Distally based posterior tibial artery perforator flap for coverage of defects around the ankle, heel and lower third of leg

ORIGINAL PAPER

Distally based posterior tibial artery perforator flap for coverageof defects around the ankle, heel and lower third of leg

Md Sohaib Akhtar & M. Fahud Khurram &

Rampukar Choudhary & A.H. Khan & Imran Ahmad

Received: 18 February 2014 /Accepted: 20 July 2014# Springer-Verlag Berlin Heidelberg 2014

AbstractIntroduction Reconstruction of distal leg region remained adifficult task. Free flaps had long been considered as a goldstandard for these regions. However, due to various limita-tions of the free flap, a local fasciocutaneous flap could beconsidered as a good alternative. In this study, the use of adistally based posterior tibial artery perforator flap had beenevaluated in the coverage of defects around the ankle, heel,and lower third of a leg. The study also outlined the donor-sitemorbidity and the technical details of the surgical procedure.Methods In this prospective study, a total of 42 patients withdistal lower leg defects were included. The defects werelocated on the lower third of the leg (n=23), ankle (n=11),and heel (n=8). Reconstruction was performed using distallypedicled posterior tibial artery perforator flaps. Patients wereevaluated in terms of viability of the flap, functional gain, anddonor-site morbidity. The technical details of the operativeprocedure have also been outlined.Results All the flaps survived well, with the exception of onepatient, who experienced complete flap loss. Minor compli-cations were, however, noted in four other patients: Onepatient developed superficial epidermolysis; one developedpostoperative venous congestion, which subsided within3 days by conservative means, and in two patients, partial lossof the skin graft occurred at the donor site but healedcompletely with dressing and antibiotics. The patients werefollowed up for an average period of 6 months, ranging from 1to 13 months. Donor-site morbidity was minimal.

Conclusions It was concluded that the distally based pedicledposterior tibial artery perforator flap was a reliable, easy, lesstime-consuming, and versatile procedure for covering thedefects around the ankle, heel, and lower third a leg.Level of Evidence: Level IV, therapeutic study

Keywords Posterior tibial arteryperforator .Distal lower leg .

Tibial defect

Introduction

Soft-tissue reconstruction around the heel, ankle, and lowerthird leg is a challenging issue for a reconstructive surgeon.There are many options for covering the distal lower leg, suchas random-pattern flaps, cross-leg flaps [1], free flap [2],fasciocutaneous flaps [3], reverse sural fasciocutaneous flaps[4], and muscle flaps [5].

Local random-pattern flap has an indistinct perfusion pat-tern with limits in size and mobility and has had high inci-dence of failure [6]. Cross-leg flap has a problem of immobi-lization; a muscle flap leads to functional deficit; free micro-vascular transfer needs long operating time; microsurgicalexpertise leads to considerable donor-site morbidity [7].

Currently, perforator flaps represent the most recent andadvanced method of reconstruction as they are safe and reli-able and have minimal donor-site morbidity.

Perforators from the anterior tibial, posterior tibial, andperoneal arteries in the lower leg within inter-muscular septaare reliable [8].

The study aims at presenting the results obtained from aconsecutive series of pedicled posterior tibial artery perforatorflaps in order to cover soft-tissue defects around the ankle,heel, and lower third of a leg.

M. Akhtar (*) :M. F. Khurram : R. Choudhary :A. Khan :I. AhmadPost Graduate Department of Burns, Plastic and ReconstructiveSurgery, JNMC, AMU, Aligarh, Uttar Pradesh, Indiae-mail: [email protected]

Eur J Plast SurgDOI 10.1007/s00238-014-0998-5

Materials and methods

The study was conducted at the authors’ center betweenNovember 2008 and March 2013. It was approved by theEthics Committee of the hospital. With the consent of eachpatient, 42 consecutive patients with distal lower leg defectswere studied. Patients’ medical records, including demo-graphic profile cause, location and size of the defects, flapdimension, location of perforator from the tip of medialmalleolus, complications, and the postoperative result weretaken into consideration for the study (Table 1).

The defects were located on the lower third of the leg(n=23), ankle (n=11), and heel (n=8). The causes of thedefects were road traffic accident (n=26), fall from height(n=2), burn (n=3), diabetes mellitus (n=2), infection (n=5),and mechanical injury (n=4).

Reconstruction was performed using distally pedicled pos-terior tibial artery perforator flaps (Figs. 1, 2, 3, 4 and 5).

All of the flaps were harvested from the posterior region ofthe lower leg, and the raw surface created was covered with asplit-thickness skin graft. The size of the flaps was slightlybigger than that of the defects. All flaps were based on a singlemost distal perforator arising from posterior tibial artery.

Surgical techniques

The procedure was performed in supine position and underspinal anesthesia with tourniquet control. The leg was slightlyabducted and externally rotated, and a pillow was kept belowthe lateral malleolus before raising the flap. The followingsteps were performed:

1. The axis of the flap was delineated 4.5 cm behind andparallel to the reference line drawn between the tibialtuberosity and the midmalleolar point or 1.5 cm from themedial border of the tibia.

2. The location of the posterior tibial artery perforator wasconfirmed using hand-held Doppler, 1 cm away from theaxis of the posterior tibial artery.

3. Recipient site was debrided, and the actual size of thedefect was measured.

4. The size and location of the flap were designed using theprinciple of planning in reverse (to overcome primarycontraction of the flap, half centimeter was added in bothdimensions of the flap).

5. Flap dissection was performed proximodistally in thesubfascial plane under loupe magnification (some extralength of the flap was taken depending on the degree ofrotation (5 % for 45°, 40 % for 180°).

6. The dissection was continued distally up to half centi-meter proximal to the distal perforator to ensure its

preservation (the width of the pedicle was narrowed upto half of the width of the flap).

7. After deflation of the tourniquet, hemostasis wasachieved and the viability of the flap was evaluated.

8. The flap was then transferred to the recipient site, andfinally, setting and suturing of the flap were done into thedefect.

9. Proximal donor site was partially skin-grafted remainingclosed primarily by dermoepidermal flaps.

10. Raw area over the pedicle was covered by split-thicknessskin graft.

In the heel region, the pedicle was divided after 21 days,and a proximal margin was inset into the defect in order toaccommodate well-fitting shoes. However, in the lower thirdleg and ankle region, the skin between the perforator andproximal margin of the defect was incised and reflected onboth sides of the pedicle as a collar, and the remaining rawarea was skin-grafted. All the precautions were taken to re-duce pressure on the pedicle.

Results

All the patients were evaluated in terms of flap viability,functional gain, and donor-site morbidity. All the flaps sur-vived and were taken up well except for the one in a patientwho experienced complete flap loss.

Minor complications were noted in four other pa-tients. One patient developed superficial epidermolysis;one developed postoperative venous congestion, whichsubsided within 3 days by conservative means, and intwo patients, partial loss of the skin graft occurred atthe donor site, but it was completely healed with dress-ing and antibiotics. The patient who developed completeflap loss required a cross-leg flap. There was minimalscarring along the flap boundaries and no distortion of adja-cent normal tissue anatomy on the follow-up periods, and allof the donor sites were completely treated with a split-thickness skin graft.

In all adult patients, the presence of a constant perforator ofthe posterior tibial artery was found within 7 cm above themedial malleolus. This distance in a 10-year-old child wasfound to be 3 cm.

The length of the flap ranged from 5 to 9 cm and the widthfrom 3 to 7 cm with a mean operating time of 1.5 h. Theaverage size of the flaps was 28.4 cm2 (range, 15 to 43 cm2).

Out of 42 patients, 38 were male and 4 were female. Theaverage age of the patients was 34.4 years (ranging from 10 to60 years).

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Table 1 Patient’s profile

Patients Age/Sex Etiology Location Defect size Complications

1 23/M FFH Ankle 4×8 None

2 42/M RTA Lower 1/3rd 6×9 Partial graft loss

3 35/M RTA Heel 3×8 None

4 33/M RTA Ankle 4×7 None

5 25/M RTA Lower 1/3rd 3×7 None

6 15/M Mechanical injury Ankle 3×9 None

7 26/M FFH Lower 1/3rd 4×9 None

8 60/M Diabetes mellitus Heel 5×9 Complete flap loss

9 52/M Infection Ankle 4×8 None

10 28/F RTA Lower 1/3rd 3×8 None


12 10/M Infection Ankle 5×9 None

13 55/M Burn Heel 6×8 Epidermolysis



16 30/M Burn Lower 1/3rd 4×8 None

17 42/M Infection Lower 1/3rd 3×8 Partial graft loss






23 48/M Diabetes mellitus Heel 4×8 Mild venous congestion








31 28/F RTA Heel 4×8 None












FFH fall from height, RTA road traffic accident

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The patients were followed for an average period of6 months, ranging from 1 to 13 months. No newly developedfunctional deficits of the lower leg were noted in any patient.

The average time for partial-weight bearing was 3 monthsfor a patient with normal tibia. Eighty six percent of patients(36 out of 42), including those having fractured and non-fractured tibia, started full-weight bearing at 5 months. Threepatients reported pain in the limb while walking. This painreduces with the passage of time. Two patients required sup-port for walking even after 6 months. These were the caseswith severe trauma.

Discussion

The soft-tissue defects at the level of distal leg, heel, and ankleregions present a difficult task for a reconstructive surgeon.Soft-tissue defects of these regions are usually accompaniedby exposed bone, tendon, or prosthesis. Additionally, many

comorbid conditions, including infections, further complicatethe situation.

The various reconstructive options used for this region arelocal flaps, distant flap, and free flap. Random-pattern flaps,fasciocutaneous flaps, reverse sural fasciocutaneous flap [4],and muscle flaps come in the category of local flaps. Localfasciocutaneous flaps have limited availability in the distallower leg. Local muscle flaps, including the soleus [9] andperoneus brevis, are too bulky to cover skin defects in theanterior tibial area and are usually associated with functionaldeficit and cosmetic concern. Muscle flap has a limited rolefor the coverage of ankle defects with a disadvantage ofsacrifice of function. [10–12] Distant flaps include cross-legflaps and free flaps.

There are several recent clinical studies on the appli-cation and results of pedicled perforator flaps in lowerleg reconstruction. Pedicled perforator flaps are bestsuited for small- and medium-sized defects in the lowerleg, but their dimensions should be large enough tocover these defects.

Fig. 1 a Preoperative photographof a patient showing a defect overthe right heel. b Photographshowing a defect over the heel. cPosterior tibial artery perforator-based flap raised and islanded. dAnother photograph showing aposterior tibial artery perforator-based flap. e Photograph showingapplication of the flap over thedefect and skin-grafted donor site.f Follow-up photograph showinga well-taken flap and minimaldonor-site morbidity

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Saint-Cyr et al. reviewed and outlined the history andcontroversies surrounding perforator flaps and described theanatomy of the “workhorse” perforator flaps and their use inmicrosurgical reconstruction. In the same study, they havedescribed that perforator flaps have minimal donor-site

morbidity, which are versatile and have a longer pedicle thanachievable with the parent musculocutaneous flap and havefreedom from the orientation of the pedicle [13]. We alsofound that perforator flaps used in this series were versatileand had minimal donor-site morbidity.

Schaverien and Saint-Cyr [8] used 20 limbs harvested fromfresh cadavers and analyzed perforator locations and clinicalapplication for pedicled perforator flaps. They found that

Fig. 2 a Photograph showing soft-tissue defect over the anteromedialaspect of the right distal leg. b Postoperative photograph showing a well-taken flap over the defect. c Another photograph showing a well-takenflap (anterior view). d Photograph showing a skin-grafted donor site withminimal morbidity

Fig. 3 a Photograph showing a soft-tissue defect over the anteromedialaspect of the lower leg. b Postoperative photograph showing a well-takenflap

Fig. 4 Postoperative photograph showing a well-taken flap and donor-site skin graft in a patient of postburn soft-tissue defect over thetendoachilles region

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reliable perforators from the anterior tibial, posterior tibial,and peroneal arteries can be found in distinct 5-cm intervalswithin inter-muscular septa, which can be very helpful indesigning lower leg flaps.

The posterior tibial artery is the direct continuation of thepopliteal artery. Usually, it is the dominant vessel of thetrifurcation [14]. The posterior tibial artery is accompaniedby two venae comitantes and through its course in the legsupplies two to four perforators, each accompanied by twovenae comitantes (venous perforators from the greater saphe-nous vein), predominantly septocutaneous, arising from with-in two inter-muscular septa: one between the soleus and theflexor digitorum longus muscle and the other between theflexor digitorum longus muscle or tendon and the medialaspect of the tibia [15, 16].

The most recent study to evaluate the anatomic location ofmost distal perforators of the posterior tibial artery was con-ducted by Bulla et al. [17] to provide an anatomic rationale forsafe elevation of distally based medial adipofascial flaps of theleg using 30 lower limbs from 15 cadavers. They found adistal perforator in all specimens with a mean caliber of.77 mm passing through a septum between the flexor hallucislongus muscle and flexor digitorum longus muscle, the lowestperforator lying at a median distance of 6.75 cm (ranging from3.5 to 8.2 cm).

Our study finds the presence of a constant perforator of theposterior tibial artery within 7 cm above the medial malleolusin all adult patients. The distance was 3 cm in a 10-year-oldchild.

The veins accompanying these arteries show anatomicvariations (two, one, or even none of the veins accompanyingthe artery). This is very important to the initial survival of thisflap [18, 19].

One of the patients in our study developed venous conges-tion that subsided by conservative means. Compression of thepedicle could be the reason of congestion.

The posterior tibial artery perforators are connected in anaxial network. This anatomy allows the surgeon to raise largedesigned flaps that can inset into defects of different sizes andshapes [20, 21].

Hafeez et al. [22] conducted their study on 24 patients withdefects over the lower half of the leg. They covered thesedefects using a posterior tibial artery perforator island flapharvested from the medial aspect of the leg. The major etiol-ogy of soft-tissue defect was road traffic accident, whichcorresponds to our study. The average length of the flapswas 12.3 cm. Nineteen patients had good outcome, fourpatients had fair, and one patient had poor outcome.

In our study, one total flap necrosis was observed in a patientwith diabetes mellitus. In another case, distal superficialepidermolysis was noted that was taken care by debridementand split-thickness skin grafting. In two other cases, partial graftloss at donor site was noted because of infection that was takencare of by appropriate antibiotics and proper dressing.

Schaverien et al. [23] described the use of an islandedpropeller-design posterior tibial artery perforator flap for de-fects of the lower leg, ankle, heel, and foot. A total of 106 flapswere islanded on a single perforator from the posterior tibialartery in 100 patients. There was an 8.5 %complete and 12 %partial flap failure rate, both associated with cigarettesmoking, diabetes, and peripheral vascular disease.

Though propeller flaps have less donor-site morbidity ascompared to a pedicle flap, they, however, have certain dis-advantages, including the requirement of microsurgical dis-section, which need more expertise and have a higher failurerate as compared to a pedicled flap used in our series where aremarkably low complication was observed.

Sananpanich et al. [24] used pedicled perforator flapsfor lower limb reconstruction in 25 patients. In theirstudy, one total flap loss in a diabetic patient, onesuperficial epidermolysis, and one partial flap loss werereported. Superficial epidermolysis healed without fur-ther intervention, and partial flap loss needed debride-ment and resuturing.

We used pedicled perforator flaps, measuring up to 9×7 cm, to cover the soft-tissue defects without major compli-cations. This large flap territory can be raised on a singleperforator due to extensive axial communications betweenthe perforators within the flap. Hyperperfusion in a perforator

Fig. 5 a Preoperative photograph showing a soft-tissue defect withexposed tibia distal leg. b Postoperative photograph showing a well-taken-up PTA perforator flap with skin-grafted donor site

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allows the capture of multiple adjacent perforasomes throughdirect and indirect lining vessels [25]. These characteristicsmake pedicled perforator flaps predictable and reliable forcoverage of pretibial defects.

Our study has proved that small and moderately sized soft-tissue defects around the ankle, heel, and lower third of the legarea can be covered easily and safely, using locally availableversatile pedicled perforator flaps. Also, the uncomplicatedintraoperative supine position simplifies the work of surgeonsand anesthetist, thereby minimizing the cost and effort ofsurgery.

Koshima et al. [26] described perforator flaps in lowerextremity reconstruction. These flaps have the advantage ofrelatively rapid dissection and flap elevation and reliable skinterritory.

We also found that the perforator flap used in this study wasrapidly and easily harvested without any technical difficultyand functional sequelae, which was highly reliable.

Conclusion

From this study, it was concluded that a distally based pedi-cled perforator flap from the posterior tibial artery for coveringdefects around the ankle, heel, and lower third leg is a reliable,easy, less time-consuming, and versatile procedure.

It is a good alternative to other flaps like fasciocutaneousflaps, adipofascial flaps, cross-leg flaps, and free flaps forlower leg defects. Donor-site morbidity was negligible. Weobserved that the functional gain in terms of weight bearing,mobility in the affected limb, and movement at the ankle joint,i.e., dorsiflexion and plantarflexion, was good.

Conflict of Interest None

Ethical Standards This study has been approved by theappropriateethics committee and have therefore been performed in accordancewiththe ethical standards laid down in the 1964 Declaration of Helsinki anditslater amendments. All patients gave their informed consent prior totheir inclusionin the study. Details that might disclose the identity of thesubjects under studywere omitted.

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Distally based posterior tibial artery perforator flap for coverage of defects around the ankle, heel and lower third of leg