Mid-tibia exposed wounds pose challenges in reconstructive surgery, especially when they are complicated with extensive tissue loss, degloving injury and fractures, limiting the availability of flap options.
Methodology and Operative technique
Twelve consecutive cases with open Tibial injuries from June 2018 to June 2020 (2 years) were included in this study where no local fascio-cutaneous flaps or free tissue transfer were possible due to the extent of injury zone. Segmental and comminuted tibial fractures were excluded.
After debridement, washout and fracture fixation with IM nails or External Fixators, periosteal surface of the Tibialis Anterior (TA) muscle was mobilized along the length of the bone exposure. Multiple muscular perforator vessels from Anterior Tibial neurovascular bundle were safeguarded under 3.5X loupe magnification while flap dissection. On the deep periosteal surface, a longitudinal split of the muscle fibers was performed up to the tendon which was then split open to create a flat tendon. This unfolded muscle was then advanced over the exposed tibia as a flap and inserted to the periosteum or with another muscle flap followed by a skin graft.
These patients were prospectively followed-up for flap viability, dehiscence, graft loss, infections and the dorsiflexion power of inverted foot. Mean follow-up was 13 weeks postoperatively.
Age of patients ranged from 17 to 78 years and male:female is 2:1.
There were no flap or graft losses. Three minor flap dehiscences with culture positive wound infections were observed, which had been managed conservatively. No further surgeries were needed.
In all patients, grade 3/5 or above dorsiflexion power is observed 1 - 3 months post operatively.
Discussion / Conclusion
Functional longitudinal split Tibialis Anterior flap is a reliable and versatile flap specially when performed with other muscle flaps in patients where most of the other reconstructive options are not applicable.