The proximally based peroneal vascular bundle: an insulated extension cord for free flap reconstruction
Alexander Sailon, BA1, Otway Louie, MD1, Jason Spector, MD2, Jamie Levine, MD1, Pierre Saadeh1.
1NYU School of Medicine, New York, NY, USA, 2Weill Cornell ]Medical College, New York, NY, USA.
BACKGROUND: Large wounds around the proximal third of the lower extremity are usually adequately covered by gastrocnemius flaps. However, several injury patterns, including posterior knee dislocation, commonly disrupt the local blood supply potentially obviating pedicle reconstructive options. Free flaps to this area are technically challenging given the resulting paucity of recipient options and the depth of principal blood vessels. We present an anatomical study of the proximally based peroneal vascular bundle insulated by a protective muscle cuff to serve as a recipient option in the proximal third of the lower extremity. We also provide a clinical example of its use.
METHODS: The anatomic approach and arc of rotation of the peroneal vascular bundle was defined in 8 cadavers. A proximally based peroneal vascular bundle protected by a cuff of flexor hallicus longus was used as a recipient vessel in free flap reconstruction of an open knee wound.
RESULTS: Optimal approach to the peroneal vascular bundle was prone, through an incision over the fibula with dissection between the lateral and posterior compartments. The peroneal vascular bundle was dissected away from the fibula to the tibioperonal bifurcation with a cuff of flexor hallicus longus muscle. The peroneal vessels easily provided recipient options for the entire proximal third of the lower extremity. These distal vessels were of adequate caliber (1.8 to 2.3mm artery, 2.0 to 3.3mm veins) to support free flap anastamoses. Additionally, these vessels when transposed did not require coverage themselves since they supported a surrounding cuff of muscle. A patient with injuries including a posterior knee dislocation required coverage of an open knee wound for which local flap options were precluded due to disruption of local vasculature. A proximally based peroneal vascular leash provided excellent vessel size match for reconstruction with a free rectus abdominus flap.
CONCLUSIONS: The proximally based peroneal vascular bundle serves as an excellent recipient option for injuries of the proximal third of the lower extremity not amenable to local reconstruction. The bundle itself does not require coverage by virtue of its own local muscle cuff. Caveats for its use include the need for adequate leg inflow and foot outflow. We are investigating the potential for the muscle cuff supported by the peroneal vascular bundle to provide coverage for smaller, lateral upper third wounds.