Propeller Perforator Flap for Distal Leg Defect After Necrotising Soft-Tissue Infection débridement

Patient Information

• Age: 52 years
• Gender: Female
• Diagnosis: Post-débridement pretibial soft-tissue defect with exposed tendon after necrotising soft-tissue infection of the leg

Procedure

Locoregional propeller (perforator-based) fasciocutaneous flap transposition for distal third leg coverage after serial débridement and negative-pressure therapy.

Findings

Following ICU management and multiple returns to theatre for NSTI débridement, the patient had a 9 × 7 cm defect over the distal anteromedial leg with paratenon exposed but paratendon and bone covered. Perfusion to the foot was intact. Handheld Doppler identified a reliable perforator from the posterior tibial axis approximately 12 cm proximal to the defect, permitting propeller design without microvascular transfer.

Surgical Technique

Perforator mapped preoperatively with duplex and handheld Doppler. Flap island designed eccentric to the perforator with planned 150° clockwise rotation into the defect. Subfascial dissection preserved the perforator pedicle with a 3 cm adipofascial cuff. Small subcutaneous pedicle tunnel created; inset without tension or kinking. Donor site closed primarily with V-Y advancement where needed. Suction drain placed; limb elevated postoperatively.

Outcome

Flap viable with complete coverage of tendon at 2 weeks. Donor site healed uneventfully. Patient ambulated with protective footwear by 8 weeks. No partial necrosis of flap tip; minor distal epidermolysis managed with dressings only.

Clinical Notes

Propeller flaps are valuable when free-flap resources or operative time are constrained but perforator anatomy is favourable. Case illustrates perforator-based locoregional options in the distal leg.