Versatility of the Anterior Tibial Artery Flap System for Lower Limb Reconstruction

The author described the use of the anterior tibial artery system for pedicled composite tissue transfer in ipsilateral lower limb reconstruction. The long vascular pedicle allows for fusion of the knee and ankle joints or resurfacing of the foot and toes based on vascular anastomoses around the ankle joint. Five to seven periosteal perforators originate evenly along the length of the anterior tibial artery, lying on the lateral surface of the tibia to reach the anterolateral skin of the leg. Skin flaps, vascularized bone, or composite osteocutaneous flaps can be harvested based on these perforators.

The anterior and posterior tibial artery systems communicate at the ankle anastomoses formed by the malleolar and tarsal arteries, and further distally at the deep plantar artery. The system is versatile because the pivot point of the pedicled transfer can be designed along the length of the anterior tibial artery. A long, straight, corticocancellous graft can be raised from the anterolateral tibia for antegrade transfer for knee-joint fusion or transferred distally for ankle fusion. A reversed pedicled skin flap can also be raised to resurface the dorsum of the foot or toes. This technique limits surgery to the same limb, reducing the donor morbidity and surgical logistics required. Mobilizing the distal two-thirds of the anterior tibial system and the deep peroneal nerve does not result in muscle ischemia or denervation of the anterior compartment muscles of the leg, as the major muscle branches are given off in the proximal third of the leg.

The author has experience in nine cases in various reconstructions. Vascularized tibial bone grafts of up to 25 cm were used to augment knee fusion after resection of osteosarcoma of the distal femur in two cases, and for ankle fusion in one case. Joint fusion was achieved in these cases. The reversed pedicled anterior tibial skin flap was used to resurface the dorsum of the foot after trauma in two cases, and to resurface a big toe donor site in four cases. There were no failures, achieving a resurfacing outcome that was thin, supple, and durable. There were no complications at the donor site, and no patients reported problems with foot or toe extension weakness.

The anterior tibial artery system can be reliably utilized to reconstruct a variety of defects in the ipsilateral lower limb with little morbidity.