CTA-guided preoperative perforator selection for knee soft tissue reconstruction

Perforator flaps represent an effective and versatile option for the reconstruction of soft tissue defects around the knee. However, interindividual variability in perforator origin, course, and pedicle characteristics often complicates flap selection and increases intraoperative uncertainty. This study aimed to evaluate the role of computed tomography angiography (CTA) in guiding perforator selection and supporting individualized preoperative planning for knee soft tissue reconstruction.

Between August 2014 and March 2024, we retrospectively evaluated 16 patients who underwent 17 flap procedures after preoperative CTA for reconstruction of soft tissue defects around the knee. The location, course, and length of candidate perforators were evaluated using the Picture Archiving and Communication System (PACS). Based on comparative preoperative assessment, the most suitable perforator was selected for flap design.

Seventeen flaps were harvested in 16 patients, including 16 CTA-selected perforator-based flaps and one random-pattern local flap selected after CTA showed no suitable perforator. All 16 CTA-selected target perforators were identified intraoperatively as anticipated, yielding a target-perforator identification discrepancy rate of 0/16. Complete skin-paddle survival was achieved in 15 of 16 CTA-selected perforator-based flaps and in 16 of 17 flaps overall. One CTA-selected perforator flap developed partial distal necrosis and healed conservatively; no total flap loss occurred. The random-pattern local flap survived completely without complications.

CTA provided a practical decision-support method for preoperative assessment of perforator anatomy around the knee. In this proof-of-concept retrospective Level IV case series, the structured CTA-guided workflow was feasible and showed qualitative concordance with intraoperative findings, supporting individualized flap planning according to defect characteristics and perforator anatomy. Because no Doppler-only, non-CTA, or historical control group was included, these findings demonstrate feasibility and anatomical concordance rather than measurable clinical superiority over other mapping modalities.