Subfascial-cutaneous propeller flap for reconstruction of chronic distal lower-limb wounds with exposed bone: two-case reports

Abstract

Introduction and importance:

Propeller perforator flaps provide a reliable reconstructive option for distal lower-limb soft-tissue defects, particularly in resource-limited settings where microsurgical free-flap reconstruction may not be readily available. These cases highlight the practical application of propeller perforator flaps in a low-resource setting, demonstrate key surgical decision-making processes, illustrate the management of flap-related complications, and report favorable functional outcomes following reconstruction of complex distal lower-limb wounds.

Case presentation:

We present two patients with distal lower-limb wounds and exposed bone: a 33-year-old man with a post-traumatic medial malleolar defect reconstructed using a posterior tibial artery perforator propeller flap, and a 13-year-old boy with a chronic distal anterior leg wound secondary to osteomyelitis reconstructed using a superficial peroneal artery perforator propeller flap. Both patients had no significant comorbidities. Minor complications, including partial flap necrosis and venous congestion, were successfully managed conservatively. At the 2-month follow-up, both patients achieved satisfactory wound coverage, preservation of limb function, and acceptable cosmetic outcomes.

Clinical discussion:

Propeller perforator flaps provide effective reconstruction for complex distal lower-limb defects. Compared with free flaps, they offer a reliable, low-morbidity reconstructive option, particularly in resource-limited settings. Complications such as venous congestion and partial flap necrosis may occur but can often be successfully managed with conservative measures.

Conclusion:

Propeller perforator flaps are a reliable and effective option for reconstruction of distal lower-extremity soft-tissue defects, providing durable coverage while preserving major vascular structures and minimizing donor-site morbidity. These flaps represent a valuable alternative to local rotational and microsurgical free flaps, particularly in resource-limited settings.

Introduction

Chronic wounds are stalled wounds that fail to heal within three months, arising from trauma, diabetic foot ulcers, pressure injuries, or infectious ulcers[1].

HIGHLIGHTS

• Propeller perforator flaps achieved effective soft-tissue coverage for distal lower-limb wounds with exposed bone in two patients.

• Minor complications, including partial flap necrosis and venous congestion, were successfully managed with conservative measures.

• In resource-limited settings, propeller perforator flaps provide reliable reconstruction while avoiding the need for microsurgical free flap expertise.

• Meticulous preoperative planning, precise flap design, and vigilant postoperative monitoring are key to optimal outcomes.

They place a heavy burden on patients and healthcare systems, causing prolonged recovery, a higher risk of infection and tissue loss, reduced mobility, and significant social and economic consequences[2].

Distal lower-limb wounds, often accompanied by exposed bone, are difficult to treat due to thin soft tissue with limited padding, exposed tendons, and inadequate muscle coverage in the anterior, medial, and lateral limb regions[3]. These challenges are especially relevant in Tanzania and other resource-limited settings, where access to advanced reconstructive techniques may be restricted.

Free muscular flaps are the primary and gold-standard option for distal leg and foot reconstruction^[4,5^]. They provide urgent coverage but require specialized microsurgical expertise, which remains limited in many low- and middle-income countries, including Tanzania.

Free perforator flaps have gradually replaced robust free muscular flaps, allowing restoration of “ad integrum” anatomy with reduced donor-site morbidity[6]. Pedicled-propeller flaps, following the “like-with-like” principle, preserve main vascular trunks, nerves, and muscles, shorten operating and hospitalization times, and avoid the need for time-consuming micro-anastomosis[7].

According to the Gent Consensus, perforator flaps consist of skin and subcutaneous tissue, with or without fascia, supplied by perforating vessels arising from a deep vascular source. These perforators may follow either an intramuscular (musculocutaneous) or interseptal (septocutaneous) course. Local perforator flaps can be advanced using a V–Y technique or rotated around a perforator pedicle as a propeller flap through an arc of up to 180 degrees^[8–10^].

In the lower limb, a single perforator can reliably vascularize a substantial area of fasciocutaneous tissue, making perforator-based reconstruction feasible even in challenging regions such as the distal third of the leg and ankle. The most commonly used perforators arise from the posterior tibial, peroneal, and anterior tibial arteries, with the posterior tibial and peroneal systems providing particularly dependable vascular supply for propeller flap reconstruction[10].

In this study, we present two patients with distal lower-limb chronic wounds complicated by exposed bone who underwent reconstruction using perforator-based propeller flaps. These cases highlight the practical application and effectiveness of perforator-based propeller flaps in achieving durable soft-tissue coverage within the Tanzanian clinical context, where advanced microsurgical resources remain limited.

These case reports were prepared following the SCARE guidelines to ensure thorough, structured, and transparent documentation of the clinical presentation, management, and outcomes[11].

Case presentations

Case 01

A 33-year-old Maasai male presented to our trauma unit following a road traffic accident involving a three-wheeled cargo motorbike (tuk-tuk). The patient was the driver and sustained the injury when the vehicle overturned while attempting to avoid a head-on collision. The injury occurred 1 week prior to presentation. He initially sought treatment from a local healthcare provider, where the wound progressively worsened, developing signs of sepsis with purulent discharge. Due to the increasing severity of symptoms and lack of improvement, he decided to seek further care at our facility.

The primary survey revealed extensive soft-tissue trauma localized to the distal left lower limb, featuring a large degloving wound with exposed tendons, muscle, and bone. The wound appeared infected, with purulent discharge and necrotic tissue, findings consistent with delayed presentation after initial local treatment. Radiologic and clinical assessments demonstrated a bimalleolar fracture with heavy wound contamination, meeting criteria for a Gustilo–Anderson type IIIB open fracture.

No active bleeding was observed at the time of examination. The distal pulses were palpable, and capillary refill time was within normal limits. Sensory and motor functions of the foot were grossly intact.

Initial laboratory evaluation showed a hemoglobin level of 13.5 g/dL, indicating no significant acute blood loss. However, inflammatory markers were elevated, with a white blood cell count of 14.2 × 10⁹/L and C-reactive protein of 128 mg/L, supporting the clinical impression of wound infection. Renal function and electrolytes were within normal ranges.

After wound debridement and copious irrigation, K-wire fixation was performed for stabilization of the bimalleolar fractures. The wound was then managed with negative-pressure wound therapy for 2 weeks (Fig. 1A–D), during which healthy granulation tissue developed, allowing for subsequent split-thickness skin grafting. Postoperatively, the patient underwent negative-pressure wound therapy to enhance graft adherence and wound bed preparation, along with regular sterile dressings (Fig. 2A–D)

Figure 1.

Sequential views of the distal left leg wound in Case 1 following K-wire fixation and negative pressure wound therapy (NPWT). (A) Anterior view showing a large distal leg wound with exposed tendons, bone, and extensive soft-tissue loss. (B) Medial view showing the depth and extent of the defect. K-wire fixation for bimalleolar stabilization is visible. (C) Lateral view showing K-wire fixation in place and healthy granulation tissue formation following debridement and NPWT. (D) Posterior view showing partial granulation tissue formation with residual areas of exposed tissue.

Figure 2.

Sequential views of the distal left leg wound in Case 1, following split-thickness skin grafting (STSG). (A) Anterior view showing the grafted wound over the distal leg with areas of healthy granulation tissue. (B) Lateral view demonstrating partial graft take with persistent bone exposure over the malleolar region. (C) Medial view showing partial graft take with persistent bone exposure at the medial malleolus. (D) Oblique posteromedial view demonstrating residual areas of exposed bone and incomplete wound coverage despite grafting.

Despite these measures, at the 2-month follow-up, persistent exposure of the left medial malleolus remained secondary to graft contraction and inadequate soft-tissue coverage. Because local tissue advancement options were limited and durable coverage of the exposed bone was required, a propeller perforator flap was selected as the most suitable reconstructive option. The exposed bone posed a high risk of infection and delayed healing, prompting the decision for definitive soft-tissue reconstruction using a local propeller perforator flap. A preoperative CT angiogram was performed to assess vascular integrity and locate viable perforators, confirming the suitability of a perforator-based flap.

Under spinal anesthesia, two major posterior tibial artery perforators were identified at approximately 5 and 10 cm proximal to the medial malleolus, which were confirmed intraoperatively using Doppler. A propeller subcutaneous flap was designed around these perforators, carefully dissected, and rotated 180° to cover the exposed medial malleolus, and a corrugated drain was placed to aid drainage and prevent seroma collection (Fig. 3A–C). The exposed bone was gently nibbled, drilled, and irrigated to promote granulation, and the K-wire was removed after confirming stable fracture alignment. The donor site and any residual defects were resurfaced with a split-thickness skin graft harvested from the contralateral thigh.

Figure 3.

Intraoperative and postoperative views of propeller perforator flap reconstruction in Case 1. (A) Preoperative marking of the flap design based on posterior tibial artery perforators. (B) Intraoperative view showing flap elevation and 180° rotation to cover the medial malleolar defect. (C) Immediate postoperative appearance demonstrating stable flap positioning and inset. Skin grafting was performed over the donor site. (D) Early postoperative view at 2 weeks showing partial distal flap necrosis.

The postoperative period was uneventful except for a small area of partial necrosis at the distal tip of the flap, which was managed conservatively with serial wound dressings and topical therapy (Fig. 3D). Progressive healing was achieved over several weeks, resulting in complete wound closure, stable soft-tissue coverage, and preservation of limb function. At the 2-month postoperative follow-up, the patient was ambulatory, and the reconstructed area demonstrated good contour, durable coverage, and a satisfactory cosmetic appearance, reflecting a successful outcome in a resource-limited setting.

Case 02

A 13-year-old boy with no known comorbidities presented with a chronic wound over the distal anterior aspect of the right lower limb, measuring 3 × 5 cm, persisting for 4 months. The lesion began as an abscess managed with incision and drainage followed by dressings but gradually enlarged and was later complicated by bone exposure and osteomyelitis. He was treated with intravenous antibiotics, bone debridement using a nibbler, and placement of antibiotic-impregnated bone cement. Despite these measures, the wound failed to heal, leaving persistent bone exposure.

On presentation, the patient was afebrile, hemodynamically stable, and without systemic symptoms. Local examination revealed a chronic ulcer with healthy granulation tissue and a small area of exposed bone over the distal third of the leg, without signs of active infection (Supplemental Digital Content Files, available at: https://links.lww.com/IJSCR/A114). Biopsy of the wound edge ruled out malignancy. Laboratory evaluation showed normal CBC, electrolytes, and renal function, while wound cultures yielded no growth. X-ray of the leg revealed no evidence of active osteomyelitis or bone destruction.

Preoperative vascular mapping was performed using handheld Doppler ultrasound, which identified a dominant perforator arising from the superficial peroneal artery, located approximately 5 cm proximal to the lateral malleolus (Supplemental Digital Content Files, available at: https://links.lww.com/IJSCR/A114). The adjacent soft tissues appeared viable, with no evidence of fibrosis or scarring that could compromise flap elevation. Because local advancement and rotational flap options were unlikely to provide durable coverage of the exposed bone without excessive tension, a propeller perforator flap was selected to achieve reliable soft-tissue coverage while preserving surrounding tissues.

Intraoperatively, the flap was meticulously outlined and incised (Supplemental Digital Content Files, available at: https://links.lww.com/IJSCR/A114). Dissection proceeded in a subfascial plane, identifying the perforator vessel and its accompanying venae comitantes. The pedicle, consisting of perforator branches from the superficial peroneal artery, was carefully skeletonized to ensure adequate mobility and prevent torsion during rotation. The flap was then elevated, preserving its vascular integrity, and subsequently rotated 180 degrees to cover the distal anterior leg defect (Supplemental Digital Content Files, available at: https://links.lww.com/IJSCR/A114). The recipient site was thoroughly debrided to ensure a clean, viable wound bed, and the exposed bone was refreshed to promote vascular contact. The donor site was resurfaced with a split-thickness skin graft from the ipsilateral thigh.

Postoperatively, the patient developed mild flap congestion with seroma accumulation, which was managed conservatively with limited suture release, irrigation, and daily dressings. The flap subsequently improved and healed satisfactorily. At the 2-month postoperative follow-up, complete wound closure was achieved with durable coverage, good contour, and satisfactory functional and cosmetic outcomes.

Case discussion

The optimal reconstructive approach for lower-limb defects, whether simple or complex, should ensure “like-for-like” tissue replacement, minimize donor-site morbidity, preserve major vascular axes, and shorten both operative and hospitalization durations[7].

In appropriately selected patients, propeller perforator-based local flaps effectively fulfill these reconstructive principles, supported by improved understanding of flap perfusion and lower-limb vascular anatomy[12].

These principles guided reconstruction in both of our patients, in whom durable coverage was achieved while preserving major vascular structures and minimizing donor-site morbidity.

The propeller flap was formally recognized at the inaugural Tokyo meeting and categorized into three types: subcutaneous pedicled propeller flaps, perforator pedicled propeller flaps, and supercharged propeller flaps[13].

In a perforator-based propeller flap, a perforator strategically selected near the defect serves as the vascular axis, with the flap islanded on a single perforator branch arising from a well-defined source vessel[14].

Similarly, in our two cases, the closest perforators, located 5 cm from the malleoli, were identified preoperatively and confirmed intraoperatively with Doppler, enabling successful flap elevation and rotation to provide durable coverage of the distal leg defects. Selecting the perforator nearest to the defect is particularly important because, in some cases, the limited length of perforating vessels in the leg and ankle may restrict flap transposition, making proximity critical for achieving adequate reach and coverage[15].

Perforator propeller flaps based on branches of the posterior tibial and peroneal arteries are commonly used for lower limb reconstruction[16].

In the first case, the flap was based on posterior tibial artery perforators, while in the second case, it was based on a superficial peroneal artery perforator, both providing reliable vascular supply for distal leg coverage. These techniques are in line with prior reports employing posterior tibial and peroneal artery perforators for lower limb reconstruction with better outcomes^[17–19^].

Principles of propeller flap surgery involve (1) thorough preoperative evaluation and planning, including assessment of defect size, etiology, and patient risk factors, as well as identification of suitable perforator vessels with Doppler and the design of a flap slightly larger than the defect; (2) meticulous subfascial dissection under magnification during the surgical phase to isolate and preserve the perforator pedicle, verify perfusion with warm saline irrigation, and rotate the flap into position, followed by either direct closure or skin grafting when necessary; and (3) diligent postoperative care focused on monitoring flap viability through color and temperature assessment, removing drains within 24–48 hours, maintaining immobilization if grafting is performed, and administering anticoagulation in non-weight–bearing patients[20].

These principles were applied in both cases through preoperative perforator mapping, careful flap design and elevation, and close postoperative surveillance, which facilitated early recognition and successful conservative management of complications.

A systematic review by Gir et al demonstrated that propeller-based perforator flaps are generally safe and reliable, with favorable outcomes for covering lower limb soft-tissue defects. Additionally, the overall complication rate was reported at 25.8%, with a failure rate of 1.1%; the most common complications were partial flap necrosis (11.3%) and venous congestion (8.1%)[21].

These complications align with those observed in our cases, in which our first case was complicated by partial flap necrosis at the distal tip and the second by flap congestion with seroma.

Importantly, both complications were recognized early through routine postoperative monitoring and resolved with conservative measures, highlighting the practicality of this reconstructive approach in resource-limited settings.

According to the Clavien–Dindo classification, both partial flap necrosis and venous congestion observed in our cases were Grade I complications, as they were managed conservatively without the need for surgical, endoscopic, or radiological intervention[22].

Partial flap necrosis, which in our case began as superficial epidermolysis, is a recognized complication of propeller flap reconstruction. In the series by Jakubietz et al, involving eight patients with malleolar defects reconstructed using 180° propeller flaps based on tibial and peroneal perforators, superficial epidermolysis in two cases resolved spontaneously[23]. Similarly, in our case, the necrotic area was managed conservatively with regular dressings, resulting in complete healing without the need for surgical revision.

Venous congestion, as observed in our second case, often results from kinking of the venous pedicle during flap rotation. Adequate anterograde and retrograde venous drainage plays a crucial role in maintaining flap viability and preventing congestion[24].

While techniques incorporating additional venous pedicles or axial veins have been described to enhance outflow, in our case, congestion was effectively managed with conservative measures, including partial suture release, irrigation, and regular dressings, achieving satisfactory recovery without the need for venous supercharging.

In a clinical study involving 59 patients undergoing perforator flap reconstruction, Masia et al used propeller flaps in 35 cases for defects secondary to oncologic surgery, trauma, and unstable scars. They reported four flap losses and four cases of partial necrosis, occurring primarily in heavy smokers and patients with diabetes, highlighting these as significant risk factors[14].

In contrast, both of our patients were healthy non-smokers with no comorbidities, yet they experienced minor complications, suggesting that such outcomes may also occur in individuals without predisposing factors.

A limitation of this report is the small number of cases and the relatively short follow-up period. However, these cases provide valuable insight into the feasibility and management of perforator-based propeller flaps for distal lower-limb reconstruction in a resource-limited setting.

Propeller flaps are a reliable alternative for appropriately selected lower-limb defects, showing favorable outcomes as observed in our cases and in published studies, while free flaps remain the preferred option for larger or more complex reconstructions; microsurgical skills are increasingly essential for managing trauma, planning elective procedures, and achieving limb salvage.

Conclusion

Propeller perforator flaps offer a dependable and efficient reconstructive solution for chronic wounds of the distal lower limb, providing lasting coverage while causing minimal donor-site complications. In our two cases, despite the absence of comorbidities, minor complications such as partial flap necrosis and venous congestion occurred but were successfully managed conservatively, with satisfactory wound healing and preservation of limb function. These findings support the use of perforator-based propeller flaps in appropriately selected patients, particularly in resource-limited settings where microsurgical free-flap expertise may be scarce. Meticulous planning, flap design, and postoperative monitoring are essential to optimize outcomes, promote functional recovery, and improve patients’ quality of life.

Ethical approval

Written informed consent was obtained from the patient for the anonymized information to be published in this article.

Consent

Our institution does not require ethical approval for reporting individual cases report.

Sources of funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author contributions

M.M.: study conception, production of the initial article, collection of data and final manuscript writing; M.K.: production of the initial article, collection of data and final manuscript writing; I.R.: study conception, revision of the article, proofreading, final manuscript writing; R.O.: study conception, revision of the article, proofreading, final manuscript writing; E.M.: study conception, revision of the article, final manuscript writing.

Conflicts of interest disclosure

The author(s) declared no conflicts of interest regarding the research, authorship, and/or publication of this article.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Musa Machibya.

Provenance and peer review

Not commissioned, externally peer reviewed.

Data availability statement

All relevant data supporting the findings of this study are included in this article.