Peroneal artery perforator flap for the treatment of chronic lower extremity wounds
Cheng et al. Journal of Orthopaedic Surgery and Research
Peroneal artery perforator flap for the treatment of chronic lower extremity wounds
Liang Cheng 0
Xiaqing Yang 0
Tingxiang Chen 0
Zhijie Li 0
0 Department of Hand and Plastic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University , 109 Xue Yuan Xi Road, Wenzhou, Zhejiang , China
Background: Reconstruction of chronic lower extremity wounds remains challenging. These wounds are mainly associated with diabetes mellitus, infections, and osteomyelitis. Although several reconstructive techniques are available, the peroneal artery perforator flap has unique advantages. Methods: In this study, we discuss our experiences with peroneal artery perforator flaps in 55 patients who had suffered from chronic lower limb wounds. The size of the defect, comorbidities, etiology, flap size, and complications were recorded and analyzed based on a retrospective chart review. Results: All 55 flaps survived. In two cases, small superficial necrosis occurred, one of which healed with conservative treatment and the other was reconstructed with split thickness skin grafts. Partial necrosis was observed in nine cases, seven of which were covered with split thickness skin grafts and the remaining two sutured directly after adequate debridement. Vascular compromise was observed in one patient, which was salvaged successfully by performing an exploratory procedure and releasing a few sutures. No complications were seen in the remaining 44 cases. Conclusion: The peroneal artery perforator flap is a reliable option for reconstruction of chronic lower extremity wounds.
Peroneal artery perforator flap; Chronic lower extremity wounds; Reconstructive
Reconstruction of chronic lower extremity wounds
remains a challenging task, particularly in patients with
circulation problems. Various options including local
flaps, free flaps, and muscle flaps have been used for
reconstruction in these cases; however, rebuilding
techniques to enhance outcomes have not been identified
]. Before utilizing local flaps, free flaps, or pedicle
flaps, surgeons should reduce the amount of soft tissue
and determine the clinical application subjected to their
limited reach. In 1984, Yoshimura et al.  introduced
the peroneal artery perforator flap. The perforator flap is
based on the concept that skin can be divided into
]. Indeed, for the perforator approach, the
recipient area has a flexible rotation with remarkable
applicability, and the flap is nourished by perforator vessels
that arise from a deep vascular system [
with the traditional flap or workhorse flap (such as the
anterolateral thigh flap), the peroneal artery perforator
flap decreases bleeding, preserves muscle function, has a
multiform flap design, and enhances mobility of the flap
]. Besides, a peroneal septocutaneous or
musculocutaneous perforator stems from the parent vessel, which
directly supplies the overlying skin, and the flap helps
preserve the peroneal vessel system. Due to these
advantages, peroneal artery perforator flaps are a
suitable choice for the treatment of chronic lower
In this report, we describe our experiences with 55
patients suffering from chronic lower extremity wounds
who underwent surgical reconstruction with peroneal
artery perforator flaps.
This study was performed in accordance with the ethical
standards of the Declaration of Helsinki. Ethics approval
was obtained through the Hospital’s Regional Ethics
Committee, and all patients gave informed consent prior
to inclusion in the study.
A retrospective analysis was performed using the
medical records of 55 patients who underwent lower
extremity wound reconstruction using peroneal artery
perforator flaps between May 2008 and September 2015.
For each patient, the following data were collected and
recorded: age, sex, etiology, size of the defect,
comorbidities, dimension of the flap, complications, and
followup. The patients included 43 males and 12 females, and
their ages varied from 3 to 78 years, with an average age
of 48.87 years. A total of 22 patients suffered from open
tibia/fibula/ankle/calcaneus fractures with associated
infection; open fracture in 14, machine crash in 1,
crashinjury in 6, osteomyelitis in 4, tumble in 1, scald in 1,
skin ulcer in 1, chronic tophus gout in 1, foot mass in 1,
and 3 cases of an Achilles tendon rupture associated
with infection. The soft-tissue defect was located on the
calcaneus in 7 cases, the malleolar area in 16 cases,
around the knee in 4 cases, the acrotarsium area in 10
cases, and the lower extremity in 18 cases. Defect sizes
ranged from 1.5 to 300 cm2. The wounds were debrided
an average of 2.98 times (range, 1–8 times). All cases
were performed with vigorous debridement, after which
the peroneal artery perforator flaps were applied.
A Doppler probe was used preoperatively to locate the
peroneal artery and the most appropriate perforator
vessel. Under a combined spinal epidural analgesia, patients
were placed in a supine position with the injured legs
slightly abducted and the thigh under tourniquet
control. After vigorous debridement, the outline of the flap
was drawn based on the size and shape of the defect.
Flap design and orientations around the sited perforators
ensured adequate length and width so that the flap could
be harvested. Flap dissection was initiated along the
anterior side of the flap down to the crural fascia and was
performed in the same fashion on the posterior side.
Subfascial dissection was performed laterally until the
septocutaneous perforator or musculocutaneous
perforator was identified. Because the process of the
musculocutaneous perforator is often twisted, dissection is
performed punctiliously to avoid perforator injury. After
confirming that the perforator was a branch of the
peroneal artery, the flap was harvested. The raised flap
was able to rotate around the perforator and adapt to
the defect. In a small number of cases, split thickness
skin graft (STSG) derived from the thigh was required to
cover the defect with the peroneal artery perforator flap,
and most donor sites were closed. Over-tight bandaging
was avoided to limit vascular embarrassment, and a
window was made in the dressing to observe the flap. Before
ambulation was achieved, anticoagulation treatment with
low weight molecular heparin was introduced.
Postoperatively, all cases received appropriate antibiotic therapy
and symptomatic rehydration support treatment. All
patients were coached periodically until the wound site
was achieved and the donor had healed. Generally, flap
sutures were dismantled on the 14th postoperative day.
A 50-year-old female suffered a soft tissue defect around
the ankle joint due to a traffic accident. After radical
debridement, a peroneal artery perforator flap measuring
approximately 20 cm × 7 cm was elevated from the
ipsilateral lower leg. The flap was subsequently inset into
the defect at 150 degrees based on the pivot of the
perforator. The donor site was closed by combining the
split thickness skin graft. Postoperative recovery was
uneventful; the flap survived completely. A satisfactory
result was obtained at 1-year follow-up (Fig. 1).
A 38-year-old man developed traumatic bone exposure
with a soft tissue defect after suffering an open tibia and
fibula fracture. After debridement of the necrotic tissue,
a peroneal artery perforator flap measuring 15 cm × 3 cm
was raised from the same leg and transferred to the
defect. The donor site was closed. Postoperatively, the
distal part of the flap showed partial necrosis and was
treated with dressing changes. Fortunately, the flap
survived, and the patient was satisfied with the appearance
A 46-year-old man had a traumatic soft tissue loss of the
lower leg with exposure of the bone. To restore function,
a peroneal artery perforator flap measuring 18 cm × 4 cm
was harvested and transferred to the defect. The donor
site was closed, and the transferred tissues survived
completely (Fig. 3).
From May 1997 to September 2015, 55 peroneal artery
perforator flaps were performed in patients with chronic
lower extremity wounds. The details of all patients are
presented in Table 1. The average operating time was
132 min, and the flaps ranged in size from 1.5 to
260 cm2. All 55 flaps survived. In two cases, small
superficial necrosis occurred, one of which healed with
conservative treatment and the other reconstructed with
STSG. Partial necrosis was observed in eight cases, six
of which were covered with STSG and the remaining
two directly sutured after debridement. Vascular
compromise was only observed in one patient and was
salvaged by performing an exploratory procedure and
releasing a few sutures. In one patient, the ultra-thin flap
procedure was performed at 6 months postoperatively
due to a bulky appearance. No complications were seen
in the remaining 43 cases. The length of hospital stay
ranged from 7 to 80 days (average of 33.36 days).
Follow-up ranged from 7 to 45 months, with an average
of 25.9 months. Ultimately, all patients were satisfied
with the functional results and could walk comfortably.
Reconstruction of soft tissue defects overlying the lower
limbs remains a significant challenge, as this region is
typically associated with exposure of tendon or bone and
metal fixation of fractures. Wound healing is markedly
prolonged (leading to chronic wounds) due to a lack of
adequate soft tissue coverage and a decrease in distal
perfusion of the lower limbs. Since the freestyle
perforator construct and perforasome theory were proposed,
the use of local flaps has increased [
]. In addition,
because adjacent tissue is typically involved and massive
edema formation prevents adequate mobilization, access
to a local flap is limited. However, free tissue transfer
can be an excellent option if local tissue transfer with a
pedicled or propeller flap is unsuitable. Although free
tissue transfer is the traditional option for lower
extremity reconstruction, it is tedious and requires complex
technical expertise [
]. Muscle flaps have been used for
decades due to their rich blood supply and anti-infection
capabilities. In addition, muscle tissues are not only
suitable for the obliteration of dead space in complex
three-dimensional defects, but can expedite bone healing
during the early phases of repair. However, the
application of muscle flaps gives rise to an unflattering
appearance, interferes with daily functions, or secondary
debulking procedures [
] leading to prolonged
hospital time, additional suffering, and higher cost.
With recent progress in perforator techniques,
attention is directed towards improved methods of
reconstruction. The peroneal artery perforator flap is a
promising option for reconstruction of the lower limbs,
especially for coverage of ankle and heel defects [
In our series, the necrosis rate of the peroneal artery
perforator flap was 18.2% (N = 10, including nine men
and one woman; mean age, 58.2 years) (Table 2). In the
series, seven patients have DM (diabetes mellitus), four
patients have HTN (hypertension), and four patients
have arteriopathy. Bekara et al. [
] identified the
following risk factors: age older than 60 years, diabetes, and
arteriopathy, which play a significant role in the
rebuilding procedure. In our study, these factors also played an
important role in flap necrosis. In addition, all ten cases
had smoking histories. We believe smoking is an
important risk factor that jeopardized the perforators during
rotation. Hence, before the procedure, the clinical
history should be explored and the smoking status should
be documented. Postoperatively, the wound should be
monitored periodically. Flap necrosis occurred distally
and superficially with small ranges (less than 4 cm2);
dressing changes may address this issue. If the range is
larger, adequate debridement or STSG may be suitable.
According to the authors’ experiences, the ratio of flap
length to width, the condition of the pedicle, and the
proper thinning of flap may have an important influence
on flap survival. As we all know, the length-to-width
ratio of random skin flap must not exceed 2:1; otherwise,
ischemia and necrosis of the distal flap may occur [
However, the length-to-width ratio of perforator flap
also existed. In our series, we found that the ratio should
not exceed 8:1. When the pattern of the harvested flap
exceeded the limit, the distal blood supply would be
affected. Besides, the pedicle was of equal importance in
perforator flap survival. When the pedicle was identified,
soft tissue around it must be wiped off thoroughly under
the premise that blood supply would not be affected
because during the rotation of the perforator, the
redundant tissue might menace the blood transmission
leading to descend flap survival rate. Occasionally, two
or more perforators appeared at the same time. In our
experiences, more perforators were not good for flap
survival; on the contrary, they may be harmful, for the
reason that one of which was likely to twist or
surrounding tissue oppress the pedicle resulting in flap failure in
the rotation process. Once flap blood supply was
influenced, it was necessary to take out stitches and put the
harvested flap back instantly, and a delay transfer
procedure was done until the blood supply of the harvested
flap improved obviously. Therefore, we usually reserve
only one perforator, and it must be the distal one in
order to gain adequate blood supply, increase flap
survival rate, and enhance the repairable scope. With regard
to small defect or relative wide defect (length-to-width
ratio less than 4:1), fearless debulking procedure can be
done because of the good capillary network, while to big
defect or relative long defect (length-to-width ratio more
than 4:1), cautious debulking procedure can be done or
only margin fat granule can be removed. Moreover,
vasodilator was not used in any patient, and we
concluded that flap survival may not be related to the
application of vasodilator.
However, there were several limitations in our study,
particularly the inadequate data collection such as the
length of the pedicle, the location of the pedicle, and
Table 1 Data of the patients
Patient Age/ Etiology
Dimension of Complication
6 × 4
5 × 3
16 × 8.5
12 × 6
3 × 11
5 × 7
function and appearance quantized evaluation. In our
further research, these limitations will be put in an
In the lower limbs involving the anterior tibial area,
ankle, heel area, or the dorsum of the foot, thin, pliable,
durable, and gliding soft tissue transfer is the preferred
option to achieve a satisfactory esthetic outcome. The
peroneal artery perforator flap has these characteristics and
is an adequate candidate for this program. In addition, the
peroneal artery perforator flap is a time efficient, esthetic,
and reliable procedure with lower donor site morbidity,
enabling significant coverage for chronic infection, and it
can sustain ancillary surgical procedures. Previous studies
have shown that the settlement of chronic osteomyelitis
and infected wounds is dependent on adequate
debridement and extermination of dead spaces; in contrast, the
type of flap used to reconstruct lower extremity defects has
little impact on the ultimate result [
debridement and eradication of dead spaces with an effective
flap must be used when treating chronic wounds.
In summary, the peroneal artery perforator flap is a
beneficial and reliable technique; it is appropriate for
small to moderate extremity defects, especially in the
ankle and heel.
The peroneal artery perforator flap is a reliable and
reproducible procedure providing low postoperative
morbidity, good daily functions, and relatively satisfactory
esthetic results, without sacrificing any major vessels or
nerves. It is intended to be a suitable alternative for the
reconstruction of lower limb defects. Because
microvascular anastomosis is not required, the flap is less time
consuming and has a lower risk of vascular thrombosis
compared with other complex techniques. Hence, the
peroneal artery perforator flap is a reliable option for the
treatment of chronic lower extremity wounds.
ATRSI: Achilles tendon rupture with secondary infection; DM: Diabetes
mellitus; F: Female; HTN: Hypertension; M: Male; OFSI: Open fractures with
secondary infection; STSG: Splint thickness skin graft
The authors would like to thank the Natural Science Foundation of Zhejiang
Province (No. Y16H060039).
This article was supported by the Natural Science Foundation of Zhejiang
Province (No. Y16H060039). It payed the fee for the English language service.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
or analyzed during the current study.
CL designed the study and drafted the manuscript. TXC collected the data.
XQY participated in the design and data collection. ZJL conceived of the
study, participated in its design and coordination, and helped to draft the
manuscript. All authors read and approved the final manuscript.
CL, TXC, XQY, and ZJL concentrated on rebuilding soft tissue defects
Ethics approval and consent to participate
The use of the data from all patients has been approved by The Second
Hospital of Wenzhou Medical University Research Ethics Committee.
Consent for publication
The patients agreed for the study to be published.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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