A 45-year-old patient has a 6 cm × 4 cm full-thickness skin defect over the anterior tibia following debridement of an infected wound. There is exposed bone with viable periosteum. The most appropriate reconstruction using the reconstructive ladder is:

• A Split skin graft directly over the bone
• B Pedicled fasciocutaneous flap (e.g., reverse sural flap) ✓
• C Dermal substitute (e.g., Integra) followed by split skin grafting
• D Free muscle flap (e.g., free latissimus dorsi) with anastomosis

Explanation

Exposed bone over the anterior tibia with viable periosteum but no muscle coverage cannot be covered with a split skin graft alone as periosteum, though present, does not reliably allow graft take on exposed cortical bone. A local or regional fasciocutaneous flap (reverse sural artery flap for distal tibia/heel defects) provides well-vascularised soft tissue coverage. Free flaps are reserved when local options fail or the defect requires bulk. Dermal substitutes (Integra) over bone require periosteum for incorporation.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.