Vasculature of the peroneal artery: an anatomic study focused on the perforator vessels

Based on the dissection of 20 fresh cadaver legs, the authors have further defined the vascular anatomy of the peroneal artery and its cutaneous perforator vessels. They identified a total of 95 cutaneous perforators of the peroneal artery greater then 0.3 mm in 20 legs. The average number of cutaneous perforators was 4.8 (range: three to seven) per leg. The cutaneous perforators were either musculocutaneous (34 percent) or septocutaneous (66 percent). The musculocutaneous perforators were found predominantly in the upper two-thirds of the lower leg; the septocutaneous perforators were located in the lower two-thirds of the leg. The external diameter of the cutaneous perforators at the posterior border of the fibula was 0.6 (range: 0.3 to 1.5) mm. The blood supply of the proximal fibula epiphysis and fibula head was found not to be in the vascular territory of the peroneal artery. These results are the basis of the established osteoseptocutaneous fibula transfer, the peroneal fasciocutaneous free flap, and the double-paddle peroneal tissue transfer that all require dissection of highly vascularized tissue adjacent to the fibula, in order to reach the peroneal vessels. These constant anatomic findings should encourage the surgeon to harvest skin flaps just to the level of the posterior border of the fibula, thereby creating perforator flaps based on the peroneal system.     

Rare variant of the intrasoleus musculocutaneous perforator: clinical considerations in raising a free peroneal osteocutaneous flap

To improve the stability of the cutaneous portion of the vascularized free peroneal osteocutaneous flap (the so-called peroneal flap), various anatomic studies have been conducted, and a reliable notion of the course of cutaneous perforators has been provided; however, anatomic anomalies have occasionally been observed. The authors encountered a rare type of cutaneous perforator in the distal third of the lower leg. It was located under the inferior surface of the flexor hallucis longus muscle, after running in the soleus muscle parallel to the fibula, and then joined the posterior tibial artery. Since absolutely definite diagnostic methods have not been established for the course of the cutaneous perforator, surgery with the possibility of secondary anastomosis, always with a separate peroneal flap, should be a consideration.     

Peroneal osteocutaneous flap raised on reconstructed popliteal artery for delayed union following open tibial fractures

Two cases of delayed union following type IIIC open tibial fracture were treated by a pedicled peroneal osteocutaneous flap raised on reconstructed popliteal vessels. Dissection of the peroneal vessels from the already traumatized extremity was tedious, but this technique provided a reliable vascularized skin and bone graft that was indispensable for the fracture healing. Peroneal osteocutaneous flaps raised on the reconstructed popliteal artery have not been reported to date; they appear to be a good alternative to free osteocutaneous flaps for non-union of the proximal tibia. © 1997 Wiley-Liss, Inc. MICROSURGERY 17:230–237 1996     

Retrospective analysis of incidence of peroneal artery hypoplasia in 101 free fibula transfers and new classification of popliteal branch anomalies

It is generally recognised by surgeons that there are anatomical variations of the popliteal artery and its branches, and knowledge of these has important clinical implications for fibula flap harvest. The aim of this study was to report our experience on 101 fibula free flaps, highlighting a new type of anatomical variation of the peroneal artery in a patient undergoing osteocutaneous fibula free flap for tibial reconstruction. During flap harvest, the peroneal vascular pedicle was shown to be hypoplastic and aberrant to its origin, branching between the proximal and medium third of the leg from the posterior tibialis artery with a diameter of 1 mm. A modification of Kim's classification with the addition of a further “type IIID” group is suggested, to include peroneal artery hypoplasia or aplasia. This is an uncommon case of a rare infrapopliteal branching pattern that was undetected clinically and sonographically, exposing both the surgeon and patient to high risk of flap failure and/or leg ischaemic complication. Surgeons conducting free fibula transfer surgery should be aware of such a possibility as well as other variations, and could consider performing routine angiographic study on the donor limb, or they may be skilful enough to apply instant tricks to enable them to conduct the procedure safely.     

Successful management of free osteocutaneous fibula flap with anomalous vascularity of the skin paddle

The free osteocutaneous fibula flap is an established method of reconstruction of maxillary and mandibular defects. The vascularity of the skeletal and the cutaneous components is provided by the peroneal artery via the nutrient artery and the septo- and musculocutaneous perforators. In rare situations, these perforators may arise from other major leg arteries. In such circumstances, the procedure has to be either abandoned or modified so that neither the vascularity of the flap nor the donor limb is compromised. We present a case of an anomalous musculocutaneous perforator, which originated from the proximal part of the posterior tibial artery, passed through the soleus muscle and supplied the skin paddle. The flap was elevated as a single composite unit and was managed by two separate vascular anastomosis at the recipient site, one for the peroneal vessels and the other for the anomalous perforator.     

Flow‐through fibula flap using soleus branch as distal runoff: A case report

The flow‐through fibula flap utilizing the soleus branch as a distal runoff has not yet been reported. We herein present a patient with left tibial adamantimoma in whom wide resection of the tumor resulted in a segmental tibial defect 22 cm in length. The defect was successfully reconstructed with a flow‐through free fibula osteocutaneous flap using the soleus branch of the peroneal artery as a distal runoff. The short T‐segment of the peroneal artery was interposed to the transected posterior tibial artery. The soleus branch has a constant anatomy and a larger diameter than the distal stump of the peroneal artery. Short interposed flow‐through anastomosis to the major vessels is much easier and more reliable than the conventional methods. We believe that our method represents a versatile option for vascularized fibula bone grafting for extremity reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013     

The 'superficial' peroneal artery: a variation in cutaneous branching from the peroneal artery, nourishing the distal third of the leg.

Two different vascular patterns were encountered in cutaneous branches from the peroneal artery to the posterolateral aspect of the distal third of the leg in 22 flaps from 22 patients who underwent cutaneous or osteocutaneous peroneal flap surgery. In the type 1 vascular pattern, a branch from the peroneal artery, named the 'superficial peroneal artery', nourished the posterolateral aspect of the leg by splitting into several septocutaneous branches. In the type 2 pattern a few septocutaneous branches originated directly from the main peroneal artery and nourished the same area as that fed by the type 1 branch. The type 1 vascular pattern has not been reported to date but was seen in nine out of the 22 consecutive peroneal flaps. The superficial peroneal artery, with its considerable vascular diameter, may serve as a recipient vessel for free flaps or may serve as a donor nutrient vessel for a cutaneous flap, which can be transferred without sacrificing the main peroneal artery. Awareness of these two vascular patterns in the distal third of the leg should also help to reduce the small percentage of skin-flap failures that occur when the cutaneous or osteocutaneous peroneal flap is used.     

Inadvertent injury of critical perforator vessels during perforator flap surgery

Despite the widespread use of perforator flaps, little has been reported about the inadvertent injury of perforator vessels. We report a retrospective study of the inadvertent injury of perforator vessels. From 1992 through 2010, we transferred 467 free perforator flaps (314 anterolateral thigh [ALT] flaps, 99 fibula osteocutaneous flaps, 46 deep inferior epigastric perforator [DIEP] flaps, and 8 other flaps). Inadvertent injury of perforator vessels occurred in seven patients. The overall incidence was 1.5%. The rate of the injury was 0.95% with ALT flaps, 2.0% with fibula osteocutaneous flaps, and 4.3% with DIEP flaps. Of seven, six flaps were salvaged through anastomosis of the injured perforator vessels. Perforator injuries resulted more often from mishandling of perforator vessels than from dissection technique. Anastomosis of injured perforators is a practical salvage procedure that requires high microsurgical skill.     

An anatomic study of the superficial peroneal nerve accessory artery and its perforators, and clinical application of superficial peroneal nerve accessory artery perforator flaps

In the 1990s, skin island flaps supplied by the vascular axis of sensitive superficial nerves, like the sural and saphenous nerves, were introduced. Flaps supplied by the superficial peroneal nerve accessory artery (SPNAA), however, are still not commonly used. The aim of this study is to understand the anatomic structure of the SPNAA and its perforators in the anterior intermuscular septum and to use SPNAA perforator flaps in the clinic. We dissected 16 cadavers and assessed the location and number of the SPNAA, its perforators, and the septocutaneous perforators originating from the anterior tibial artery. A SPNAA perforator flap was applied to 12 patients, the free flap was applied to 11 patients, and the pedicled flap was applied to 1 patient. SPNAA varied from 7 to 16 cm in length, with an average of 4.5 perforators to supply the lateral aspect. An average of 3.13 septocutaneous perforators originated from the anterior tibial artery. The mean size of the SPNAA perforator flaps was 65.5 cm. The complete follow-up period was 3-20 months. Although 1 flap was lost as a result of arterial thrombosis, the procedure was successful in the remaining 11 patients. In addition, reduced flap thickness made them more esthetically appealing. SPNAA perforator flaps could be an excellent alternative to perforator flaps that use the lower leg as a donor site.     

Use of fibula pedicle as a composite interposition vascular graft to salvage large skin paddle with anomalous vascular supply

We report a case of free fibula osteomyocutaneous flap whose skin paddle had a dominant blood supply from a soleus musculocutaneous perforator which originated in the posterior tibial artery in addition to contribution from the peroneal septocutaneous perforators and was managed by two sets of anastomosis on either side of the neck, one for the peroneal vessels and the other for the dominant musculocutaneous perforator. The second anastomosis was achieved by using the excess length of the flap pedicle vessels (peroneal) as composite (both artery and vein) autologous interposition vascular graft to reach the opposite side of the neck.     

小腿前外侧岛状皮瓣修复胫骨外露的解剖研究与临床应用

目的 探讨小腿前肌间隔动脉链为蒂的岛状皮瓣修复胫骨外露的术式及手术方法.方法 40侧成人尸体下肢标本经动脉灌注红色乳胶,4侧新鲜成人尸体下肢标本动脉造影,观测小腿前肌间隔内的胫前动脉穿支与腓动脉终末前穿支的位置、走行、外径及相互吻合.临床应用小腿前外侧岛状皮瓣转位修复胫骨外露11例.男7例,女4例;年龄20～59岁,平均36岁.结果 40侧标本腓骨长度为(32.3±2.4)cm.胫前动脉发出腓浅动脉、胫前动脉下段前肌间隔穿支,与腓动脉终末前穿支在小腿前肌间隔内相互吻合,形成动脉链,这三条动脉外径分别为(1.4±0.4)mm、(1.0±0.4)mm及(1.5±0.4)mm,动脉链吻合处外径为(0.6±0.2)mm.动脉链伴腓浅神经走行,营养神经和小腿前外侧皮肤.临床应用小腿前外侧岛状皮瓣修复胫骨外露的11例中,以胫前动脉下段前肌间隔穿支为蒂2例,以胫前动脉下段前肌间隔穿支的升支为蒂3例,以胫前动脉下段前肌间隔穿支的降支为蒂3例,以腓动脉终末前穿支升支为蒂3例.皮瓣切取面积7 cm×5 cm～13 cm×5 cm.随访1～3年,平均1.5年,11例皮瓣全部成活,无破溃、臃肿.结论 根据皮肤缺损部位、面积等灵活选用小腿前肌间隔内动脉链为血管蒂,设计前外侧岛状皮瓣修复胫骨外露,术式灵活,是修复胫骨外露的理想皮瓣.

Abstract：

Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.     

Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases

The authors reviewed retrospectively the clinical results of 51 consecutive cases of vascularized osteocutaneous fibular graft to the tibia for the reconstruction of extensive tibial bone and soft-tissue defects. The mean duration of follow-up was 31 months (range: 13 to 76 months). In the 51 procedures of free vascularized osteocutaneous fibula graft from the contralateral side, bony union was achieved in 48 cases at an average of 3.74 months after the operation, except for two cases of non-union and two cases of delayed union. Forty-eight cutaneous flaps survived, and three cutaneous flaps failed due to deep infection and venous thrombosis. All united fibulae hypertrophied during the follow-up periods. Stress fracture of the grafted fibula was the most common complication (16 cases), and it was treated with above-the-knee cast immobilization or internal fixation with a conventional cancellous bone graft. The free vascularized osteocutaneous fibular graft is recommended as a useful treatment modality for the reconstruction of extensive tibial defects combined with soft tissue injury.     

Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet. © 2014 Wiley Periodicals, Inc. Microsurgery 34:629–632, 2014.     

Reconstruction of limb soft-tissue defects: using pedicle perforator flaps with preservation of major vessels, a report of 45 cases

SUMMARY: We report on 45 pedicle perforator flaps without harvesting major vessels in limb reconstruction. Of our patients, 25 had major vessel injury resulting from their initial injury. In the upper extremities, there were 13 posterior interosseous artery perforator flaps, four ulnar artery perforator flaps and three radial artery perforator flaps. In the lower extremities, there were 16 peroneal artery perforator flaps with an axis on the sural nerve, five peroneal artery perforator flaps with an axis on the superficial peroneal nerve and four posterior tibial artery perforator flaps with an axis on the saphenous nerve. There were 42 successes, one total flap loss, one epidermal necrolysis and one distal tip necrosis. Greater utilisation of pedicle perforator flaps probably will occur because they are technically simple to execute, violate only the involved extremity, do not sacrifice a major source vessel, bring similar local tissues into a defect, avoid prolonged immobilisation and do not require microsurgical expertise. The concept of the pedicle perforator flap can be applied to the same axis of a neurocutaneous flap, even in cases with injured cutaneous nerves.     

跗外侧动脉蒂小腿前外侧皮瓣的解剖基础与临床应用

目的 探讨跗外侧动脉蒂小腿前外侧皮瓣的解剖特点,以及修复足前部缺损的可行性.方法取20条经动脉灌注红色乳胶的成人下肢尸体标本,解剖观察其跗外侧动脉、腓动脉外踝上穿支、腓浅动脉等血管的分支、走行和吻合.据此设计跗外侧动脉蒂小腿前外侧皮瓣,对8例足前部组织缺损患者进行带蒂皮瓣转移修复.足背皮肤软组织缺损5例,足底皮肤软组织缺损3例.足前部缺损范围5 cm×4 cm ～ 9 cm×5 cm.供区游离植皮或直接缝合.跗外侧动脉、腓动脉穿支、胫前动脉穿支、腓浅动脉相互吻合,在足外侧、外踝前、小腿前外侧形成一条纵行血管轴.皮瓣范围6 cm×4 cm ～ 10 cm×6 cm.结果 术后8块皮瓣全部成活.所有患者均获随访,随访6～12个月,平均8个月,皮瓣色泽、质地、外形良好,皮瓣无溃疡发生.患者能自由行走.结论 以跗外侧动脉为蒂切取小腿前外侧皮瓣,皮瓣血运可靠,血管蒂长,可修复足前部任何区域,供区损伤小.     

Combined osteocutaneous microvascular flap procedure for extensive bone and soft tissue defects in the tibia

Recent experience with bone healing seems to advocate vascularized bone grafts in cases of large bone gaps or significant scarring, following irradiation, in the presence of low-grade infection, and in congenital pseudarthrosis of the tibia. When extensive bone and skin replacement are needed, the microvascular procedures currently available may not meet specific reconstructive requirements. To augment the advantages of the vascularized fibular graft for tibial substitution (strength, straightness, length, and predictability of vascular supply) with the benefits of free skin, muscle, or musculocutaneous flaps, separate on-demand harvesting of these tissue units and their microvascular combination can be useful in selected cases. In a study of 4 patients, the vascularized fibula was combined with a free latissimus dorsi flap. The procedure was facilitated and shortened by connecting the peroneal vessels to branches of the thoracodorsal or to the scapular circumflex artery and vein outside the operative field. The main supporting vessels of the combined composite tissue block were then anastomosed only to one pair of vessels in the leg.     

应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.     

Free vascularized osteocutaneous fibular graft to the tibia

We reviewed the clinical results of reconstruction performed for extensive tibial bone and soft tissue defect with a free vascularized osteocutaneous fibular graft in 46 patients (43 male and 3 female). The mean duration of follow-up was 30 months (range 13-76 months). The mean age at the time of reconstruction was 41 years (range 15-66 years). In the 46 consecutive procedures of free vascularized osteocutaneous fibular grafts, bony union was achieved in 43 grafted fibulae at an average of 3.75 months after operation. There were two delayed unions and one non-union. Forty-four cutaneous flaps survived, and two cutaneous flaps failed due to deep infection and venous insufficiency. One necrotized cutaneous flap was replaced with a latissimus dorsi free flap and the other with a soleus muscle rotational flap without replacing the grafted fibulae; unions were obtained without significance complications. All grafted fibulae hypertrophied during the follow-up periods. The most common complication was fracture of the grafted fibulae in 15 patients, and it occurred at an average of 9.7 months after the reconstruction. The fractured fibulae were treated with long leg above-the-knee cast immobilization or internal fixation with conventional cancellous bone graft. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone graft.     

穿支皮瓣移植修复四肢软组织缺损108例

目的 探讨应用穿支皮瓣修复四肢皮肤软组织缺损的临床效果. 方法2007年7月至2009年5月,分别采用腹壁下动脉穿支皮瓣、股前外侧穿支皮瓣、胸背动脉穿支皮瓣、股外侧穿支皮瓣、骨间背侧动脉穿支皮瓣、桡侧副动脉穿支皮瓣、腓肠内侧动脉穿支皮瓣、胫后动脉穿支皮瓣、旋髂深动脉穿支皮瓣、腓动脉穿支皮瓣移植修复四肢皮肤软组织缺损108例(游离移植98例,带蒂转移10例),皮瓣切取面积最小4 cm×2 cm,最大44 cm×9 cm,皮瓣供区均直接缝合.结果 术后5例发生静脉危象,其中1例松解包扎后危象解除,4例再次手术探查,2例成活,2例坏死,其余103例顺利成活,皮瓣受区与供区创121愈合良好.术后随访6-24个月(平均10个月),皮瓣颜色、质地好,外形不臃肿;皮瓣供区遗留线性瘢痕,功能无影响. 结论穿支皮瓣不携带肌肉、深筋膜及运动神经,对皮瓣供区影响小,还具有血供可靠、质地薄、不需二期去脂整形的优点,是修复四肢浅表创面的首选方法.