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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 146-151

Peroneal pedicle: An underutilized recipient vessel


Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta – The Medicity, Gurgaon, Haryana, India

Date of Submission23-Jun-2019
Date of Acceptance14-Aug-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Hardeep Singh
Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta – The Medicity, Sector 38, NCR, Gurgaon - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_55_19

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  Abstract 


Introduction: Anterior and Posterior tibial vessels are commonly used for anastomosis in lower limb reconstruction. There are situations when both of these vessels have inadequate flow or the lie of the adjacent vessel in relation to the flap is not conducive for total coverage of the defect. In these situations, Peroneal pedicle can be used as the recipient vessel for free tissue transfer. We present our experience of using Peroneal pedicle as recipient vessel for successful free tissue transfer. Methods: All the patients undergoing free tissue transfer for lower limb reconstruction having anastomosis with Peroneal vessels were included. The patients fall under two groups. 1. Trauma- 6 patients with complex defect due to trauma had normal palpable distal pulsations at ankle but the target vessel was thrombosed, flap orientation was not conducive for the other vessel hence intraoperative decision to use Peroneal vessels was made. 2. Diabetic foot- Three patients had clinically non palpable pulsations at the ankle. They had biphasic flow in both the Tibial vessels and triphasic in peroneal as confirmed preoperatively with color Doppler. Free flaps were done using the anastomosis to Peroneal vessels. Results: Of 182 free flaps for lower limb reconstruction in last 4 years we have used Peroneal vessels as recipient pedicle in nine patients for successful free tissue transfer. All the flaps survived without any complication. Conclusion: Peroneal pedicle can be safely utilized as recipient vessel for free to free transfer in special situations. This is an underutilized pedicle to reconstruct many complex defects.

Keywords: Anterior tibial, peroneal, posterior tibial


How to cite this article:
Singh H, Jain A, Mahendru S, Khazanchi RK. Peroneal pedicle: An underutilized recipient vessel. Turk J Plast Surg 2020;28:146-51

How to cite this URL:
Singh H, Jain A, Mahendru S, Khazanchi RK. Peroneal pedicle: An underutilized recipient vessel. Turk J Plast Surg [serial online] 2020 [cited 2020 Jul 10];28:146-51. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/146/284960




  Introduction Top


Microsurgery is one stop solution to many complex defects.[1] One of the absolute requirements for successful free tissue transfer is a healthy recipient vessel. The commonly used vessels for micro anastomosis for leg and foot defects are the anterior and posterior tibial vessels.[2]. The recipient vessel is chosen by considering the distance from the defect and the lie of the flap in relation to vessel for wound coverage.[3] In case the planned vessel is found to be thrombosed or has inadequate flow, adjacent healthy vessels are often explored for successful free tissue transfer. If the other pedicle is the only vessel perfusing the limb, an end-to-side or T anastomosis is a must to maintain the vascularity of limb.[4] There are situations when both of these vessels have inadequate flow (as in atherosclerosis) or the lie of the adjacent vessel in relation to the flap is not conducive for total coverage of the defect without vein graft. In these situations, peroneal pedicle can be used as the recipient vessel for free tissue transfer. We present our experience of nine cases of using peroneal pedicle as recipient vessel for successful free tissue transfer.


  Methods Top


In the last 4 years, 622 microsurgical free tissue transfers have been done in our unit, of these 182 free flaps were done for lower limb reconstruction. We have used peroneal vessels as recipient pedicle in nine patients (six males and three females) for successful free tissue transfer.

Procedure details

A curvilinear skin incision is taken for the exposure of fibula [Figure 1]. The dissection for peroneal vessels involves removal of a segment of fibula measuring 5 cm. The distal limit of the excised fibula is 6 cm proximal to lateral malleolus, so as to maintain the stability of ankle joint. Subperiosteal dissection is done circumferentially at the proposed sites of osteotomy to avoid injury to peroneal vessels which run on the medial aspect of the fibula. Osteotomy is performed with a reciprocating saw guarding the peroneal vessels with a periosteal elevator medially. After the osteotomy, subperiosteal plane is created on the lateral surface of fibula to be excised and the bone is removed [Figure 2]. This gives way to exposure of peroneal vessels for anastomosis.
Figure 1: Skin markings for exposure of peroneal pedicle

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Figure 2: Removal of fibula and pedicle exposure

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The patients fall under two groups [Table 1].
Table 1: Details of the patient

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  1. Trauma – There were six patients who had complex trauma to leg requiring free tissue transfer. As both anterior and posterior tibial vessels were palpable at the ankle, the patients did not undergo any preoperative imaging for the recipient vessels. All the defects were present on the lateral aspect of the leg and ankle; we usually take anterior tibial vessels for anastomosis in these cases. The anterior tibial vessels were found to have poor flow on division (although it had good pulsations) at the time of anastomosis. The flow did not improve even with use of vasodilators and Fogarthy's catheter. Usually, when anterior tibial vessel is thrombosed, anastomosis is done with posterior tibial vessel. In these six patients, posterior tibial vessel was in continuity but was present in the zone of trauma. Moreover, the lie of the posterior tibial vessel was not conducive for end-to-side anastomosis and full coverage of the defect if anastomosis was done proximally without the need of vein graft. All of these patients had fracture of fibula along with tibia. Removal of 5 cm of this fractured fibula led to exposure of peroneal vessels. As there was wound already present, no skin incision was required in all of these cases. All were end-to-end anastomosis. The decision to do anastomosis with peroneal vessels in all these 6 patients was made intraoperatively
  2. Diabetic foot – There were three diabetic patients with complex defects of foot. In these patients, both anterior and posterior tibial vessels were not palpable at the ankle preoperatively. Color Doppler assessment showed biphasic flow in both of these vessels while there was triphasic flow in the peroneal pedicle. No exploration of the anterior or posterior tibial vessels was done. The peroneal vessels were explored in the way explained earlier, and this was planned preoperatively. Two anastomoses were done end-to-side and one to a branch of peroneal artery in end-to-end fashion.


All the flaps survived completely. There were no reexplorations, and none of the patients had any issues with vascularity of the limb distally.

Representative cases

Case 1 – A 50-year-old female diabetic patient presented to us with dry gangrene of forefoot. She underwent forefoot amputation [Figure 3]. The exposed tarsal bones needed a flap cover. There was absence of both posterior tibial and dorsalis pedis pulsations. Color Doppler showed biphasic flow in both anterior and posterior tibial vessels. Whereas there was triphasic flow in peroneal [Figure 4]. Anterolateral thigh free flap [Figure 5] and [Figure 6] was done for coverage and anastomosed with peroneal vessels in end-to-side fashion.
Figure 3:Exposed metatarsal bones status post forefoot amputation

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Figure 4: Exposed peroneal pedicle

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Figure 5: Harvested anterolateral thigh flap

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Figure 6: Flap covering the defect

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Case 3 – A 55-year-old female patient with compound fracture of both bones right leg and defect on lateral aspect of leg and ankle [Figure 7]. She underwent debridement and external fixator in previous hospital and was referred to us for reconstruction. She had palpable distal pulsations. She underwent external fixation realignment and ALT free flap [Figure 8], [Figure 9], [Figure 10]. Although the anterior tibial vessel showed good pulsations, it had poor flow on division which did not improve with any maneuver. The lie of posterior tibial vessels was not conducive for complete coverage of defect without vein graft. Peroneal vessels were exposed near the defect by removing 5 cm of fractured fibula. Anastomosis was done in end-to-end fashion.
Figure 7: Posttraumatic defect of leg and foot

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Figure 8: External fixator realignment and dissected peroneal vessels

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Figure 9: Harvested anterolateral thigh flap

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Figure 10: Well settled flap after 1 year

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Case 9 – An 18-year-old male patient with crush injury of the left foot had defect on lateral aspect of the leg and foot [Figure 11]. Anterior tibial vessels were exposed as classically done for anastomosis. Anterior tibial vessel was thrombosed, and even on exploring proximally, the flow did not improve. The lie of posterior tibial was not conducive for full coverage of defect; hence, peroneal vessels were exposed by taking out 5 cm of fractured fibula [Figure 12], [Figure 13], [Figure 14]. End-to-end anastomosis of free latissimus dorsi flap was done for successful reconstruction.
Figure 11: Crush injury left leg

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Figure 12: Postdebridement status with exposed peroneal vessels

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Figure 13: Harvested latissimus dorsi flap

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Figure 14: Well-settled flap at 3 months

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  Discussion Top


Microsurgery has revolutionized the reconstruction of complex limb defects. There are three important steps in free tissue transfer for the limb defects – (1) recipient vessel selection, (2) flap harvest, and (3) pedicle positioning and microanastomosis.[1]

The commonly used vessels for free tissue transfer in leg and foot defects are anterior and posterior tibial pedicles depending on the location of the defect. These vessels are commonly chosen because they have good caliber, reasonably consistent anatomy, and there are numerous branches of each of these which can be used for successful free tissue transfer. When one of these vessels planned as recipient pedicle is thrombosed, the other vessels are generally used for anastomosis.

When the blood flow in these vessels is not good, the microsurgeon needs to look for alternatives to achieve a free tissue transfer. The options include (1) look for another adjacent healthy vessel, (2) vein graft for the artery (to go proximally on the same vessel), (3) arteriovenous loop, and (4) cross-leg free flaps.[5]

The peroneal vessels can be used as recipient vessels in these special situations. When one of the vessel is thrombosed and the foot is supplied by single vessel, many young microsurgeons are uncomfortable doing end-to-side anastomosis to this single vessel (especially when this vessel also lies in zone of trauma). To go out of zone of trauma for this single vessel, the reach of flap for complete coverage of defect sometimes becomes difficult without vein graft. Vein graft is an additional source of thrombosis which should be avoided whenever possible. One solution to this problem is to look for peroneal vessels which are deep and unexplored. Moreover, usage of peroneal vessel for anastomosis to free flap does not affect the vascularity of the foot. The exposure of the peroneal vessels is technically more demanding as compared to anterior and posterior tibial vessels. However, it is not difficult for surgeons regularly doing free fibula flap.

The use of peroneal pedicle as recipient vessel is sparsely reported. Most of the literature is regarding choosing the best vessel for the leg taking into consideration anterior and posterior tibial vessels.[2] Sailon et al. had used the peroneal pedicle for free tissue transfer around the knee in one case.[6] Kang et al. in their review of 52 free flaps for lower extremity reconstruction had used peroneal pedicle as recipient vessel in one case. They have neither provided the indications of using this vessel nor the details of the procedure.[7]

It is reported that peroneal artery is the last vessel in the lower limb to be affected by atherosclerosis; still, this fact is discounted and no advantage is extracted out of this inherent property of peroneal vessels. Santos et al. did angiographic study of 161 patients with critical limb ischemia. Their study concluded that the peroneal vessels were last to get atherosclerosis as compared to anterior and posterior tibial vessel even in patients with critical limb ischemia, irrespective of diabetic status of the patient.[8] However, we should be cautious in using peroneal vessels in diabetic patients as it may be the major source of blood supply for the distal limb (if both anterior and posterior tibial vessels have poor flow). We prefer using one of the branches or end-to-side anastomosis to peroneal vessels to avoid any distal ischemia in patients with atherosclerosis.

Literature review regarding cross-leg free flaps consists mostly of case reports and small series.[5],[9] Most of these give information regarding inadequate flow in the anterior and posterior tibial vessels but does not comment on the peroneal vessels. Their criteria of selection of recipient vessels in the contralateral leg are the absence of suitable anterior and posterior tibial vessels. Peroneal vessels are not evaluated.[9] We believe that before doing cross-leg free flaps, peroneal vessel should be adequately evaluated by color Doppler, so as to avoid looking for the recipient vessel on the contralateral limb.

We did not get computed tomography (CT) angiography in any of our patients as CT angiography only tells about the patency of vessels but not the quality of the flow. We agree that flow pattern assessment in color Doppler is subjective evaluation and might differ. However, dedicated radiologists who have vast experience with color Doppler flow assessment for foot and ankle diseases are more likely to be correct. According to literature, the best investigation to assess the quality of blood flow in a vessel to limb is by color Doppler.[10]

Grassbaugh et al. concluded in their study that color Doppler significantly helped to choose the best vessel for revascularization of the foot. They also suggested that color Doppler should be used as first investigation modality to choose the healthy recipient vessel and angiography can be used in case the color Doppler is not able to localize the peroneal vessels.[11] As we could trace the peroneal vessel in all the 3 cases and comment on the flow, we could get away with color Doppler avoiding the use of angiography in any case.

We have made use of this inherent property of peroneal vessels to withstand the pathological changes and injury to do successful free tissue transfer in the absence of good flow in anterior and posterior tibial vessels. This is the first case series of use of peroneal vessels for free tissue transfer as recipient vessel. We recommend that this option should always be kept in mind before looking for more complicated measures such as arteriovenous loop or cross-leg free flaps to tide over this difficult situation.


  Conclusion Top


Peroneal pedicle can be safely utilized as recipient vessel for free tissue transfer. This is an underutilized pedicle to reconstruct many complex defects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aggarwal A, Singh H, Mahendru S, Brajesh V, Singh S, Khare A, et al. Pedicle streaking: A novel and simple aid in pedicle positioning in free tissue transfer. Indian J Plast Surg 2015;48:274-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Chen HC, Chuang CC, Chen S, Hsu WM, Wei FC. Selection of recipient vessels for free flaps to the distal leg and foot following trauma. Microsurgery 1994;15:358-63.  Back to cited text no. 2
    
3.
Mahendru S, Singh H, Sarin D, Aggarwal A, Brajesh V, Singh S, et al. Microvascular free tissue transfer in vessel compromised neck: Techniques and recommendations. Int Microsurg J 2019;3:2.  Back to cited text no. 3
    
4.
Kim JT, Kim CY, Kim YH. T-anastomosis in microsurgical free flap reconstruction: An overview of clinical applications. J Plast Reconstr Aesthet Surg 2008;61:1157-63.  Back to cited text no. 4
    
5.
Ozkan O, Cinpolat A, Bektas G, Akcal A, Simsek H. Reconstruction of the lower extremity with cross-leg free flaps. J Reconstr Microsurg 2016;1:12-8.  Back to cited text no. 5
    
6.
Sailon AM, Reformat DD, Hecht EM, Garfein ES, Spector JA, Levine JP, et al. The proximally based peroneal vascular bundle: An insulated extension cord for free flap reconstruction. Ann Plast Surg 2009;62:556-9.  Back to cited text no. 6
    
7.
Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg 2013;40:575-83.  Back to cited text no. 7
    
8.
Santos VP, Alves CA, Fidelis C, Filho JS. Arteriographic findings in diabetic and non-diabetic with critical limb ischemia. Rev Assoc Med Bras (1992) 2013;59:557-62.  Back to cited text no. 8
    
9.
Turgut G, Kayalı MU, Köse O, Baş L. Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: A case report. Strategies Trauma Limb Reconstr 2010;5:155-8.  Back to cited text no. 9
    
10.
Ascher E, Mazzariol F, Hingorani A, Salles-Cunha S, Gade P. The use of duplex ultrasound arterial mapping as an alternative to conventional arteriography for primary and secondary infrapopliteal bypasses. Am J Surg 1999;178:162-5.  Back to cited text no. 10
    
11.
Grassbaugh JA, Nelson PR, Rzucidlo EM, Schermerhorn ML, Fillinger MF, Powell RJ, et al. Blinded comparison of preoperative duplex ultrasound scanning and contrast arteriography for planning revascularization at the level of the tibia. J Vasc Surg 2003;37:1186-90.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1]



 

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