Vascularized medial sural cutaneous nerve based on the superficial sural artery: a reliable nerve graft

The sural nerve is nourished by the single superficial sural artery proximally, but distally receives multiple contributions from musculocutaneous and fasciocutaneous perforators of the posterior tibial and peroneal (fibular) arteries. The prevalence of this proximal arterial supply is largely unknown. The authors report a large anatomic study (n = 56), together with two clinical cases, to assess the incidence and potential suitability of the sural nerve as a vascularized nerve graft. Dissections were performed on 6 fresh cadavers injected with Microfil dye and on 22 preserved cadavers. The superficial sural artery was present in 91 percent of the dissections. The mean diameter of this extrinsic artery was 1.5 mm. The mean percentage of neural tissue within the sural nerve in the region where it is supplied by the superficial sural artery was 62 percent compared to 34 percent distally, where it was supplied by the posterior tibial and fibular (peroneal) arteries. This anatomic difference provides a solid rationale for preferential utilization of the proximal portion of the nerve, as opposed to its distal segment. When a vascularized nerve graft is indicated, the proximally-based sural nerve appears to offer clear advantages, compared to other vascularized nerve grafts.