Anterior Tibial Artery Flap: State-of-the-Art after 20 Years of Description

A study of the septocutaneous branches of the anterior tibial artery flap was performed by the senior author in 1984 in Paris (Faculté d'Anatomie René Descartes) after vascular injections of colored and contrasted latex in 50 fresh cadaver lower legs. In the same year, the first clinical case was done by Prof. A. Gilbert at the Hopital Trousseau. Consequently, several articles were published describing the possibilities of use of this new technique in lower leg reconstruction. Nevertheless, some problems appeared when distally transposing the flap, especially insufficient venous drainage and subsequent congestion. For years, the flap was partially abandoned and other local fasciocutaneous flaps were used.

In the early ‘90s, the authors’ group began a new surgical approach in the treatment of extended tibia chronic osteomyelitis presenting low-flow fistulas. It consisted of wide bone and soft tissue resection in a very extended area, and induction of cement with Vancomicin to substitute for the resected bone and skin coverage with a long anterior tibial artery transposition flap. The majority of patients were aged and suffered with multicentric infected fistulas for years or decades. The flap was transposed under the extensor compartment muscles with its superior and inferior lateral peroneous septocutaneous vessels to reach the anteromedial aspect of the tibia.

Fifteen flap transfers were carried out in the last 12 years. Patients were aged from 58 to 81 years. In all cases, the etiology was trauma with exposed fracture of the tibia and osteomyelitis for years ( 8 to 40 years, with a mean of 17 years). Recurrent low-flow fistulas were present in all cases. Patients were followed up for a minimum of 3 years and the results showed bone healing in 11 cases, recurrent fistulas in 3 cases, and flap necrosis in 1 case. The cases of primary healing did not need removal of the cement. The two cases of recurrent fistulas were re-operated to enlarge bone resection and substitute with bone cement. In one case of flap necrosis and exposure of the tibia, leg amputation and prosthesis substitution were performed.

The anterior tibial artery flap remains a good flap for skin coverage of the lower leg, especially in situations of chronic and poorly healed anteromedial defects of the tibia and in elderly patients as a paliative method of bone healing.