Lateral sural cutaneous artery island flap in the treatment of soft tissue defects at the knee

Versatility of Proximal Sural Island Sensate Fasciocutaneous Flap in Reconstruction of Soft Tissue Defects of Knee and Proximal Leg

Background: The proximal sural island sensate (PSIS) fasciocutaneous flap presents an ideal alternative in reconstruction of defects of the knee and proximal leg. It provides a thin sensate flap with good aesthetic outcomes and reduced donor site morbidity. However, only limited reports exist in the literature about this flap.Methods: This is a retrospective study done between December 2018 and December 2021 including 30 patients, among which seven cases had defects located on the knee and 23 cases in the proximal part of the leg. Mean age of the study population was 41 years. The maximum flap size was 8×12 cm, while the maximum pedicle length was 15 cm.Results: All 30 flaps survived well with only minimal complications occurring in a few patients such as epidermal loss and distal tip necrosis. No arterial or venous crisis occurred postoperatively in any case. Donor sites were managed with one-stage primary closure or split-thickness skin grafts. Functional deficits were not detected in any of the cases.Conclusion: We found the PSIS fasciocutaneous flap to be a simple and reliable technique to perform. The flap offers extensive coverage, reaching from the knee to the proximal leg, and provides thin, pliable, and sensate skin, resulting in excellent aesthetic and functional outcomes.

A Novel Fasciocutaneous Flap Design for Reconstructions in Scarred Tissue: A Case Report

This article aims to introduce a technically easy and reliable flap design for the coverage of soft tissue defects in areas where traditional flap options are limited by trauma or scarring. We applied the boomerang design in cases with defects around the knee and also extrapolated it to other regions like the wrist and sacrum. Patients with soft tissue defects in regions with scarred tissues or limited flap reconstructive options were recruited. The procedures resulted in uneventful recovery and excellent cosmetic outcomes for the patients. The authors of this article recommend the usage of this uncomplicated flap design in areas with otherwise limited flap options due to restricted vascularity or surrounding scar tissue.

Free neurosensory flap based on the accompanying vessels of lateral sural cutaneous nerve: anatomic study and preliminary clinical applications

BACKGROUND

The posterior aspect of the leg is an ideal donor site for flap surgery. In this study, the anatomy was investigated of the lateral sural cutaneous nerve (LSCN) and its accompanying artery, superficial lateral sural artery (SLSA), and a lateral sural neurocutaneous flap was designed.

METHODS

Five fresh adult cadaver legs perfused with red latex were dissected to observe the course and relationship between LSCN and SLSA. The outer diameter of SLSA at its origin was measured. Then a lateral sural neurocutaneous flap was designed and used to repair soft tissue defects in six patients.

RESULTS

The anatomic results showed that the SLSA gave rise to branches that followed the LSCN and ramified into terminals at the ramification of the nerve. It originated directly from the popliteal artery 4.2 ± 0.2 mm above the fibular head, where its outer diameter was 0.96 ± 0.23 mm. Several perforators penetrated from the crural fascia and anastomosed to the SLSA, creating a fine anastomotic network. The clinical results showed that the size of the flap ranged from 12 × 6 cm to 25 × 8 cm. All six flaps survived completely without complications. Follow-up ranged from 6 to 18 months with 11 months on average. The overall contour and sensory recovery of the flap were satisfied.

CONCLUSION

A free innervated flap may be elevated safely based on the LSCN and its accompanying vessels. It provides an alternative in reconstruction of soft tissue defects where sensory recovery is important.

Lower limb perforator flaps: Current concept

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

Comparison of the outcomes of adipofascial and two-staged fasciocutaneous reverse sural flap in patients with lower leg trauma

BACKGROUND

Distal one - third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature.

MATERIAL & METHODS

In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months.

RESULTS

The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment.

DISCUSSION

Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity.

CONCLUSION

Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.

Soft Tissue Coverage for Defects around the Knee Joint

Soft tissue injuries around the knee present a challenge for providing a cover when there is loss of tissue. Various flaps comprising of skin and muscles around the joint have been described. Understanding the anatomical basis and the design of these flaps can aid in choosing the right flap for a given situation. A prompt cover of the defects aids in quicker healing and quicker rehabilitation of the patient.

Pedicled Peroneal Artery Perforator Flap for Knee Defect Reconstruction: Case Presentation and Literature Discussion

There have been very limited data on the use of pedicled peroneal artery perforator flaps in knee soft-tissue reconstruction, especially for anterior and medial defects. Here, we present a case of proximally based peroneal artery perforator flap for knee soft-tissue reconstruction in a defect that included lateral, anterior, and medial surfaces of the knee presenting the technical challenges associated with this flap. A 15-year-old girl presented with extruded knee implant after osteosarcoma resection of femur. The defect involved the whole knee with the anterior and mostly the lateral knee surfaces. Her medical condition precluded the use of free tissue transfer. During her previous surgery, gastrocnemius muscles were detached with injured vascular pedicled and posterior tibial artery. Successful single-stage coverage was achieved using a large proximally based pedicled peroneal artery perforator flap. There are only few reports that described the use of peroneal artery flaps for knee soft-tissue coverage. The reach of a proximally based flap can be increased when it is raised on a distal perforator or when peroneal artery has a proximal takeoff. Furthermore, removing the fibula can facilitate the dissection and the reach of the flap till the most medial aspect of the knee. Pedicled peroneal artery perforator flap provides superior soft-tissue coverage with limited morbidity for knee soft-tissue reconstruction; however, flap reach is usually affected by anatomic variation. Preoperative planning can help to determine the reach of the flap and ease the dissection.

Locating the sural nerve during calcaneal (Achilles) tendon repair with confidence: a cadaveric study with clinical applications

The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve crosses the lateral border of the Achilles tendon, an important surgical landmark. In most cases, the sural nerve crossed the lateral border of the Achilles tendon 8 to 10 cm proximal to the superior border of the calcaneal tuberosity. By simply measuring the leg length of the patient (from the base of the heel to the flexor crease of the popliteal fossa), surgeons can approximate the location of this intersection point with an interval length of 0.68 to 1.80 cm, with 90% confidence, or 0.82 to 2.15 cm, with 95% confidence. For example, for a patient with a lower leg length of 47.0 cm, the mean measurement in the present study, a surgeon can be 90% confident that the sural nerve will cross the lateral border of the Achilles tendon 8.28 to 8.96 cm (interval width of 0.68 cm) proximal to the calcaneal tuberosity. Currently, ultrasound and clinical techniques have been implemented to approximate the location of the sural nerve. The results of the present study offer surgeons another method, that is less intensive, to locate reliably and subsequently avoid damage to the sural nerve during calcaneal (Achilles) tendon repair and other procedures of the posterolateral leg and ankle.

Locating the sural nerve during calcaneal (Achilles) tendon repair with confidence: a cadaveric study with clinical applications

The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve crosses the lateral border of the Achilles tendon, an important surgical landmark. In most cases, the sural nerve crossed the lateral border of the Achilles tendon 8 to 10 cm proximal to the superior border of the calcaneal tuberosity. By simply measuring the leg length of the patient (from the base of the heel to the flexor crease of the popliteal fossa), surgeons can approximate the location of this intersection point with an interval length of 0.68 to 1.80 cm, with 90% confidence, or 0.82 to 2.15 cm, with 95% confidence. For example, for a patient with a lower leg length of 47.0 cm, the mean measurement in the present study, a surgeon can be 90% confident that the sural nerve will cross the lateral border of the Achilles tendon 8.28 to 8.96 cm (interval width of 0.68 cm) proximal to the calcaneal tuberosity. Currently, ultrasound and clinical techniques have been implemented to approximate the location of the sural nerve. The results of the present study offer surgeons another method, that is less intensive, to locate reliably and subsequently avoid damage to the sural nerve during calcaneal (Achilles) tendon repair and other procedures of the posterolateral leg and ankle.

The pediculated gastrocnemius muscle flap as a treatment for soft tissue problems of the knee - indication, placement and results

With the increase of endoprosthetic knee replacements, there is also an increase of critical wounds to the knee due to a high incidence of soft tissue problems (ranging from wound healing defects to severe wound infections). The literature describes a general rate of soft tissue complications of up to 20% [1], [2], with 5% [3] involving exposed bone. These complications are an increasingly important problem for surgeons. Since sufficient coverage of bones, tendons and prosthetic material with soft tissue is a necessity, the use of a pediculated muscle flap is the only solution in some cases. The gastrocnemius muscle is very useful for this purpose. It is an elaborate procedure which is associated with a high rate of complications. However, this procedure can establish a secure coverage with soft tissue, and the function of the prosthesis and the patient’s extremity can be saved. We have treated 23 patients with a gastrocnemius rotation flap after knee prosthesis or knee arthrodesis infection with consecutive soft tissue damage at our hospital from 8/2004 through 3/2011. The overall rate of healing of the knee infections with stable soft tissue status is almost 87%. The revision rate with lifting of the flap and revision of the sutures at the point of insertion as well as the point of extraction was about 35% with long-term conservative or additional surgical treatments.

The anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: clinical cases and anatomic study

Soft-tissue reconstruction of traumatic patella and proximal tibial defects is challenging. Pedicled perforator-based adipocutaneous rotation flaps are a versatile local option as they have axial perfusion and greater freedom of transposition compared with random-pattern flaps, and replace the ideal tissue properties of this anatomic region.

EXPERIMENTAL

Anatomic dissections were performed on 15 fresh cadaver legs and location of the dominant perforator measured. Clinical: A retrospective review was conducted at the University of Maryland/R Adams Cowley Shock Trauma Center evaluating patients over a 3-year period.

EXPERIMENTAL

Cadaver dissections confirmed a principal perforator at 11.4 +/- 1.6 cm inferior to the patella. This vessel is consistently suitable in length and caliber for large rotation flap design. Clinical: Anterior tibial artery perforator flaps were performed on 4 patients following Gustilo IIIB wounds to the patella and tibial plateau. Two patients had rotation flap reconstructions to salvage failed gastrocnemius muscle flaps. All flaps were successful, however, one patient had overwhelming hardware infection several months later despite successfully healed flap.Local anterior tibial artery perforator flaps based on predictable perforators provide reliable coverage of patella and knee defects, bestowing versatility and flexibility to the reconstructive surgeon's armamentarium.

The distal superficial femoral arterial branch to the sartorius muscle as a recipient vessel for soft tissue defects around the knee: anatomic study and clinical applications

Complex wounds surrounding the knee and proximal tibia pose a significant challenge for the reconstructive surgeon. Most of these defects can be managed using local or regional flaps alone. However, large defects with a wide zone of injury frequently require microvascular tissue transfers to aid in soft tissue coverage and closure of large cavities. We describe a unique recipient vessel for microvascular anastomosis for free flap reconstruction involving the knee and proximal tibia through anatomic and clinical studies.

Three-dimensional analysis of perforators of the posterior leg

BACKGROUND

Three-dimensional evaluations of cutaneous perforator vessels provide useful clinical information to aid in the design of perforator flaps. By combining three-dimensional digital imaging and angiography, the authors developed a new three-dimensional visualization technique for vascular perforators. Their purpose was to produce a digitized model of the posterior leg to determine the anatomical relationships of perforators in each zone of the posterior leg.

METHODS

Eight cadavers were injected with a modified lead oxide-gelatin mixture. Two cadavers were selected for three-dimensional reconstruction using a spiral computed tomography scanner and specialized volume-rendering software. Dissection, angiography, and photography of each layer were performed to outline the course of every perforator in the posterior leg. The area of the vascular territory supplied by each source vessel was calculated. Surface areas were measured using Scion Image software.

RESULTS

The arterial supply to the integument of the posterior leg was divided into proximal, middle, and distal zones. There were 13 +/- 2.3 perforators with diameters of greater than or equal to 0.5 mm; the average external diameter was 0.8 +/- 0.2 mm. Each perforator supplied an average area of 38 +/- 9.0 cm. Perforators from the popliteal artery were large and consistent and supplied an average area of 55 +/- 20 cm; there were multiple anastomoses between perforators from the popliteal, posterior tibial, and peroneal arteries. The distal zone received its arterial supply from two to three smaller septocutaneous perforators, which are arranged longitudinally in one to two parallel chains.

CONCLUSIONS

The posterior leg is an excellent donor site for local and distant flaps. Perforator flaps could be based in a variety of ways from each zone.

The Distally Based Sural Flap

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Describe the anatomy of the posterior lower leg as it is relevant to the distally based sural flap. (2) Describe the basic surgical technique of the distally based sural fasciocutaneous flap. (3) Understand the common complications associated with the sural flap and their approximate incidences in both a healthy and a multimorbid patient population. (4) Describe how skin, fascia, and muscle can be used to customize the sural flap for different purposes. (5) Understand the various modifications of the sural flap that have been described in the literature.

SUMMARY

Over the past decade, the distally based sural flap has become increasingly used in reconstruction of the foot and lower leg. The rise in popularity of this flap has been paralleled by an increase in the number of cases, innovations, and technical refinements reported in the medical literature. This review summarizes the 79 publications in the English language literature on the subject of the distally based sural flap. The anatomical studies are summarized in a unified description of the relevant flap anatomy. The flap's indications and composition and a variety of modifications are described. Technical aspects are discussed and clinical insight to minimize complications is provided. In conclusion, the distally based sural flap offers an alternative to free tissue transfer for reconstruction of the lower extremity.

Lambeaux fasciocutanés bipédiculés dans la réparation des pertes de substance du genou

We presented three cases in which two bipedicled fasciocutaneous flaps were used for coverage defects of the knee. These bipedicled flaps can be harvested to cover long and narrow sized defects on the anteromedial aspect of the knee region. This procedure is easy, quick and versatile without compromising the principal vessels and muscles of the leg.

Perforator-Plus Flaps: A New Concept in Traditional Flap Design

BACKGROUND

Conventional fasciocutaneous flaps in reconstructive surgery, especially in the lower extremities, have limited utility. Traditional flaps are essentially random pattern, often require delays, and are limited in mobility and reach. Islanded fasciocutaneous flaps pedicled on perforators can be raised anywhere on the body and have a reliable blood supply and greater freedom of movement. However, venous compromise is a common problem.

METHODS

A new approach to raising conventional fasciocutaneous flaps while including and retaining perforators in their substance was used to offset these disadvantages. This concept offers a dual blood supply to the flap from the dissected perforator plus the flap base. The approach was attempted in 12 cases and used successfully in 10. In two cases, the flaps were converted to pure islanded perforator flaps because of limited movement. Fasciocutaneous perforator-plus flaps were used in six patients with lower limb trauma and one patient with postburn elbow contracture. Peninsular flaps were planned to include known or identified perforators, which were dissected to allow mobility.

RESULTS

All flaps survived completely and none exhibited venous compromise. In three patients, perforator-plus flaps were used to the medial hemisoleus muscle while providing coverage to exposed tibial fractures. The muscle flap was based either proximally or distally, and a segmental perforator was dissected and retained. There were no complications relating to flap congestion or necrosis except wound infection in two patients, one each in the fasciocutaneous and muscle flap groups. Both responded to conservative treatment. No case required reoperation.

CONCLUSION

The perforator-plus flap appears to be a versatile and reliable option in lower limb injuries and other diverse indications, in both the emergency and the elective settings.

A novel reconstruction technique for the knee and upper one third of lower leg

Various reconstructive choices for the coverage of soft tissue defects around the knee joint or upper one third of lower leg are available depending on the location, size and depth of the defect. The authors have found the medial sural artery perforator island flap a useful method for reconstruction of the upper one third of lower leg and knee. From January 2003 to November 2005, medial sural perforator island flaps were used on six patients, five were men and one was a woman. The largest flap obtained was 16 x 7 cm. In three cases, defects were located on the upper one third of lower leg and in the other cases, on the knee. Four of them bone exposed, and two cases had a post-burn contracture. All six flaps survived completely, without even minor complications. Postoperative follow up of the patients ranged from 2 to 33 months. The main advantages of the medial sural perforator island flap are a constant location and reliable blood supply without sacrifice of any main source artery and underlying muscle. This procedure is a valuable extension of local flap for defect coverage with minimal functional deficit of donor site and good aesthetic result on the defect and is a useful method for reconstruction of the upper one third of lower leg and knee.

Weichteildefekte als Komplikation nach Knieendoprothetik

Soft tissue defects after knee arthroplasty are a severe problem, which can even result in a loss of the prosthesis or the limb. Well-planned strategies are necessary for sufficient soft tissue reconstruction, resulting in optimal functional and aesthetic results. This report provides information on the classification of the tissue defects and the appropriate options for surgical reconstruction. Besides the basic therapy principles of immobilisation, débridement, planned lavages and antibiotic therapy, defect-dependent surgical techniques of reconstructive surgery are implemented. These include skin transplantation, local fasciocutaneous flaps, local pedicled muscle flaps and free flaps. For best results, interdisciplinary treatment by orthopaedic surgeons, plastic surgeons, microbiologists and physiotherapists is mandatory.

The composite vastus medialis-patellar complex osseomuscular flap as a salvage procedure after complex trauma of the knee--an anatomical study and clinical application

BACKGROUND

In the setting of severe perigenicular trauma or complicated endoprosthetic knee surgery, primary knee fusion may be the last resort for salvage of the limp. In this case, the patella looses its destination as an anterior knee stabilizer and can become a substantial donor of bone substance, especially if osseous defects are involved.

PATIENTS AND METHODS

12 formalin fixated cadavers were studied in terms of vascular anatomy, pedicle reliability, arc of rotation and their relation to sex, age, and height. Moreover, the operation was performed on a suitable patient.

RESULTS

The quadriceps with the vastus medialis and the patella can be raised from the tibial tuberosity up to the entrance of the osteoarticular branch of the superficial femoral artery into the vastus medialis muscle ca 16 cm (15-19 cm) from the inferior patellar pole. This distance correlated well to the overall height of the cadavers (P=0.009). The vascular prerequisites were always present. In the clinical case, there was a favorable outcome with knee fusion after 4 months, despite of the lateral condylar defect.

DISCUSSION

The composite vastus medialis-patellar complex osseomuscular flap can be safely used as a source of vascularized femoral condyle substitute in the setting of primary knee fusion.

Distally Based Anterolateral Thigh Flap: An Anatomic and Clinical Study

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 x 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 +/- 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.

The Medial SuralMedial Gastrocnemius Perforator Local Flap

The medial sural(MEDIAL GASTROCNEMIUS) perforator flap has previously been described as a free flap distinguished by the potential for a large yet thin cutaneous flap that incorporates the calf skin territory. Its medial sural vascular pedicle can be tailored to allow reach extending from the popliteal fossa to the suprapatellar area also as a local flap without any need for microsurgery. Two variations presented are possible as either a broad-based peninsular or island flap. Both are alternatives to the more traditional medial gastrocnemius muscle flap and, because this is a true muscle perforator flap, function is always preserved.

The medial sural MEDIAL GASTROCNEMIUS perforator free flap: an 'ideal' prone position skin flap

The medial sural MEDIAL GASTROCNEMIUS perforator flap is a potentially large, thin cutaneous flap that encompasses the calf skin territory. Its medial sural vascular pedicle has a long leash of large caliber that simplifies microanastomoses when used as a free flap. Because the identification of the requisite perforators and their subsequent intramuscular dissection is facilitated with the patient in a prone position, this can be an "ideal" skin free flap for the posterior aspect of the body. This is especially true for the lower limb where all surgical morbidity could then be restricted to the ipsilateral extremity. This approach has been used in 5 clinical cases, with success except once when the flap was aborted as a result of anatomic anomalies, which is always a concern with muscle perforator flaps.

Anatomical variations of the sural nerve

An anatomical study of the formation of the sural nerve (SN) was carried out on 76 Thai cadavers. The results revealed that 67.1% of the SNs were formed by the union of the medial sural cutaneous nerve (MSCN) and the lateral sural cutaneous nerve (LSCN); the MSCN and LSCN are branches of the tibial and the common fibular (peroneal) nerves, respectively. The site of union was variable: 5.9% in the popliteal fossa, 1.9% in the middle third of the leg, 66.7% in the lower third of the leg, and 25.5% at or just below the ankle. One SN (0.7%) was formed by the union of the MSCN and a different branch of the common fibular nerve, running parallel and medial to but not connecting with the LSCN, which joined the MSCN in the lower third of the leg. The remaining 32.2% of the SNs were a direct continuation of the MSCN. The SNs ranged from 6-30 cm (mean = 14.41 cm) in length with a range in diameter of 3.5-3.8 mm (mean = 3.61 mm), and were easily located 1-1.5 cm posterior to the posterior border of the lateral malleolus. The LSCNs were 15-32 cm long (mean = 22.48 cm) with a diameter between 2.7-3.4 mm (mean = 3.22 mm); the MSCNs were 17-31 cm long (mean = 20.42 cm) with a diameter between 2.3-2.5 mm (mean = 2.41 mm). Clinically, the SN is widely used for both diagnostic (biopsy and nerve conduction velocity studies) and therapeutic purposes (nerve grafting) and the LSCN is used for a sensate free flap; thus, a detailed knowledge of the anatomy of the SN and its contributing nerves are important in carrying out these and other procedures.

Anatomic basis of the gastrocnemius perforator-based flap

The gastrocnemius muscle is rarely considered today as a musculocutaneous flap. Yet, the posterior calf skin by itself can still be used to advantage as a source of local or perhaps free flaps. Fascial perforators in this region were reexamined in an anatomic study in 10 fresh cadaveric specimens to investigate the possibility of a gastrocnemius muscle perforator-based flap. At least two substantive perforators were found in all limbs, and there was always one overlying the medial gastrocnemius muscle (overall mean, 4.0 +/- 1.8 perforators; range, 2-7 perforators). The origin of these perforators in any given specimen was most commonly as a secondary branch from the medial or lateral sural arteries alone (60%), from the median sural artery as a direct cutaneous branch alone (10%), or from either of the muscle pedicles and/or the median sural artery (30%). Thus, in 90% of limbs, the potential for elevating a gastrocnemius perforator-based flap exists without the need for any muscle sacrifice. Otherwise, a more traditional posterior calf fasciocutaneous flap was possible. Other deeper intramuscular collaterals were also identified so that sequential use of the muscle as a separate flap does not seem to be compromised.

Selection of the recipient vessel in the free flap around the knee: the superior medial genicular vessels and the descending genicular vessels

In reconstructions around the knee, the use of a free flap is indicated in a limited number of cases, but it plays a critical role in cases of extensive defects or unavailability of local flaps. The selection of the recipient vessel is an essential and challenging step for a successful free tissue transfer. Popliteal vessels and other small vessels around the knee have been reported to be used as recipient vessels, but the choice of recipient vessels around the knee has not been established. In this study, after a thorough investigation of the vascular anatomy at the knee region, the superior medial genicular vessels and the descending genicular vessels were considered to be the proper recipient vessels, and a clinical application was tried. From July of 1997 to July of 1999, a total of seven cases of soft-tissue defects around the knee-four cases in the posterior region and three cases in the anterior region-were reconstructed with free flaps, using the superior medial genicular vessels and the descending genicular vessels, respectively. All flaps survived completely, with no flap loss. The advantages of these vessels are their proximity to the knee and their reliability, versatility, simplicity, and size match. The outstanding characteristic of this combination of vessels is their versatility, because the combination can cover all defects around the knee. The clinical application and the versatility of the combination of the superior medial genicular vessels and the descending genicular vessels as the recipient vessels was confirmed for the reconstruction of posterior and anterior knee defects.

An easy and versatile method of coverage for distal tibial soft tissue defects

BACKGROUND

The distally based superficial sural artery flap, first described as a distally based neuroskin flap by Masquelet et al., is a skin island flap supplied by the vascular axis of the sural nerve. In the difficult area of defects in the lower leg and the ankle and heel region, it has a wide variety of indications, even in the vascularly compromised patients. It has the largest arc of rotation of all flaps that have been described in this region. The most important advantage is that it does not compromise a major artery. It is simple to dissect and has a low donor morbidity.

METHODS

We reported our experience with this new flap in 15 cases and also described a new indication for the patients with neglected ruptures of the Achilles tendon.

RESULTS

In 13 patients, the flap was successfully transferred. In two cases, partial necrosis of the flap ensued, which healed with secondary intention.

CONCLUSION

This flap deserves a high degree of interest in the reconstructive armamentarium of the trauma surgeon.

Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects

The principle of the V-Y advancement flap has been used since its first description by Blasius (1848) for reconstruction of smaller defects. We wish to describe V-Y advancement flaps, the design of which includes distinct perforator or fascial feeder vessels, which may originate from periosteum, muscle, cutaneous nerve or from large tendon sheaths. These flaps are planned in an oblique manner when there is a defect over the anterior, antero-lateral or antero-medial aspect, and in a vertical manner when there is a defect over the posterior aspect of the leg. The main advantage of this design is the ability to close the secondary defect primarily, allowing adequate cover of the defect, particularly in the pre-tibial region, without the unsightly divot left by a split skin graft in this area. When the flap includes branches of the long saphenous nerve on the medial aspect, superficial peroneal nerve laterally or sural nerve posteriorly it results in a sensate flap, giving protection in this vulnerable area, which has previously not been possible. We describe 40 cases where perforator-based V-Y advancement flaps have been used to cover large defects of the lower leg following excision of malignant skin lesions and in selected trauma cases that do not involve degloving injuries. This technique allows adequate soft tissue cover in the pre-tibial area and around the ankle with excellent aesthetic results. The planning, operative technique and the results with case presentations have been described.

The arterial communication between the gastrocnemius muscle heads: a fresh cadaveric study and clinical implications

The purpose of this investigation was to describe the anatomy of the communicating (anastomotic) vessels between the gastrocnemius muscle heads and to record the extent of their supply potential. Ensuing clinical implications are discussed. Fourteen fresh cadaveric gastrocnemius muscles were examined. Detailed dissections of the communicating vessels were facilitated after injections of methylene blue or cadaveric blood solutions through the medial, lateral, or both sural arteries. The extent of the arterial cross-supply between the muscles' heads through these vessels was determined in-eight specimens after methylene blue perfusions through the lateral sural arteries, while one specimen was examined after injection of methylene blue and yellow ink through the lateral and medial sural arteries, respectively. Communicating vessels were detected in all 14 specimens. A mean number of 5.8 vascular bundles and single vessels was found. The bundles consisted of arterioles and, as all indications suggested, of concomitant venules as well. Regarding arterial cross-supply, it was clearly evident that each head could be vascularized solely from the contralateral one, mostly through these bundles. However, even if only a part of the bundles was preserved intact, vasculature was not affected.

The island posterior calf fasciocutaneous flap: an alternative to the gastrocnemius muscle for cover of knee and tibial defects

The gastrocnemius muscle remains the workhorse for providing soft tissue over the knee and upper tibia. Nevertheless, we have found the island posterior calf fasciocutaneous flap to be a valuable alternative. We describe 10 cases in which an island posterior calf fasciocutaneous flap was used to cover defects over the knee and tibia. Three cases were after knee arthroplasty wound dehiscence, three cases were of traumatic soft-tissue loss, three cases involved replacement of unstable skin, and one case required closing a synovial fistula. This series is compared with 10 contemporaneous consecutive cases of soft-tissue loss around the knee that were reconstructed with a gastrocnemius muscle flap. Nine posterior calf fasciocutaneous flaps survived completely, and one flap had to be replaced because of poor flow. Although this flap is technically more demanding, we have found that it offers some advantages over the gastrocnemius. These include a greater flexibility of size and shape, a longer arc of rotation to reach suprapatellar defects, the provision of sensate skin with protective though crude sensation, less bulk, and the avoidance of a twitch. The flap is also easy to re-elevate from the recipient site for subsequent orthopedic work.