Introduction: An open tibial wound associated with fracture in the distal leg is commonly secondary to orthopedic trauma and a free-tissue transfer is a typical choice of soft-tissue coverage for such a wound in the distal leg. However, some distal tibial wounds appear to be relatively too small for a free flap reconstruction but clearly too large for primary wound closure. The medial hemisoleus muscle flap as a local reconstructive option for soft tissue coverage of an open tibial wound in the distal leg has recently been used by the author. The purpose of the present study is to report the author's experience of the medial hemisoleus muscle flap as a local reconstructive option for soft-tissue coverage of the distal tibial wound.

Patients and Methods: In the past 2 years, 20 patients (15 males, 5 females; ages: 17 to 57 years) all had an open tibial wound associated with fracture in the distal leg secondary to orthopedic trauma. The tibial wound was located at the junction of the middle and distal thirds of the leg (4 x 3 to 12 x 6 cm) in 14 patients and within the distal third of the leg (4 x 3 to 9 x 4 cm) in 6 patients. Each patient underwent a soft-tissue reconstruction of the tibial wound with a proximally based medial hemisoleus muscle flap and a skin graft. The flap was elevated with emphasis on the preservation of several perforators from the posterior tibial vessels to the flap as possible while allowing adequate rotation of the flap to cover the exposed tibial fracture site and hardware. Only the medial half of the soleus muscle was dissected and used for soft-tissue coverage of the distal tibial wound so that more remaining function of the muscle could be preserved and longer arc of the flap rotation could be achieved. All patients were followed for up to 2 years.

Results: In this series, no total flap loss occurred and limb salvage was accomplished in all patients. Only one patient developed insignificant distal flap necrosis and was treated subsequently with debridement and flap re-advancement. The open tibial wound healed and reliable soft-tissue coverage, evidenced fracture healing, and excellent cosmetic appearance were achieved in all patients during the follow-up.

Conclusions: The medial hemisoleus muscle flap, therefore, can be a good choice for soft-tissue coverage of a less extensive tibial wound in the distal leg, especially when a free-tissue transfer is not an option. It offers a cost-effective approach for managing this complex clinical problem and can be performed in non-university community hospitals. Detailed knowledge of the flap anatomy and meticulous flap elevation are the keys for such a success.
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