Perforator anastomosis of the sural artery system and its application in extended gastrocnemius flap

Abstract

IntroductionThe conventional management for long defects involving the middle one third of leg with exposed bone is cover by a combination of soleus with fasciocutaneous or gastrocnemius flap. To decrease operative time, donor site morbidity and complexity of surgery we offer a simpler flap where the territory of the gastrocnemius myocutaneous flap can be extended by including the septocutaneous perforators in the leg. Material & MethodsThe vascular basis of the flap was determined by studying Digital Subtraction Angiography(DSA) images of lower limbs of 10 patients who had undergone the procedure for pathology in systems other than the lower limb.Following this study, we operated 18 cases over 2 years. All cases were of post-traumatic defects of middle and proximal part of lower third of leg that were treated with extended gastrocnemius myocutaneous flap in department of plastic surgery. The length of defect, length of flap used, means operative time and flap complications in the post op Period would be recorded. ResultsThe DSA study revealed various perforator anastomosis between the distal branch of the sural with the posterior tibial and peroneal system. Of these a grade 2- grade 2 perforator anastomosis was most common.On evaluation of the 18 patients of Gustillo Type 3b fracture that were covered with the extended flap, we found the mean operative time for the procedure to be 86 min (range 68–108 min). The average length of defect covered was 9.7 cm and the average dimension of flap was 23.09 cm in length and 7.9 cm in breadth. In the postoperative period no patient has a flap failure of necrosis of the distal stich line. ConclusionThis extended gastrocnemius myocutaneous flap is a good option to tackle long defects overlying the middle and lower thirds of tibia. It offers a much simpler and faster alternative to using two flaps in combination. The vascular basis of the flap appears sound as there is usually a grade 2-grade 2 perforator anastomosis between the sural system with the posterior tibial and peroneal systems.