Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest

Purpose: Previous studies of cutaneous perforators of the peroneal artery have shown great variability, and attest to the significant anatomical variability in this region. Furthermore, the vascular anatomy of the region has been considered unreliable in the prediction of ideal perforator topography. Preoperative imaging has been suggested as a means for improving preoperative awareness, with Doppler ultrasound and eco-colour (duplex) ultrasound as useful tools. Multi-detector row computed tomographic angiography (CTA or angio CT), has emerged as a significant improvement, providing non-invasive operator-independent details of the vascular anatomy. We utilised this tool to perform an in vivo, anatomical study of the peroneal artery perforators, and demonstrating the usefulness of CTA in planning the osteocutaneous free fibula flap.\ud \ud Methods: Forty-one consecutive patients (82 limbs) underwent CTA of the lower limb vasculature, with the anatomical details of the peroneal artery cutaneous perforators assessed.\ud \ud Results: CTA was able to demonstrate the size, course and penetration pattern of all perforators over 0.3 mm in diameter, with measurements for perforators over 0.8 mm diameter recorded for analysis. Of 171 such perforators, accurate identification of the size (mean diameter 1.91 mm), course (59.6% septocutaneous, 29.2% musculocutaneous and 11.1% septomusculocutaneous) and location was achieved.\ud \ud Conclusion:The vascular anatomy of peroneal artery perforators is highly variable, and thus there is a role for preoperative imaging. CTA can demonstrate cases where there is aberrant or non-preferred anatomy, or select the limb of choice for harvest