Early results of the distally based medial hemisoleus muscle flap in high-risk patients: A case series


  • Lance J. Johnson, DPM The Reconstruction Institute, The Bellevue Hospital, Bellevue, Ohio, USA
  • Paul Leatham, DPM The Reconstruction Institute, The Bellevue Hospital, Bellevue, Ohio, USA
  • Peter D. Highlander, DPM The Reconstruction Institute, The Bellevue Hospital, Bellevue, Ohio, USA; Associate Clinical Professor, University of Toledo College of Medicine & Life Sciences, Toledo, Ohio, USA
  • Coleman O. Clougherty, DPM The Reconstruction Institute, The Bellevue Hospital, Bellevue, Ohio, USA; Cleveland Lower Extremity Specialists, Cleveland, OH, USA


lower extremity, limb salvage, heel ulceration, wound dehiscence, diabetes


The lower one-third of the leg, ankle, and posterior heel are devoid of robust soft tissue coverage. Coverage of exposed tendons, hardware, and bone can be challenging. The distally based medial hemisoleus flap is a viable option for soft tissue coverage. The medial hemisoleus flap is supplied by perforators from the posterior tibial artery. Complications of the flap are low, ranging around 8-20%; the most common complication is partial necrosis due to venous congestion. Patients with comorbidities are more prone to partial or complete flap loss and subsequent major amputation. The purpose of this study is to present a case series of medial hemisoleus flaps in high-risk patients with follow-up of 40-52 weeks. We present a case series of five multi-comorbid patients that underwent treatment of osteomyelitis for posterior heel wounds or chronic ankle wounds due to Charcot deformity. Patients were treated with surgical debridement, pathogen directed parenteral antibiotic therapy if indicated, deformity correction, if applicable, and distally based medial hemisoleus flap coverage of wounds. In contrast to free flaps, it allows for shorter operating time and does not necessitate microsurgical experience. The flap has a relatively low complication rate in the literature. In the setting of venous congestion and partial flap necrosis, this can often be managed with various techniques to prevent total flap loss. At follow-up of at least 40 weeks, the medial hemisoleus is a reliable procedure for soft tissue coverage of the lower leg, ankle, and posterior heel.


Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality After Nontraumatic Major Amputation Among Patients With Diabetes and Peripheral Vascular Disease: A Systematic Review. J Foot Ankle Surg. 2016 May-Jun;55(3):591-9. doi: 10.1053/j.jfas.2016.01.012. Epub 2016 Feb 19. PMID: 26898398.

Chopra A, Azarbal AF, Jung E, Abraham CZ, Liem TK, Landry GJ, Moneta GL, Mitchell EL. Ambulation and functional outcome after major lower extremity amputation. J Vasc Surg. 2018 May;67(5):1521-1529. doi: 10.1016/j.jvs.2017.10.051. Epub 2018 Mar 1. PMID: 29502998.

Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J. 2016 Oct;13(5):892-903. doi: 10.1111/iwj.12404. Epub 2015 Jan 20. PMID: 25601358; PMCID: PMC7950078.

Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003 Feb;26(2):491-4. doi: 10.2337/diacare.26.2.491. PMID: 12547887.

Darter BJ, Hawley CE, Armstrong AJ, Avellone L, Wehman P. Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature. J Occup Rehabil. 2018 Dec;28(4):656-665. doi: 10.1007/s10926-018-9757-y. PMID: 29397480; PMCID: PMC6076349.

Kaptein S, Geertzen JHB, Dijkstra PU. Association between cardiovascular diseases and mobility in persons with lower limb amputation: a systematic review. Disabil Rehabil. 2018 Apr;40(8):883-888. doi: 10.1080/09638288.2016.1277401. Epub 2017 Jan 27. PMID: 28129515.

van Schaik L, Geertzen JHB, Dijkstra PU, Dekker R. Metabolic costs of activities of daily living in persons with a lower limb amputation: A systematic review and meta-analysis. PLoS One. 2019 Mar 20;14(3):e0213256. doi: 10.1371/journal.pone.0213256. PMID: 30893346; PMCID: PMC6426184.

Batten HR, McPhail SM, Mandrusiak AM, Varghese PN, Kuys SS. Gait speed as an indicator of prosthetic walking potential following lower limb amputation. Prosthet Orthot Int. 2019 Apr;43(2):196-203. doi: 10.1177/0309364618792723. Epub 2018 Aug 16. PMID: 30112982.

Pu LLQ. Further experience with the medial hemisoleus muscle flap for soft-tissue coverage of a tibial wound in the distal third of the leg. Plast Reconstr Surg. 2008 Jun;121(6):2024-2028. doi: 10.1097/PRS.0b013e318171240c. PMID: 18520891.

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 Jan;58(1):78-83. doi: 10.1097/01.sap.0000250744.62655.38. PMID: 17197948.

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 Jan;115(1):245-51. PMID: 15622258.

Pu LL. The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg. Ann Plast Surg. 2006 Jan;56(1):59-63; discussion 63-4. doi: 10.1097/01.sap.0000185465.45380.26. PMID: 16374098.

Tobin GR. Hemisoleus and reversed hemisoleus flaps. Plast Reconstr Surg. 1985 Jul;76(1):87-96. doi: 10.1097/00006534-198507000-00015. PMID: 4011783.

Kauffman CA, Lahoda LU, Cederna PS, Kuzon WM. Use of soleus muscle flaps for coverage of distal third tibial defects. J Reconstr Microsurg. 2004 Nov;20(8):593-7. doi: 10.1055/s-2004-861516. PMID: 15630652.

Houdek MT, Wagner ER, Wyles CC, Sems SA, Moran SL. Reverse Medial Hemisoleus Flaps for Coverage of Distal Third Leg Wounds: A Technical Trick. J Orthop Trauma. 2016 Apr;30(4):e138-42. doi: 10.1097/BOT.0000000000000491. PMID: 26606601.

Rabbani MJ, Haq AU, Riaz A, Tarar MN, Aslam F. Distally Based Medial Hemisoleus Flap: Reliable Option for Distal Tibial Wounds. J Coll Physicians Surg Pak. 2018 Feb;28(2):129-132. doi: 10.29271/jcpsp.2018.02.129. PMID: 29394973.

Rosado P, Cheng HT, Wu CM, Wei FC. Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: a systematic review and meta-analysis. Head Neck. 2015 Apr;37(4):615-8. doi: 10.1002/hed.23624. Epub 2014 Apr 3. PMID: 24532197.

Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg. 2011 Jul;128(1):173-180. doi: 10.1097/PRS.0b013e3182173d3a. PMID: 21399565.

Kramers-de Quervain IA, Läuffer JM, Käch K, Trentz O, Stüssi E. Functional donor-site morbidity during level and uphill gait after a gastrocnemius or soleus muscle-flap procedure. J Bone Joint Surg Am. 2001 Feb;83(2):239-46. doi: 10.2106/00004623-200102000-00012. PMID: 11216686.

Riccio M, Zingaretti N, Verdini F, Marchesini A, De Francesco F, Parodi PC. Functional donor-site morbidity after soleus muscle-flap procedure in the treatment of lower limb severe injuries. Handchir Mikrochir Plast Chir. 2019 Dec;51(6):453-463. English. doi: 10.1055/a-0972-1247. Epub 2019 Nov 7. PMID: 31698488.

Schierle, C. F., Rawlani, V., Galiano, R. D., Kim, J. Y., Dumanian, G. A. (2009). Improving outcomes of the distally based hemisoleus flap: principles of angiosomes in flap design. Plastic and reconstructive surgery, 123(6), 1748-1754.

Wiewiorski M, Barg A, Hoerterer H, Voellmy T, Henninger HB, Valderrabano V. Risk factors for wound complications in patients after elective orthopedic foot and ankle surgery. Foot Ankle Int. 2015 May;36(5):479-87. doi: 10.1177/1071100714565792. Epub 2014 Dec 30. PMID: 25550453.

de Blacam C, Colakoglu S, Ogunleye AA, Nguyen JT, Ibrahim AM, Lin SJ, Kim PS, Lee BT. Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis. J Plast Reconstr Aesthet Surg. 2014 May;67(5):607-16. doi: 10.1016/j.bjps.2014.01.044. Epub 2014 Feb 7. PMID: 24662152.

Peters EJ, Lavery LA, Armstrong DG. Diabetic lower extremity infection: influence of physical, psychological, and social factors. J Diabetes Complications. 2005 Mar-Apr;19(2):107-12. doi: 10.1016/j.jdiacomp.2004.06.002. PMID: 15745841.

Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am. 2010 Feb;92(2):287-95. doi: 10.2106/JBJS.I.00080. PMID: 20124054.

Wukich DK, Crim BE, Frykberg RG, Rosario BL. Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery. J Bone Joint Surg Am. 2014 May 21;96(10):832-9. doi: 10.2106/JBJS.L.01302. PMID: 24875024; PMCID: PMC4018772.

Wukich DK, McMillen RL, Lowery NJ, Frykberg RG. Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes. Diabetes Care. 2011 Oct;34(10):2211-3. doi: 10.2337/dc11-0846. Epub 2011 Aug 4. PMID: 21816974; PMCID: PMC3177737.

Whalen JL, Spelsberg SC, Murray P. Wound breakdown after total ankle arthroplasty. Foot Ankle Int. 2010 Apr;31(4):301-5. doi: 10.3113/FAI.2010.0301. PMID: 20371016.

SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am. 2009 May;91(5):1042-9. doi: 10.2106/JBJS.H.00653. PMID: 19411451.

Hill SL, Holtzman GI, Buse R. The effects of peripheral vascular disease with osteomyelitis in the diabetic foot. Am J Surg. 1999 Apr;177(4):282-6. doi: 10.1016/s0002-9610(99)00050-1. PMID: 10326843.

Otte J, van Netten JJ, Woittiez AJ. The association of chronic kidney disease and dialysis treatment with foot ulceration and major amputation. J Vasc Surg. 2015 Aug;62(2):406-11. doi: 10.1016/j.jvs.2015.02.051. Epub 2015 May 1. PMID: 25937604.

Valabhji J. Foot problems in patients with diabetes and chronic kidney disease. J Ren Care. 2012 Feb;38 Suppl 1:99-108. doi: 10.1111/j.1755-6686.2012.00284.x. PMID: 22348369.




How to Cite

Lance, Paul, Peter, Coleman. Early results of the distally based medial hemisoleus muscle flap in high-risk patients: A case series. J Int Foot Ankle [Internet]. 2021 Dec. 31 [cited 2022 Jan. 19];1(1). Available from: https://internationalfootankle.org/journal/index.php/JIFAF/article/view/4