Introduction -
Medial Sural Artery(MSA) is a direct branch from popliteal artery and embedded superficially in the medial gastrocnemius muscle.
MSA sends musculocutaneous perforators(MSAP) & these perferosomes are harvested with a long vascular pedicle & tunneled under the skin medial to upper tibia.
Random flaps are futile as skin is adhered to periosteum. Some defects are smaller for major muscle flaps whereas local muscle injury and periosteal stripping may limit flap options.
Procedure -
We selected two patients; 32-year-old farmer, nonsmoker following MVA sustained Gustilo 3b upper tibial fracture & a 42-year-old housewife, nonsmoker with no co-morbidities presented with infected Gustilo Type 2 laceration over the patella tendon.
MSA was surface marked by drawing a line from the middle of the popliteal crease to the medial malleolus & MSAPs were dopplered. With a measuring tape we estimated the pedicle length and flap dimensions.
Flap was elevated through marked incisions and around perforators. The pedicle was dissected and lifted off the gastrocnemius; tunneled and inserted to the defect.
Results.
Both flaps survived well although one suffered minor congestion at the distal tip. With conservative management this recovered well. One patient recovered from a wound infection. Both patients had excellent long-term results in view of stable soft tissue cover, fracture healing & functional outcome.
Discussion / Conclusion.
MSAP flap is an excellent option for upper tibial and patella defects with soft tissue loss. This comes from the posterior aspect away from the zone of injury. It's a wise option when there is significant local soft tissue injury or infection.
Furthermore, this fascio-cutaneous flap dissection is quick, lateral damage is lower than the conventional techniques leaving less pain, no weakness & lesser disturbance to biomechanics of walking. So this is a very versatile option for smaller defects around the lower knee and upper tibia.