The instep flap for anterior ankle coverage with bone and hardware exposure

The instep medial plantar flap is a well-known flap based on the medial plantar artery of the foot and usually used for coverage of soft tissue defects of the heel area. It has seldom been reported for coverage of anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures. The primary purpose of this study is to evaluate the feasibility and viability of this flap as well as its reliability saving the internal fixation devices and efficiency protecting bone healing; the secondary purpose is to assess the condition of the flap and its cosmetic appearance, as well as occurrence of complications related to its harvesting.

This is a retrospective review of medical records of patients operated from December 2015 to December 2020 with application of an instep flap for coverage of the anterior ankle area with exposure of the bone and metallic hardware secondary to open reduction and internal fixation of distal tibial fractures. All patients were reviewed for the purpose of this study; they were assessed for the viability and functional and sensory condition of the flap, signs of local infection, as well as for residual pain and sensory impairment of the toes; subjective cosmetic appearance of the flap was also judged.

There were four patients with 32 years mean age and 35 months mean follow-up. The mean flap size was 7.75 cm × 5.75 cm. At final follow-up, all fractures were completely consolidated, and all flaps were living, stable, and sensitive. No distal sensation disturbance was noticed, and none of the patients had pain or annoyance caused by the flap or presented signs of infection. Only one patient expressed mild aesthetic complain.

The fascio-cutaneous instep medial plantar flap is a reliable solution to cover the anterior ankle area with exposure of the bone and metallic hardware after open reduction and internal fixation of distal tibial fractures, especially for defects measuring up to 9 cm × 6 cm. This flap is technically valid and reproducible; it offers good quality of soft tissue coverage with satisfactory cosmetic appearance and minimal morbidity.