Distally based perforator flaps for reconstruction of post-traumatic defects of the lower leg and foot. A review of the anatomy and clinical outcomes

Study aims To report the surgical anatomy of the perforator arteries at the lower leg, analyse clinical outcomes in previous studies, and forward methodological recommendations for future studies of post-traumatic perforator flap reconstructions. Methods A study sample of 640 human patients drawn from 24 clinical reports was included for review. The sample comprised of four subsets: sural flap reconstructions (n=257), saphenous flaps (n=122), supramalleolar flaps (n=92), and propeller flaps (n=169). Results Statistical analysis of samples from anatomical studies documents significant differences in the perforator distribution from the tibial and peroneal artery; peroneal perforator arteries are randomly organised whereas tibial artery perforators are clustered at three definite levels. The failure rates in clinical studies ranged from 0% to 6%, being lowest for supramalleolar flap reconstructions and highest for saphenous flaps; however, differences between the four subsets were not statistically significant at the 95% confidence level. Due to methodological flaws, outcome comparisons in the actual study sample should be interpreted cautiously; in most clinical studies both risk variables and outcome indicators are poorly defined. The outcome of Dynamic Infrared Thermography imaging of post-transposition changes of flap perfusion is reported. Summary Fasciocutaneous perforator flaps seem to have high survival rates and represent a feasible approach to post-traumatic reconstructions, especially in low-resource settings. A template for data gathering is recommended for higher accuracy in future comparative studies, and for scientific analysis of success and risk factors. New imaging techniques indicate a promising potential of micro-circular angiogenesis during the first two weeks after flap transpose.