Peroneal Artery Perforator Flap Research Articles

Clinical application of posterior tibial artery or peroneal artery perforator flap in curing plate exposure after ankle fracture fixation.

The study aims to evaluate the clinical application of posterior tibial artery or peroneal artery perforator flap in the treatment of plate exposure after ankle fracture fixation. A posterior tibial artery or peroneal artery perforator flap was used on 16 patients with plate exposure after ankle fracture fixation in our hospital between July 2018 and July 2021. The time required to harvest the flap, the amount of intraoperative blood loss, the duration of postoperative drainage tube placement, the outcome of the flap and the healing observed at the donor site are reported. The sizes of the flaps were 2.5-7.0 cm × 5.0-18.0 cm and averaged 4.0 cm × 12.0 cm. The time required to harvest the posterior tibial artery or peroneal artery perforator flap ranged from 35 to 55 min and averaged 45 min. The amount of intraoperative blood loss ranged from 20 to 50 mL and averaged 35 mL. The duration of postoperative drainage tube placement ranged from 3 to 5 days and averaged 4 days. A total of 15 flaps survived and one flap had partial necrosis and survived after conservative treatment. All donor area defects were directly sewed and stitched without complications. There are multiple advantages of the posterior tibial artery or peroneal artery perforator flap, including simple preparation technique, reliable repair of the defects and without the need for performing microvascular anastomosis. It can be safely used in curing plate exposure after ankle fracture fixation and worth popularizing in grassroots hospitals.

Analysis of Survival Quality of Peroneal Artery Perforator Flap in Immediate Repairment and Reconstruction of Oral and Maxillofacial Malignancies.

This study aimed to investigate the survival quality of peroneal artery perforator flap in the reconstruction of oral and maxillofacial malignant tumors. Thirty-two cases with a diagnosis of oral and maxillofacial malignant tumors admitted to our hospital from January 2019 to December 2019 were randomly divided into 2 groups. The observation group was reconstructed with free open artery perforator flaps, and the control group was repaired with free forearm flaps. The observation group had significantly lower scores in terms of postoperative pain, appearance, and anxiety, compared with the control group ( P <0.05). Both groups had high scores on taste, saliva, and shoulder function although there was no significant difference ( P >0.05). The scores of the observation group were significantly higher than those in the control group in terms of chewing, swallowing, speech, activity, mood, and entertainment ( P <0.05). There was 1 case accompanied by postoperative wound dehiscence and 2 cases with wound infection in the observation group while there were 3 cases with wound dehiscence and 2 cases with wound infection in the control group ( P >0.05). Compared with the forearm flap, the peroneal artery perforator flap can improve the survival quality of patients, especially in postoperative function with the fibula joint to repair the oral and maxillofacial defects. It has a wide application prospect as one of the ideal flaps in oral and maxillofacial postoperative repair and reconstruction.

Efficacy of Locoregional Perforator Flaps for Resurfacing of Peri-ankle Soft Tissue Defects: A Single Centre Prospective Cohort Study

Introduction: The foot and ankle serve as vital components in supporting mobility. When afflicted by trauma, infections, burns, or tumours, they often present challenging defects that expose tendons, bones, joints, and nerves. Managing softtissue reconstruction in this area is complex, primarily due to limited local tissue resources and inadequate muscle coverage. A range of reconstructive options exists, encompassing local, locoregional, and distant flaps, with microvascular free flaps as the gold standard. Recent studies have explored newer pedicled and perforator-based flaps as promising alternatives for lower extremity soft-tissue defects. Aim: To explore the efficacy of perforator-based local and locoregional flaps for resurfacing peri-ankle defects. Materials and Methods: This prospective cohort study was conducted at the Department of Plastic Surgery, SSKM Hospital, and IPGME&amp;R, Kolkata, West Bengal, India, from April 2019 to March 2022. A total of 49 patients with soft-tissue defects around the ankle were included. The reconstructive approach primarily involved perforator-based flaps from various arterial sources. Outcomes were categorised as complete defect coverage, minor flap necrosis without intervention, or major necrosis necessitating additional surgical intervention. For this descriptive study, proportion was used to compare categorical variables such as the number of cases with different aetiology, and the number of different flaps used were compared. For the continuous variable like age, mean has been used as a measure of central tendency. Results: The mean age of the study population was 39.6±4.1 years. Thirty-four out of 49 patients (69.38%) presented with defects stemming from Road Traffic Accidents (RTA), and the posterior aspect of the ankle was the most common defect location (14 out of 49 patients, 28.57%). Peroneal Artery Perforator Flaps (PAPF) exhibited the highest success rate, with 18 out of 20 cases where this flap was used (90%), closely followed by Lateral Supramalleolar Flaps (LSF), with 13 out of 15 cases (86.7%). Overall, in 42 out of 49 cases (85.7%), the perforator-based flaps effectively resurfaced the defects. Conclusion: Pedicled perforator-based flaps, including those based on the peroneal artery and lateral supramalleolar, have emerged as valuable options for the reconstruction of softtissue defects around the ankle.

Analysis of the effect of free posterior lateral peroneal artery perforator flap of lower leg in repairing oropharyngeal cancer

Objective:To analyze the clinical effect of free posterior lateral peroneal artery perforator flap of lower leg in repairing postoperative defect of oropharyngeal carcinoma. Methods:Thirty-six patients with oropharyngeal carcinoma admitted to the Department of Oral and Maxillofacial Surgery, the First Affiliated Hospital of Bengbu Medical College from June 2016 to June 2019 were analyzed and followed up, eighteen patients were treated with free posterior lateral peroneal artery perforator flap of the lower leg to repair the postoperative defects（experimental group）, and eighteen patients were treated with free forearm flap（control group）. The survival rate of the transplanted flap, the wound stageⅠhealing rate and average hospitalization time were compared between the two groups. Kaplan-Meier method was used to calculate the 1-year and 3-year survival rates of patients after operation, and log-rank test was used to compare the difference between the survival curves of the two groups; The recovery of swallowing and palatopharyngeal closure function of patients in the two groups at 3, 6, 12 and 18 months after operation was calculated and statistically analyzed through the water swallow test and the air blowing method. Results:There was one case of skin flap necrosis in both the experimental group and the control group, and the survival rate was 94.4%. The wound stageⅠhealing rate in the surgical area was 94.4% in both groups. The wound healing rates of the donor area in the experimental group and the control group were 100.0% and 94.4% respectively. The average hospitalization time of the experimental group and the control group was 16.9 days and 17.2 days, respectively, with no significant difference （P>0.05）. The overall survival rates of all patients at 1-year and 3-year were 91.2% and 66.5% respectively; The 1-year and 3-year survival rates of the experimental group and the control group were 94.1%, 69.3% and 88.2%, 63.7%, respectively, and there was no significant difference between the two groups （P>0.05）. The 1-year and 3-year survival rates of P16+ and P16 - patients were 100.0%, 80.0% and 85.7%, 64.3%, respectively, and there was no significant difference between the two groups （P>0.05）. There was no significant difference in the evaluation of swallowing and velopharyngeal closure function between the two groups at 3 and 6 months after operation （P>0.05）, but there was a significant difference at 12 and 18 months after operation （P<0.05）. Conclusion:The anatomic position of the perforating vessels of the free posterior lateral peroneal artery perforator flap of the lower leg is constant, and it can be prepared into single leaf, multi leaf, chimeric and other flaps according to the tissue defect space. And the concealed supply area can be directly drawn to suture. At the same time, the skin flap has strong plasticity. Therefore, the skin flap can be used as a common skin flap to repair the defects after the operation of oropharyngeal carcinoma.

Map of perforators of the posterior tibial artery and peroneal artery using handheld doppler ultrasound evaluating clinical outcome of perforator flaps which cover soft tissue defects of the lower leg and foot

Background: Soft tissue defects of the lower leg and foot are complicated injuries with numerous causes including trauma, ulcers, and Gout. Widespread treatment of these defects has been effectively applied with perforator flaps of the peroneal artery and posterior tibial artery. Objectives: 1. Construct a map of the perforators of the peroneal artery and posterior tibial artery using a handheld Doppler ultrasound. 2. Evaluate the clinical outcome of perforator flaps to cover soft tissue defects in the lower leg and foot. Materials and method: Cross-sectional study of 34 volunteers with no previous history of vascular diseases and the prospective study of 31 patients with soft tissue defects treated with peroneal artery perforator flap and posterior tibial artery perforator flap. Results: There are, on average, 4.7 peroneal perforating arteries. From the lateral malleolus to the fibula’s head, the percentage of perforating arteries in the 2/10 and 6/10 segments is 85.3% and 97%, respectively. In the 2-3/10 segment, 94.1% have perforator arteries. There are, on average, 3.3 posterior tibial artery perforators. From the medial malleolus to the medial tibial plateau, it was found that 100% of volunteers had perforating arteries in the 3-4/10 segments and 61.7% in the 5/10 segment. Evaluation of postoperative results in 31 patients: 77.49% showed the right flap. The most common complications were edge necrosis (12.9%), partial necrosis (6.44%), and infection (3.23%). The donor sites showed good survival in 96.4% of patients, while partial necrosis resulted in 3.6%. A follow-up examination revealed that 90.32% of flaps had a good result, 9.68% had an average result, and no poor results were shown. 100% of donor sites had good results. Conclusion: An average of 4.7 perforators of the peroneal artery is detected by handheld Doppler ultrasound. Also, there are 1-2 relatively constant perforators in segments 2/10 and 5-6/10 from the lateral malleolus. On average, there are 3.3 perforators of the posterior tibial artery, primarily in the 3-4/10 and 5/10 segments proximally from the medial malleolus. 90.32% of the flap had good results. Key words: Perforator flap, Soft tissue defect, Lower leg, Foot, Reconstruction.

Clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux

Objective: To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods: A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results: A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S3 in 2 cases, grade S2 in 9 cases, and grade S1 in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions: The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.

Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region

Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.

Application of infrared thermography technique to assist peroneal artery perforator flap in the repair of oral and maxillofacial defects

To explore the application value of infrared thermography (IRT) technique assisted peroneal artery perforator flap in repairing oral and maxillofacial defects. The clinical data of 20 patients with oral and maxillofacial malignant tumors treated with peroneal artery perforator flap between October 2020 and December 2021 were retrospectively analysed. There were 13 males and 7 females, with an average age of 56.5 years (range, 32-76 years). There were 8 cases of tongue cancer, 5 cases of parotid gland cancer, 4 cases of buccal cancer, and 3 cases of mandibular gingival cancer; and 12 cases of squamous cell carcinoma, 3 cases of adenoid cystic carcinoma, and 5 cases of mucoepidermoid carcinoma. Color Doppler ultrasound (CDU) and IRT technique were performed before operation to locate the peroneal artery perforator and assist in the design of the flap. The sensitivity, specificity, positive predictive value, and negative predictive value of CDU and IRT technique were compared with the actual exploration during operation. The accuracy of CDU and IRT technique in detecting the number of peroneal artery perforator and the most viable perforating points was compared. The patients were followed up regularly to observe the recovery of donor and recipient sites, the occurrence of complications, and the recurrence and metastasis of tumors. The sensitivity, specificity, positive predictive value, and negative predictive value of peroneal artery perforators detected by IRT technique before operation were 72.22%, 50.00%, 92.86%, and 16.67% respectively, which were higher than those by CDU (64.17%, 33.33%, 84.62%, and 14.29% respectively). Forty-five peroneal artery perforators were found by CDU before operation, and 35 were confirmed during operation, with an accuracy rate of 77.8%; 43 "hot spots" were found by IRT technique, and 32 peroneal artery perforators were confirmed within the "hot spots" range during operation, with an accuracy rate of 74.4%; there was no significant difference between the two methods ( χ²=0.096, P=0.757). The accuracy rates of the most viable perforating points found by CDU and IRT technique were 80.95% (17/21) and 94.74% (18/19), respectively, and there was no significant difference between them ( χ²=0.115, P=0.734). The localization errors of CDU and IRT technique were (5.12±2.10) and (4.23±1.87) mm, respectively, and there was no significant difference between them ( t=1.416, P=0.165). All the perforator flaps survived, and the incisions of donor and recipient sites healed by first intention. All patients were followed up 5-18 months, with an average of 11 months. The skin flap was soft and had good blood supply, and the lower limb scar was concealed and the lower limb had good function. No lower limb swelling, pain, numbness, ankle instability, or other complications occurred, and no tumor recurrence and metastasis were found during the follow-up. Compared with the CDU, using the IRT technique to assist the preoperative peroneal artery perforator flap design to repair the oral and maxillofacial defects has a high clinical application value.

Clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography

Objective: To investigate the clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography (3D-CTA). Methods: A retrospective observational study was conducted. From March 2017 to September 2019, 15 patients with skin and soft tissue defect wounds in the forefoot were treated in the Department of Burn and Plastic Surgery of Yidu Central Hospital of Weifang, including 12 males and 3 females, with age of 18-60 years. The wound area on admission was 3.0 cm×3.0 cm-9.0 cm×8.0 cm. The 3D-CTA examination before operation was performed to select the peroneal artery perforating vessels with appropriate length of vascular pedicle and good blood perfusion. According to the wound area and the perforating vessels of the peroneal artery located by 3D-CTA, the peroneal artery perforator flaps of 3.5 cm×3.5 cm-9.5 cm×8.5 cm carried with lateral sural cutaneous nerve was designed and cut, and the nerve was anastomosed with the nerve of the wound. The wound in the donor site of the flap was directly sutured or covered with medium-thickness skin graft from the thigh. The consistencies of type, diameter, and perforating position of perforating vessel of the peroneal artery detected by 3D-CTA before the operation with those of the actual measurement during operation were observed. The length of time for flap cutting and the survival of the flap after operation were recorded. During follow-up of 12 months after the operation, the patients were instructed to evaluate the foot function according to the Maryland foot function score standard, and the wound healing in the donor area and the occurrence of complications affecting the motor function of limb were observed. Data were statistically analyzed with paired sample t test. Results: The types of peroneal artery perforating vessels in patients measured during the operation were septocutaneous perforator of 12 cases, musculocutaneous perforator of 2 cases, and musculomuscular septal perforator of 1 case, which were consistent with those measured by preoperative 3D-CTA. The diameter of the peroneal artery perforating vessel measured by preoperative 3D-CTA was (1.38±0.17) mm, which was close to (1.40±0.19) mm measured during the operation (t=0.30, P>0.05). The horizontal distance from the starting point of the perforating vessel to the outer edge of the shank was (42±6) mm, and the vertical distance from the starting point of the perforating vessel to the level of the lateral ankle tip was (219±14) mm measured by preoperative 3D-CTA, which were respectively close to (43±6) and (221±15) mm of intraoperative measurement (with t values of 0.46 and 0.38, respectively, P>0.05). The length of time for cutting flap was (31±6) min. All flaps survived post operation without vascular crisis. During follow-up of 12 months after the operation, the foot function was evaluated as excellent in 11 cases, good in 3 cases, and fair in 1 case, the donor site wound healed well, the scar was not noticeable with no contracture, and the motor function of joints was not affected. Conclusions: Free peroneal artery perforator flap is one of the effective methods to reconstruct skin and soft tissue defect wounds in the forefoot, and the risk of surgery can be reduced when the anatomical location of the perforating vessels is confirmed by 3D-CTA.

Soft Tissue Reconstruction Around the Ankle with Peroneal and Posterior Tibial Artery Perforator Flaps: A Randomized Controlled Trial

Soft Tissue Reconstruction Around the Ankle with Peroneal and Posterior Tibial Artery Perforator Flaps: A Randomized Controlled Trial

Different Modalities of Flap Coverage of Achilles Tendon Region Defects: Functional and Aesthetic Outcomes

Abstract Background: In the decision-making process toward covering various Achilles' tendon region, knowledge about patient related outcomes after surgery and rehabilitation is important. Therefore, we aimed to present an overview of outcomes and select the most appropriate flaps used for covering soft tissue defects over Achilles' tendon region. Aim of Study: Study aimed to analyse and determine the suitable reconstructive surgical options for Achilles' tendon coverage and to evaluate the clinical, functional and aesthetic outcomes. Patients and Methods: Between September 2017 and December 2019, 25 patients with skin loss over Achilles' tendon region were admitted to Menoufia University Hospital and Shebin-Elkom Teaching Hospital. The soft tissue defects ranged from 3x2 to 16x12 cm. Six types of flaps were used for the coverage of concomitant skin defects. Results: There was no complete flap loss and all flaps survived. Lateral supra malleolar flap (28%) was used in seven patients, distally based peroneus brevis muscle flap (16%) in four patients, posterior tibial artery perforator flap (24%) in six patients, peroneal artery perforator flap (4%) in one patient, reversed sural artery flap (24%) in six patients, and free latissimus dorsi musculocutaneous flap (4%) in one patient. Two patients were subjected to debridement and covered with split thickness skin graft (STSG). One patient suffered from chronic ulcer formation which was covered with lateral supra malleolar artery flap. The algorithm of one-stage reconstruction was established, according to the defect size of skin. Conclusion: Perforator flaps, lateral supra malleolar artery flap, and the distally based peroneus brevis muscle flap were a suitable option for coverage of small to intermediate sized defects; reversed sural artery flap is best for coverage of moderate to large size defects and free flaps are the best choices for complex wide reconstructions.

Clinical application of free peroneal artery perforator flap in soft tissue defect of foot and ankle

To investigate clinical application of the free peroneal artery perforator flap in soft tissue defect of foot and ankle. The clinical data of 18 patients with soft tissue defects of foot and ankle who were repaired with free peroneal artery perforator flaps between March 2019 and March 2020 were retrospectively analyzed. Among them, there were 11 males and 7 females; the age ranged from 21 to 58 years, with an average age of 45 years. The defect was located in the ankle in 2 cases, in the hindfoot in 4 cases, in the midfoot in 5 cases, and in the forefoot in 7 cases. The causes of injury included 11 cases of traffic accident, 4 cases of machine injuries, 3 cases of infection and necrosis after internal fixation. The time from injury to flap repair was 12-48 days, with an average of 24 days. The range of wound was 3 cm×3 cm to 15 cm×8 cm, and the range of skin flap was 4 cm×3 cm to 16 cm×9 cm. The flap harvesting time, operation time, intraoperative blood loss, and complications were recorded; the flap survival and patient satisfaction were observed during follow-up; and the American Orthopaedic Foot and Ankle Society (AOFAS) foot function score was used to evaluate the foot function. The flap harvesting time was 15-33 minutes (mean, 22 minutes); the operation time was 120-160 minutes (mean, 150 minutes); the intraoperative blood loss was 90-180 mL (mean, 120 mL). There were 3 cases of vascular crisis after operation, including 2 cases of arterial crisis, which survived after vascular exploration and vein graft repair; 1 case of venous crisis, partial necrosis of the skin flap, and skin grafting to cover the wound after repeated debridement. The remaining 15 skin flaps survived completely. All patients were followed up 6 months. The skin flaps were in good shape without obvious bloat. According to the AOFAS foot function score, 5 cases were excellent, 10 cases were good, and 3 cases were fair. The excellent and good rate was 83.3%. The free peroneal artery perforator flap is easy to harvest, the shape and size of the flap are easy to design, and it does not damage the main blood vessels of the limb. The appearance and function of the limbs are satisfactory after operation. It can be widely used in the repair of soft tissue defects of the foot and ankle.

Clinical Application of the Peroneal Artery Perforator Flap for Reconstruction of Lateral Malleolus Defects.

The reconstruction of defects of the lateral malleolus involving the exposed fibular bone or tendon is challenging. This study aimed to evaluate the clinical application of the peroneal artery perforator flap with or without split-thickness skin grafting for soft tissue reconstruction of the bony defect of the lateral malleolus of the ankle joints. Reconstruction using a peroneal artery perforator flap with or without split-thickness skin grafting was performed for 15 patients (10 men, 5 women) between January 2007 and December 2018. The mean age was 53.7 years, and the mean size of the flaps was 40 cm2. The flaps were elevated in the form of a perforator flap, and split-thickness skin grafting was performed over the flaps and adjoining raw areas. The flaps survived in all cases; however, partial necrosis was observed in 3 cases. In cases of small-sized defects of the lateral malleolus of the ankle joints where a flap is required for the exposed bone or tendon, reconstruction using the peroneal artery perforator flap is advantageous, since the morbidity rate of the donor site is low and soft tissue is reconstructed.

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

IntroductionAchilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue. Methods7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel. ResultsThe size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage. ConclusionDistally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Multiple free homologous superficial peroneal artery perforator flaps of crus for repair of multiple hand wounds

Objective: To explore the effects of multiple free homologous superficial peroneal artery perforator flaps of crus for repair of multiple hand wounds. Methods: From November 2017 to December 2018, eight cases with eighteen hand wounds were hospitalized in our unit. Among them, wounds were distributed in the forefinger and middle finger in four cases, wounds were distributed in the middle finger and ring finger in two cases, wounds were distributed in the forefinger, middle finger, and ring finger in one case, and wounds were distributed in the middle finger, ring finger, and little finger in one case. The area of skin defect ranged from 1.5 cm×0.8 cm to 4.0 cm×3.0 cm. There were 4 males and 4 females, aged 34-62 years. Wounds of six cases were repaired by two free superficial peroneal artery perforator flaps from homolateral crus, and those of two cases were repaired by three free superficial peroneal artery perforator flaps from homolateral crus. Superficial peroneal artery and its accompanying vein of flap were anastomosed by end to end with digital artery and palmar or dorsal subcutaneous vein of recipient site during the operation. The area of flap ranged from 2.5 cm×1.2 cm to 5.0 cm×4.0 cm. No nerve was harvested during the operation, and donor site was sutured directly. The survival of the flaps and the healing of donor sites were recorded. During follow-up, the recovery of donor and recipient sites was observed. Results: All flaps survived well, donor site healed well. No vascular crisis occurred. Follow-up for 4 to 12 months showed that the appearance of flap was satisfactory with good color, texture, elasticity, and function. Protective sensation of recipient site was recovered. Five months after operation, flap of finger pulp in one case was swollen slightly with two-points discrimination of 10 mm, which received the thinning surgery. Obvious scar formation was not observed in donor site of crus. The appearance of the donor site was good without functional damage. Conclusions: The application of multiple free homologous superficial peroneal artery perforator flaps of crus to repair the multiple hand wounds has advantages of easy acquisition, easy operation, little effect on donor sites, and satisfactory clinical effects.

The Microvascular Peroneal Artery Perforator Flap as a "Lifeboat" for Pedicled Flaps.

Background:Pedicled perforator flaps have expanded reconstructive options in extremity reconstruction. Despite preoperative mapping, intraoperative findings may require microvascular tissue transfer when no adequate perforators can be found. The free peroneal artery perforator flap may serve as a reliable back-up plan in small defects.Methods:In 16 patients with small soft tissue defects on the upper and lower extremities, perforator-based propeller flaps were planned. The handheld Doppler device was used to localize potential perforators for a propeller flap in close proximity to the defect. Perforators of the proximal peroneal artery were also marked to allow conversion to microvascular tissue transfer.Results:In 6 cases, no adequate perforators were found intraoperatively. In 4 patients, the peroneal artery perforator flap was harvested and transferred. The pedicle length did not exceed 4 cm. No flap loss occurred.Conclusions:When no adequate perforator capable of nourishing a propeller flap can be found intraoperatively, the free peroneal artery flap is a good option to reconstruct small soft tissue defects in the distal extremities. The short vascular pedicle is less ideal in cases with a large zone of injury requiring a more distant site of anastomosis or when recipient vessels are located in deeper tissue planes.

Using the posterior tibial artery and peroneal artery perforator flaps to repair heel wounds: 18 cases report

Objective To investigate the clinical efficacy of using the posterior tibial artery and peroneal artery perforator flaps to repair the heel wounds. Methods From January, 2011 to May, 2018, heel soft tissue defect caused by trauma in 18 cases were treated by posterior tibial artery and peroneal artery perforator flaps respectively. The posterior tibial artery perforator flap was used in 11 cases, and the peroneal artery perforator flap was used in 7 cases. The area of flaps ranged from 5.0 cm×3.0 cm to 11.0 cm×9.0 cm. The length of the vascular pedicle was from 10.0 cm to 16.0 cm. After operation, the patients were followed-up regularly. The time of wound healing, appearance and texture of the flap, and function of ankle joint were observed. Results After the operation, 13 flaps survived uneventfully. The wound achieved primary healing. Partial necrosis occurred in the distal of posterior tibial artery perforator flap in 2 cases, and repaired by skin graft 1 or 2 months later. Marginal necrosis occurred in posterior tibial artery perforator flap in 2 cases and in peroneal artery perforator flap in 1 case. And scar healing occurred in these 3 cases finally. All the 18 patients were followed-up for 3 to 60 months, with an average of 10 months. Fracture healing time was from 3-6 months, with an average of 4 months. Flap was soft with satisfied appearance in 16 cases. Obvious scar formation occurred in 2 cases. There was no obvious scar contracture in donor sites. There was no obvious limitation of the flexion and extension function of the ankle joint in 18 cases. According to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, there was excellent in 16 cases, and good in 2 cases. Conclusion As for the characteristics of the heel wound, it is a simple and practical method to use leg perforator flap to repair. The flap is based on a long vascular pedicle. And the clinical effect is satisfied. Key words: Posterior tibial artery; Peroneal artery; Perforator flap; Heel; Repair

Treating Foot Injuries by Grafting Pedicled Distal Peroneal Artery Perforator Flaps.

Treating mid- and forefoot wounds is challenging. We share our clinical experience and describe the treatment of foreand midfoot wounds by grafting pedicled distal peroneal artery perforator (PNAP) flaps. The study enrolled 21 patients with fore- and midfoot injuries, who underwent grafting with a pedicled distal PNAP flap between August 2013 and May 2016. All of the flaps survived and were followed for 2 to 11 months. The appearance and texture of these flaps were good. The range of motion of the injured ankle was similar to the unaffected side. There were no complications, such as scar contracture, ulcer, or tenderness. The pedicled distal PNAP flaps can effectively extend the length of the flap pedicles and are better for repairing fore- and midfoot wounds than the traditional distally pedicled sural neuro-fasciocutaneous flaps.

Repair of soft tissue defect of foot and ankle with the supercharged peroneal artery perforator propeller flap

Objective To explore the clinical technical points of the treatment of soft tissue defect of the foot and ankle with the supercharged peroneal artery perforator propeller flap, and to provide theoretical support by anatomical observation. Methods From January, 2010 to February, 2018, a total of 10 patients with soft tissue defect of foot and ankle were treated with supercharged peroneal artery perforator propeller flap. Cause of injury: trauma in 7 cases, wound ulcer in 1 case, and poor healing of the calcaneus incision in 2 cases. Defect site: 5 cases of heel, 2 cases of medial and lateral malleolus, and 3 cases of dorsum and sole. The size of flap ranged from 6.0 cm×3.0 cm to 16.0 cm×5.0 cm. All patients were followed-up at 1, 3, 6 months after operation, and the function recovery was judged by AOFAS Ankle Hindfood Scale at 3 months post-opertively. From November, 2016 to May, 2017, the anatomical basis and operative points of the supercharged peroneal artery perforator flap were summarized. Results All the 10 cases of supercharged peroneal artery perforator propeller flap survived. Two of them had local epidermal necrosis at the proximal end of the flap. After 1 to 2 weeks of dressing, they finally healed. The other 8 cases healed well. Anatomical studies showed that different planes of the supercharged peroneal artery perforator propeller flap can only reduce the compression of the double pedicles and reduce the distal necrosis rate of the flap by rotating in different rotation directions. Conclusion The supercharged peroneal artery perforator propeller flap can enhance the blood supply and venous return in the big paddle artery of the flap, preventing distal necrosis. Key words: Peroneal artery perforator flap; Propeller flap; Supercharged; Foot and ankle

Pedicled perforator flaps for leg reconstruction

Objective The objective of this study was to assess the efficacy of perforator flaps for the reconstruction of an injured leg. Background Defects of the lower limb remain a health problem. Application of perforator flaps for reconstruction of these defects represents a very good option giving good coverage. Patients and methods This was a prospective study. It was performed at Menofia University Hospital and Shebin El-Kom Teaching Hospital during a period of 14 months from February 2017 to March 2018. The study was carried out on 20 patients with leg defects; six types of perforator flaps were used; seven patients were treated by posterior tibial artery perforator flap, seven patients by reversed sural perforator flap, two by peroneal artery perforator flap, two by lateral supramalleolar flap, one by anterior tibial artery perforator flap and one by medial sural artery perforator flap. Results The mean ± SD age of the patients was 36.85 ± 16.60 years. Of 20 patients, 15 (75%) were male individuals and five (25%) were female individuals. The mean ± SD area size of the defect was 43.90 ± 33.47 cm. Of 20 flaps, 14 (70%) flaps had no complications, four (20%) flaps were complicated by distal-end congestion, 18 (90%) flaps passed successfully, and two (10%) flaps were complicated by necrosis and failed to survive. Conclusion Perforator flaps represent an effective method for reconstruction of leg defects, giving good satisfactory, functional and aesthetic results, as leg defects were successfully covered and healed by using perforator flaps, giving normal function and shape of the leg.