|Year : 2012 | Volume
| Issue : 1 | Page : 45-52
Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique
Jose Tharayil, Rahul K Patil
Department of Plastic and Reconstructive Surgery, Lakeshore Hospital, Cochin, Kerala, India
|Date of Web Publication||25-May-2012|
Department of Plastic Surgery, Lakeshore Hospital, Cochin 682 040, Kerala
Background: Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases. Materials and Methods: Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years. Results: Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management. Conclusions: RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.
Keywords: Distally based peroneal flaps; extended reverse sural flaps; foot reconstruction; peroneal artery; reverse peroneal flaps
|How to cite this article:|
Tharayil J, Patil RK. Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique. Indian J Plast Surg 2012;45:45-52
|How to cite this URL:|
Tharayil J, Patil RK. Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique. Indian J Plast Surg [serial online] 2012 [cited 2015 Jan 26];45:45-52. Available from: http://www.ijps.org/text.asp?2012/45/1/45/96584
| » Introduction|| |
Complex soft tissue defects around the ankle and foot represent a difficult reconstructive problem due to exposure of the bones, joints and tendons. Several reconstructive procedures have been proposed to repair soft tissue defects in these regions, including local cutaneous flaps, pedicled fascial or fasciocutaneous flaps and pedicled muscle flaps. , Local flaps in the foot have limitations of reach and reduced amount of soft tissue that can be transported at the cost of unacceptable donor site morbidity. ,
Donski and Fogdestam  described distally based fasciocutaneous flap based on the perforators of the peroneal artery around the ankle and their communications with the superficial sural artery. This flap, with its modifications, has been used for moderate-sized defects. ,,, The skin territory supplied by these lower peroneal perforators is limited, and useful flaps therefore have to be based on its communications with another fascial, fasciocutaneous or neurofasciocutaneous plexus. This limits its dimensions, pedicle length and the distal reach.
Microvascular tissue transfers provide a large amount of soft tissue at the most desired places, and are quiet reliable in experienced hands. But, non-availability of microsurgical expertise and facility at peripheral centres, the cost and, sometimes, the patient-related factors may preclude the option of free flap.  Although free-tissue transfer plays an important role in limb salvage, better understanding and applications of regional flap designs have sometimes provided easier and more cost-effective alternatives for soft tissue coverage of the injured lower extremity. 
Peroneal perforators supply skin over the lateral and posterior aspects of the leg. Flaps based on these perforators of peroneal artery have been proposed ,, for the coverage of lower third of leg and foot. These flaps include the skin supplied by the peroneal perforators either as propeller flap or as island flap with inclusion of peroneal vessels. Multiple communications exist between the peroneal artery and the tibial arteries (both anterior and posterior), as demonstrated by Cormack and Lamberty.  Based on these communications, the authors have described reverse peroneal artery flaps (RPAF). , Distally based islanded peroneal artery flap, although a versatile tool for foot reconstruction, is prone to venous congestion. Venous anastomosis in the foot to overcome this problem has been suggested. 
Inclusion of superficial vein for easier drainage has been tried successfully by multiple authors for similar distally based flaps.  Short saphenous system in the leg has constant anatomy and drains the whole posterior leg. Unlike in the radial forearm flap where the pedicle is very close to the superficial vein, peroneal vessels are further away from the short saphenous system. To harvest these two systems together and to maintain their communication was challenging. Hence, flap designs of reverse sural and RPAF were combined to get the advantages of both the systems. It also minimises disadvantages like low perfusion pressure in the upper third and inadequate venous drainage, respectively, of both flaps.
In the present study, the standard reverse sural flap design was modified to include the peroneal artery with its perforator in the middle third of the leg. This makes the flap from the upper third (normally an extension of reverse sural) robust and reliable, allowing inclusion of the entire posterior calf skin as well as increasing its reach. As there is a good fasciocutaneous pedicle, venous congestion has never been a problem. The present paper gives detailed technical description of the flap design, dissection of the peroneal artery and the results in 22 consecutive cases.
| » Materials and Methods|| |
Between June 2005 and December 2011, a total of 22 patients with soft tissue defects over the ankle and distal foot underwent reconstruction by RPAF transfer. Details like age, sex, aetiology, dimensions of defects, reason for flap cover and complications, if any, were noted from patients' medical records.
Pre-operatively, any history of previous injuries/surgeries to the limb, size and the site of the defect and peripheral pulses were assessed. This flap was planned when at least one of the major vessels is palpable. Arterial Doppler examination was carried out only when there was suspicion of lower limb ischaemia or history of vascular injury. Peroneal perforators were not routinely marked pre-operatively. All the procedures were performed under spinal anaesthesia. Most of the steps of surgery were carried out under the permissible time of tourniquet control. Patients were kept in lateral position.
Flap was planned in reverse with pivot point 5 cm above the lateral malleolus. The flap can be safely extended to the upper end of the leg, up to the line of the knee joint and laterally up to the mid lateral line on either side. Dissection of reverse sural flap has been well described. ,,, To avoid injury to the important communicating vessels, an area of 5 cm above the lateral malleolus is kept undisturbed. The dissection starts at the upper end of the marked flap. Incision is taken straight down deep to the fascia. The short saphenous vein in the subcutaneous tissue, sural artery and nerve lying deep between the heads of the gastrocnemius muscle are ligated. The flap is raised in a subfascial plane [Figure 1]b. After dissecting the flap, the pedicle is delineated by elevating the skin on either side of the axis at the sub-dermal level. Some skin is preserved in the centre of the pedicle [Figure 1]a to facilitate coverage of pedicle at the recipient site. After raising the sub-dermal flaps, the subcutaneous pedicle is divided medially and is raised at the sub-fascial plane towards the lateral side, looking for the perforators in the septum [Figure 1]c. These are reasonably constant in the middle third of the leg. One or two good-sized perforators are chosen and traced for a short distance to the peroneal artery [Figure 1]d. The flap is kept back in its position.
|Figure 1: (a) Flap planning. Flap has been marked symmetrically around the posterior midline with pivot point around 5 cm above the lateral malleolus. Small skin paddle marked over the pedicle area helps in easy closure after transposition. (b) Flap dissection from the medial to the lateral side. Sural vessels are carefully included. (c) Pedicle area is also dissected just above the paratenon over tendoachillis and reflected laterally till good perforators are visible. (d) Perforators are tracked down to the peroneal artery through the posterior septum. (e) Dissection from the lateral side. Sub-periosteal dissection helps in easy retrieval of the peroneal system from behind the fibula. The peroneal vessels are clamped just above the perforator. (f) Dissection is continued along with the peroneal system as much as needed to reach the defect, without violating the lower 5 cm above the malleoli. (g) The post-operative position. The leg is well supported by padding above and below the pedicle area. A strong plaster is applied over this so that the pedicle area is completely off-loaded without disturbing the patient|
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Dissection is then continued from the lateral side till the septum [Figure 1]e. The periosteum over the fibula is incised above the level of the perforator and reflected with the septum medially to visualise peroneal artery. Peroneal artery is now dissected from the fibula and a soft clamp is applied over the artery proximal to the perforator. The tourniquet is released. Perfusion of the flap after clamping the artery indicates sufficient perfusion of the limb and good communications with other arteries distally. The peroneal artery is then divided proximal to the selected perforator [Figure 1]f. Peroneal vessels with the perforator are then dissected distally as required. Multiple muscular branches need to be tackled carefully. After adequate mobilization, the flap is taken down to the defect. The area for incorporation of pedicle on way to recipient site is also marked and skin flaps are raised at a sub-dermal plane as before.
After giving flap inset, the sub-dermal skin flaps are tacked to the central skin paddle, making sure that there is no tension. This will provide good skin cover over the pedicle. Rarely, if it is not adequate, we cover the exposed part of the pedicle with skin graft. The peroneal vessels always get covered with pedicle. The donor site can be reduced at the upper and the lower ends. The remaining area is covered with skin graft.
In this flap, the pedicle and, most of the time, the flap itself lies over the posterior aspect of the leg and sometimes the heel. Because of the dependent position and possibility of the pedicle getting compressed, off-loading of the pedicle and the flap is very important. To achieve this, extra padding is placed above the level of the pedicle to give it good clearance from the plaster slab. A strong below-knee Plaster of Paris slab consisting of 20 layers of 15 cm plaster is applied and moulded in such a way that there is a good clearance of the pedicle and the heel flap from the slab. This also protects the skin graft applied over the donor site [Figure 1]g.
| » Results|| |
Of 22 patients, 18 were men and four were women, with an average age of 41.22 years (3-72 years). Soft tissue defects of variable aetiology, like post-traumatic tissue loss (11 cases), severe Congenital talipus equino varus (CTEV) resistant to soft tissue release (one case), chronic ulcers and contractures (five cases), diabetic foot (one case), squamous cell carcinoma (two cases) and malignant melanoma (two cases) were covered. The flap dimensions ranged from 11 cm × 6 cm to 26 cm × 13 cm in size, and the average size was 16.5 cm × 11 cm.
Twenty-one of the 22 flaps survived. There was no incidence of partial flap loss, marginal necrosis or venous congestion in any of these patients. In one patient, atherosclerotic occlusion of the peroneal artery was seen and no flap perfusion was evident on table, and the procedure was abandoned.
The graft take was generally satisfactory and all the patients were ambulant after 3 weeks following the surgery. There were minor problems at the donor site or over the pedicle area in nine patients, delaying the complete wound healing by another 2-3 weeks. Problems noted were wound dehiscence in two cases, partial necrosis of subdermal flaps (three cases) and partial skin graft loss at the donor site or over the pedicle (five cases). These cases were advised dressings, twice-a-week, as out-patients. All of them settled with conservative management. Details of aetiology, flap dimensions and complications have been summarized in [Table 1].
The average period of follow-up was 2½ years. Patients were asked to use elastocrepe bandages for 6 months. Patients with flap over the heel and sole were given special shoes. Although we noted callus formation at the pressure points in two patients, none of the patients reported problems associated with weight bearing. One patient with squamous cell carcinoma had recurrence of the disease through the flap. In six patients, the pedicle prominence over the back of the heel was cosmetically unacceptable. Even though secondary correction was offered, none accepted a second procedure.
| » Case Reports|| |
A 26-year-old male (case 13) sustained traumatic forefoot amputation in a run-over injury and presented with defect over forefoot amputation stump and the ankle [Figure 2]a. The defect was proximally extending into the heel tissue [Figure 2]b and the skin over the extensor retinaculum and the dorsum of the foot was completely avulsed and lost [Figure 2]c. A large reverse peroneal flap extending into the superior third of the leg was planned [Figure 2]d. The flap covered the defect completely [Figure 2]e. The flap survived completely and provided durable cover over the dorsal and plantar aspects. He was under follow-up for 3 years and did not have any flap-related complications. [Figure 2]f and g show the condition of the flap at the time of suture removal.
|Figure 2: (a-c) A 26-year-old male with traumatic forefoot amputation and degloving of the skin over the dorsum of the foot and anterolateral aspect of the lower leg and part of the sole distal to the heel. (d) Flap planned for complete cover of the defect. (e) Flap used to cover the defect. (f and g) Well-settled flap from the lateral and plantar aspects at the time of suture removal|
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A 45-year-old male (case 3) sustained run-over injury to his left foot and presented with closed degloving of his heel and sole skin [Figure 3]a and b. When the necrotic skin demarcated, he was taken up for debridement [Figure 3]c. Following the debridement, the defect was proximally extending from the posterior aspect of the heel to the junction of the middle and distal third of the sole [Figure 3]d. A large reverse peroneal flap including the superior third of the leg was planned and raised to cover the defect [Figure 3]e. The flap survived completely and provided durable cover over the dorsal and plantar aspects. He was under follow-up for 4 years and did not have any flap-related complications. [Figure 3]f, g and h show the condition of flap medial, plantar and lateral aspects along with well-settled donor site [Figure 3]h 2 months following the surgery. The pedicle area had no prominence.
|Figure 3: (a and b) A 45-year-old male with avulsion of the heel and sole tissue. (c) One week following the injury, the non-viable tissue is well demarcated. (d) Following debridement, the raw area was extending from the posterior heel to the junction of the middle and distal thirds of the sole. (e) Large flap planned on the posterior calf. (f, g and h) Well-settled flap and the donor site few months following the surgery|
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A 4-year-old boy (case 21) presented with run-over injury to the casualty [Figure 4]a. After debridement, although the tendons could be retained, he had a large soft tissue defect exposing multiple bones, joints and tendons [Figure 4]b. RPAF was used to cover the extensive defect reaching up to the bases of the toes [Figure 4]c. The flap survived completely and the donor site graft take was acceptable [Figure 4]d. Flap donor site reaching the back of the knee joint can be appreciated. The flap settled well in 3 weeks time [Figure 4]e.
|Figure 4: (a) A 4-year-old boy with run-over injury just before debridement. (b) Following debridement, multiple bones and joints got exposed. (c) Reverse peroneal flap was used to cover this defect. (d) Two weeks post-operatively, the flap settled well except a small raw area over the pedicle. (e) Well-settled flap 1 month following the surgery|
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| » Discussion|| |
Successful soft tissue reconstruction of large defects over the lower leg, ankle and foot is often a limb-saving procedure.  Fasciocutaneous or neurofasciocutaneous flaps from the leg are useful and versatile reconstructive options for patients with moderate-sized soft tissue defects of the leg, ankle and foot. Inability to reach distal defects with limited arc of rotation of wide and short adipofascial pedicles and the precarious venous drainage has been their problems. Although a free flap can provide sufficient tissue for reconstruction, not all patients are suitable candidates for free tissue transfer because of the existing comorbidities and economic constraints.
The presented flap design has included reverse flow peroneal artery along with the reverse sural design to achieve reliable cover. A sural flap has limited dimensions. Authors reporting successful reverse sural flaps are not in favour of harvesting flap from the proximal third of the leg. ,, This neurofasciocutaneous flap is perfused by lower peroneal perforators and has an axial pattern of circulation in the lower 2/3 rd of the leg. Flap harvested from the upper leg behaves as a random pattern extension of this flap and is unreliable. Inability to harvest reliable tissue from the upper third of the leg limits flap dimensions, the pedicle length and, ultimately, the distal reach of this flap. , Multiple modifications like delaying,  wider than usual pedicle,  supercharging  and taking part of gastrocnemius muscle with the flap  have been attempted to extend the flap to proximal the leg, with doubtful benefit. Ayyapan and Chaddha  tried to secure the skin from the proximal third by adding all the connective tissue between the heads of the gastrocnemius (as "mesentry" containing septocutaneous perforators). This improved the results only marginally, and the same study has reported 27% complication rates.
Lateral and posterior leg is normally supplied by perforators of peroneal artery reaching the skin via the posterior intermuscular septum. There are constant perforators 7-21 cm from the fibular head.  Although they were not marked pre-operatively in this study, it may be safer for beginners to do so. In our experience, these perforators were mostly direct septocutaneous perforators. Intramuscular course if present is through the flexor hallucis longus, and is very short. Thus, dissection of the perforator to the source vessel is quick. Once the perforator has been dissected to the peroneal vessels, the periosteum over the fibula is reflected just proximal to the selected perforator. This helps in complete visualization of the main pedicle and further dissection. The peroneal vessels are ligated proximally and are reflected distally as necessary for comfortable reach.
The presented technique of including the peroneal artery along with its perforator in the pedicle acts as arterial supercharging of the flap based on the supramalleolar perforators (routine reverse sural flap). This significantly increases the perfusion pressure in the flap taken from the upper third of the leg. When these advantages are combined, flap from the upper leg achieves all the advantages of an axial pattern flow. Harvesting the flap from the upper leg improved the effective pedicle length and helped reaching distal defects up to the bases of the toes. Inclusion of both sural and peroneal systems improves venous drainage and makes the pedicle more substantial to avoid any kink while taking the flap to foot. Additionally, peroneal vessels get covered with well-vascularised tissue. We did not encounter any venous or arterial insufficiency in any of the flaps, and all but one of them survived uneventfully. The maximum flap dimension was 26 cm × 13 cm. Irrespective of the dimensions of the flap, no augmentation procedure like extra anastomosis of either artery or vein as described by few authors was necessary.  None of the cases in this study required any delay procedure.
The main disadvantage of this flap is sacrifice of the peroneal artery. As long as either the posterior or the anterior tibial artery is patent, this was inconsequential in our patient population.Reverse radial artery forearm flap is the established method of the reconstruction in cases of injury to the wrist and hand. On the contrary, we propose RPAF for reconstruction of injuries to the ankle and foot, preferably where the leg is uninjured. Peroneal artery is the least important source of blood supply to the ankle and foot, where the main supply comes from the anterior tibial and posterior tibial arteries. With two major supply vessels intact, the risk to the foot is minimal while successful cover achieved is a major reconstructive achievement in an otherwise difficult area. Even for free tissue transfer in the distal extremities, most of the surgeons prefer end-to-end anastomosis (privileged communication with multiple authors), ultimately losing one of the major vessels. We did not observe any ischaemia-related complications anywhere in the leg attributable to harvest of the RPAF. The increased amount of soft tissue transferred, the more distal reach, increased reliability and ease of rotation compared with any other regional flap including the sural flap helped us in the salvage of these limbs.
Peroneal artery is least likely to have atherosclerosis.  In the presented series, two patients had successful flap cover even when arterial doppler study had reported partial occlusion of some of the peripheral arteries. These are cases where one hesitates to do a free flap. ,
This flap offers the following multiple advantages over other distally based fasciocutaneous flaps: (1) reliable flap dimensions can be extended up to the knee joint line, (2) pedicle length can be planned liberally to avoid acute kinking and (3) with longer pedicle, the flap can reach more distal areas over the sole and dorsum of the foot.
This modified flap can be suitable for (1) soft tissue defects of large dimensions, especially over the heel, sole and the dorsum of the foot, (2) patients with more distal defects where the routine reverse sural flaps may not reach, (3) patients with large raw area around the ankle and foot, where the standard reverse flap may not be adequate and (4) salvage in case of failed free flap.
Some of these flaps were performed in elderly patients who otherwise would have required free flaps. The procedures were carried out under spinal anaesthesia, and the average operating time was around 2-h. No intra-operative change in position was required as the flaps were harvested from the same limb. Post-operative positioning was simple and patients tolerated the procedure well. In most of the presented cases, this flap has helped in avoiding microsurgical tissue transfer.
| » Conclusion|| |
In our experience, extension of reverse sural flaps to the proximal third of the leg as RPAF was safe and reliable. These promising results persuaded us to refine our techniques to deliver reliable cover in the distal foot defects. Paddle in the superior third of the leg adds versatility in planning and tensionless reach of the flap to the recipient defect. In majority of these cases, free flap was the only other option. Under these circumstances, RPAF has been used with very good results for reconstruction of dorsal and plantar foot defects of larger dimensions.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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