Finding an appropriate soft-tissue coverage without functional deformity and donor site morbidity to reconstruct lower extremity defects can be a difficult task because of the lack of musculocutaneous soft tissue elements available for reconstruction without major morbidities.5
Although microsurgical procedures provide excellent results in the head and neck region, the success rate is usually less in the lower limbs, especially in infected cases.6
The free flap covers the defect successfully in a one-stage operation but it requires a long operative time, an experienced, skilful technique, and good circulation at the recipient site. Free flap transfer to the lower limb in chronic post-traumatic conditions is known to have a higher complication rate with flap loss in up to 10% of cases, mainly due to the recipient vessel.7
The dissection of these vessels often leads to refractory spasm, due to the so-called post-trauma vessel disease.8
Despite recent advances in microsurgical techniques that have improved the quality of lower limb reconstruction, the coverage of lower leg defects by locoregional flaps remains indicated in selected cases. A local randompattern skin flap has an indistinct perfusion pattern and is limited in size. The disadvantage of the muscle flap is that it may lead to functional deficit and donor site morbidity.9
Defects of the middle third of the tibia can be covered with a soleus flap.10
However, the functional deficit and the unacceptable donor-site scar limited the use of this technique.
Fascial and fasciocutaneous flaps can provide an excellent alternative for coverage of defects, even when bone has to be covered.1
The medial adipofascial flap based on the vascular network supplied by the saphenous artery, and the posterior tibial artery perforators can be harvested on the anteromedial aspect of the leg and mobilized to cover defects located between the patella and the heel.11
However, it causes relative hypoaesthesia at the donor site.
The cross-leg flap has the disadvantage of long-term immobilization and it requires several operative stages.12
Because of the importance of vascular “economy” in lower limb reconstruction, perforator pedicled flaps provide an excellent solution, as all these flaps spare the limb’s major vessels.13
Reconstruction with neurocutaneous flaps is a versatile alternative to the use of local or distant muscle flaps.14
The neurocutaneous sural flap has been amply described for reliable coverage of lower leg defects without sacrificing a major vessel in the foot, but the flap’s major donor deficits are the loss of sensibility along the lateral aspect of the foot and the unsatisfactory donor-site scars that are left because of the need of skin grafting.15
The risk factors, which can potentially impair successful defect coverage using the reversed sural flap and thus contribute to flap complications, include concomitant diseases, particularly diabetes mellitus; peripheral arterial disease or venous insufficiency, which increase the risk of flap necrosis five- to six-fold; and patient age over 40 years because of an increase in the co-morbidity rate, underlying osteomyelitis, and the use of a tight subcutaneous tunnel.2
The advantages of the distally based sural fasciocutaneous cross-leg flap over the standard cross-leg flap are clear, including the extremely comfortable leg positioning and the simplicity of the immobilization, made possible by the distal pedicle location.12
The distally based lesser saphenous venofasciocutaneous flap, mobilized from the posterior aspect of the upper leg, used as an island pedicle skin flap, can also be used.16
The tibialis anterior flap procedure is a useful option for providing soft tissue to cover open tibial injuries in the middle and distal thirds of the tibia. It is limited by the transition of the muscle to the tendon in the distal third of the tibia. The tibialis anterior can be used like a pivoted flap 180 degrees around its longitudinal axis without any cutting of its tendon, so that there is no significant impairment of its function.17
The gastrocnemius musculoadipofascial flap based on the fascial plexus and cutaneous perforators of gastrocnemius muscle can be used for soft-tissue reconstruction of wider and longer areas used by the classic gastrocnemius muscle flap.18
This study covered 16 patients (13 males/3 females; age range, 14 to 67 yr), seven post-burn and nine posttrauma, suffering from middle-third leg defects with exposed tibia. All the defects were reconstructed using a lateral split tibialis anterior muscle flap pivoted 180 degrees around its longitudinal axis without major impairment of its function because the muscle is partially split, without dividing its origin or insertion with intact medial fibres. The follow-up period ranged from six months to two years. Partial flap loss occurred in one patient (6.25%) and there was no post-operative haematoma or infection; only one case of wound dehiscence (6.25%) occurred and this was managed by secondary suture. Donor site morbidity was acceptable, there was no significant functional affection, the subjective aesthetic results were satisfactory, and soft tissue coverage was achieved.