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Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report
+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e3
CASE REPORT
Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report ´nole ´ Kermarrec*, Alain-Charles Masquelet Gwe Department of Orthopedic and Reconstructive Surgery, Hospital Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France Received 26 June 2013; accepted 20 December 2013
KEYWORDS Sural flap; Occluded artery; Angiography
Summary Coverage of soft-tissue defects of the leg has improved with the discovery of new flaps. However, surgeons now have to deal with new lesions on top of previous reconstructive surgeries. We present a case of soft-tissue defect of the anterior lower third of the leg presenting 20 years after reconstructive surgery for an open fracture and its management. The anterior tibial and fibular arteries were occluded with a retrograde vascularisation of the fibular artery; this provided a perforator artery that we used as a pivot point for an atypical sural island flap with a good result at 6 months. This case challenges the classic contraindication of this flap in case of occluded arteries. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Coverage of soft-tissue defects of the distal third of the leg is challenging for plastic and orthopaedic surgeons. Management relies on the multiple anatomic studies and flaps described since the 1970s. Diffusion of these techniques has made them easier and safer to perform but has led to a new situation arising: management of soft-tissue defects in patients who have already undergone reconstructive surgery. This requires meticulous preoperative planning and, in many cases, intra-operative adaptation of tactics to the local conditions. * Corresponding author. Department of Orthopedic and Reconstructive Surgery, Hospital Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France. Tel.:þ33 148955555. E-mail address: [email protected] (G. Kermarrec).
In this case, we used a distally based sural neurofasciocutaneous island flap as described by the senior author,1 but with a modified technique due to the local vascular conditions. According to the literature, the sural flap is reliable,2,3 has a constant vascularisation1,4,5 and can be performed as a single-stage operation without microsurgery and with minimal donor site morbidity5: there is no sacrifice of major arteries and no significant functional loss.
Case report A 51-year-old man had a motor vehicle accident in 1989 causing a Cauchoix 3 open fracture at the junction of the middle and lower thirds of the left leg, which was initially treated by external fixation associated with a Papineau
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.022
Please cite this article in press as: Kermarrec G, Masquelet A-C, Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.022
+
MODEL
2
G. Kermarrec, A.-C. Masquelet
procedure. Consolidation and coverage of the soft-tissue defect necessitated several reconstructive surgeries including a latissimus dorsi musculocutaneous free flap, a distally pedicled peroneus brevis muscle flap and an intertibiofibular graft. The result was satisfying for almost 20 years until the spontaneous appearance of a necrotic lesion on the anterior aspect of the distal fourth of the leg resulting in exposure of the tibia (Figure 1). In view of the prior lesions and treatments, it was decided conditions were not favourable for spontaneous healing, and a coverage procedure was planned. An arteriogram (Figure 2) showed occlusion of the anterior tibial and fibular arteries. The fibular artery was probably interrupted during the previous inter-tibiofibular graft procedure, which was done through a posterolateral approach. The distal third of the fibular artery was retrogradely vascularised by the posterior tibial artery through the posterior metaphyseal arcade and provided a perforator artery 11 cm above the lateral malleolus. We decided to use this perforator artery as the pivot point for an atypical sural island fasciocutaneous flap. The patient was installed in lateral decubitus with an upper thigh tourniquet. The pivot point was first marked, according to the preoperative arteriography, 11 cm above the lateral malleolus (Figure 3). From this point, the flap and its pedicle were drawn and harvested following the usual technique,1 except that the saphenous vein was not included with the pedicle. The tourniquet was released with the flap in its original position to check its vascular supply. The recipient site was prepared. The flap was transferred to the defect. The pedicle was passed without
Figure 2 Arteriogram of the left leg, anterior view: the fibular artery (F) is interrupted, but the distal portion of the artery is revascularized by the anastomosis (Red Arrow) with the posterior tibial artery (TP). A small cutaneous branch is visible, about 11 cm proximal to the lateral malleolus (Black arrow).
tunnelling to prevent compression by the fibrotic skin. We used several interrupted sutures to diminish the size of the donor site that could not be closed primarily. The donor site was secondarily grafted on the eighth day. The flap survived entirely and the donor area healed well (Figure 4).
Discussion
Figure 1 Chronic ulceration at the distal third of the anterior aspect of the left leg e Anterior view.
Since its original description,1 the vascularisation of the distally based neurofasciocutaneous sural flap has been the subject of several anatomic studies.4,6 Occluded arteries were described as a contraindication to this flap,2,6,7 but this has been questioned recently3,8: Malokov et al.4 confirmed, in an anatomic study, the existence of a constant arterial network following the sensory nerves of the leg in arteritis patients allowing the harvesting of a distal pedicle sural flap. Hsieh et al.3 described
Please cite this article in press as: Kermarrec G, Masquelet A-C, Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.022
+
MODEL
Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery
3
artery is known to provide multiples perforators to the sural network.9 The most distal one is the most used because it increases the pedicle length. In this case, the pedicle length was not an issue; so, a more proximal perforator was used, which was located by preoperative angiography. Angiography was described as a reliable technique by Higueras Sune et al.10 in perforator flaps although most authors use the Doppler ultrasound to locate the perforator.2,8 This case shows the possibilities of the distally based neurofasciocutaneous sural flap when based on meticulous preoperative evaluation of the lower limb vascularisation.
Conflict of interest Figure 3 Design of the flap in supine position, lateral view, including the skin paddle (S), the pedicle (P) and the pivot point (*).
the use of a sural flap in a patient with occluded anterior and posterior tibial arteries. In our case, the previous reconstructive surgery and the vascularisation of the lower limb did not favour a free flap. However, the preoperative arteriogram showed a perforator artery of the peroneal artery that was retrogradely vascularised by the posterior tibial artery through the posterior metaphyseal arcade. This perforator artery provided a sufficient blood flow to allow the harvesting of the flap. The pivot point was more proximal than commonly described2,8 because of the local condition. The peroneal
Figure 4
Result six months after surgery.
None.
Funding None.
References 1. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg June 1992;89(6):1115e21. 2. Spyriounis PK. The use of the reverse sural neurovenocutaneous flap in distal tibia, ankle and heel reconstruction. Eur J Plast Surg 2005 Sep 7;28(5):309e14. 3. Hsieh CH, Liang CC, Kueh N-S, Tsai HH, Jeng SF. Distally based sural island flap for the reconstruction of a large soft tissue defect in an open tibial fracture with occluded anterior and posterior tibial arteriesda case report. Br J Plast Surg 2005 Jan;58(1):112e5. 4. Malokov S, Casanova D, Magalon G, Branchereau A. Sural flap vascularization in arteritic patients: an anatomic study of 24 amputation specimens. Surg Radiol Anat 2003 Dec 1;25(5e6): 372e8. 5. Parodi PC, DeBiasio F, Vaienti L, DeLorenzi F, Riberti C. Distally based sural neuro-fasciocutaneous island flap to cover tissue loss in the distal third of the leg. Eur J Plast Surg 2003 Jul 1; 26(4):175e8. 6. Bowen Jones E, Cronwright K, Lalbahadur A. Anatomical studies and five years clinical experience with the distally based medial fasciocutaneous flap of the lower leg. Br J Plast Surg 1993 Dec;46(8):639e43. 7. Le Nen D, Stindel E, Caro P, Dubrana F, Lefe `vre C. Therapeutic possibilities of the lateral supra-mallolar flap and its variations. Apropos of 6 clinical cases. Ann Chir Plast Esthe´tique 1996 Apr;41(2):127e35. 8. Ahmed S, Fung B, Ip W, Fok M, Chow S. The versatile reverse flow sural artery neurocutaneous flap: a case series and review of literature. J Orthop Surg Res 2008;3(1):15. 9. Mojallal A, Wong C, Shipkov C, et al. Vascular supply of the distally based superficial sural artery flap: surgical safe zones based on component analysis using three-dimensional computed tomographic angiography. Plast Reconstr Surg 2010 Oct;126(4):1240e52. 10. Higueras Sun ˜e ´ MC, Lo ´pez Ojeda A, Narva ´ez Garcı´a JA, et al. Use of angioscanning in the surgical planning of perforator flaps in the lower extremities. J Plast Reconstr Aesthet Surg 2011 Sep;64(9):1207e13.
Please cite this article in press as: Kermarrec G, Masquelet A-C, Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.022
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e3
CASE REPORT
Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report ´nole ´ Kermarrec*, Alain-Charles Masquelet Gwe Department of Orthopedic and Reconstructive Surgery, Hospital Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France Received 26 June 2013; accepted 20 December 2013
KEYWORDS Sural flap; Occluded artery; Angiography
Summary Coverage of soft-tissue defects of the leg has improved with the discovery of new flaps. However, surgeons now have to deal with new lesions on top of previous reconstructive surgeries. We present a case of soft-tissue defect of the anterior lower third of the leg presenting 20 years after reconstructive surgery for an open fracture and its management. The anterior tibial and fibular arteries were occluded with a retrograde vascularisation of the fibular artery; this provided a perforator artery that we used as a pivot point for an atypical sural island flap with a good result at 6 months. This case challenges the classic contraindication of this flap in case of occluded arteries. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Coverage of soft-tissue defects of the distal third of the leg is challenging for plastic and orthopaedic surgeons. Management relies on the multiple anatomic studies and flaps described since the 1970s. Diffusion of these techniques has made them easier and safer to perform but has led to a new situation arising: management of soft-tissue defects in patients who have already undergone reconstructive surgery. This requires meticulous preoperative planning and, in many cases, intra-operative adaptation of tactics to the local conditions. * Corresponding author. Department of Orthopedic and Reconstructive Surgery, Hospital Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France. Tel.:þ33 148955555. E-mail address: [email protected] (G. Kermarrec).
In this case, we used a distally based sural neurofasciocutaneous island flap as described by the senior author,1 but with a modified technique due to the local vascular conditions. According to the literature, the sural flap is reliable,2,3 has a constant vascularisation1,4,5 and can be performed as a single-stage operation without microsurgery and with minimal donor site morbidity5: there is no sacrifice of major arteries and no significant functional loss.
Case report A 51-year-old man had a motor vehicle accident in 1989 causing a Cauchoix 3 open fracture at the junction of the middle and lower thirds of the left leg, which was initially treated by external fixation associated with a Papineau
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.022
Please cite this article in press as: Kermarrec G, Masquelet A-C, Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.022
+
MODEL
2
G. Kermarrec, A.-C. Masquelet
procedure. Consolidation and coverage of the soft-tissue defect necessitated several reconstructive surgeries including a latissimus dorsi musculocutaneous free flap, a distally pedicled peroneus brevis muscle flap and an intertibiofibular graft. The result was satisfying for almost 20 years until the spontaneous appearance of a necrotic lesion on the anterior aspect of the distal fourth of the leg resulting in exposure of the tibia (Figure 1). In view of the prior lesions and treatments, it was decided conditions were not favourable for spontaneous healing, and a coverage procedure was planned. An arteriogram (Figure 2) showed occlusion of the anterior tibial and fibular arteries. The fibular artery was probably interrupted during the previous inter-tibiofibular graft procedure, which was done through a posterolateral approach. The distal third of the fibular artery was retrogradely vascularised by the posterior tibial artery through the posterior metaphyseal arcade and provided a perforator artery 11 cm above the lateral malleolus. We decided to use this perforator artery as the pivot point for an atypical sural island fasciocutaneous flap. The patient was installed in lateral decubitus with an upper thigh tourniquet. The pivot point was first marked, according to the preoperative arteriography, 11 cm above the lateral malleolus (Figure 3). From this point, the flap and its pedicle were drawn and harvested following the usual technique,1 except that the saphenous vein was not included with the pedicle. The tourniquet was released with the flap in its original position to check its vascular supply. The recipient site was prepared. The flap was transferred to the defect. The pedicle was passed without
Figure 2 Arteriogram of the left leg, anterior view: the fibular artery (F) is interrupted, but the distal portion of the artery is revascularized by the anastomosis (Red Arrow) with the posterior tibial artery (TP). A small cutaneous branch is visible, about 11 cm proximal to the lateral malleolus (Black arrow).
tunnelling to prevent compression by the fibrotic skin. We used several interrupted sutures to diminish the size of the donor site that could not be closed primarily. The donor site was secondarily grafted on the eighth day. The flap survived entirely and the donor area healed well (Figure 4).
Discussion
Figure 1 Chronic ulceration at the distal third of the anterior aspect of the left leg e Anterior view.
Since its original description,1 the vascularisation of the distally based neurofasciocutaneous sural flap has been the subject of several anatomic studies.4,6 Occluded arteries were described as a contraindication to this flap,2,6,7 but this has been questioned recently3,8: Malokov et al.4 confirmed, in an anatomic study, the existence of a constant arterial network following the sensory nerves of the leg in arteritis patients allowing the harvesting of a distal pedicle sural flap. Hsieh et al.3 described
Please cite this article in press as: Kermarrec G, Masquelet A-C, Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.022
+
MODEL
Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery
3
artery is known to provide multiples perforators to the sural network.9 The most distal one is the most used because it increases the pedicle length. In this case, the pedicle length was not an issue; so, a more proximal perforator was used, which was located by preoperative angiography. Angiography was described as a reliable technique by Higueras Sune et al.10 in perforator flaps although most authors use the Doppler ultrasound to locate the perforator.2,8 This case shows the possibilities of the distally based neurofasciocutaneous sural flap when based on meticulous preoperative evaluation of the lower limb vascularisation.
Conflict of interest Figure 3 Design of the flap in supine position, lateral view, including the skin paddle (S), the pedicle (P) and the pivot point (*).
the use of a sural flap in a patient with occluded anterior and posterior tibial arteries. In our case, the previous reconstructive surgery and the vascularisation of the lower limb did not favour a free flap. However, the preoperative arteriogram showed a perforator artery of the peroneal artery that was retrogradely vascularised by the posterior tibial artery through the posterior metaphyseal arcade. This perforator artery provided a sufficient blood flow to allow the harvesting of the flap. The pivot point was more proximal than commonly described2,8 because of the local condition. The peroneal
Figure 4
Result six months after surgery.
None.
Funding None.
References 1. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg June 1992;89(6):1115e21. 2. Spyriounis PK. The use of the reverse sural neurovenocutaneous flap in distal tibia, ankle and heel reconstruction. Eur J Plast Surg 2005 Sep 7;28(5):309e14. 3. Hsieh CH, Liang CC, Kueh N-S, Tsai HH, Jeng SF. Distally based sural island flap for the reconstruction of a large soft tissue defect in an open tibial fracture with occluded anterior and posterior tibial arteriesda case report. Br J Plast Surg 2005 Jan;58(1):112e5. 4. Malokov S, Casanova D, Magalon G, Branchereau A. Sural flap vascularization in arteritic patients: an anatomic study of 24 amputation specimens. Surg Radiol Anat 2003 Dec 1;25(5e6): 372e8. 5. Parodi PC, DeBiasio F, Vaienti L, DeLorenzi F, Riberti C. Distally based sural neuro-fasciocutaneous island flap to cover tissue loss in the distal third of the leg. Eur J Plast Surg 2003 Jul 1; 26(4):175e8. 6. Bowen Jones E, Cronwright K, Lalbahadur A. Anatomical studies and five years clinical experience with the distally based medial fasciocutaneous flap of the lower leg. Br J Plast Surg 1993 Dec;46(8):639e43. 7. Le Nen D, Stindel E, Caro P, Dubrana F, Lefe `vre C. Therapeutic possibilities of the lateral supra-mallolar flap and its variations. Apropos of 6 clinical cases. Ann Chir Plast Esthe´tique 1996 Apr;41(2):127e35. 8. Ahmed S, Fung B, Ip W, Fok M, Chow S. The versatile reverse flow sural artery neurocutaneous flap: a case series and review of literature. J Orthop Surg Res 2008;3(1):15. 9. Mojallal A, Wong C, Shipkov C, et al. Vascular supply of the distally based superficial sural artery flap: surgical safe zones based on component analysis using three-dimensional computed tomographic angiography. Plast Reconstr Surg 2010 Oct;126(4):1240e52. 10. Higueras Sun ˜e ´ MC, Lo ´pez Ojeda A, Narva ´ez Garcı´a JA, et al. Use of angioscanning in the surgical planning of perforator flaps in the lower extremities. J Plast Reconstr Aesthet Surg 2011 Sep;64(9):1207e13.
Please cite this article in press as: Kermarrec G, Masquelet A-C, Sural flap for coverage of a soft-tissue defect of a leg with an occluded fibular artery: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2013.12.022