Anatomical Study And Clinical Application Of Medial Sural Vessels

Objectives To discuss the effectiveness and feasibility of free flaps pedicled with medial sural vessels for treatment of leg skin and soft tissue defect through anatomic study of medial sural vessels.and offer anatomical foundation for clinical practice.Methods 1 Basic anatomy: 11 cases,22 sides(7 males, 14 sides; 4 females, 8 sides) frozen fresh adult cadaver lower limb specimens of anatomy were observed with vernier caliper(accuracy 0.02mm) pointed medial femoral condyle of the rear to the highest point and measured the following indexes:(1)The origin and distribution rule of the medial sural vessels.(2)Anastomosis of the medial sural vessels and lateral sural vessels and other vessels around the knee.(3)The start point and entry point into muscle of diameter of medial sural vessels.(4)Vascular pedicle length from the start point to the point of the medial gastrocnemius. All the results were statistically analyzed by spss 17.0 software, and the results were expressed as mean plus or minus standard deviation. 2 Clinical application: Between July 2011 and January 2016, 12 cases of serious skin and soft tissue defects in the leg were repaired by using free flaps. Of them there were 8 males and 4 females, aged 23 to 50 years(mean,35.5 years). Defects were caused by traffic accidents injury in 4 cases, crash injury of heavy object in 5 cases, and machine twist injury in 3 cases. The left side was involved in 7 cases and the right side in 5 cases. The mean interval of injury and admission was 2.3 hours(range,1-4 hours). The location was the upper, middle, and lower one third of the anterior tibia in 3 cases, 5 cases, and 4 cases respectively. The area of the defect ranged from 10 cm×5 cm to 23 cm×9 cm. All wounds had osteomyelitis, bone, nerve and tendon exposure requiring flap coverage reconstruction. There was no local flap could be raised around the wound. The result of the Doppler confirmed that there was only one main artery was patency at the injuried leg. After debridement and vaccam sealing drainage treatment, the anterolateral thigh flap ranging from 12 cm×7cm to 25 cm×11 cm pedicled with the medial sural vessels was used to repair the wound. The donor site was sutured directly or repair with the skingrafts. The survival, sensation, complications and limb function of the postoperative patients were followed up.Results 1 Basic anatomy: Medial sural artery is located in leg rear,originating from the posterior wall of the popliteal artery and in the medial head of the gastrocnemius muscle deep into the muscle, in the belly of the muscle, deep one-third of smooth muscle fibers downward, and sends out branches to the gastrocnemius muscle and skin. Average length of 41.8mm, minority and lateral sural cutaneous artery is dry, dry long about 110.6mm. Due to the popliteal artery is deeper than the location of popliteal vein and slightly to the left, so the medial sural artery and popliteal vein cross was 63.9%, shallow cross 33.9%, deep cross, 30.0%. We measured 11 cases of 22 sides of medial sural artery :(1)The starting point of vessel diameter was(2.8±0.3) mm and muscles outer diameter(2.0±0.2) mm; and with blood vessels around the knee, such as the knee, lateral artery, knee medial and lateral artery, tibialis anterior, posterior tibial artery of traffic;(2) Starting point to point of muscular artery length for 79.0~102.2.0mm average(111±20) mm. The same name with vein was divided into two branches, diameter slightly larger than the diameter of artery, in muscles outer diameter for(2.1±0.3) mm. 2 Clinical application: All flaps and skingrafts survived after operation, and primary healing of wound was obtained. After 6-23 months(mean, 14.5months) follow-up, all flaps were characterized by soft texture, good color and satisfactory appearance. The sensation of the flaps were recovered to S2~S3+ according to the Britain's Medical Research Council at 6 months after operation. No obvious scar contracture was observed at donor site. All fractures were healed, and the healing time was 6 to 11 months, with an average of 8 months.Conclusions 1 The medial sural artery is located in the deep medial head of the gastrocnemius muscle, and the anatomical position is constant. It has the advantages of constant anatomical position, large diameter, rich blood flow, and a long artery pedicle. There is a wide range of traffic branches around the knee joint, and no significant effect on the muscle function of the leg after cutting off. 2 So the medial sural vessels is an ideal choice as recipient vessels for the reconstruction of leg skin and soft tissue defect. It is worth to be applied and popularized and providing a new treatment method for clinical practice.