|Year : 2014 | Volume
| Issue : 1 | Page : 69-72
Use of dorsalis pedis artery flap in the coverage of distal lower leg defects
Sohaib Akhtar Md. , Fahud Khurram, Rampukar Choudhary, A. H. Khan, Imran Ahmad, Ehsan Rashidi
Post Graduate Department of Burns, Plastic and Reconstructive Surgery, JNMC, AMU, Aligarh, Uttar Pradesh, India
|Date of Web Publication||6-Jun-2014|
Post Graduate Department of Burns, Plastic and Reconstructive Surgery, JNMC, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the role of dorsalis pedis artery flap in the coverage of distal lower leg defect. Materials and Methods: a retrospective review of patients who underwent soft tissue coverage over distal lower leg with dorsalis pedis artery flap was performed. A total of 16 patients were identified and included in this study. Soft tissue defects ranged in size from 3 × 7 cm to 6 × 10 cm were located over lower one-third of leg either, anteriorly (n = 8), posteriorly (n = 4), laterally (n = 2), or medially (n = 2). Associated injuries included open fractures of only tibia (n = 5), fibula (n = 2), both tibia and fibula (n = 3), or calcaneum (n = 2). Results: all flaps survived uneventfully except in three cases there was mild venous congestion in the distal part of the flap, two resolved within 4 days without further surgical intervention but one required skin grafting. Three patients developed donor site problems. Wound coverage was achieved in a mean duration of 14 days (range: 11 to 30 days). Conclusion: The dorsalis pedis artery flap is a reliable procedure to cover difficult wound such as distal lower leg.
Keywords: Distal lower leg, dorsalis pedis artery flap, soft tissue coverage
|How to cite this article:|
Akhtar S, Khurram F, Choudhary R, Khan AH, Ahmad I, Rashidi E. Use of dorsalis pedis artery flap in the coverage of distal lower leg defects. J Orthop Traumatol Rehabil 2014;7:69-72
|How to cite this URL:|
Akhtar S, Khurram F, Choudhary R, Khan AH, Ahmad I, Rashidi E. Use of dorsalis pedis artery flap in the coverage of distal lower leg defects. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Mar 22];7:69-72. Available from: http://www.jotr.in/text.asp?2014/7/1/69/134023
| Introduction|| |
Soft tissue reconstruction of distal lower leg region is difficult and remains a challenge to the plastic surgeons. There are many possible reconstructive options for this region such as local flaps, cross leg flap,  and free flap.  Local flap includes random pattern flaps, fasciocutaneous flaps,  reverse sural fasciocutaneous flap,  and muscle flap.  Random pattern flaps have high incidence of failure. The use of cross-leg flap has been limited by the difficulty of immobilizing both legs for 3 weeks, joint stiffness, and concern about donor site cosmetic deformity in normal leg. Muscle flap leads to functional deficit. Free flap is costly with significant donor site morbidity and long operating time and a high anesthesia risk. This demands a well equipped microsurgical set up and expertise. ,, Basically dorsalis pedis artery flap has been used for coverage of foot and ankle defects.  For the coverage of heel or Achilles tendon defects, the dorsalis pedis artery may have to be lengthened by a graft.  In this series, we have used the DPA flap for the coverage of distal lower leg defects without any lengthening of the artery by using graft. This flap has a wide arc of rotation, reliable, and can also be used as a sensory flap.
The long-term donor site morbidity associated with this flap is major problem. However, if meticulously dissected donor site problems can be minimized.
| Materials and methods|| |
This study was conducted in the author's centre between February 2009 to December 2012. A retrospective review of patients who underwent soft tissue coverage over lower one-third of leg with dorsalis pedis artery flap was done. A total of 16 patients were identified and included in this study. These 16 patients consisted of 12 men and 4 women with their age ranging from 16 to 60 years. The flaps were used for coverage of soft tissue defects due to trauma (n = 11), infection (n = 3), and electric burns (n = 2). Soft tissue defects ranged in size from 3 × 7 cm to 6 × 10 cm, and were located over lower one-third of leg either, anteriorly (n = 8), posteriorly (n = 4), laterally (n = 2), or medially (n = 2). Associated injuries included open fractures of only tibia (n = 5), fibula (n = 2), both tibia and fibula (n = 3), or calcaneum (n = 2) [Table 1].
- Intact and preserved dorsum foot.
- Presence of dorsalis pedis artery confirmed by hand held Doppler examination.
- Involved proximal part of leg, so that other flap could not be harvested.
All those patients having soft tissue defect over distal lower leg with following criteria were excluded from the study.
- Absence of dorsalis pedis artery.
- Involved dorsum foot.
The dorsum of foot is supplied by the dorsalis pedis artery. DPA is the continuation of anterior tibial artery below the ankle joint. It runs along the tibial side of the dorsum of the foot up to the proximal part of first intermetatarsal space. At this point it turns into the sole between the two heads of first dorsal interosseous muscle and completes the planter arch. At the junction with the planter arch it gives first planter metatarsal artery. ,
The patient was placed in a supine position and the flap was raised under tourniquet control. The surface marking of the skin on the dorsum of the foot that can be included in the flap extends from the ankle joint up to the metatarsophalangeal joint. The lateral and medial border of the flap extends 1 cm beyond the lateral and medial borders of the dorsal venous arch. First, the distal incision was made at the first webspace then first dorsal metatarsal artery and branches of deep peroneal nerve was identified, ligated, and divided. Similarly, branches of superficial peroneal nerve were identified and divided laterally. The dissection of the flap was performed disto-priximally deep to the metatarsal artery, deep peroneal nerve and extensor hallucis brevis. The paratenon of the extensor tendons were preserved; the dissection of the flap was continued proximally. Further as dissection proceeds from medial to lateral side, dorsalis pedis artery and deep peroneal nerve was dissected from the underlying tarsal bones and maximum amount of tissue was preserved between the extensor hallucis longus and extensor digitorum longus tendons. With the proximal incision completed, extensor retinaculum was opened and dorsalis pedis artery its vena comitantes and nerves were identified. The extensor hallucis brevis muscle belly was divided where it passes beneath the second toe extensor digitorum longus tendon; its tendon and distal muscle were left with the flap. Finally, flap was isolated on the vascular pedicle and proximal dissection continued until desired length was achieved [Figure 1] and [Figure 2].
|Figure 1: (a) Preoperative photograph showing defect over lateral aspect of right distal lower leg and marking of the dorsalis pedis artery flap, (b) Photograph showing DPA flap elevation (c) Photograph showing DPA flap elevation after islanding (d) Immediate postoperative photograph after flap insetting (e) Postoperative Photograph on day 4|
Click here to view
|Figure 2: (a) Preoperative photograph showing defect over medial aspect of left distal lower leg and marking of the dorsalis pedis artery flap. (b) Photograph showing DPA flap insetting (c) Immediate postoperative photograph after flap insetting and graft application at donor site. (d) Postoperative photograph on day 4 showing well taken up graft and flap|
Click here to view
| Results|| |
In this series, 16 patients with distal lower leg wound were managed with dorsalis pedis artery flaps. All flaps survived uneventfully except in three cases where there was mild venous congestion in the distal part of the flap; amongst them two of them resolved within 4 days without further surgical intervention but one needed further skin grafting. Three patients developed donor site morbidity on long term follow up. First patient developed donor site contracture that required release and split thickness grafting, second patient developed wound breakdown with exposed tendon requiring cross leg flap cover, and in the third patient there was donor site ulcer recurrence and was lost to follow up. In the immediate postoperative period color, texture and viability of the flaps were good up to the tip of the flaps. Two of the three complicated flaps occurred in patients with history of smoking and the other in a patient with atherosclerosis. Wound coverage was achieved in a mean duration of 14 days (range, 11 to 30 day).
| Discussion|| |
Soft-tissue defects of the distal lower leg remain a challenging problem for reconstructive surgeon. Currently there are many possible reconstructive options for this region like local fasciocutaneus flaps, local muscle flaps and, cross leg flaps and free flaps. There are few reports on the use of dorsalis pedis artery flap for distal lower leg defect. Though this flap is uncommonly used nowadays because of its donor site morbidity and sacrifice of an important vessel of the foot, it can be used in selected patients by meticulous dissection. In our series we have successfully used this flap in 16 cases with good results.
In the last few decades, coverage of these defects is often by use of free flap because of advancements in microsurgical and anesthetic techniques. However, there are disadvantages in the use of free flaps such as the need for a remote donor site, long operative time, use of a major vessel, and microsurgical expertise. Additionally, trauma in the limb usually causes damage to a major vessel of the leg so the use of free tissue transfer in these patients may lead to a higher incidence of complications. There are certain associated pathologies including diabetes and vasculopathy that may increase the incidence of unsuccessful free flap. In a study by Mileto et al., 11 patients were treated for soft tissue defects of lower limb and foot using the distally based sural artery flap. They concluded that sural reverse flap had good reliability with low incidence of complications and good surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the distal third of lower limb, ankle, and heel. 
Distally based superficial sural artery flap is a good alternative to reconstruct distal leg defects. The sural nerve is not important for vascularization of the distally based superficial sural artery flap and can be spared during flap elevation. ,,
Hughes et al. clinically found that several local muscles can be used reliably in the distal third of the leg. They concluded that soleus, extensor digitorum longus, peroneus tertius, extensor hallucislongus, peroneus brevis, and flexor digitorum longus were found to be the most anatomically suited muscles for local transposition to selected lower third defects. 
Muscle flap has a limited role to address the ankle defects with the disadvantage of sacrifice of function. ,,
Bhattacharya et al. performed 12 contralateral retrograde fasciocutaneous perforator-based flap for distal leg and foot defects. They concluded that cross leg retrograde fasciocutaneous flaps are good options in cases of unsuccessful free flap, non availability of proximal tissue in the calf region and damaged distal perforators. 
The main disadvantages of dorsalis pedis artery flap are difficult dissection, sacrifice of a main vascular axis of foot and the donor area always has to be skin grafted. However, if properly planned and meticulously dissected, this flap can reliably be used for soft tissue defect in the distal lower leg.
| Conclusions|| |
The dorsalis pedis artery flap is a reliable flap to cover difficult wound such as distal lower leg. The main advantages of this flap are the reliable blood supply, wide arc of rotation, and its use as a sensory flap.
| References|| |
|1.||Barclay TL, Cardos E, Sharpe DT. Cross leg facsiocutaneus flaps. Plast Reconstr Surg 1983;72:843-7. |
|2.||May JW Jr, Gallico GG 3rd, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. N Engl J Med 1982;306:253-7. |
|3.||Tolhurst DE, Haeseker B, Zeeman RJ. The development of the fasciocutaneous flap and its clinical applications. Plast Reconstr Surg 1983;71:597-606. |
|4.||Akhtar S, Hameed A. Versatility of the suralfasciocutaneous flap in the coverage of lower third leg and hind foot defects. J Plast Reconstr Aesthet Surg 2006;59:839-45. |
|5.||Mathes S, Nahai F, editors. Clinical application of muscles and musculocutaneus flaps. St. Louis: Mosby;1982. |
|6.||Rainer C, Schwabegger AH, Bauer T, Ninkoviæ M, Klestil T, Harpf C, et al . Free flap reconstruction of the foot. Ann Plast Surg 1999;42:595-607. |
|7.||Langstein HN, Chang DW, Miller MJ, Evans GR, Reece GP, Kroll SS, et al. Limb salvage for soft-tissue malignancies of the foot: An evaluation of free-tissue transfer. Plast Reconstr Surg 2002;109:152-9. |
|8.||vanLanduyt K, Hamdi M, Blondeel P, Monstrey S. The compound thoracodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot. Br J Plast Surg 2005;58:371-8. |
|9.||McCraw JB, Furlow LT Jr. The dorsalispedis arterialized flap. Plast Reconstr Surg 1975;55:177-85. |
|10.||Caffe HH, Hoefflin SM. The extended dorsalispedis flap. Plast Reconstr Surg 1979;64:807-10. |
|11.||Sinnatamyby CS. Lasts' anatomy, regional and applied. 10th ed. Edinburgh London New York Philadelphia Sydney. Toronto: Churchill Livingstone; 1999. pp. 139, 145. |
|12.||Standring S, Ellis H,Healy CJ, Johnson D, Williams A, Collins P,et al. Gray's anatomy. Vol. 8, 39th ed. London: Churchill Livingstone 2005. p.1507-25. |
|13.||Mileto D, Cotrufo S, Cuccia G, Delia G, Risitano G, Colonna MR, et al. The distally based sural flap for lower leg reconstruction: Versatility in patients with associated morbidity.Ann Ital Chir 2007;78:323-7. |
|14.||Mojallal A, Wong C, Shipkov C, Bailey S, Rohrich RJ, Saint-Cyr M, et al. Vascular supply of the distally based superficial sural artery flap: Surgical safe zones based on component analysis using three-dimensional computed tomographic angiography. Plast Reconstr Surg 2010;126:1240-52. |
|15.||Hyakusoku H, Tonegawa H, Fumiiri M. Heel coverage with a T-shaped distally based Sural Island fasciocutaneous flap. Plast Reconstr Surg 1994;93:872-6. |
|16.||Aoki S, Tanuma K, Iwakiri I, Mizuno H, Ogawa R, Ozawa H, et al. Clinical and vascular anatomical study of distally based sural flap. Ann Plast Surg 2008;61:73-8. |
|17.||Hughes LA, Mahoney JL. Anatomic basis of local muscle flaps in the distal third of the leg.Plast Reconstr Surg 1993;92:1144-54. |
|18.||Hartrampf CR Jr, Scheflan M, Bostwick J 3rd. The flexor digitorumbrevis muscle island pedicle flap: A new dimension in heel reconstruction. Plast Reconstr Surg 1980;66:264-70. |
|19.||Hallock GG. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 2006;56:540-2. |
|20.||Hallock GG. Lower extremity muscle perforator flaps for lower extremity reconstruction. Plast Reconstr Surg 2004;114:1123-30. |
|21.||BhattacharyaV, Reddy GR. Distal perforator based cross leg flaps for leg and foot defects,Indian J Plastsurg 2005;38:18-21. |
[Figure 1], [Figure 2]