title: Medial sural artery as a salvage recipient vessel for complex post traumatic microvascular lower limb reconstruction.
abstract: BACKGROUND
  Complex lower extremity trauma still poses a formidable challenge for micro vascular reconstruction. The extensive surrounding zone of trauma can make it difficult to find a suitable recipient pedicle for anastomosis. A need was felt for exploration of newer recipient vessels in lower extremity which could be harnessed for reliable and tension free micro anastomosis. The purpose of the present report is to highlight the possibility of using medial sural artery for safe micro vascular anastomosis in selected scenarios like vessel depleted extremity.
  
  
  METHODS
  Between 2008 and 2013, we used the medial sural vessels for micro anastomosis in 10 cases of lower extremity trauma. All the cases had severe soft tissue trauma with or without a bony defect. A computed tomography angiogram (CTA) of the involved extremity revealed either severe perivascular scarring around the standard recipient vessels or patency of just a single vessel. However, in all cases a patent medial sural pedicle was identified on CTA. Interposition vein grafts (IVGs) were used in most cases to ensure a tension free anastomosis.
  
  
  RESULTS
  In all cases, unscarred medial sural vessels were identified with average dissected length and diameter being 6.2 cm (range 4 to 7.5 cm) and 2 mm (range 1.5 to 2.5 mm) respectively. Vein graft [average length 5.6 cm (range 4 to 15 cm)] was interposed in seven cases, while in remaining three, long saphenous vein was used for vein anastomosis. All the flaps survived after the surgery. There was one re-exploration for evacuation of peri-anastomotic hematoma with no adverse effect on flap survival. The mean follow up period was 27.6 months. In the four cases with bone reconstruction, bony union was seen between 5 and 8 months. They were able to walk without aids and resume work after 10-14 months, following a structured rehabilitation program. The patients with soft tissue reconstruction (6 cases) could carry out aid free locomotion and resume their routine after 4-6 weeks. There were no long term complications in any of the flap.
  
  
  CONCLUSIONS
  Medial sural artery may prove to be a reliable recipient pedicle for use in complex lower extremity trauma cases and could possibly provide a safer alternative in cases with severe perivascular scarring or in a "single vessel" extremity.
authors.affiliation: Department of Plastic and Reconstructive Surgery, T. N. Medical College (TNMC), Mumbai, India.
authors.forename: Amresh
authors.initials: A
authors.lastname: Baliarsing
authors.affiliation: Department of Plastic and Reconstructive Surgery, T. N. Medical College (TNMC), Mumbai, India.|Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.|Department of Plastic and Reconstructive Surgery, Dr. D. Y. Patil Medical College, Navi Mumbai, India.
authors.forename: Shivprasad
authors.identifier: http://orcid.org/0000-0003-0337-8677
authors.initials: S
authors.lastname: Date
authors.affiliation: Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
authors.forename: Pedro
authors.identifier: http://orcid.org/0000-0003-4646-2676
authors.initials: P
authors.lastname: Ciudad
mesh_terms: D000328:Adult; D015331:Cohort Studies; D000072226:Computed Tomography Angiography / Q000379:methods; D006085:Graft Survival; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000175:diagnosis / Q000601:surgery*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods; D020127:Recovery of Function; D012189:Retrospective Studies; D017695:Soft Tissue Injuries / Q000175:diagnosis / Q000601:surgery*; D013524:Surgical Flaps / Q000098:blood supply* / Q000637:transplantation; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D014945:Wound Healing / Q000502:physiology; D055815:Young Adult