basic concepts relevant to the design and reconstruction

www.elsevier.com/locate/injury

Injury, Int. J. Care Injured (2008) 39S4, S55– S66

0020–1383/$—see front matter © 2008 Published by Elsevier Ltd.doi:10.1016/j.injury.2008.08.032

Basic concepts relevant to the design anddevelopment of the Point Contact Fixator (PC-Fix)

Stephan M. Perren andJoy S. Buchanan

AO/ASIF Research Institute, Clavadelerstrasse, 7270 Davos, SwitzerlandAO/ASIF Research Institute, Clavadelerstrasse, 7270 Davos, Switzerland

KEYWORDS:One silly fountain;Progressive dwarves;Umpteen mats;Five silly trailers;

Summary1 bla bla bla bla One aardvarkmarries the pawnbroker, even though fivebourgeois cats tickled umpteen Macintoshes, but two obese elephants drunkenlytowed umpteen almost irascible sheep. Two bureaux easily telephoned Paul, eventhough the wart hogs gossips, but one elephant tastes partly putrid wart hogs,because umpteen purple botulisms kisses Mark, although the subways bought oneextremely angst-ridden lampstand, even though five obese televisions perusedsubways, then five progressive mats auctioned off the bureau, although two trail-ers grew up, but irascible Jabberwockies untangles five speedy fountains, yet onecat ran away, then the trailer very cleverly kisses two irascible bureaux.

Introduction

Soft-tissue defects of limbs commonly occur in thecontextofhigh-energy trauma.Standard reconstruc-tive paradigms serve as a broad guide to planningthat can be tailored to the demands of the situation.Simpler reconstructive options such as secondaryintention healing, delayed primary closure or skingrafting have a role in smaller defects or where tis-sue loss has not left important or relatively poorlyvascularised tissues exposed.

Frequently, however, amoredurableandexpedientsoft-tissue coverage is required. Particular areas inlimbs require thin and pliable fasciocutaneous flapsto reconstruct soft-tissue defects, especially in thedistal parts of limbs and knee and elbow joints. Thereare many conventional retrograde-flow pedicle flapsfor limb reconstruction that require harvesting ofmajor vessels such as the radial forearm retrogradeflow [19], the ulnar artery reverse-flow flap [20,21, 33], the anterior tibial artery reverse-flow flap[37] and the posterior tibial artery reverse-flow flap[25]. These flaps have notably contributed to distallimb reconstruction because large areas of relativelythin skin and fascia with a robust blood supply could

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

Kanit Sananpanich1, Yuan Kun Tu2, Jirachart Kraisarin1, Preecha Chalidapong1

1 Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2 Department of Orthopedics, E-DA Hospital, Kaohsiung Country, Taiwan

KEYWORDS:Perforator flap,neurocutaneous flap,vascular injury,skin coverage.

Summary1 We report on 45 pedicle perforator flaps without harvesting majorvessels in limb reconstruction. Of our patients, 25 had major vessel injury result-ing from their initial injury. In the upper extremities, there were 13 posteriorinterosseous artery perforator flaps, four ulnar artery perforator flaps and threeradial artery perforator flaps. In the lower extremities, there were 16 peronealartery perforator flaps with an axis on the sural nerve, five peroneal artery perfo-rator flaps with an axis on the superficial peroneal nerve and four posterior tibialartery perforator flaps with an axis on the saphenous nerve. There were 42 suc-cesses, one total flap loss, one epidermal necrolysis and one distal tip necrosis.Greater utilisation of pedicle perforator flaps probably will occur because theyare technically simple to execute, violate only the involved extremity, do not sac-rifice a major source vessel, bring similar local tissues into a defect, avoid pro-longed immobilisation and do not require microsurgical expertise. The concept ofthe pedicle perforator flap can be applied to the same axis of a neurocutaneousflap, even in cases with injured cutaneous nerves.

1 Abstracts in German, French, Spanish, Japanese andRussian are printed at the end of this supplement.

S56 K Sananpanich et al

be harvested from within the same surgical fieldand transferred without the need for microvasculartechnique in a single-stage procedure that facilitatedpostoperative elevation and early mobilisation.However, several drawbacks to these flaps have be-

come apparent with collective experience. Sacrificeof the major vessels may lead to acute ischaemia ofthe limb [30]. Some surgeons recommended routinevein-graft reconstruction after radial forearm flapharvesting, although there is a risk of Morbidity ofdonor site and skin-graft loss with tendon exposure,and a displeasing appearance of the skin grafted do-nor site [9, 47]. More importantly, this issue precludestheir use inpatientswithclinically absentorquestion-able distal vascular communications, for example,distal radial-ulnar communication in a reverse flowradial forearm flap. These limitations, together withadvances in knowledge of angiosome [27, 45, 46],neurocutaneous flap [5, 35, 48, 44] and perforatorflap [8] concepts, have driven the development ofalternative pedicle perforator flaps.Therearepossiblereconstructiveoptionsthatcould

be undertaken without sacrificing a major artery tothe limb, including theposterior interosseous forearmflap [10, 41, 53], the dorsoulnar flap [2], the ulnarartery perforator flap [52], the neurocutaneous flapaxis in upper extremities [5], the radial artery pedicleperforator flap [18, 28, 48], the neurocutaneous flapaxis in lower extremities [35], the sural artery flap[3, 4, 23, 42], the lateral supramalleolar flap [34] andthe saphenous neurocutaneous flap [12, 13].This report describes the results of pedicle perfora-

tor flaps from forearms and legs to cover soft-tissuedefects in an adjacent area. This technique could

preserve major vessels in the limbs and be operatedwithout distal major vascular communication. Itcould also be applied similarly to the neurocutaneousflap, even in cases with cutaneous nerve trauma.

Patients and methods

We retrospectively analysed the patients who un-derwent procedures using pedicle perforator flapsbetween January 2001 and December 2005. A total of45 patients (10 females, 35 males) with a mean ageof 33 years (range 5−76 years) were included. All flapswere nourished by perforator branches without har-vesting the major vessels in those limbs. Five arterieswere sources of the pedicle perforator flaps, includ-ing a radial artery pedicle perforator, an ulnar arterypedicle perforator, a posterior interosseous pedicleperforator, a posterior tibial artery pedicle perforatorand a peroneal artery pedicle perforator flap (Table 1,Figure 1). All these cases presented with exposure ofvital structures that required early soft-tissue cover-age. Data collection included source vessel of perfora-tor, length and axis of pedicle, flap size, site of defectand donor and the result of the flap coverage.

Operative technique

The perforators were identified by audible handheldDoppler examination (IMEXDOP CT +, CTX-0198, USA)in every patient prior to the operation. Most of theperforators connected with each other longitudinallyby anastomoses, along the course of the main artery.

Figure 1. Pedicle perforator flaps in upper extremity:a) reverse flow radial artery perforator pedicle flap,b) reverse flow ulnar artery perforator pedicle flap andc) reverse flow posterior interosseous pedicle perforator

flap.

Pedicle perforator flaps in lower extremity:d) posterior tibial artery perforator pedicle flap,e) reverse flow peroneal artery perforator flap on super-

ficial peroneal nerve axis andf) reverse flow peroneal artery perforator flap on sural

nerve axis.Asterisk (*) are sites of perforator detected by handheldaudible Doppler. Highlighted areas are usual sites of flapharvesting.

Reconstruction of limb soft-tissue defects S57

These vessels formed a deep fascial plexus and werearranged longitudinally along the main arterial axis.There are some reduced-caliber choke anastomosesoriented transversely between the perforators of themain arteries. These anastomoses form a plexus ofhorizontally oriented perforators. This informationis clinically useful for planning the skin flaps with aDoppler probe [49, 50].Typeof flap selectiondependson the donor site availability and the choice of clos-est distance between the defect and the donor. Theshortest pedicle that did not cause tension or exces-sive torsion was selected. The extent and size of theflap was planned to be sufficient to reach to the de-fect. The axis of each flap was plotted on perforatorswhich were determined by Doppler detection. Thesuperficial vein and cutaneous nerve was used as thereliable guideline for the flap axis [5, 38].

Reverse flow radial artery perforator pedicle flap

The arterial inflow was based only on the septocuta-neous perforator arising from the distal radial artery

at 2−8 cm proximal to the radial styloid [51]. Thepivot point was determined by site of the last one ortwo perforators detected. The flap axis was usuallyclose to a cephalic vein, the superficial radial nerveand the lateral cutaneous nerve of forearm [7]. Anincision was planned between the flap and the pivotpoint that would enable elevation of thin skin flaps toexpose the adipofascial pedicle. The fasciocutaneousflap was raised from proximal to distal on a 3−4 cmwide adipofascial tissue that included deep fascia,the antebrachial nerve and a cephalic vein as a pivotpoint. Care was taken to preserve the integrity of thesuperficial radial nerve and its branches. It was pos-sible to restore the sensate flap by neurotisation of asuitable sensory nerve stump to the proximal lateralcutaneous nerve of the forearm [28].

Reverse flow ulnar artery perforator pedicle flap

The ulnar artery produces a dominant perforatorcalled the dorsal ulnar artery (DUA) at 2−4 cmproximal to the pisiform bone. DUA and its venae

Table 1. Pedicle perforator flap in this series, source of perforator, axis of flap, names of flap in other articles andnumber of patients in this report

Source ofperforator

Axis of flap Name of flap in previous articles No.

radial artery lateral cutaneous nerve offorearm, superficial radialnerve, cephalic vein

distally based radial forearm fasciosubcutaneous flap withpreservation of the radial artery [48]retrograde-flow neurocutaneous (lateral forearm cutaneous nerve)island flap [7]distally based forearm island flap perfused by the perforators of thedistal radial artery [28]island adipofascial flap based on distal perforators of the radialartery [18]reversed forearm island flap supplied by the septocutaneousperforator of the radial artery [51]

3

ulnar artery medial epicondyle topisiform, medial cutaneousnerve of forearm, basilicvein

dorsal ulnar artery flap [2]ulnar artery perforator flap [52]retrograde-flow neurocutaneous (medial forearm cutaneous nerve)island flap [7]Flap based on the fasciocutaneous perforator of the ulnar artery [26]

4

posteriorinterosseousartery

lateral epicondyle to DRUJ posterior interosseous flap [10, 41, 53]posterior interosseous artery perforator flap [43]

13

posteriortibial artery

saphenous nerve, greatersaphenous vein

skin island flaps supplied by the vascular axis of the sensitive super-ficial nerves (saphenous nerve) [35]Posterior tibial perforator-based flap [31]Reversed saphenous neurocutaneous island flap [12]

4

peronealartery

superficial peroneal nerve,between extensor digi-torum longus tendon andperoneus brevis tendon

lateral supramalleolar flap [34]skin island flaps supplied by the vascular axis of the sensitive super-ficial nerves (superficial peroneal nerve) [35]

5

peronealartery

sural nerve, lesser saphen-ous vein

skin island flaps supplied by the vascular axis of the sensitive super-ficial nerves (sural nerve) [35]posterolateral malleolar flap, sural neurocutaneous flap [40]sural artery flaps [4, 23, 42]sural neurofasciocutaneous flaps [3]lesser saphenous venofasciocutaneous flap [15]

16


comitantes pass deep to themusculotendinous junc-tion of the flexor carpi ulnaris muscle and divide intoascending and descending branches. The ascendingbranch forms the vascular basis of a reverse flowulnar artery perforator flap up to 5−9 cm wide and10−20 cm long [2].The tissue requirements were determined by the

cut-to-fit template of the defect. The required pedi-cle length was measured from the proximal edge ofthe defect and the pivot point was determined byDoppler detection. The flap wasmarked along an axisbetween the ulnar artery’s perforators .Flap eleva-tion commenced proximally and proceeded distally ina subfascial plane toward thepivotpoint.Adipofascialtissue 2−3 cm in width was included in the pedicle toprotect the fine vessels in the pedicle. The flap wasthen rotated and inset into the defect.

Reverse flow posterior interosseous arteryperforator pedicle flap

Retrograde perfusion depends on intact distal com-munication between the anterior and posteriorinterosseous arteries (PIA), which may be approxi-mately 5% absent [16].The pivot point of this flap was 2 cm proximal to

the distal radioulnar joint (DRUJ), which should beexplored before flap elevation to ensure the distalanastomosis of the interosseous arteries. Flap axiswas from the DRUJ and the lateral epicondyle orbetween the extensor digiti minimi (EDM) and theextensor carpi ulnaris (ECU), the vessels of whichwere identified on the septum. The planned ulnarborder of the flap was incised next and elevated ina subfascial plane toward the septum. Retractingthe ECU muscle in an ulnar direction facilitated thevisualisation of the septocutaneous perforator andthe pedicle. Following radial incision and retraction,the EDM was completed. Dissection of the septumand pedicle with ligation or cautery of muscularbranches continued until the flap was attachedonly by the septum containing the intact PIA. Afterconfirming adequate retrograde flow, the flap wasislanded and rotated to inset into the defect.

Posterior tibial artery pedicle perforator flap

Perforators from the posterior tibial artery nourishthe leg skin on themedial aspect along the axis of theleg. According to the anatomical studies of Masque-let et al [35], the arterial axis of the saphenous nerveprovides many minute branches to the skin and thesuprafascial plexus and has 2−7 anastomoses to theseptal perforating branches of the tibialis posterior

artery. Pedicle perforator flaps can be designed ona reverse flow or a proximal basis. On a proximalbasis, using superior perforators, the flap can coverdefects on the proximal two-thirds of the leg involv-ing the knee region. For reverse flow pedicles usinglower perforators, the flap can be used to resurfaceskin defects from distal leg to foot [31].Tissue requirements were determined by the cut-

to-fit template of the defect. The required pediclelength was measured from the defect and the pivotpoint, which was determined by Doppler detection.The flap was marked along an axis between the pos-terior tibial artery perforators. Flap elevation com-menced in a subfascial plane toward the pivot point.Adipofascial tissue 2−3 cm in width was included inthe pedicle to protect the fine vessels in the pedicle.The flap was then rotated and inset into the defect.Due tohigh incidenceof venous congestion in reverseflow saphenous neurocutaneous flap, venal branulewas inserted into the proximal stump of the saphe-nous vein, which was used for intermittent venousbleeding in cases of venous congestion [17].

Reverse flow peroneal artery pedicle perforatorflap

Four to five perforators arise from the peronealartery, occupying a zone 5−13 cm above the tip oflateral malleolus [24]. There are two axes of theperoneal artery perforator reverse flow with a pivotpoint at ankle level.First, a sural neurocutaneous flapwasaccompanied

by a sural nerve and lesser saphenous vein, which washalfway between the Achilles tendon and the lateralmalleolus distally, and on the midline between thetwo heads of the gastrocnemius muscle proximally.Second, the lateral supramalleolar flap was moreanterior along the septum between the extensor digi-torum longus and the peroneus brevis [34], whichwasaccompanied by the superficial peroneal nerve. Theperforating branch of the posterior peroneal arteryemerged from the groove between the tibia and fibu-lar just proximal to the distal tibiofibular ligamentswhere it perforated the interosseous membrane 5 cmabove the lateral malleolus. It was possible to extendthe proximal end of the flap to a level halfway up thefibula. The design of the flap must not overlap theposterior margin of the fibula.After Doppler detection, every effort was made to

incorporate these perforators into the flap, whichoften determined the point of rotation. Tissue re-quirements were determined by the cut-to-fit tem-plate of the defect. The required pedicle length wasmeasured from the defect and the pivot point. Flapelevation commenced proximally and proceeded


distally in a subfascial plane toward the pivot point.Adipofascial tissue 2−3 cm in width was included inthe pedicle to protect its fine vessels. The flap wasthen rotated and inset into the defect.

Figure 2a) A 23-year-old man sustained an open fracture distalradius, Gustilo type 3C, with radial artery rupture andskin loss. Finger flexor tendons and median nerve wereexposed. b) Preoperative evaluation with handheld Dop-pler to detect perforators of ulnar artery, a ulnar arteryperforator flaps 6.5 x 10.5 cm was elevated to cover theskin defect. c) Final result showed good motion of allfingers with good median nerve sensation.

Results

In this series of 45 cases, pedicle perforator flapswere used in 20 upper extremity cases and 25lower extremity cases. In the upper extremities,there were 13 posterior interosseous artery perfo-rator flaps, four ulnar artery perforator flaps andthree radial artery perforator flaps. In the lowerextremity, there were 16 peroneal artery perfo-rator flaps with an axis on the sural nerve, fiveperoneal artery perforator flaps with an axis onthe superficial peroneal nerve and four posteriortibial artery perforator flaps with an axis on thesaphenous nerve (Table 2). Of the 45 patients, 25had major vessel injury from their initial injury. Inthese cases, conventional flaps with major vesselelevation were contraindicated.41 flaps had good perfusion and survived com-

pletely. One reverse flow posterior tibial arterypedicle perforator flap had early venous congestionand completely survived by intermittent bleeding(Case 21). One peroneal artery pedicle with anaxis on the sural nerve had diabetic vasculopathyand suffered total flap necrosis and required lateramputation (Case 30). One peroneal artery pedi-cle perforator flap with an axis on the superficialperoneal nerve for heel coverage developed anepidermal necrolysis from an arterial insufficiencyand required skin grafting (Case 29). In this case, wetried to elevate the flap with superficial peronealnerve separation and preservation, which may bethe reason for the arterial insufficiency. One pero-neal artery pedicle perforator flap with an axis onthe sural nerve 6 x 12.5 cm in size developed distaltip necrosis. This case recoveredwith simple woundcare, debridement and resuturing (Case 43).

Example case reports

Case 5: Ulnar artery perforator pedicle flap forwrist coverage with radial artery rupture

A 23-year-old man sustained an open fracture ofthe distal radius, Gustilo type 3C, with radial arteryrupture and skin loss. Finger flexor tendons and themedian nerve were exposed (Figure 2a). Debride-ment and external fixation was performed on thedate of the injury. Preoperative evaluation withhandheld Doppler to detect perforators of ulnarartery was undertaken. 3 days after the injury,ulnar artery perforator flaps 6.5 x 10.5 cm wereelevated to cover the skin defect (Figure 2b). Thefinal result showed good motion of all fingers withgood median nerve sensation (Figure 2c).

A)

B)

C)


Table 2. Pedicle perforator flap, summary of patients

No. Source ofperforator

Age Sex Diagnosis Vascular injury Pedicle(cm)

Dimen-sion(cmxcm)

Result

1 radial 26 m crushed hand, skin loss radial hand radial, 1st web 9 3.8x7 CS

2 radial 16 m blast hand injury, skin loss rightthumb

palmar arch 7.2 3.5x4.5 CS

3 radial 38 f cicartricial scar, carpal tunnel no 1.5 3x5 CS

4 ulnar 23 m shot gun injury, open fracture radius radial, wrist 3 5.2x10.4 CS

5 ulnar 23 m open fracture distal radius, skin loss Radial, wrist 4.5 6.5x10.5 CS

6 ulnar 13 m blast hand injury, ulnar skin defect palmar arch 3.5 5.5x9.5 CS

7 ulnar 41 m synovial sarcomar, palmar hand no 3.5 4.7x5.3 CS

8 posteriorinterosseous

45 f crushed hand, skin loss dorsal radial, 1st web 7.5 5.5x6.5 CS


23 f skin necrosis dorsal hand no 6.5 5.5x9 CS


44 m 1st web contracture radial, 1st web 7.6 3.3x7.2 CS


16 m 1st web contracture radial, 1st web 10.5 3.5x6.5 CS


23 m crushed hand, skin loss dorsal palmar arch 6.5 4.5x6.5 CS


20 m crushed hand, skin loss dorsal no 10.5 3.5x10.5 CS


16 m shot gun injury, ulnar skin bone loss ulnar, hand 9 4x9.5 CS


33 f car accident, skin avulsion dorsal radial, 1st web 8.7 5.3x8.5 CS


56 m saw injury, scar dorsal hand no 5.8 3.7x7.9 CS


19 m crushed hand, skin loss dorsal no 8.8 5.2x9.2 CS


51 m chronic ulcer, skin tendon loss dorsal no 11.5 3x4 CS


14 m blast hand injury, exposed stump radial, 1st web 7.2 5.3x11.4 CS


16 m blast hand injury, exposed stump radial, 1st web 6.7 5.5x12.3 CS

21 posteriortibial

10 m skin loss dorsal foot dorsalis pedis,foot

9 4.3x7 CS(venousconges-tion)

22 posteriortibial

44 f skin necrosis proximal tibia no 4 3.6x4 CS

23 posteriortibial

69 f skin necrosis knee no 7.5 4x7 CS


24 posteriortibial

26 m open floating knee fracture no 9 4.5x9 CS

25 peroneal(SP)

6 m chronic ulcer, heel no 4.5 3.5x4.5 CS

26 peroneal(SP)

14 m crushed ankle injury, achilles tendon no 5.5 5x8.7 CS

27 peroneal(SP)

69 f crush injury, heel defect posterior tibial,ankle

4.5 4.2x7.9 CS

28 peroneal(SP)

23 f crush injury, heel and foot defect posterior tibial,ankle

5.2 5.5x12.4 CS

29 peroneal(SP)

29 m crush injury, heel defect no 5.3 5.4x9.7 EN

30 peroneal(SR)

76 f crush injury, dorsal foot, DM anterior tibial,ankle

7 7x11.5 TN

31 peroneal(SR)

59 m open fracture tibia, exposed distaltibia

anterior tibial,leg

7.5 5.5x8 CS

32 peroneal(SR)

61 m chronic ulcer, exposed distal tibia no 7 5.5x9.5 CS

33 peroneal(SR)


anterior tibial,leg

3.5 5.3x7.7 CS

34 peroneal(SR)


anterior tibial,leg

6 6.5x11.5 CS

35 peroneal(SR)

5 m crush injury, heel defect no 6 4.5x6 CS

36 peroneal(SR)

36 m open fracture tibia, exposed hard-ware

no 8 4x6.5 CS

37 peroneal(SR)

11 m ankle and foot scar contracture,medial

posterior tibial,ankle

2 6.5x18 CS

38 peroneal(SR)

18 m open fracture tibia IIIC, exposeddistal tibia

anterior tibial,leg

6 8x15 CS

39 peroneal(SR)

56 f skin necrosis leg, exposed extensortendon

anterior tibial,leg

8 4x5 CS

40 peroneal(SR)

57 m pressure sore skin necrosis, Heel no 3 5x12 CS

41 peroneal(SR)

17 m open fracture dislocation, anteriorankle

anterior tibial,leg

4.5 6.5x14.5 CS

42 peroneal(SR)

49 m soft tissue sarcomar, anterior mid leg no 9 6x9.5 CS

43 peroneal(SR)

26 m parosteal sarcomar tibia middlethird

no 7 6x12.5 PN (10%)

44 peroneal(SR)

56 m chronic ulcer, lateral heel no 8 4x6.5 CS

45 peroneal(SR)

40 m open fracture tibia, expose distaltibia

anterior tibial,leg

6.7 4.5x7.3 CS

Result of operation: CS = complete survival, PN = partial necrosis, CN = complete necrosis, EN = epidermal necrolysisPeroneal (SP): Peroneal artery perforator flap on superficial peroneal nerve axisPeroneal (SR): Peroneal artery perforator flap on sural nerve axis


Case 21: Reverse flow posterior tibial arteryperforator pedicle flap for foot coverage

A 10-year-old boy was injured during a pedestrianaccident. His right foot sustained skin, dorsalispedis artery and tendon loss with bone exposure(Figure 3a). A reverse flow posterior tibial arteryperforator flap 4.3 x 7 cm was elevated and rotated

Figure 3a) A 10-year-old boy whose right foot sustained skin, dor-salis pedis artery and tendon loss with bone exposure. b)The patient had a good range of motion of his foot andankle at the 17th month after coverage with reverse flowposterior tibial perforator pedicle flap.

to cover the skin defect. The venal branule wasinserted into the proximal stump of the saphenousvein, which was used for intermittent venous bleed-ing during venous congestion that occurred on thethird to seventh days. The flap completely survivedafter a bleeding procedure that relieved severe ve-nous congestion. At the 17th month postoperatively,the patient had a good range of motion of his footand ankle (Figure 3b).

Case 23: Proximal base posterior tibial arteryperforator pedicle flap for knee coverage

A 69-year-old woman was diagnosed with malignantfibrous histocytoma. She had a chronic ulcer on theright knee after receiving brachy-radiotherapy andwide excision (Figure 4a). Posterior tibial arteryperforators were detected along the course of thesaphenous nerve and vein. The pedicle perforatorflap 4 x 7 cm was elevated and rotated to cover theskin defect at knee. The postoperative course wassmooth and there was no postoperative infection orcombined flap necrosis (Figure 4b).

A)

B)

Figure 4a) A 69-year-old female sustained a chronic ulcer on theright knee after receiving brachy-radiotherapy and wideexcision. b) Posterior tibial artery pedicle perforatorflap 4 x 7 cm was elevated and rotated to cover the skindefect at the knee.

A)

B)


Case 31: Peroneal artery perforator flap on thesural nerve axis with a sural nerve injury

A 59-year-old man sustained an open fracture,Gustilo 3C, of the right tibia and fibula during alawnmower accident. There was a skin defect on theanterior aspect with a rupture of the sural nerve,the anterior tibial artery and the extensor tendons(Figure 5a). Despite a sural nerve tear, the intactperforators of the peroneal artery were detectedby handheld Doppler proximal to the scar of theinjured sural nerve. Reverse flow pedicle perfora-tor flap 5.5 x 8 cm from the peroneal artery baseon the sural nerve axis was elevated and rotated tocover the skin defect (Figure 5b). The postoperativecourse was smooth and the flap survived unevent-fully (Figure 5c).

Figure 5a) A 59-year-old man sustained an open fracture, GustiloIIIC, of right tibia and fibula during a lawnmower acci-dent. There was a skin defect on the anterior aspect witha rupture of the sural nerve, anterior tibial artery andextensor tendons. b) Despite a sural nerve tear (whitearrow), intact perforators (white asterisk) of peronealartery were detected by handheld Doppler proximal tothe scar of the injured sural nerve. Reverse flow pedicleperforator flap 5.5 x 8 cm from the peroneal artery baseon the sural nerve axis was elevated and rotated to coverthe skin defect. c) The wound healed primarily and theflap survived uneventfully.

A)

B)

C)


Discussion

In 1989, Isao Koshima was the first surgeon to namea perforator flap [32]. Neurocutaneous flaps are anexcellent example of indirect, nonmuscular perfora-tor flaps.These flaps rely onan intrinsic andextrinsicneurocutaneous or venocutaneous vascular supplythat accompanies a peripheral cutaneous nerve.Often, the extrinsic vascular supply can be a trueartery. Depending on the nerve, both structurescan simultaneously pierce the deep fascia beforeproceeding within the subcutaneous tissue [6, 22,35, 38]. In an upper extremity, Bertelli [7] intro-duced the concept of a neurocutaneous flap whosearterial vascularisation is provided by the vascularplexus around and inside the cutaneous nerve. Theyreportedon reversedneurocutaneous island flaps forreconstructions in the distal third of the forearm.The flap is distally based on a pedicle that includesthe lateral antebrachial cutaneous nerve and thecephalic vein. The blood is supplied to the flap bythe paraneural vascular plexus, which is formed byperforators from the radial artery. Because vesselsthat “hitchhike” with the cutaneous nerves [44]serve as a vascular relay between perforators fromsource vessels [35], pedicles of neurocutaneous flapson any reliable perforator are feasible.In various articles, different surgeons have used dif-

ferentnames for thesameflap,whichhasobviously ledto substantial confusion [39]. For example, the super-ficial sural artery flap [23], distally based sural islandflap [29], sural neurocutaneous flap [35, 40], lessersaphenous venofasciocutaneous flap [15] and veno-neuroadipofascial sural flap [38] have all been used fora similar area and axis. Irrespective of the name, theblood supply for this flap comes from a similar source,theperforators of theperoneal artery.Thename“neu-rocutaneous flap” may mislead surgeons into thinkingof an axial nerve flap. However, the nerve itself maynot even need to be included [15], although this couldresult in compromised flap viability. One of our caseexamples with sural nerve injury still had successful aresult from a distally based sural axis flap (Case 31). Inthis case,we detected perforators proximal to the siteof the sural nerve injury. Therefore, the blood supplyand the pivot point were designed on intact perfora-tors that confirmed a “relay” or “link” pattern of theneurocutaneous flap [14].The reverse flow posterior interosseous flap has

shown its reliability and versatility in widespreadexperiences [1, 36, 43, 53]. Recently, it has also beenincluded in the pedicle perforator flap type [43]. Ourcase series report uses the name “pedicle perfora-tor flap” because all of the flaps were nourished byperforator vessels and all the major vessels in thoselimbs were preserved.

Soft-tissue defects with vital structure exposurerequire early coverage and reconstruction. Success-ful soft-tissue reconstruction of the wound providesa critical means for limb salvage and still representsa formidable challenge to orthopaedic and plasticsurgeons. In the past decade, free-tissue transferhas been considereda standard surgical procedureofchoice for large soft-tissue reconstruction of woundsin some areas such as the distal part of the extrem-ity and the knee and elbow region. Flow-throughfree tissue transfer has been used for simultaneousmajor vascular and soft-tissue defect reconstruction[11]. However, not all surgeons or hospitals maybe equipped to undertake microvascular free flapsurgery and postoperative flap monitoring. Patientsmay not be candidates for free-tissue transfer be-cause of their overall medical conditions, ie, unableto tolerate prolonged general anaesthesia or noncompliance with proper postoperative care afterfree tissue transfer. Free-tissue transfer may resultin flap donor site morbidity remote to the injuredextremity. Therefore, in these situations, simplersurgical procedures are more suitable.Conventional fasciocutaneous retrograde-flow

pedicle flaps provide large areas of relatively thinskin and fascia with a robust blood supply from thesame operative field without microvascular anas-tomosis. However, when a major vessel is injured,these flaps should be avoided because further ia-trogenic vascular injury may lead to vascular insuf-ficiency of the limb. Furthermore, there is a highchance of flap necrosis because these flaps needretrograde blood supply from distal major vascularcommunication. Therefore, in themajor vessel inju-ry situation, pedicle perforator flap should be betterthan conventional fasciocutaneous retrograde-flowpedicle flaps.In our case series report, the success rate was 42

out of 45 cases, which is comparable to other re-ports. Baumeister et al reported 36% necrosis in 70reverse sural artery flaps in a high risk multimorbidelderly group [4]. Their results revealed the fol-lowing risk factors that can potentially impair suc-cessful defect coverage and thus contribute to flapcomplications: concomitant diseases, particularlydiabetes mellitus; peripheral arterial disease orvenous insufficiency, which increase the risk of flapnecrosis 5−6-fold and patient age over 40 years, be-cause of an increased rate of comorbidity, underlyingosteomyelitis and the use of a tight subcutaneoustunnel. These risk factors may explain one of ourtotal necrosis cases with diabetic vasculopathy os-teomyelitis in a 76-year-old woman (Case 30).From a technical view point, we agree with Naka-

jima that wide pedicle supra fascial flap elevation,including cutaneous vein and nerve, is the most


reliable and easiest method for a neurocutaneousperforator flap [38]. Separation and an attempt topreserve the cutaneous axis nerve may cause arte-rial insufficiency (Case 29). Venal branule, beinginserted into proximal stump of cutaneous vein, canbe used for intermittent venous bleeding in caseswhere venous congestion occurs [17] (Case21). Per-forator mapping is clinically useful in planning skinflaps with a Doppler probe [49] and we recommendthis procedure in every case.The weaknesses in this report are that it is a

descriptive retrospective study with a moderatenumber of patients. The mean age of our patients isyoung (33 years), which may have a positive effecton survival rate. However, our case series reportpresents a variety of options for pedicle flaps inboth upper and lower extremities based on perfora-tor vessels.Greater utilisation of pedicle perforator flaps

probably will occur because they are technicallysimple to execute, violate only the involved extrem-ity, do not sacrifice a major source vessel, bringsimilar local tissues into a defect, avoid prolongedimmobilisation and do not require microsurgical ex-pertise [22]. The concept of the pedicle perforatorand “relay” or “link” vascular plexus on vein andcutaneous nerve is important because the designof the flap can depend on any point of the reliableperforator. Modification of the pivot point dependson the perforator rather than the constant distant,as was reported recently [54].

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Corresponding author

Kanit Sananpanich, M.D.Department of Orthopedics, Faculty of Medicine,Chiang Mai University, Chiang Mai 50200, ThailandPhone +66-53-945544Fax +66-53-946442email: [email protected]

This paper has been written entirely by the authors, andhas received no external funding. The autors have nofinancial interest or other relationship.

basic concepts relevant to the design and reconstruction

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