Sacramento, Calif.From the Division of Plastic Surgery, University of California, Davis.
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The role of a local flap for soft-tissue reconstruction of a tibial wound in the distal third of the leg has not been clearly defined in the literature. Since the initial experience was published,1 the author has successfully used the medial hemisoleus muscle flap in more patients who had a relatively less extensive tibial wound in the distal third of the leg. In this follow-up report, further refinements in flap dissection and results from long-term experience on the outcome of fracture healing and ambulation are reported. The indications for the medial hemisoleus muscle flap are also clearly outlined.PATIENTS AND METHODSOver a 6-year period, a total of 21 patients (16 men and five women) aged 11 to 57 years had either the proximally or distally based medial hemisoleus muscle flap for soft-tissue coverage of a tibial wound (3 × 3 cm to 10 × 6 cm) in the distal third of the leg. The flap was performed in an additional 15 patients since the report of the author's initial series.1 In the current series, 11 patients had the proximally based and 10 patients had the distally based medial hemisoleus muscle flap. All patients had a minimum 2-year follow-up, and the longest follow-up was 5 years (Table 1). The selection of either the proximally or distally based medial hemisoleus muscle flap was based on the location and size of the soft-tissue defect located in the distal third of the leg. When the size of a tibial wound is less than 50 cm2 (only the area of exposed bone and hardware was measured), the proximally based medial hemisoleus muscle can safely be selected for a relatively proximal tibial wound in the distal third of the leg and the distally based one can possibly be selected for a relatively distal tibial wound in the distal third of the leg.Refinements in Flap DissectionThe basic flap dissection for either the proximally or distally based medial hemisoleus muscle flap was described in the initial report.1 Over the past few years, several refinements in the flap dissection have been made. The author now often uses a knife to sharply dissect the medial half of the distal soleus muscle off the “conjoint” tendon of the soleus muscle and medial gastrocnemius muscle during the proximally based medial hemisoleus muscle flap dissection. Only the muscular portion of the soleus muscle is used as the flap, and the tendon portion of the soleus is left intact. The spared tendon is then approximated to the remaining lateral half of the soleus muscle with nonabsorbable sutures in a figure-of-eight fashion. This technique may minimize the functional loss of the leg after flap harvesting. In addition, the distal soleus muscle can be split longitudinally in a more laterally extended fashion than a “standard” medial hemisoleus flap so that the distal portion of the flap can be made large enough to adequately cover a tibial wound in the distal third of the leg (Fig. 1, left).During the distally based medial hemisoleus muscle flap dissection, the author now often explores and frees the first large perforator from the posterior tibial vessels as one would during a perforator flap dissection. This maneuver could provide a longer arc of flap turnover because the level of this particular perforator would serve as a pivot point for flap turnover and be able to determine how far this flap can reach to the distal leg.