A Systematic Review and Pooled Analysis of Peroneal Artery Perforators for Fibula Osteocutaneous and Perforator Flaps

Abstract

Despite the availability of cadaveric, anatomic, and clinical models to identify peroneal artery perforators in the lower leg, there is no consensus on the optimal fibula interval to reliably capture perforators for flap and skin paddle design. A systematic review of the MEDLINE and Cochrane databases was performed to identify all anatomical, clinical, and radiographic reports of peroneal artery perforators in the lower leg. Locations were indexed along tenths of the total fibula length to incorporate a uniform format. Three clinical and six cadaveric reports identified 445 legs and 1710 perforators. The 0.6 interval had the greatest total perforator frequency at 19.1 ± 1 percent, with 310 perforators and a positive probability of 79.1 ± 2.1 percent. Chi-square analysis found a statistical difference in perforator frequency at the flanking intervals of 0.5 and 0.8 (p = 0.0058 and p = 0.0019) and beyond. Subgroup analysis of septocutaneous perforators was based on 345 legs and 608 perforators. The 0.6 interval was the densest, with 110 perforators and a frequency of 18.1 ± 1.6 percent. The musculocutaneous subgroup analysis found 292 legs and 831 perforators, and a densest interval at 0.4, based on 157 perforators and a frequency of 18.9 ± 1.4 percent. This systematic review and pooled analysis of all available and complete peroneal artery perforator data demonstrates clustering over the 0.6 interval of the lateral leg. This interval should be considered during flap design and elevation to reliably capture irrigating perforators for free and local flap applications.