AAMJ, Vol. 7, N.

1, January, 2009
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DIASTALLY BASED MEDIAL HEMI-SOLEUS MUSCLE
FLAP BASED ON THE POSTERIOR TIBIAL VESSELS
Ahmed Taha Sayed
Department of Plastic and Reconstructive surgery, Faculty of Medicine
Al-Azhar University
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ABSTRACT
Background: Wound coverage of exposed lower third tibia and
ankle region remains a difficult task. Muscle flaps are preferred for infected
wounds especially where there are exposed bone, joint and/or tendons. Most
reported muscle flaps in this region are small and have very limited arc of
rotation. These seriously limit their applications. The key anatomy is the
direct muscle branches (DMBs) to the soleus muscle from the posterior
tibial vessels. This flap has the following advantages: it has a long vascular
pedicle and the area that could be covered is wide, a large piece of the
soleus muscle could be used and no microvascular anastomosis is required.
Aim of the work: The aim of this work is evaluation and capability for using
of distally based hemi-soleus muscle flap for coverage and reconstruction of
the lower 1/3rd leg soft tissue defect with infected exposed fracture bones
and proximal part of the ankle joint region. Patients and methods: We
report nine patients, operated on Al-Azhar university and Al-Haram
hospitals between March 2008 – January 2009, presented with
posttraumatic (fire arm or rood traffic accident) with exposed infected
fractures of lower 1/3rd tibia, and/or proximal part of the ankle joint. All
patients underwent to carful vascular study of the affected limb through
Dopplex ultra-sonography, beside routine laboratory and radiological
investigations. The average soft tissue defects was 7 X 4cm that received
distally based medial half soleus muscle flap based on the posterior tibial
vessels and covered immediately by split thickness skin graft. Results: The
flap used for nine patients (7 male and 2 female), with average age 45 years
old, 5 patients injured by gun shot and 4 by rood traffic accidents, One
patient presented with middle and lower 2/3rds defects with infected tibial
bone fractures caused by gun shot injury received distally based medial
head of gastrocnemeus muscle flap for covering the middle 1/3rd and
distally based medial hemisoleus muscle flap for the lower 1/3rd defects. All
flaps survived without complication. The follow up continued for period
ranged from 8-16 weeks (average 12 weeks) with orthopedic surgeon during
and after completing his job. Conclusion: Uses of the distally based medial
hemi-soleus muscle flap in lower 1/3rd leg and or proximal ankle joint

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defects is one the limited choices flaps for covering this areas of defects and
has a advantages over the other complicated techniques like as
microsurgical free flaps addition to not scarifying the main vessels of the
leg . The durability of uses this flap is depends on the site and size of the
defect, state of the vascular supply of the affected limb and prior knowledge
of anatomy

Key Words: Lower 1/3rd tibia and ankle, Soleus, Muscle flap

INTRODUCTION

Management of wounds in lower 1/3rd leg, foot and ankle regions

remains a difficult problem. It is used more with infected wounds and
wounds with deep defects that exposed bone and important structures had
been found. Muscle flaps are preferred in these situations. 6 Free muscle
flaps require microvascular anastomosis and have definite risk of failure.
Most of the reported local muscle flaps around the ankle and foot region are
small in size, have limited arc of rotation and cannot resurface the distal
sole. 2,7,12,14,17,18 Based on our previous anatomic study of the posterior tibial
vascular system, the hemi-soleus muscle flap based on the posterior tibial
vessels was developed.21 the soleus muscle is located in the posterior region
of the leg, inferior to the gastrocnemius muscles, and is classified as type II
according to the classification of Mathes and Nahai. Its major pedicle is the
posterior tibial artery, and the perforating branches of this artery are the
secondary pedicles3, 4.

Soleus is what allows foot to move up and down, and that motion is
used for many daily activities. The main movement of the soleus is the
flexing of the foot. The use of this muscle when stand on toes as if reaching
high. Ballet dancers use the soleus when they rise up onto their toes into a
point position, and swimmers contract the soleus to keep their toes pointed
as they kick through the water. An advantage of using the hemisoleus flap
rather than the entire soleus muscle flap is the preservation of plantar flexion
of the foot performed by the lateral portion of the muscle, which is left in its
original location. Moreover, the medial flap has a greater rotation angle than
that of a conventional soleus muscle flap1-4. The medial part of the muscle is
supplied in its whole length by perforators of the posterior tibial artery.
Because of this constant arterial supply, the medial part of the soleus muscle
is viable as a flap distally based in a reverse manner1-4.

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The soleus muscle is frequently used for the reconstruction of
defects of the middle third of the leg, based on its major pedicle. However,
the viable use of the soleus muscle in a reverse manner, based on its
secondary pedicles, has been described by several authors for the
reconstruction of defects of the lower third of the leg as an alternative to the
use of microsurgical flaps1-9.this paper reports our experience in the
application of this flap.

ANATOMY
Anatomy of the Soleus muscle has been explored thoroughly, 16, 19 providing
the basis for the technically more comfortable and safe dissection of this
flap. The bipennate nature of the soleus and the independent neurovascular
supply to both medial and lateral halves of the muscle16 are the key
anatomical features that allow splitting the muscle longitudinally along the
raphe. In the leg, as the posterior tibial vessels run distal to the popliteus
muscle, they lay between the flexor digitorum longus (FDL) muscle
anteriorly and the soleus muscle posteriorly. Along their course in the leg,
they give direct cutaneous branches (DCBs) to the skin and direct muscle
branches (DMBs) to the adjacent muscles (Fig. 1). If one divides the leg into
four equal segments (from the tip of the medial malleolus to the medial knee
joint line), zone I being the most distal and zone IV the most proximal, the
DCBs are found mainly around zone II.21 The DMBs to the soleus muscle
are found mainly in zone II and zone III. On the average, there are 3-4
DMBs to the soleus muscle. The size of these arterial branches is usually
less than 2 mm in diameter. Those at the proximal part of the leg are usually
larger and a big branch, 1.5 mm to 2.0 mm in diameter, was often found in
zones III or IV.21

Fig. (1)

SURGICAL PROCEDURE

Preoperatively, one must confirm the presence of both the posterior

tibial and the dorsalis pedis pulses and all patients submitted for Doppler
ultrasongraphy study of leg vessles. Patients should have no evidence of
arteriosclerosis or distal ischaemia. We routinely avoid taking blood.

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The length of the muscle flap, the length of its vascular pedicle and
the pivot point of the flap for rotation should be planned before the
operation. They are all inter-related. This will be discussed below.

The patient is placed in supine position under general or epidural

anaesthesia. A tourniquet is placed in the thigh of the limb to be operated.
The lower limb is then elevated for 2 to 3 minutes and the tourniquet is
inflated without the use of Esmarch bandage. This step is very useful
because short duration of limb elevation without the use of Esmarch
bandage would render the DMBs to the soleus muscle more prominent. The
dissection would be easier.

A longitudinal skin incision is made on the medial side of the leg at

about 1 cm posterior to the posteromedial subcutaneous border of the tibia.
The incision lies mainly in zone II and zone III of the leg. Any further
extension would depend on the condition of the limb. We recommend to
start the dissection in zone II or zone I as the deep transverse fascia of the
leg is more prominent in this area (Fig. 1).3 Anatomically, from anterior to
posterior lies the following structures: the FDL muscle, the posterior tibial
vascular pedicle, the deep transverse fascia of the leg and the soleus muscle.
Distally the deep transverse fascia of the leg is continuous with the flexor
retinaculum. Once the deep fascia of the leg is incised, the deep transverse
fascia of the leg is identified, incised and reflected posteriorly. The FDL
muscle would then be exposed. The posterior tibial vascular pedicle is found
lying between the FDL anteriorly and the deep transverse fascia of the leg
posteriorly. The vessels are exposed and protected from injury during the
dissection.

Following the posterior tibial vascular pedicle proximally, one

would find the DCBs to the skin, the DMBs to the FDL, and the soleus
muscles. The DCBs and the DMBs to FDL muscle are ligated and divided.
The posterior tibial nerve is dissected carefully and protected.

Three parameters have to be determined at this point. They are the

pivot point of this solus muscle flap, the length of the vascular pedicle and
the length of the muscle flap required. The length of the vascular pedicle
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should be about 120% of the distance between the pivot points of the
vascular pedicle to the proximal edge of the wound to be resurfaced. This
will avoid kinking of the vascular pedicle when the flap is transposed. The
length of the vascular pedicle is important as it determines from which zone
the muscle flap should be harvested from. It is best to raise the muscle flap
in zone II or III of the leg as the DMBs to the soleus muscle are most
abundant in these regions. The size of the muscle flap required would
depend on the size of the wound.

Once all these are decided, the appropriate size of muscle could be
raised from the medial half of the soleus muscle (medial hem-isoleus) (Fig.
2). The DMBs to this part of the soleus muscle must be preserved. When the
dissection is ready, the tourniquet is released. The soleus muscle flap is
raised and transposed to cover the wound. Partial thickness skin grafts were
then laid on the surface of the muscle flap.

RESULTS
This flap was employed for wound resurfacing in nine patients
(Table 1). There were seven males and two females patients, aged from 28
to 72 (average 46.5) years. Five patients had shot gun or bullet injuries with
infected compound comminuted fracture of the distal tibia and four were
trauma patients caused by road traffic accidents with exposed bone fractures
of distal tibia and exposed proximal ankle joint. One patients presented with
gun shot injury had exposed middle and lower 2/3rd tibia with infected
comminuted fracture of the middle 1/3rd tibia, was submitted for covering
the middle 1/3rd leg by medial head gastrocnameus muscle flap and hemi-
soleus muscle flap for the lower 1/3rd tibial coverage. The follow up period
ranged from 8 to 16 weeks (average 12 weeks). All flaps used in our
patients survived with no complications.
Table (1): the clinical data of the included patients
No Ages/y sex Cause of injury Site of the soft Other associated
. tissues defect injuries
th
1 28 male Fire arm (bullet) Lt.distal 1/4 Non
leg
2 30 male Shot gun Rt.distal 1/3rd Non
leg
3 35 fema Road traffic Rt.distal 1/4th Fracture femur

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le accident leg and ankle (Lt. side)
joint
4 36 male Shot gun Rt. Middle Non
and lower
2/3rds leg
5 44 Male Shot gun Lt.distal 1/4th Non
leg
6 46 Male Shot gun Rt.distal 1/3rd Non
leg
7 50 Male Road traffic Lt.lower half Non
accident leg
8 60 Male Road traffic Lt.distal 1/4th Fracture upper
accident leg and ankle 1/3rd tibia
joint (Rt.Side)
9 72 fema Road traffic Rt. Ankle Rt.side shoulder
le accident region dislocation

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CASES REPORTS

Case 1

A 35-year-old man had gun shot injury with infected exposed

fracture of distal tibia with a discharging wound at the lateral side of the
joint. After thorough debridement, the reverse-flow soleus muscle flap from
the medial side of the leg was prepared. It was then transposed to the
exposed bone to cover the defect. Split thickness skin graft was laid on the
muscle flap immediately. A plaster slab was applied after the operation to
immobilise the joint. It healed well subsequently (Fig. (3): A, B, C, D, E, F,
G, H).

Fig.(3);

Case 2

A 36-year-old male sustained type III B open fracture9 of the right

tibia caused by gun shot injury. The wound was debrided and the fracture
was fixed with Orthofix external fixator initially. After further debridement,
the wound covered with medial head gastrocnemeus muscle flap for the
middle third and medial hemi-soleus muscle flap for the lower third defects.
The wound and the muscle flap were skin grafted one week afterward. The
wound and the fracture healed without complications (Fig.(3); A, B, C, D,
E, F).

Fig. (4);

Case 3

A 28-year-old male presented with fir arm injury (bullet) causing

comminuted open distal tibial bone fracture of the right lower leg with loss
of soft tissue covering.(Fig.(4); A, B, C, D).

Fig.(5);

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(A) Musculocutaneous perforator (B) The direct muscular branches

through soleus muscle supplying the soleus and flexor

Fig. (1); the vascular supply of the soleus muscle.

(B): Rrotation of the medial portion of

(A) Eexposure and dissection of the
the soleus muscle and and coverage of
muscle soleus
the lesion area

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Fig. (2); Surgical technique.

(A)Open comminuted fracture lower third (B) plain X-ray; showing gun shot injury
leg with loss of soft tissues coverage and fractures of both bones lower leg

(C) Medial hemi-soleus muscle (D) The muscle is rotated for covering
elevated the defect

Fig. (3); Case (1): Gun shot injury of Rt. Lower 1/3rd Leg, medial hemi-
soleus muscle flap used for covering of the defect.

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(E) Skin graft was laid on the muscle

flap immediately (F) Two weeks postoperative

(G) Plain X-ray Postoperative (H) Three month postoperative

Fig. (3): Case (1): Gun shot injury of Rt. Lower 1/3rd Leg, medial hemi-

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soleus muscle flap used for covering of the defect (cont.)

coverage of (B) Plain X-ray leg showing the gun

of lower shot
fected fractures

(C) Medial head gastrocnameus (D) Medial hemi-soleus muscle flap

muscle flap covering the middle third covering the lower third tibia
tibia

(E) Three months postoperative after (F) Postoperative X-ray bone of the
covering of both muscle flaps by skin tibia
graft

Fig. (4); Case (2) Exposed infected fractures of the middle and lower two
thirds left tibia caused by gun shots injury

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(A)Firearm injury to the lower leg (B) After insetting the medial hemi-
soleus musle

(C) Split thickness skin graft sitting

over the hemi-soleus muscle flap (D) two weeks postoperative view with
graft
immediately

Fig. (5); Case (3) Medial hemi-solius muscle flap for covering the fracture
comminution of lower 1/3rd of the lt.tibia with loss of the soft tissue
coverage.

DISCUSSION

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Management of wounds at the distal 1/4th leg and ankle regions
remains a challenging problem. Reverse-flow island fasciocutaneous flaps
like the anterior tibial flap; the peroneal flap and the posterior tibial flap
have the advantages of having a wide arc of rotation and can reach all sides
of the ankle, the heel and the foot. They are especially suitable for medium
size defects.20-22
Different authors had confirmed the usefulness and reliability of
various distally based fasciocutaneous flaps in the leg.5,8,16 Masquelet et al
reported the anatomic basis and clinical applications of neurocutaneous
flaps in the leg.15 Other authors also reported similar experience. The main
advantage of the distally based fasciocutaneous flaps and the
neurocutaneous flaps is the preservation of the main arteries to the lower leg
and foot. The most significant advantage of hemisoleus muscle flap is
preservation of foot plantar flexion power by the hemisoleus muscle belly
left insitu.16 The medial half of the muscle is supplied constantly throughout
its length by the perforators from the posterior tibial artery. This feature
makes medial hemisoleus muscle flap more reliable than the lateral half.16

The drawbacks include a high failure rate and the flaps being unable
to reach the middle or distal sole region for wound resurfacing.10,12-14 , in
addition injury of the harvested skin.
In the management of infected wounds and bones or where there are cavities
in the defect, muscle flaps are preferred. Local muscle flaps reported like the
abductor hallucis muscle flap, abductor digiti minimi muscle flap and the
flexor digitorum brevis muscle flap are small in size and have limited arc of
rotation. These seriously limit their applications.2, 15; 17The extensor
digitorum brevis muscle flap has quite a satisfactory arc of rotation and is
suitable for small defects.7

The medial hemi-soleus muscle flap based on muscular branches of

the posterior tibial vessels bears the advantages of a muscle flap and has an
appropriate arc of rotation if it used for covering lower third defect in the
leg.20. The size of the muscle flap can be up to about 7 cm long x 5cm wide.
This is suitable for most small to medium size defects. The bulk of the
muscle flap is not a serious problem as it will gradually atrophy. Donor site
cosmesis is very acceptable. The wound could be closed and left with a

349
 Ahmed Taha Sayed
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
linear scar. The power and the range of motion of the ankle joint would
primarily be determined by the disease or bone injuries. The operation is not
technically demanding and no microvascular anastomosis is required. The
main advantage with this method is not scarifying of the posterior tibial
artery. We have been using flaps based on the posterior tibial muscular
branches for soleus for more than 3 years, provided that the patients are
carefully selected, preoperative vascular assessement by Doppler
ulterasonogrphy study and the indications are appropriate, so we encounter
no long-term problems after the use of these flaps.

REFERENCES

1. Barclay TL, Sharpe DT, Chisholm EM. Cross-leg

fasciocutaneous flaps. Plast Reconstr Surg 1983;72:843-6.
2. Bostwick J. Reconstruction of the heel pad by muscle
transposition and split skin graft. Surg Gynaecol Obstet
1976;143:972-4.
3. Clemente CD. Anatomy of the human body. 30th American ed.
Philadelphia: Lea & Febiger, 1985:577.
4. De Roche R, Vogelin E, Regazzoni P, Luscher NJ. How does a
pure muscle cross-leg flap survive? An unusual salvage
procedure reviewed. Plast Reconstr Surg 1994;94:540-3.
5. Donski PK, Fogdestam I. Distally based fasciocutaneous flap
from the sural region. Scand J Plast Reconstr Surg 1983;17:191-
6.
6. Fisher J, Wood MB. Experimental comparison of bone
revascularization by musculocutaneous and cutaneous flaps.
Plast Reconstr Surg 1987;81-90.
7. Giordano PA, Argenson C, Pequignot JP. Extensor digitorum
brevis as an island flap in the reconstruction of soft-tissue
defects in the lower limb. Plast Reconstr Surg 1989;83:100-9.

350
 AAMJ, Vol. 7, N. 1, January, 2009
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
8. Gumener R, Zbrodowski A, Montandon D. The reversed
fasciocutaneous flap in the leg. Plast Reconstr Surg
1991;88:1034-43.
9. Hasegawa M, Torii S, Katoh H, Esaki S. The distally based
superficial sural artery flap. Plast Reconstr Surg
1994;93(5):1012-20.
10. Ikuta Y, Murakami T, Yoshioka K, Tsuge K. Reconstruction of
the heel pad by flexor digitorum brevis musculocutaneous flap
transfer. Plast Reconstr Surg 1984;74:86-96.
11. Jeng SF, Wei FC. Distally based sural island flap for foot and
ankle reconstruction. Plast Reconstr Surg 1997;99(3):744-50.
12. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied
by the vascular axis of the sensitive superficial nerves -
Anatomic study and clinical experience in the leg. Plast Reconstr
Surg 1992;89(6):1115-21.
13. Mathes SJ, Vasconez LO. Reconstruction of the lower extremity.
In: Mathes SJ, Nahai F, editors. Clinical applications for muscle
and musculocutaneous flaps. St. Louis: The CV Mosby
Company, 1982:532-80.
14. Pu LL. Soft-tissue reconstruction of an open tibial wound in the
distal third of the leg: a new treatment algorithm. Ann Plast
Surg. 2007;58(1): 78-83.
15. Pu LL. Successful soft-tissue coverage of a tibial wound in the
distal third of the leg with a medial hemisoleus muscle flap. Plast
Reconstr Surg. 2005;115(1):245-51.
16. Raveendran SS, Kumaragama KGJL. Arterial Supply of the
Soleus Muscle: Anatomical Study of Fifty Lower Limbs. Clin
Anat 2003;16:248–52.
17. Robotti E, Verna G, Fraccalvieri M, Bocchiotti MA. Distally
based fasciocutaneous flaps - A versatile option for coverage of
difficult war wounds of the foot and ankle. Plast Reconstr Surg
1998;101(4):1014-21.
18. Scheflan M, Nahai F. Reconstruction of the foot. In: Mathes SJ,
Nahai F, editors. Clinical applications for muscle and
musculocutaneous flaps. St Louis: The CV Mosby Company,
1982:594-609.

351
 Ahmed Taha Sayed
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
19. Tobin GR. Hemisoleus and reversed hemisoleus flaps. Plast
Reconstr Surg 1985;76:87-96.
20. Wee JTK. Reconstruction of the lower leg and foot with reverse-
pedicled anterior tibial flap: preliminary report of a new
fasciocutaneous flap. Br J Plast Surg 1986;39:327-37.
21. Wu WC, Chang YP, So YC, Yip SF, Lam YL. The anatomic
basic and clinical applications of flaps based on the posterior
tibial vessels. Br J Plast Surg 1993;46:470-9.
22. Yoshimura M, Shimada T, Imura S, Shimamura K, Yamauchi
S. Peroneal island flap for skin defects in the lower extremity. J
Bone Joint Surg 1985;67A:935-41.

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‫إستخدام النصف الداخلي من العضلة النعلية في تغطية قصور األنسجة المغطية‬
‫للجزء السفلي من الساق ومقدمة مفصل القدم‬
‫أحمد طه سيد‬
‫قسم جراحة التجميل والحروق– كلية الطب بنين – جامعة األزھر – القاھرة‬
‫إن إصابة الجزء السفلي من الساق والذي ينتج عنه قصور في األنسجة المغطية لعظمة الساق من‬
‫اإلصابات الصعبة التي يصعب عالجھا وتغطيتھا باألنسجة‪ ،‬وذلك لعدم كفاية األنسجة والجلد المحيط‬
‫باإلصابة‪ .‬ومن المعروف ايضا ً‪ ،‬انه ال يمكن تغطيتھا برقعة جلدية حرة‪ ،‬ولكن تحتاج الي شريحة‬
‫حرة أو شريحة جلدية أو شريحة عضلية متغذية علي شرايين وأوريدة وذلك لتغطية الجزء الذي به‬
‫قصور‪ ،‬يضاف الي ذلك مساعدة الشريحة الجلدية او العضلية في إلتئأم الكسر العظمي ومقاومة‬
‫إلتھابات العظمة المكشوفة‪.‬‬
‫ولقد اشتمل ھذا البحث علي عدد ‪ 9‬مرضي ‪ 7‬من الرجال و‪ 2‬من النساء أجريت لھم العمليات في‬
‫الفترة ما بين مارس ‪ 2008‬حتي يناير ‪ 2009‬في مستشفيات جامعة األزھر بالقاھرة والھرم التابعة‬
‫لوزارة الصحة ‪.‬وتتراوح اعمارھم بين ‪ 72 – 28‬سنة )متوسط ‪ 46.5‬سنة( يعانون من قصور في‬
‫األنسجة المغطية للجزء السفلي من الساق وظاھر مفصل القدم مما نتج عن ھذا‪ ،‬إنكشاف لجزءمن‬
‫العظام أو مفصل القدم ‪.‬وكانت اسباب اإلصابة كاآلتي‪ :‬خمسة مرضي كانت اصابتھم نتيجة للتعرض‬
‫لحادث إطالق نار واألربعة الباقين كانت نتيجة لحوادث الطرق‪ .‬وقد تمت تحضير المرضي جميعا‬
‫وذلك بالتحاليل الروتينية وعمل أشعة موجات فوق صوتية علي الشرايين واألوردة بالساق المصابة‬
‫وتم التأكد من الحالة الجيدة للدورة الدموية بالساق المصابة قبل التدخل الجراحي وھو‪ ،‬تغطية الجزء‬
‫المفقود من األنسجة وانكشاف العظام بالعضلة النعلية وذلك باستخدام النصف الداخلي لھذه العضلة‬
‫متغذية علي الشريان الظنبوبي الخلفي ثم تغطية العضلة في الحال برقعة جلدية حرة‪.‬‬
‫وقد تمت متابعة الجرح مدة تتراوح بين ‪ 16-8‬اسبوع )متوسط ‪ 12‬اسبوع( وكانت النتائج اآلتي‪ :‬لم‬
‫يحدث أيا من‪ :‬فقدان للشريحة العضلية أو جزء منھا ولم تتأثر الدورة الدموية بالقدم نتيجة الجراحة‬
‫ويرجع ذلك للتحضير الجيد والدراسة الجيدة لحالة الشرايين واألوردة المغذية للساق والقدم‪.‬‬
‫التوصية‬
‫‪ -1‬ان استخدام الشرائح العضلية بالساق لتغطية قصور األنسجة المغطية لعظام الساق والقدم‬
‫آمن إذا تم بدراسة ودقة لوظيفة العضلة واإلستعانة بھا دون اإلضرار الجسيم بالوظيفة‬
‫الحركية لھذه العضلة‪.‬‬
‫‪ -2‬ان مقارنة استخدام الشريحة العضلية ) العضلة النعلية( بغيرھا من طرق معالجة القصور‬
‫في األنسجة المغطية للجزء األسفل من عظمة الساق كالشريحة الحرة والتي تعتمد علي‬
‫الجراحة الميكروسكوبية المتقدمة لھو في صالح استخدام الشريحة العضلية النعلية لما فيھا‬
‫من سھولة إجرائھا و كذلك إبقاء الشريان المغذي للقدم )الشريان الظنبوبي الخلفي( علي‬
‫حالتة وعدم تعريضة للتلف‪.‬‬
‫‪ -3‬أحيانا يكون التوجه إلستخدام العضلة النعلية لتغطية العظام او التھاب العظام المكشوفة‬
‫للجزء األسفل من الساق ومفصل القدم القريب إلزاميا ًوذلك لعدم وجود بديل‪.‬‬
‫‪ -4‬التحضير الجيد وانتقاء الحاالت لما يناسبھا من طرق العمليات المختلفة ‪.‬‬

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