Free Arterialized Venous Sural Nerve Flap for Complex Traumatic Tibial Nerve Injury

Area of Science:

• Reconstructive Surgery
• Peripheral Nerve Injury
• Microsurgery

Background:

• Segmental peripheral nerve injuries with long gaps present significant reconstructive challenges.
• Conventional nerve grafts (autografts, allografts) have limitations in length and regenerative capacity, especially in compromised wound beds.
• Nerve flaps offer potential for enhanced regeneration via improved perfusion but are technically demanding and have limited donor sites.

Purpose of the Study:

• To present a unique case utilizing a free vascularized sural nerve flap for extensive peripheral nerve defect reconstruction.
• To demonstrate the feasibility of this technique in a patient with a large tibial nerve defect post-blast trauma.

Main Methods:

• A composite free sural nerve flap, including the lesser saphenous vein and bridging adipofascial tissue, was used to bridge a 7-cm tibial nerve defect.
• The flap's perfusion was maintained via preserved adipofascial connections and confirmed with intraoperative Doppler and SPY angiography.
• The sural nerve was employed as a double-barrel cable graft, with the vein anastomosed retrograde to the peroneal artery.

Main Results:

• Successful reconstruction of a 7-cm segmental tibial nerve defect using the free vascularized sural nerve flap.
• Intraoperative confirmation of flap perfusion.
• At 17 weeks postoperation, the patient was ambulatory, despite undetectable 2-point discrimination in the foot.

Conclusions:

• A free vascularized sural nerve flap is a feasible and potentially valuable technique for reconstructing extensive peripheral nerve defects.
• This approach may be particularly useful in challenging cases where standard nerve grafting methods are insufficient.