Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases

Identification of peroneal artery perforators using non-contrast-enhanced T2prep multi-shot gradient echo planar imaging MRA

The purpose of this study was to investigate the spatial resolution of non-contrast-enhanced (CE) T2prep multi-shot gradient echo planar imaging (MSG-EPI) magnetic resonance angiography (MRA) required to identify peroneal artery perforators and demonstrate its effectiveness in preoperative simulation. Twenty-six legs of 13 volunteers were scanned using non-CE T2prep MSG-EPI-MRA at three spatial resolutions: 1.0-, 0.8-, and 0.6-mm isotropic voxels. The location and number of peroneal artery perforators that could be candidates for free fibula flaps were identified by consensus among three plastic surgeons. Surgeons distinguished between septocutaneous and musculocutaneous perforators using MRA, and confirmed the accuracy of their presence and identification using ultrasonography (US). The ability to detect hypoplasia or stenosis of the anterior tibial, posterior tibial, and peroneal arteries was evaluated by confirming the consistency between the MRA and US results. The number of cutaneous perforators identified using MRA and confirmed using US was 39, 51, and 52 at each respective resolution. The discrimination accuracies between septocutaneous and musculocutaneous perforators were 92.3%, 96.1%, and 96.2%. The number of identified septocutaneous perforators was 1.3 ± 0.6, 1.6 ± 0.8, and 1.7 ± 0.8 at 1.0-, 0.8-, and 0.6-mm data, respectively. All the MRA results, including hypoplasia and stenosis, were consistent with the US results. Non-CE T2prep MSG-EPI-MRA with a spatial resolution of 0.8 mm or less shows promise for identifying septocutaneous perforators of the peroneal artery, suggesting its potential as an alternative to conventional imaging methods for the preoperative planning of free fibula osteocutaneous flap transfers.

Safety of free fibula flap harvest in IIIA and IIIB tibio-peroneal trunk variations

INTRODUCTION

In head and neck cancer malignancies, free fibula flap is the gold standard for reconstruction of segmental bone defects owing to its predictable anatomy, long bone length, and feasibility for multiple osteotomies. However, sometimes because of variations in anatomy of tibio-peroneal trunk, it is a dilemma for the surgeons to use free fibula flap for reconstruction. This case series aimed to evaluate the safety of harvest of fibula in such cases in terms of acute and chronic donor-site complications.

MATERIAL AND METHODS

A retrospective study was conducted from January 2018 to May 2021. All the patients with tibio-peroneal trunk anomaly, diagnosed during surgery, who underwent successful harvest of the free fibula were included in the study and analyzed for the early major and minor donor wound complications, long-term donor complications, and late functional deficit using the Foot and Ankle Disability Index (FADI).

RESULTS

Out of 714 free fibulae operated, 26 patients (3.6%) had such tibio-peroneal trunk variations: 22 (2.9%) cases of type III A and B anomalies and 4 (0.56%) cases of type III C anomalies. The average FADI score was 95.3%. No one had any difficulty in personal care and activity of daily living.

CONCLUSIONS

The free fibula flap can be safely harvested in patients with type III A and B anomalies if vascularity of foot after clamping of peroneal vessels is good and anterior tibial vessels are normal.

An Unreported Variation of Origin of Posterior Tibial Artery Encountered During Free Fibula Flap Harvest

ABSTRACT

Variations in the division of popliteal artery and origin of the 3 vascular systems are well documented. Here, we report a case in which the posterior tibial artery originated from the peroneal artery, in lower leg and then followed the normal course. The anomaly was detected intraoperatively precluding the harvest of free fibula flap. The procedure was abandoned and fibula was fixed using plates and screws and a free radial forearm flap was done over 2 mini-plates, which spanned the bone gap. A second bone flap procedure was to be planned in another sitting.The anomalous origin of posterior tibial artery from the peroneal artery in lower leg did not fall into any of the categories described previously by Kim et al (Ann Surg 1989;210:776-81.). In the event such atypical anatomy is encountered, it must be delineated, and the surgical plan adjusted accordingly. Flexibility in surgical approach can prevent vascular catastrophe.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

The Role of Imaging in Mandibular Reconstruction with Microvascular Surgery

Imaging plays a critical role in the diagnosis, staging, and management of segmental mandibular defects. Imaging allows mandibular defects to be classified which aids in microvascular free flap reconstruction. This review serves to complement the surgeon's clinical experience with image-based examples of mandibular pathology, defect classification systems, reconstruction options, treatment complications, and Virtual Surgical Planning.

A Lucky Case of Successful Free Fibula Osteocutaneous Flap Harvest in Peronea Arteria Magna

The free fibula flap (FFF) is based on the peroneal artery (PA) system, and it is well known that several anatomical variations of the lower limb vascular system exist, including peronea arteria magna (PAM). PAM is a rare congenital variation in which both anterior tibial artery and posterior tibial artery are either aplastic or hypoplastic, and as a result, PA will be the dominant blood supply to the foot. This variation was described as type III-C in Kim-Lippert's Classification of the Infra-Popliteal Arterial Branching Variations. The awareness of its existence is crucial as it often precludes FFF from being harvested due to the risk of significant limb ischemia and limb loss. Despite some literature reporting donor site complications and impending limb loss following FFF harvest in PAM, preoperative vascular mapping before FFF transfer remains controversial among the microsurgeons. We present a case with an incidental intraoperative finding of PAM that had a successful FFF harvest by luck, without preoperative vascular mapping.

Standardize routine angiography assessment of leg vasculatures before fibular flap harvest: lessons of congenital and acquired vascular anomalies undetected by color Doppler and physical examinations

BACKGROUND

Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered.

PURPOSE

Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection.

MATERIAL AND METHODS

A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings.

RESULTS

A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one.

CONCLUSIONS

Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.

The congenital popliteal vasculature patterns in fibular free flap reconstruction by means of surgical anatomy in cadavers

Fibular free flap (FFF) is frequently used for reconstruction requiring vascularized bone. Thus, understanding its vasculature variation is crucial. This study investigates the popliteal artery branching variations in Thai cadavers and compares them with previous studies. One hundred and sixty-two legs from 81 formalin-embalmed cadavers were dissected. The popliteal artery branching patterns were classified. The previous data retrieved from cadaveric and angiographic studies were also collected and compared with the current study. The most common pattern is type I-A (90.7%). For the variants, type III-A was the majority among variants (6.2%). Type IV-A, hypoplastic peroneal artery, was found in one limb. A symmetrical branching pattern was found in 74 cadavers. Compared with cadaveric studies, type III-B and III-C are significantly common in angiographic studies (p = 0.015 and p = 0.009, respectively). Type I-A is most common according to previous studies. Apart from this, the prevalence of type III-A variant was higher than in previous studies. Furthermore, type III-B and III-C are more frequent in angiographic studies which might be from atherosclerosis. Thus, if the pre-operative CTA policy is not mandatory, the patients at risk for atherosclerosis and population with high variants prevalence should undergo pre-operative CTA with cost-effectiveness consideration.

FFF Utilizing an Arteriovenous Vascular Loop of Two Peroneal Venae Comitantes for a PAM

Vascularized bone grafting is widely used for reconstruction of osseous defects of the forearm. Fibular free flap (FFF) is one option, which relies on harvesting the peroneal artery. This procedure is subject to lower extremity anatomic variants; therefore, some recommend preoperative angiography. However, high quality evidence for this approach and its cost-effectiveness are lacking and instead one can diligently assess the vascular anatomy intraoperatively. Here, we describe a case of a 73-year-old man who was found to have a peronea arteria magna intraoperatively during an FFF for a left radius reconstruction secondary to an infectious nonunion. We describe an approach to performing an FFF using an arteriovenous vascular loop through the fibula employing the two accompanying peroneal venae comitantes. The patient had no complications and was found to have appropriate healing of the upper extremity without lower extremity compromise at 3-month follow-up. This report illustrates an alternative to using an interpositional venous graft for peronea arteria magna found intraoperatively during FFFs.

Preoperative Angiography for Free Fibula Flap Harvest: A Case Series

Purpose:

To assess if preoperative angiography of the lower extremity is necessary to detect abnormalities that alter operative planning of a free fibula flap (FFF). The secondary objective is to determine whether abnormalities are identified on physical examination.

Methods:

A retrospective case series of patients receiving preoperative lower extremity angiography for FFF was performed. Between November 2004 and July 2016, patients assessed for FFF reconstruction by a single surgeon were reviewed. Outcomes analyzed were preoperative physical examination, angiography findings, changes in operative plan, and perioperative complications including flap failure and limb ischemia. Level of agreement between physical examination and angiography findings was analyzed.

Results:

A total of 132 consecutive patients were assessed for FFF, of which 70 met the inclusion criteria. Mean age was 60.9 (range: 22-88) years old. All patients underwent aortic angiogram runoff, except for 2 who received computed tomography angiography. The surgical plan was altered based on angiography findings in 9 (12.9%) patients, and 7 (77.8%) of these cases had a normal physical examination. A further 6 (8.6%) patients had physical examination findings precluding the use of FFF, whereas imaging demonstrated the contrary. Physical examination demonstrated low predictability of aberrant vascular anatomy, with a sensitivity of 22.2%. There were no limb ischemia complications.

Conclusions:

Routine preoperative angiography of the lower extremity for all patients being evaluated for FFF is important to ensure safety and success of the procedure. Physical examination alone is insufficient to detect vascular abnormalities that may result in limb or flap compromise.

Chimeric Free Fibula Flap: An Encounter With Aberrant Anatomy

A 59-year-old male presented with recurrent mucoepidermoid carcinoma of the mandible. A resection with immediate free fibula flap reconstruction was done. The osteocutaneous free fibula flap relies on the peroneal artery and its distal perforators. Variant patterns necessitate consideration of the challenging to dissect proximal myocutaneous perforator raised on a single or double anastomosis, depending on origin. Even in cases of flap salvage, the fibula flap remains a reliable flap. This case describes a fibula flap with a sole proximal myocutaneous perforator identified during dissection despite a normal preoperative Doppler.

Magnetic resonance angiography for free fibula harvest: anatomy and perforator mapping

The purpose of this study was to outline lower leg vessel anatomy and to investigate reliability and limitations of magnetic resonance angiography (MRA) in patients proposed for microvascular fibula transplantation (free fibula flap (FFF)). We retrospectively investigated MRAs of 99 patients considered for FFF. Frontal MRA planes and maximal intensity projections (MIPs) were evaluated for fibula lengths, anatomical branching pattern, arterial stenoses and fibular perforator positions in both legs (n=198). Normal branching patterns were observed in 168 (85.3%) legs. Twenty-nine (14.7%) legs presented abnormal branching patterns. Once (0.5%) the anterior, 19 times (9.6%) the posterior tibial artery were absent or hypoplastic. Nine (4.6%) lower legs presented an arteria peronea magna. Average length of the tibiofibular trunk (TFT) was 3.3±0.15cm. A total of 492 perforators were found with an average of 2.5 (±0.82±0.99) perforators per leg. A mapping of perforator run-offs was illustrated true to scale. Lower limb stenoses were distributed in the anterior tibial artery (14.1%), in the posterior tibial artery (11.1%) and in the fibular artery (8.1%). Smoking (P=0.828), diabetes (P=0.727) and peripheral arterial occlusive disease (P=0.172) did not correlate with presence of stenoses. Preoperative lower limb angiography avoids postoperative complications. MRA reliably and non-invasively identifies anatomical variants and arterial stenoses without radiation. Illustration of perforator run-offs enhances incision planning for fibula harvest.

Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report

Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.

Influence of preoperative imaging on fibula free flap harvesting

INTRODUCTION

The fibula free flap (FFF) is the gold standard for the reconstruction of large maxillofacial defects. Magnetic resonance angiography (MRA) seems to supersede digital subtraction angiography (DSA) as the reference in preoperative evaluation, being non-invasive and having equivalent diagnostic results. The aim of this study was to assess the impact of preoperative MRA versus DSA on the viability of FFF and its success rate.

MATERIAL AND METHODS

A total of 216 patients, who underwent mandibular or maxillary FFF reconstruction from January 1995 to January 2011, were retrospectively included in the study. Of them, 101 patients underwent preoperative DSA and 115 underwent MRA. Recorded criteria were as follows: age, sex, tobacco consumption, defect etiology, preoperative vascular assessment, donor-site choice and flap failure. The DSA group was compared to the MRA group.

RESULTS

The harvested side was switched in 15.7% of cases with preoperative MRA versus 4% with DSA. Our success rate was higher (96.1%) with MRA than with DSA (88.1%) (P<0.05). More atherosclerotic patients (P=0.004) were diagnosed through MRA. MRA and DSA showed similar results in anatomical variation detection.

CONCLUSION

MRA is less invasive and more effective in atherosclerosis detection than DSA. Therefore, donor-site switching was more frequent in the MRA group, which led to a better success rate. MRA should replace DSA as the reference in preoperative assessment.

Anterior Cervical Reconstruction Using Free Vascularized Fibular Graft after Cervical Corpectomy

Study Design Prospective study. Objective The aim of this study was to evaluate the clinical and radiologic results of using free vascularized fibular graft (FVFG) for anterior reconstruction of the cervical spine following with varying levels of corpectomy. Methods Ten patients underwent anterior cervical reconstruction using an FVFG after cervical corpectomy augmented with internal instrumentation. All patients were evaluated neurologically according to the Japanese Orthopaedic Association (JOA) and modified JOA scoring systems and the Nurick grading system. The neurologic recovery rate was determined, and the clinical outcome was assessed based on three factors: neck pain, dependence on pain medication, and ability to return to work. The fusion status and maintenance of lordotic correction by the strut graft were determined by measuring the lordosis angle and fused segment height (FSH). Results All patients achieved successful fusion. The mean follow-up period was 35.2 months (range, 28 to 44 months). Graft union occurred at a mean of 3.5 months. The mean loss of lordotic correction was 0.95 degrees, and the mean change in FSH was <1 mm. The neurologic recovery rate was excellent in four patients, good in five, and fair in one. All patients achieved satisfactory clinical outcome. No neurologic injuries occurred during the operations. Conclusion The use of FVFG is a valuable and effective technique in anterior cervical reconstruction for complex disorders.

Foot ischemia after a free fibula flap harvest: immediate salvage with an interpositional sapheneous vein graft

The most dreaded major donor-site complication of free fibula flap is a foot ischemia, which is fortunately rare. Various authors have discussed the efficacy of the use of preoperative imaging methods including color Doppler, magnetic resonance angiography, and conventional angiography. A 25-year-old man presented with a 10-cm mandibular defect after a facial gunshot injury. Lower extremity color Doppler revealed triphasic peroneal, tibialis anterior, and posterior artery flows. A fibula osteocutaneous flap was harvested, and the mandible was reconstructed. However, the suture sites at the donor site began to demonstrate signs of necrosis, abscess formation, and widespread cellulitis beginning from postoperative day 9. Angiogram of the lower extremity on the 13th day demonstrated no flow in the right posterior tibial artery distal to the popliteal artery, whereas the anterior tibial artery had weak flow with collateral filling distally. An emergency bypass with a saphenous vein graft between the popliteal artery and the distal posterior tibial artery was performed. Repeated debridements, local wound care, and vacuum-assisted closure were applied. A skin graft was placed eventually. The extremity healed without severe functional disability. In conclusion, although the arterial anatomy is completely normal in preoperative evaluation, vascular complications may still ocur at the donor fibula free flap site. In addition, emergency cardiovascular bypass surgery, as we experienced, may be necessary for limb perfusion.

Technique of harvest of the free vascularized fibula

Vascularized free fibula transfer is an attractive option for the treatment of segmental bone defects because of faster union rates, fewer fatigue fractures, rapid hypertrophy, and less resorption compared with nonvascularized bone transfer. It is classically indicated for those patients with segmental bone defects >6 to 8 cm. The presence of several peroneal artery fasciocutaneous perforators also makes the inclusion of a skin paddle possible. Although rare, the surgeon must be aware of possible complications associated with this procedure. A careful operative technique is necessary for obtaining excellent surgical outcomes.

Assessment of vascularized free fibula transplantation revealing a congenital aplastic posterior tibial artery: a case report

Introduction

Anatomical abnormalities in the lower limb vessels are uncommon. However, the preoperative evaluation of the anatomical variations is very important for planning the operation procedure to prevent jeopardizing the donor leg.

Case presentation

In this case report, a 23-year-old Asian woman who was scheduled to have vascularized free fibula transplantation for reconstruction of her wrist after excision of bone tumor in her distal radius, was found to have congenital aplastic posterior tibial arteries in both legs. These findings were found on magnetic resonance angiography (our preferred methodology due to its simplicity). We planned testing the sufficiency of her pedal pulses after temporarily clamping her peroneal artery but prior to harvesting, to ensure minimal risk to the longevity of her donor leg. During the operation, after dissection of a 10cm segment of her fibula with the peroneal artery, the peroneal artery proximal to the graft was temporarily clamped and the tourniquet was released. As adequate sustainable pedal pulses were confirmed, the graft was harvested and transplanted to her wrist. There was no morbidity in her right leg postoperatively and the union of the grafted fibula was substantiated 10 months postoperatively.

Conclusions

We concluded two findings: firstly, for accurate preoperative planning of a vascularized free fibula procedure, examination of the bilateral lower leg vasculature either by angiography or other imaging should be performed. Secondly, abnormalities are not in themselves reason to abandon the vascularized free fibula procedure. We contend that pedal pulses should be evaluated preoperatively and provided that adequate foot circulation can be confirmed (by temporarily clamping the vessels and releasing the tourniquet during the operation prior to harvesting the free vascularized fibula) the procedure should be successful without jeopardizing the donor leg.

Retrospective analysis of incidence of peroneal artery hypoplasia in 101 free fibula transfers and new classification of popliteal branch anomalies

It is generally recognised by surgeons that there are anatomical variations of the popliteal artery and its branches, and knowledge of these has important clinical implications for fibula flap harvest. The aim of this study was to report our experience on 101 fibula free flaps, highlighting a new type of anatomical variation of the peroneal artery in a patient undergoing osteocutaneous fibula free flap for tibial reconstruction. During flap harvest, the peroneal vascular pedicle was shown to be hypoplastic and aberrant to its origin, branching between the proximal and medium third of the leg from the posterior tibialis artery with a diameter of 1mm. A modification of Kim's classification with the addition of a further "type IIID" group is suggested, to include peroneal artery hypoplasia or aplasia. This is an uncommon case of a rare infrapopliteal branching pattern that was undetected clinically and sonographically, exposing both the surgeon and patient to high risk of flap failure and/or leg ischaemic complication. Surgeons conducting free fibula transfer surgery should be aware of such a possibility as well as other variations, and could consider performing routine angiographic study on the donor limb, or they may be skilful enough to apply instant tricks to enable them to conduct the procedure safely.

Reconstructive Surgery for Head and Neck Cancer Patients

The field of head and neck surgery has gone through numerous changes in the past two decades. Microvascular free flap reconstructions largely replaced other techniques. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based approach wherever possible.

Factors influencing the necessity for preoperative vascular imaging before harvesting a vascularized fibular flap

OBJECTIVE

This study was carried out to identify groups of patients who would benefit from this angiography. The angiographic images of a random group of patients were studied; the correlations between the vascular state of the lower extremities and vessel pathology were investigated; and the possible links of these findings with certain medical conditions were explored.

STUDY DESIGN

Three experienced observers independently evaluated the angiograms of 185 patients. The status of all 3 vessels of the lower extremities (anterior tibial artery, posterior tibial artery, and peroneal artery) was evaluated. The patients' gender, age, drinking and smoking habits, and medical conditions were documented.

RESULTS

We found a significant correlation between pathology of the arteries of the lower extremity and blood cholesterol level, blood pressure, coronary heart disease, diabetes mellitus, and age.

CONCLUSIONS

We suggest that preoperative vascular imaging be carried out in patients with comorbidities to reduce the potential for flap failure and to minimize donor site complications.

Preoperative MR angiography for free fibula osteocutaneous flap transfer

INTRODUCTION

Magnetic resonance angiography (MRA) is currently considered the most useful test to evaluate the vascular anatomy of the lower leg prior to free fibula osteocutaneous flap transfer. This study aimed to confirm the validity of preoperative MRA.

METHODS

In 19 patients underwent free fibula osteocutaneous flap transfer for maxillary and mandibular reconstruction, the MRA and intraoperative findings and the postoperative complications were retrospectively analyzed. The location and number of distal septocutaneous perforators (dSCPs) that were preoperatively identified and harvested with flaps were documented.

RESULTS

Preoperative MRA detected dSCPs with 100% sensitivity. MRA findings also revealed the diversity of vascular structures, such as the tibio-peroneal bifurcation location and the anatomical relationship between the peroneal vessels and the fibula. No patients suffered postoperative ischemic complications in the donor leg. The total flap survival rate was 95 %.

CONCLUSIONS

Preoperative MRA effectively excluded large vessel anomalies and peripheral vascular disease, and precisely identified the septocutaneous perforators. Additionally, preoperative MRA contributed to a safer fibular osteotomy by predicting the anatomical relationship between the peroneal vessels and the fibula.

Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7-cm-wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot.

Technical considerations in microsurgical treatment of paediatric hand injuries

Microsurgical techniques are vital for the treatment of many aspects of trauma in the child, both in initial management and later reconstructive surgery. The basic principles of microsurgery pertain to all patients, but there are nuances of technique and of the psycho-social and peri-operative aspects of treatment which are particularly important in the child. It is these distinctions that are examined in this paper.

Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques

BACKGROUND

Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject.

METHODS

The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress.

RESULTS

The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA.

CONCLUSION

While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.

Anatomic variations in head and neck reconstruction

Head and neck reconstruction is a technically challenging procedure. Variations encountered in the recipient vessels and commonly used flaps add to the complexity of surgery. This article reviews the commonly encountered variations in the recipient vessels in the neck with emphasis on alternatives and techniques to circumvent these variations. Flaps commonly used in head and neck reconstruction are also reviewed in detail. Furthermore, safety, potential pitfalls, and technical pearls are highlighted.

A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction

BACKGROUND

In designing an osteocutaneous fibula flap, poor planning, aberrant anatomy, or inadequate perforators may necessitate modification of the flap design, exploration of the contralateral leg, or additional flap harvest. The authors studied the predictive power of computed tomographic angiography in osteocutaneous fibula flap planning and execution.

METHODS

The authors studied a prospective cohort of 40 consecutive patients who underwent preoperative computed tomographic angiography mapping of the peroneal artery and its perforators and subsequent free fibula flap reconstruction of mandibular or maxillary defects. The authors compared their analysis of perforator anatomy, peroneal artery origin, and fibula length with intraoperative clinical findings.

RESULTS

Overall, computed tomographic angiography identified 94.9 percent of the cutaneous perforators found intraoperatively. Clinically, perforators were located an average of 8.7 mm from their predicted locations. The peroneal artery origin from the tibioperoneal trunk averaged 6.0 mm from its predicted location. The average length of the fibula differed from the predicted length by 8.0 mm. Computed tomographic angiography accurately predicted perforators as either septocutaneous or musculocutaneous 93.0 percent of the time. Perforator size was accurately predicted 66.7 percent of the time. Skin islands and osteotomies were modified in 25.0 percent of the cases on the basis of computed tomographic angiography findings. Two patients had hypoplastic posterior tibial arteries, prompting selection of the contralateral leg. There were no total flap or skin paddle losses.

CONCLUSIONS

Computed tomographic angiography accurately predicted the course and location of the peroneal artery and perforators; perforator size was less accurately estimated. Computed tomographic angiography provides valuable information to facilitate osteocutaneous fibula flap harvest.

Raising the osteocutaneous fibular flap for oral reconstruction with reduced tissue alteration

Raising the osteocutaneous fibular flap offers excellent possibilities for oral reconstructive surgery but is associated with specific donor-site risks. Moreover, with inadequate surgical technique, flap-specific complications can occur, such as loss of the skin paddle or inadequate pedicle length. A flap-raising technique has been used to decrease surgical damage but provide maximal pedicle length. Sixty-six osteocutaneous fibular flaps were raised by the lateral approach with the following modifications: 1) flap-raising was carried out without a tourniquet, 2) only the amount of bone needed was removed, leaving the rest of the fibula intact, 3) only a minimal muscle cuff was included, and 4) the complete pedicle was dissected along the posterior intermuscular septum without opening the interosseous membrane and without touching the deep flexor muscles proximal to the osteotomized fibular segment. The skin paddle was placed distally in the leg, perfused by only 1 perforator in most cases. Medical records were analyzed and patients were examined postoperatively for up to 32 months to evaluate the above-mentioned complications. Of the 66 reconstructions, 44 were performed in a previously operated or irradiated neck. Three flaps and 1 skin paddle were lost. The most common donor-site complications were temporary wound-healing disturbances of the skin graft (n = 17) and transient pain or sensory alterations (n = 12). No compartment syndrome, ankle instability, or need for walking aids was recorded. A hammertoe deformity developed in 1 patient. On average, pedicle length was 9 cm and flap-raising took 130 minutes. In conclusion, maximal pedicle length and minimal bone and muscle resections can be achieved with a small number of donor-site complications. The skin paddle is highly reliable based on only 1 perforator. Perforators can be precisely controlled when raising the flap in the perfused leg.

Vascularised fibular graft for the treatment of congenital pseudarthrosis of the tibia: long-term complications in the donor leg

Treatment of congenital pseudarthrosis of the tibia is still controversial, and vascularised fibula graft is a reliable method for consolidation, although complications can occur in the donor leg after fibula grafting. This study evaluates 16 patients with congenital pseudarthrosis of the tibia (CPT) treated with contralateral fibular graft, with regard to complications in the donor leg, and assesses the influence of distal tibiofibular joint arthrodesis in these complications. All patients with CPT were consecutively submitted to surgical treatment with contralateral fibular graft. The mean follow-up was 94 months, varying from 44 to 162 months. The long-term effects in the donor leg were determined, and 12 cases with distal tibiofibular arthrodesis (group 1) were compared with a group without arthrodesis (group 2). Half of the patients had proximal migration of the lateral malleolus. Eight patients had ankle valgus. Group 1 had an average valgus tilt angle of 5.8°, while group 2 had an average angle of 1.5°. There was no significant difference between the patients with or without distal tibiofibular joint arthrodesis. The patients with a distal fibula remnant smaller than 5 cm had greater valgus tilt angle measurements. Distal tibiofibular arthrodesis was not effective in preventing all the complications in the donor leg; however, it can lessen the severity of the complications. Our results show that a distal fibular remnant greater than 5 cm should be retained to prevent ankle valgus.

Evaluation of the vessels of the lower leg before microsurgical fibular transfer. Part II: magnetic resonance angiography for standard preoperative assessment

The peroneal artery is the dominant supply of the osteomyocutaneous fibular flap. It has been shown that there can be anatomical variants that could jeopardise the blood supply to the lower limb during harvest of the flap. To avoid postoperative ischaemia of the lower leg, preoperative evaluation of adequate collateral perfusion is essential. We investigated whether magnetic resonance angiography (MRA) accurately shows anatomical variants and pathological stenoses of the vessels of the lower leg and whether it can replace conventional invasive techniques. Conventional digital subtraction angiography (DSA) was used in a prospective study of 15 patients, and contrast-enhanced MRA postoperatively. Arteries were evaluated by three radiologists for: size of vessel at the trifurcation; hypoplastic or missing vessels; appreciable stenosis or vascular occlusion, or both; atherosclerotic malformations; and overall vascular topography. High resolution MRA enabled a reliable judgement to be made of the vessels of the lower leg. MRA definitively detected hypoplastic vessels, stenoses, occlusion, or atherosclerotic changes of the vessels, and enabled both accurate assessment of the quality of vessels and the preferred site for the harvest of the flap. As it is a low risk procedure, it can be done in the outpatient department with no risk of radiation. It can easily replace conventional DSA.

Anomalies of the arterial tree that coexist with arteriovenous malformations in the lower extremity

Several previous reports have documented arteriovenous malformations associated with anomalies of the arterial tree. We report two cases in which a malformation on the foot coexisted with arterial variants of the popliteal artery. Careful therapeutic planning was required to avoid jeopardising perfusion to the distal area.

Use of solid and cancellous autologous bone graft for fractures and nonunions

Bone is the second most commonly implanted material in the human body, after blood transfusion, with an estimated 600,000 grafts performed annually. Although the market for bone graft substitutes is more than $1 billion, that of bone graft itself is still more than half that amount. Reports of autologous bone grafting date back to the ancient Egyptians, yet the modern scientific study of grafting began in the early 19th century. Since then, the indications, methodology, and science of bone grafts in nonunion and bone loss have been established and refined, and new methods of harvesting and treatment are being developed and implemented. This article describes the use of solid and cancellous bone graft in the treatment of acute bone loss and nonunion.