Reverse Sural Artery Flap: Anatomic Study of Peroneal Perforators and Modifications for Coverage of Medial and Distal Foot Defects
Xiao Zhu, MD1, Guilherme Barreiro, MD, PhD2.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2State University of Campinas (UNICAMP), Sao Paulo, Brazil.
BACKGROUND: The Reverse Sural Artery Flap (RSAF) is a powerful option for coverage of ankle, heel, and foot defects. We describe peroneal perforator distribution in cadaveric legs, and our clinical experience with four novel modifications (perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, proximal peroneal artery ligation) to allow greater reach for the RSAF, especially for medial and distal forefoot defects.
METHODS: 38 cadaveric legs were dissected to identify peroneal perforators along the length of the fibula. Details regarding fibula length, total number of perforators, and perforator location/diameter/length were obtained for every leg. 12 patients between 5-73 years-old underwent the RSAF and the described modifications for a variety of defects, including those along the medial and distal forefoot. Patient demographics, flap dimensions, perforator location/length, pivot point, modifications, and complications were reported.
RESULTS: There were on average 3.63 perforators per cadaveric leg. The terminal perforator had an average length of 4.10 cm, and was found a mean distance of 10.96 cm above the lateral malleolus. The majority (70.1%) of terminal perforators was located between 60-80% of the fibular length, or 6.76-13.52 cm proximal to the lateral malleolus, and only 10.6% was found within the last 20% (within 6.76 cm). These results were comparable to those found in our clinical series, where the terminal perforator in adults was identified on average 9.3 cm from the lateral malleolus. However, due to improved perforator/pedicle mobility provided by the described modifications, the pivot point was able to be lowered to a mean distance of 6.7 cm. Of the 12 patients that underwent RSAF, all received perforator skeletonization and Achilles tendon release. Four were tunneled under the Achilles tendon for medial foot defects, and one received proximal peroneal artery ligation for further reach. Two had <10% distal tip necrosis and one had 50% superficial epidermolysis, all of which healed with local wound care.
CONCLUSIONS: This study highlights the effectiveness of four novel modifications to the RSAF: perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, and proximal peroneal artery ligation. Furthermore, anatomic studies demonstrate that the terminal peroneal perforator may lie higher than the recommended 5 cm pivot point above the lateral malleolus, making these modifications crucial in some cases. With proper technique, these modifications can allow the RSAF to cover defects along the medial and distal forefoot, making the RSAF an even more versatile local reconstructive option for distal lower limb defects.
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