The Medial Sural Artery Perforator Island Flap as a Simpler Alternative for Prophylactic Skin Augmentation Prior to Total Knee Arthroplasty

Abstract

Surgical Anatomy At the very least, the medial sural artery perforator [MSAP] flap will capture the skin territory overlying the medial gastrocnemius muscle. The medial sural artery is the source vessel to that muscle as it is to this flap; and is a branch of the popliteal artery, originating at or about the knee joint [4]. After entering the undersurface of the muscle, most commonly the medial sural artery bifurcates to run superficial [posterior] or deep within the muscle surface [5]. Although the distribution of major medial sural artery musculocutaneous perforators that can sustain this flap can be quite variable [6-9], almost always at least a single such perforator can be found [6]. On average, these can be found 13 ± 2 cm. below the popliteal crease, and 2.5 ± 1 cm from the posterior midline (Figure 1) [5]; but in reality can emanate anywhere from within the medial gastrocnemius muscle. The actual possible pedicle to practically sustain an island MSAP flap depends on the location of the perforator, and can range in length from 9-16 cm [5]. Venous outflow parallels the course of the perforators. As an island flap this will usually be insensate. Since in the lower extremity interconnections between perforasomes are oriented in a longitudinal direction [11], the major axis of any MSAP flap should also parallel that pattern to

Attributes of Perforator Flaps for Prophylatic Soft Tissue Augmentation Prior to Definitive Total Knee Arthroplasty

“…Thus, any patient with tenuous soft tissues in the knee region, including the presence of a skin graft or multiple preexisting scars, should be considered at risk for eventual wound breakdown and be a candidate for prophylactic soft-tissue augmentation preceding or at the same time as the arthroplasty. 1,2,4,5 Casey et al corroborate this opinion as they showed that in such situations disastrous skin-healing complications after TKA virtually never occurred if some form of prophylactic flap were used in advance. 2 They accomplished this using the medial gastrocnemius muscle as a local flap, or with a free flap using both muscle and perforator flaps for larger defects.…”

Medial sural artery perforator flap in reconstruction of soft tissue defect in upper and lower extremities: a clinical study

“…The results of flap success in other studies were: Kao et al [10] had one failed case from 29 patients, Agrawal et al [14] worked on 10 patients with one failed case, Toyserkani et al [8] had worked on 10 patients with 6 uncomplicated cases, 2 total flap losses due to venous congestion, one case had a venous problem that was salvaged and one the flap was changed intraoperative, Chen et al [9] worked on 11 patients with one flap failed, Shun et al [15,16] worked on 31 patients with one flap failed due to pressure on the pedicle and Balan et al [13] worked on seven patients with one flap has a partial loss.…”

The Medial Sural Artery Perforator Flap: A Historical Trek from Ignominious to “Workhorse”

“…24,75,82 Prophylactic para-patellar soft-tissue augmentation especially for secondary knee surgery such as a repeat total knee prosthesis can prevent later untoward wound healing issues leading to loss of the prosthesis. 104,105 The popliteal space such as following a knee scar flexion contracture can also be resurfaced with a pedicled MSAP flap to avoid a skin graft that might recontract. 67 V-Y advancement island flaps requiring minimal perforator intramuscular dissection can reach other adjacent calf defects.…”

“… 24 75 82 Prophylactic para-patellar soft-tissue augmentation especially for secondary knee surgery such as a repeat total knee prosthesis can prevent later untoward wound healing issues leading to loss of the prosthesis. 104 105 …”