Bririvh Journul of Phtic Surgery ( 1996). IY, I I I-l 14 D 1996 The B&h Association of Plastic Surgeons

The distally based posterior tibia1 myofasciocutaneous island flap in foot reconstruction

H. Costa, E. Malheiro, A. Silva, R. Fidalgo* and J. Trigo

Depurtments of Plastic Surgery and *Orthopaedic Surgery, Hospitals S. Maria md S. Jodo, Oporto, and Hospitul S. Murcos, Brugu, Portugal

S UMMAR Y. We report 3 cases of foot reconstruction with a distally based posterior tibia1 island flap incorporating both muscle and a fasciocutaneous part. The medial half of the soleus muscle which is included in the flap is well vascularised and can be used to fill cavities, for example after debridement of chronically infected wounds.

Reconstruction of the foot has long been recognised to be a difficult clinical problem. Distally based pedicled flaps have been used to cover defects in the lower third of the leg, the heel and ankle region but cannot reach more distal defects of the foot.1*2 They may also have redundant tissue in their pedicles. Distally based island flaps, with a major leg artery in

their pedicles, have a greater range and can cover foot defects.3-7 In their paper on the anatomical basis and clinical applications of flaps based on the pos- terior tibia1 vessels, Wu et al. presented one case of a distally based myofasciocutaneous island flap.’ We report our experience in three cases in which this flap was used.

Fig. I

Figure l-(A) Crush-degloving injury of the right foot, including the hallux, first and second toes. (B) Foot after debridement. Outline of flap drawn. (C) Island flap, including medial part of soleus. (D) Flap and donor site, 4 months after surgery.

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Case reports

Case 1

A lo-year-old boy sustained a severe crush-degloving injury of his right foot, which was run over by a car (Fig. 1A). There was extensive necrosis of the dorsal and plantar surfaces of the foot, including the hallux, second and third toes which were fractured. Under tourniquet control, a radical debridement of all devitalized and infected tissues, including the necrotic toes, was performed (Fig. 1B). One week later, a distally based posterior tibia1 myofasciocut- aneous flap, including the medial half of the soleus muscle, was elevated (Fig. lB, C) and transposed to the foot. The muscle provided padding for the plantar surface of the foot and the amputation stumps of the metatarsal bones. One week later, meshed split skin graft was applied to the flap donor site and an area of granulation tissue on the dorsum of the right foot. Healing was uneventful. At &month follow-up, the flap and foot were stable with no signs of infection (Fig. 1D) and the patient had an almost normal gait.

Case 2

A 46-year-old man sustained a crush injury of the medial and plantar aspects of his left foot and ankle with a heavy metal beam. He was referred two weeks later with a necrotic and infected wound with exposed tarsal and metatarsal bones (Fig. 2A). Under tourniquet control, a radical debri- dement was performed. A distally based posterior tibia1 myofasciocutaneous flap, including the medial half of the

British Journal of Plastic Surgery -

soleus muscle, was elevated (Fig. 2B,C) and transposed to the foot and ankle, with the muscle of the flap filling the cavity in the foot. One week later, the flap donor site was skin grafted. All wounds healed uneventfully. At 3-month follow-up, the flap and foot were stable (Fig. 2D) and the patient had a normal gait.

Case 3

A 20-year-old man sustained a crush-degloving injury of the heel and plantar regions of his right foot in a motorcycle accident. He was referred three and a half weeks later with a necrotic and infected wound with exposed calcaneum (Fig. 3A). Under tourniquet control, a radical debridement was performed including all devitalized and infected bone. A distally based posterior tibia1 myofasciocutaneous flap, including a small portion of the medial soleus, was elevated and transposed to the defect. One week later, the flap donor site was skin grafted. All wounds healed uneventfully. At 8-month follow-up, the flap and foot were stable (Fig. 3B) and the patient had a normal gait.

Discussion

There are now several reports of different types of island flaps distally based on the posterior tibia1 vessels. They can be fasciocutaneous,6-8 muscle,‘s9 myofasciocutaneous’ or adipofascial.” From our short experience of reconstruction of the ankle and foot, the reverse flow posterior tibia1 island flap has

Fig. 2 Figure 2-(A) Crush injury of left foot and ankle. The posterior tibia1 vessels were jeopardised distal to the medial malleolus. (B) Flap outlined. (C) Flap elevated. (D) Flap and donor site, 3 months after surgery.

Posterior tibia1 myofasciocutaneous flap in foot reconstruction

A

Fig. 3

Figure3-(A) Crush-deglobing injury of right heel and plantar surface of foot. Flap outlined. (B) Stable flap in place, 4 months after surgery.

several advantages compared with the distally based pedicled flap described by Amarante et al.’ Transfer of the island flap is not restricted by a skin bridge in its pedicle, the pivot point can be 2-3 cm distal to the medial malleolus,6 large flaps can be harvested, the island flaps can reach all parts of the foot. and well vascularised muscle can be included in the flap. However. a potentially serious disadvantage is the need to sacrifice one of the main arteries of the leg.

Muscle flaps have long been considered very useful for filling defects, revascularising tissue and con- trolling chronic infection. Experimental flaps which include muscle have a greater resistance to bacterial inoculation than random pattern skin flaps1’.12 and myocutaneous flaps are similarly more effective than fasciocutaneous flaps.13 In their series of 12 flaps based on the posterior tibia1 vessels. Wu et al. pre- sented one distally based myofasciocutaneous island flap which included soleus muscle.7 They noted that the muscle was supplied by direct muscle branches while the skin was supplied by direct cutaneous branches. Wu et al. used the flap to treat a 40-year- old man with chronic osteomyelitis of the calcaneum with a discharging sinus on its lateral surface. After debridement of the wound, the defect was closed with the flap which was passed under the tendo achillis to the lateral aspect of the foot. As with the case of Wu et al., the flaps in our three cases were also successful in providing stable wound coverage.

Muscle and musculocutaneous free flaps are another option to be considered. They have several advantages, for example: they also achieve one-stage cover of lower leg and foot defects; with end-to-side microvascular anastomoses, neither the distal arterial inflow nor the venous return is impaired; the flaps do not rely on local blood vessels with possibly impaired flow but can contribute to the blood supply of the wound; and finally, free flaps can be used in legs with only one functioning major artery.

Another point which must be brought into the debate is the possible use of the distally based pos- terior tibia1 island flap when the posterior tibia1 artery has been damaged distal to the medial malleolus. The flap can be based on the anastomosis between the posterior tibia1 and peroneal arteries which is constant and about 5 cm above the medial malleolus.9.‘4 Our

experience has clearly demonstrated this important point; all flaps were based on this anastomosis, and in the first and second cases the posterior tibia1 vessels were damaged distal to the medial malleolus.

Acknowledgements

The authors would like to thank Dr Barbosa Leal. Senior Consultant Orthopaedic Surgeon. fol- the invitation to operate on his patient (Case I ).

Our thanks also go to Mr Albert0 Alfaia of the Anatomy Department. Oporto University. for providing the medical illus- trations and to Ms Fernanda Zenha for typing the manuscript.

References

I. Donski PK. Fogdestam I. Distally based fasciocutaneous flap from the sural region. Stand J Plast Reconstr Surg 1983: 17: 191-5.

2. Amarante J. Costa H. Reis J. Soares R. A nw distally based fasciocutaneous flap of the leg. Br J Plast Surg 1986; 39: 338 40.

3. Yoshimura M. Imura S, Shimamura K, Yamauchi S, Nomura S. Peroneal flap for reconstruction in the extremity: preliminary report. Plait Reconstr Surg 1984: 74: 402 7.

4. Wee JTK. Reconstruction of the lower lee and foot with the reverse-pedicled anterior tibia1 flap: prezminary report of a new fasciocutaneous flap. Br J Plast Surg 1986; 39: 327-37.

5. Satoh K, Yoshikaba A. Hayashi M. Reverse-flow anterior tibia1 flap type III. Br J Plast Surg 1988; 41: 624-7.

6. Hong G. Steffens K. Wang FB. Reconstruction of the lower leg and foot with the reverse pedicled posterior tibia1 fasciocutaneous flap. Br J Plast Surg 1989; 42: 512 16.

7. Wu WC. Cha?g,YP. So YC. Yip SF. Lam YL. The anatomic basis and clmlcal applications of flaps based on the posterior tibia1 vessels. Br J Plast Surg 1993: 46: 470-9.

8. Sharma RK. Kola G. Cross leg posterior tibia1 artery fasciocut- aneous island flap for reconstruction of lower leg defects. Br J Plast Surg 1992: 45: 62-5.

9. Landra AP. Q.E.D. flaps (?demonstrandum. disputandum or deprecandum): three useful axial pattern flaps in troplcal African suraerv. Br J Plast Surg 1984: 37: 580-3.

IO. Lin SD. Lai ?S: Chou CK. Tsai CW. The distally based posterior tibia1 arterial adipofascial Rap. Br J Plast Surg 1992: 45: 28447.

I I. Chang N. Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1982; 70: I 9.

12. Murphy R, Robson MC, Heggers JP. et al. The effect of microbial contamination on musculocutaneous and random flaps. J Surg Res 1986: 41: 75-8.

13. Robson MC. Comparison of the effect of bacterial inoculation

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in musculocutaneous and fasciocutaneous flaps (discussion). Plast Reconstr Surg 1986; 77: 79334.

14. Amarante J, Reis J. Flaps based on posterior tibia1 vessels (letter). Br J Plast Surg 1994: 47: 291-2.

The Authors

Horkcio Costa MD, PhD, Professor of Plastic Surgery Edgardo Malheiro MD, Registrar in Plastic Surgery Alvaro Silva MD, Registrar in Plastic Surgery

British Journal of Plastic Surgery

Ramiro Fidalgo MD, Consultant Orthopaedic Surgeon Jorge Trig0 MD, Senior Consultant Plastic Surgeon

Hospitals S. Maria, S. Joao, Oporto and Hospital S. Marcos, Braga, Portugal.

Correspondence to: Horatio Costa, Consultant Plastic Surgeon, Rua do Corvo 323, Praia da Granja, 4405 Arcozelo VNG, Portugal.

Paper received 8 June 1995. Accepted 25 September 1995, after revision.