A Supercharged Pedicled PTAP-Saphenous Flap for Distal Lower-Limb Reconstruction.

BACKGROUND: In distal lower-limb reconstruction, reverse-flow pedicled flaps remain vulnerable to venous congestion and partial flap loss, particularly after crush injury or major trauma, in elderly or comorbid patients and when longer flaps are required. We evaluated a standardized distally-based pedicled posterior tibial artery perforator (PTAP)-plus saphenous flap with planned supercharging and a temporary cutaneous bridge to reinforce venous outflow in that high-risk subset. METHODS: A retrospective study of 26 consecutive reconstructions (2010-2025) performed under a uniform protocol by the senior author was conducted. Inclusion criteria comprised patients at high risk for flap loss, defined by crush injury or major trauma; elderly or patients with relevant comorbidities; and longer flaps targeting distal reach. Preoperative Doppler identified the most distal reliable perforator as pivot. Supercharging was performed end-to-end between the saphenous system and a superficial vein near the defect. RESULTS: Twenty-six patients (21 men, 5 women; mean age, 34 years; range, 18-61 years) underwent reconstruction. Trauma accounted for 21 cases. Defects were located in the lower leg (n = 15), ankle (n = 9), and foot (n = 2). Tibia or ankle joint was exposed in 18 cases and tendons in 8. Venous supercharging was performed using a GSV branch in 23 flaps and the LSV in 3. Mean flap size was 5 × 16 cm (width range, 4-7 cm; length range, 7-20 cm); mean distal perforator distance from the medial malleolus was 9 cm (range, 5-12 cm). The estimated mean arc of rotation was 100° (range, 90°-150°). Complete survival occurred in 24/26 flaps (92.3%). CONCLUSIONS: A "tripedicled," routinely supercharged PTA perforator plus saphenous flap, combined with a skin pedicle, provided reliable coverage of distal-leg, ankle, and foot defects with a low rate of flap loss. Based on our data and experience, this configuration is feasible and safe for crush injuries, elderly/comorbid patients, and longer flaps.