgeries, the soft-tissue defect, the indemnity of the nourishing vascular bed and the topography of the defect to be covered (Table 1).
|Case||Number of previous sugeries||Topography of the defect||Nourishing vascular bed||Type of soft-tissue defect|
|1||yes||middle third anterior||undamaged||Fistula of 1 cm|
|2||yes||anteromedial||previous sural flap||Necrosis of 10 cm|
|3||yes||middle third anterior||undamaged||Necrosis of 4 cm|
|4||yes||distal third medial||undamaged||Necrosis of 3 cm|
|5||yes||anteromedial||previous sural flap||Defect of 3 cm|
|distal third||Peroneal artery|
|6||No||anteromedial||injured||Defect of 5 cm|
|distal third||No peroneal artery|
|7||yes||anteromedial||perforators||Fistula of 1 cm|
|8||yes||anteromedial||undamaged||Necrosis of 4 cm|
|9||yes||anterior||undamaged||Fistula of 3 cm|
|distal third||No peroneal artery|
|10||yes||anteromedial||perforators||Necrosis of 4 cm|
|11||yes||anterior||undamaged||Necrosis of 5 cm|
|12||No||middle third anterior||undamaged||Necrosis of 4 cm|
In the proximal defects and in the third half defects in which it is usual to perform muscle flaps we chose to preserve the muscle, performing the PTAPF. Furthermore the aesthetic result was mostly satisfactory (Figure 6).
On the other hand, the choice of this flap in six patients with defects in the distal leg, was due to therapeutic limitations regarding the vascular aspect. Two patients had already had a previous sural flap, while another patient had had an injury in the peroneal artery. The remaining three patients didn’t show good perforators at the pulsed Doppler sonography. The fasciocutaneous sural flap depends on vascular pedicles from the peroneal artery, thus the PTAPF was the most viable option in view of this limitation.
Summarizing, the flap influence area was: two flaps for the proximal third of the leg, four flaps for the middle third and six flaps for the distal third.
The surgery was performed in one surgical time in three cases, two of which had an active fistula. The third patient with an active fistula required a second surgical time in which we performed an additional gastrocnemius muscle flap due to a partial failure of the PTAPF. The second surgical time in six patients was to complete the flap closure and in one of them to add a skin graft.
In two patients a venous congestion was observed, requiring the flap to be released. After the event was overcome, the wound was closed. Only one patient presented a complete failure. There were no intraoperative complications.
Two perforators were included in six flaps. In the remaining six flaps, just one perforator was included. The rotation degree was different according to each case (Table 2). The average size of the skin paddle was 12 × 5 cm. The average follow-up was 18 months (range 5 to 55 months) excluding the failed case. As already mentioned, there were two flaps with distress due to congestion which resolved in a brief period, a partial failure and a total failure.
|Case||Size of flap||Rotation degrees||Surgical Time||Flap complication|
|1||10 cm × 4 cm||45°||1||–|
|2||14 cm × 5 cm||180°||2||venous congestion|
|3||11 cm × 4 cm||30°||2||–|
|4||14 cm × 4 cm||180°||2||venous congestion|
|5||8 cm × 4 cm||160°||1||total failure|
|6||10 cm × 4 cm||90°||2||–|
|7||14 cm × 4 cm||170°||1||–|
|8||12 cm × 4 cm||180°||1||–|
|9||15 cm × 5 cm||90°||2||partial failure|
|10||16 cm × 5 cm||180°||2||–|
|11||14 cm × 5 cm||170°||2||–|
|12||10 cm × 6 cm||30°||2||–|
The lack of knowledge of the local tissue vascularization pattern has been the main cause of disappointment with local fasciocutaneous flaps . The situation is even more complicated when the blood flow is affected by the limb trauma or the peripheral vascular pathology .
Reliable perforator arteries have been known thanks to several anatomic studies, such as those from the posterior tibial artery [13, 14] which are easily identified by Doppler sonography. Most of them are septocutaneous and they have a higher diameter on the proximal third of the leg [13, 16]. The inclusion of the deep fascia allows the design of larger size flaps nourished by just one perforator, due to the extensive axial communication with the flap .
The PTAPF is nowadays an alternative that meets the conditions to be considered as a first-line choice for orthopedic surgeons. It was described by Pontén in 1981 , who suggests it as the first viable alternative in distal defects in lower limbs due to their versatility, aesthetics and little morbility of the donor site.
Its versatility lies in the possibility of being carried or rotated up to 180° over its pedicle, being possible its pivot point to be proximal or distal, so widening the range of coverage to all the anterior face of the leg [4, 8, 12]. By using the PTAPF, the principal arteries that nourish the foot are preserved as the primary closure is feasible to be performed. The surgical time is short as it does not require microvascular anastomosis. The PTAPF advantages include the aesthetics, as the skin texture, its thickness and its pigmentation are homogeneous to the recipient site, so avoiding the interfaces [9, 10, 13, 18].
It is emphasized its usefulness as a rescue flap in case of a failed sural flap as well as in those cases in which the use of a reverse flow sural flap is impossible to perform because the pedicle that nourishes it has become compromised during a lower limb trauma or previous procedures on the area.
The posterior tibial artery perforator flap is considered a relevant option to treat small to medium size defects from the proximal third to the distal third of the leg. It provides similar tissue to the recipient area regarding thickness, texture and pigmentation, with little morbility in the donor site resulting in good clinical and aesthetic outcomes. At the same time, it is a good option when it is not possible to use a reverse flow sural flap or as a rescue in case of flap failure.
The funding is going to be supported by the authors.
The authors have no competing interests to declare.
Carabelli Surgeon/Manuscript, De Cicco Manuscript, Barla Manuscript, Taype Manuscript, Sancineto Manuscript.
Guido Carabelli is the guarantor.
This is a non-commissioned paper that has undergone external peer review according to journal policy.
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