Clinical outcomes of a distally based wide-pedicle medial lower-leg fasciocutaneous flap incorporating a posterior tibial artery perforator and the saphenous nerve-associated vascular plexus for foot and ankle soft-tissue defects: a retrospective case series

Distal foot and ankle soft-tissue defects with exposed bone or tendon remain difficult to reconstruct. We evaluated a distally based wide-pedicle medial lower-leg fasciocutaneous flap that retains the distal posterior tibial artery perforator territory together with the saphenous nerve-associated vascular plexus. The study was descriptive and was not designed to establish the flap as a new reconstructive concept or to test superiority over established options. We retrospectively reviewed 15 patients treated between March 2018 and July 2022. The cohort comprised 13 men and 2 women with a mean age of 36.73 years (range, 27–49 years). Preoperative Doppler examination was used to localize the distal posterior tibial artery perforator. The skin paddle was harvested as part of a distally based pedicled fasciocutaneous unit with an approximately 5-cm-wide nonskeletonized pedicle. Follow-up ranged from 6 to 18 months (mean, 12 months). All 15 patients retained viable flap coverage at final follow-up. Two patients (13.3%) developed early flap swelling with dark-purple discoloration on postoperative days 2 and 3, respectively; both improved after release of constricting pedicle sutures, manual massage, and limb elevation. Mild residual pedicle swelling was noted in 3 patients (20.0%) at final follow-up. All donor-site skin grafts survived. Final ankle dorsiflexion ranged from 10 degrees to 20 degrees and plantar flexion from 20 degrees to 40 degrees. Cosmetic satisfaction was not assessed with a validated questionnaire, and footwear tolerance and the need for secondary flap thinning were not systematically recorded. This small retrospective series suggests that the distally based wide-pedicle medial lower-leg fasciocutaneous flap can provide durable regional coverage for selected foot and ankle defects without microvascular anastomosis. The data do not demonstrate superiority or an independent haemodynamic advantage over established posterior tibial perforator, reverse sural, or free-flap techniques. Larger prospective comparative studies with standardized patient-reported and functional outcomes are required.