Peroneal artery perforator-based flaps for reconstruction of middle and lower third post-traumatic defects of the leg Jerry R. John,* Satyaswarup Tripathy,* Ramesh Kumar Sharma,* Jyoshid R. Balan,† Chandan Jadhav* and Saptarshi Bhattacharya* *Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India †Department of Plastic Surgery, Elite Hospital, Thrissur, Kerala, India Key words leg reconstruction, local flap, open fracture, perforator flap, trauma. Correspondence Dr Jerry R. John, Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India. Email: jerryrjohn@hotmail.com J. R. John MCh; S. Tripathy MCh; R. K. Sharma MCh, DNB; J. R. Balan MCh; C. Jadhav MCh; S. Bhattacharya MCh. Accepted for publication 15 January 2014. doi: 10.1111/ans.12556 Abstract Background: Grade IIIb open tibial fractures require local or free flaps for cover of the fracture site. Perforator flap surgery is an innovative method for wound cover in this setting. The anatomy of perforating vessels of the peroneal artery is well described. Methods: All patients who underwent peroneal artery perforator-based flap cover for acute Grade IIIb fracture tibia between December 2011 and March 2013 were pro- spectively studied. The wounds were located either in middle or in lower third of the tibia. Flaps were performed under loupe magnification after identifying perforators preoperatively with handheld Doppler. All flaps were of a hockey stick or J design, incorporating the peroneal skin territory and completely islanded. Patients were fol- lowed up until all wounds were epithelialized. Results: Eleven patients were identified. Eleven flaps were performed, out of which 10 survived entirely and served the purpose of stable wound cover. One patient sustained partial flap necrosis, which was debrided, and another local flap was performed. More than one perforator could be identified and retained in six of these 11 patients. Conclusion: The peroneal artery perforator-based flap is reliable and reproducible in an acute post-traumatic setting. It should be considered as a suitable alternative for reconstruction for limited defects with exposed fractured tibia over the middle and lower third of the leg. Introduction Compound fractures of the lower leg continue to be challenging to treat. This is especially so when the reconstruction demands a flap. Local skin or muscle flaps are often considered. They must be located outside the zone of injury for them to be useful tissue for transfer. It is commonly taught in reconstructive algorithms for exposed tibia that a gastrocnemius be first choice for the upper third of the leg, a soleus for the middle third and a free flap for the lower third. 1 Perforator flaps have been in vogue for the last two and a half decades. Their use was a corollary of the discovery that the integu- ment of the leg derives its supply from various perforating branches of the major arteries of the leg. These flaps have been used extensively in limited defects of the leg. Addition of the propeller and the perforator- plus concepts has enlarged the inventory. Researchers 2 have envis- aged that perforator flaps could contribute to a scale down of the reconstructive ladder, necessitating lesser number of complex, lengthy procedures like free tissue transfers.Yet, the role of perforator flaps in post-traumatic leg reconstruction has not been standardized. It is our proposition that peroneal perforator-based flaps be the first choice for limited defects of the middle and lower third of the leg. Their inherent advantages and some of the disadvantages of the ‘standard’ options are dwelt upon. Methods We prospectively analysed patients who underwent peroneal artery perforator-based flap for middle and lower third Grade IIIb defects from December 2011 to March 2013. All of them were referred to the Emer- gency Plastic Surgery Service for wound cover at the time of index admission, after undergoing debridement and skeletal stabilization. Patients were selected to undergo the perforator-based flap when the wound was predominantly on the anteromedial aspect of the tibia. Patients who sustained degloving of the skin on the lateral and posterior aspect were not considered for the procedure. Post-operatively, wounds were inspected daily. Patients were discharged from the hospital after 1 week, when the wound cover was deemed to be stable. All patients were followed up until total epithelialization of the wound. PLASTICS ANZJSurg.com © 2014 Royal Australasian College of Surgeons ANZ J Surg 85 (2015) 869–872