Propeller flap as a workhorse for distal leg reconstruction in a limited resource setting: a case series

Objective. To report the experience of using propeller perforator flaps for reconstructing distal third leg and ankle defects at the National Orthopaedic Hospital, Enugu, between January and July 2025.

Case series. Six propeller perforator flaps were performed in five patients (aged 13-49 years). Flaps were based on the posterior tibial artery (n = 5) and the anterior tibial artery (n = 1). The perforator was identified using a handheld Doppler, skeletonized, and the flaps were rotated. All secondary donor defects were covered with split-thickness skin grafts. Indications included soft tissue loss from open tibiofibular fractures (n = 5) and post-traumatic ankle contracture (n = 1).
Propeller flaps were chosen over reverse sural flaps due to traumatic or iatrogenic injury to the sural pedicle (n = 4) and as a primary option without any sural pedicle damage (n = 2).

Four flaps survived completely. One developed venous congestion and was managed with negative pressure wound therapy, debridement, and skin grafting. The flap survival rate was 66.67% (n = 4/6) and the salvage rate was 50% (n = 1/2). One anterior tibial artery flap was lost and replaced with a posterior tibial artery propeller flap, which healed successfully.

Conclusion. Propeller perforator flaps demonstrated favourable outcomes in distal third leg and ankle reconstructions, even serving as an effective salvage option after flap failure. They offer reliable coverage and should be considered as a primary option in the reconstructive armamentarium for lower limb defects in resource-limited settings.