The Distally Pedicled Peroneus Brevis Muscle Flap Anatomic Studies and Clinical Applications

Defects in the distal third of the lower leg with bone or tendon exposure may require local or free flap reconstruction. For small and moderate lesions, the distally pedicled peroneus brevis muscle flap may be an effective procedure with less morbidity than a free tissue transfer. Six cadaveric specimens were dissected to determine the location of distal pedicles and the flap type. This flap was found to be a Type IV flap, and the location of distal pedicle was always located within 6 cm from the fibula tip. This flap was performed on 6 patients to cover defects in the distal third of the lower leg. The defect areas were the pretibial region in 2 cases, the lateral malleolus in 3 cases, and the Achilles tendon in 1 case. The peroneus brevis muscle was detached from the uppermost point of the fibula to obtain enough length to cover the defect. All flaps survived except 1 that experienced distal flap necrosis. Minor complications included skin graft failure in 2 cases. However, the final results demonstrated a smooth contour that eliminated dead space. Limited donor site morbidity was obtained in all cases. The distally peroneus brevis muscle flap therefore offers an alternative for reconstructive surgeons dealing with soft tissue defects of the lower leg.     

The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg

Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps. The authors successfully used the distally based peroneus brevis muscle flap for the treatment of 15 patients with osteomyelitis (n = 5), melanoma (n = 1), Achilles tendon defects (n = 6), posttraumatic bone defects (n = 2), and chronic diabetic heel ulcer (n = 1). The size of the defects ranged from 6 to 60 cm. All defects were covered successfully without major complications by the muscle flap. The distally based peroneus brevis muscle represents a very reliable flap for coverage of small and moderate defects of the medial and lateral malleolus, the Achilles tendon, and the heel area. This flap offers a convincing alternative for covering defects in the distal leg region and is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise.     

The peroneus brevis muscle flap for lower leg defects

The peroneus brevis is a small muscle with a Mathes-Nahai type II vascular pattern found in the lateral compartment of the leg. It is supplied by branches of the peroneal artery and it maintains its muscular component to the lateral malleolus, allowing it to be transposed to cover small distal third defects. The authors describe their experience with eight peroneus brevis flaps covered with split-thickness skin grafts utilized to cover lateral malleolar fractures with exposed hardware or bone and one case of exposed Achilles' tendon. Seven flaps were successful and one (in a diabetic) underwent partial necrosis, requiring a small fasciocutaneous flap. The peroneus brevis flap provides limited coverage of the distal third of the leg but can be quite useful for problematic wounds of this difficult area.     

Distally-based peroneus brevis muscle flap: a successful way of reconstructing lateral soft tissue defects of the ankle.

Sixteen distally-based peroneus brevis muscle flaps were used to cover soft tissue defects in the lateral side of the ankle. The defect in 13 cases was on the lateral malleolus, in two on the lateral side of the calcaneus, and in one case in the Achilles tendon. The patients were all followed up until full recovery (mean 7.6 months, range 1.5-22 months). One flap failed to cover the defect and was replaced with a microvascular latissimus dorsi flap. In three cases minor revision and new skin grafting of the distal end of the flap was necessary. In 15 of the 16 patients the distally-based peroneus brevis muscle was successful in covering the lateral defect in the ankle. The technique of harvesting a flap is reliable, fast, and the overall success of the flap is good. The flap is particularly suitable for covering small or moderate sized defects on the lateral malleolus.     

Distally-based peroneus brevis muscle flap: A successful way of reconstructing lateral soft tissue defects of the ankle

Sixteen distally-based peroneus brevis muscle flaps were used to cover soft tissue defects in the lateral side of the ankle. The defect in 13 cases was on the lateral malleolus, in two on the lateral side of the calcaneus, and in one case in the Achilles tendon. The patients were all followed up until full recovery (mean 7.6 months, range 1.5–22 months). One flap failed to cover the defect and was replaced with a microvascular latissimus dorsi flap. In three cases minor revision and new skin grafting of the distal end of the flap was necessary. In 15 of the 16 patients the distally-based peroneus brevis muscle was successful in covering the lateral defect in the ankle. The technique of harvesting a flap is reliable, fast, and the overall success of the flap is good. The flap is particularly suitable for covering small or moderate sized defects on the lateral malleolus.     

The split peroneus muscle flap: a new flap for lower leg defects.

The peroneus brevis tendon mechanism is more effective than the peroneus longus mechanism in rotating the navicular externally and the calcaneus into valgus. A longitudinal vertical split of the peroneus brevis muscle is a new technique that allows coverage of the fibular and pretibial region defects without impairing the muscle function. The essential features of the flap are: transposition of the muscle without disinsertion, splitting the muscle longitudinally along a distinct anatomical plane, and preservation of the anatomical continuity of the muscle. The flap has been tested on seven male patients who had sustained open fractures of the ankle region with metal implant exposure of the fibula. The size of the flap ranged from 13x6cm to 15x7cm (mean 13.8x6.5cm). The soft tissue defects were located between the pretibial region and the lateral malleolus. Their ages ranged from 22 to 39 years (mean 28.7 years). Follow up was from 3 to 24 months (mean 14.5 months). The technique of split peroneus muscle flap was applied successfully in all patients. There was no necrosis of the muscle flap and stable wound healing was achieved. The cosmetic result was good and the function of the muscle was preserved. The advantages offered by this new flap include: technical simplicity, reliability, and the allowance of future use of other local skin and muscle flaps. With the help of this new technique it is possible to cover defects of up to 20x7cm and to preserve the muscle function.     

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

Objective:

Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle.

Patients and Methods:

A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles.

Results:

Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients.

Conclusion:

This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.KEY WORDS: Ankle defects, lateral malleolus defects, lower leg defect, muscle flap, peroneus brevis flap, pedicle flap, tendo achilles defects     

Der distal gestielte M.-peroneus-brevis-Lappen zur Defektdeckung am Unterschenkel

BACKGROUND: Defects of the lower leg with exposed tendons or bone require either a local or free flap coverage. The distally pedicled peroneus brevis muscle flap has been proven to be a sufficient local flap alternative. MATERIAL AND METHOD: Using this technique the muscle is perfused by the non dominant distal perforators. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split skin graft. Between 2000 and 2004 12 patients with defects of the lower leg in the distal lower third have been treated by using this muscle flap. The defects were located over the tibial bone, the extensor tendons, the achilles tendon and the lateral malleolar region. RESULTS: All muscles healed primarily, 4 patients had minor wound healing complications of the skin graft, which in all cases healed conservatively. The muscle and skin graft remained stable. Donor site morbidity is restricted to the scar in the lateral lower leg. Pronation of the foot is not impaired. CONCLUSION: These cases show that the distally based peroneus brevis muscle has a wide range of coverage and even allows a closure down to the calcaneal tuberosity. Additionally, a local flap management with a safe muscle transposition is an economic procedure with short operation time and decreased hospital stay. If the muscle does not cover the wound sufficiently, free flap surgery can still be performed.     

The distally based peroneus brevis muscle flap—clinical series and review of the literature

The distally pedicled peroneus brevis muscle flap is rarely used for defect coverage in the distal lower leg. The purpose of this article was to present our clinical series and provide a review of the literature to analyze the overall complication rates and safety of this flap. In our clinical series of 10 patients undergoing reconstruction with the flap, one necrosis of the distal half of the flap and one necrosis of a skin graft occurred. Our review of the literature identified 192 patients undergoing reconstruction with distally pedicled peroneus brevis flaps. The overall complication rate was 41.6%. Typical indications, complications, advantages and disadvantages to alternatives are discussed. The distally pedicled peroneus brevis flap is an interesting option for soft tissue coverage in the distal lower leg. The donor site can always be closed primarily, the anatomy is constant and complication rates are comparable to alternatives in this region like the distally based sural fasciocutaneous flap. © 2013 Wiley Periodicals, Inc. Microsurgery 34:203–208, 2014.     

Distally based peroneus brevis muscle flap: A single centre experience

Purpose: Defects around the distal one third of the leg and ankle are difficult to manage by conservative measures or simple split thickness skin graft. Distally based peroneus brevis muscle flap is a well described flap for such defects. Methods: This is a retrospective analysis conducted on 25 patients with soft tissue and bony defects of distal third of lower leg and ankle, which were treated using distally based peroneus brevis muscle flap from January 2013 to January 2018. Information regarding patient demographics, etiology, size and location of defects and complications were collected. All patients were followed up for at least 3 months after surgery. Results: There were 21 males and 4 females with the mean age of 39 (5-76) years. The most common cause of injuries was road traffic accident, followed by complicated open injury. The average size of defects was 20 (4-50) cm2. The mean operating time was 75 (60-90) min for flap harvest and inset. We had no patient with complete loss of the flap. Five patients (20%) had marginal necrosis of the flap and two patients have graft loss due to underlying hematoma and required secondary split thickness skin grafting. Conclusion: The distally based peroneus brevis muscle flap is a safe option with reliable anatomy for small to moderate sized defects following low velocity injury around the ankle. The commonest complication encountered is skin graft loss which can be reduced by primary delayed grafting.     

Redefining the vascular anatomy of the peroneus brevis muscle flap

The peroneus brevis flap can be used as either proximally or distally based flap for coverage of small to medium‐sized defects in the lower leg. The purpose of this study was to clarify the vascular anatomy of the peroneus brevis muscle. An anatomical dissection was performed on 17 fixed adult cadaver lower legs. Altogether, 87 segmental branches (mean 5.1 ± 1.6 per leg) either from the fibular or anterior tibial artery to the muscle were identified. Sixty‐two were branches from the fibular artery (mean 3.4 ± 1.1 per fibular artery), whereas 25 (mean 1.4 ± 0.9 per anterior tibial artery) originated from the anterior tibial artery. The distance between the most distal vascular branch and the malleolar tip averaged 4.3 ± 0.6 cm. An axial vascular bundle to the muscle could be identified in all cadavers; in one leg two axial supplying vessels were found. Their average length was 5.5 ± 2.4 cm and the average arterial diameter was 1.1 ± 0.5 mm, the average venous diameter was 1.54 ± 0.7 mm. The constant blood supply to the peroneus brevis muscle by segmental branches from the fibular and tibial artery make this muscle a viable option for proximally or distally pedicled flap transfer. The location of the most proximal and distal branches to the muscle and conclusively the pivot points for flap transfer could be determined. Furthermore, a constant proximal axial vascular pedicle to the muscle may enlarge the clinical applications. Perfusion studies should be conducted to confirm these findings. © 2014 Wiley Periodicals, Inc. Microsurgery 35:39–44, 2015.     

The peroneus brevis muscle flap-plasty. A simple procedure for covering fibular soft tissue defects after osteosynthesis

Fractures in the region of the ankle associated with soft tissue trauma often present a problem for the traumatologist. After osteosynthetic repair, primary closure of the skin may be prevented by soft tissue oedema or a local circulatory disorder. However, it is necessary for the wound to be closed in such a way that the fibula and metal implant are covered with vital soft tissue. The peroneus brevis muscle flap represents a local and simple method of covering soft tissue defects in the region of the distal fibula. With help of this flap it is possible to cover defects of up to 20 x 4 cm without disinsertion of the tendon. After performing anatomical studies, we successfully performed the above-mentioned technique on 21 patients. At no stage did we observe ischaemia or necrosis of the muscle flap. Our modification of the peroneus brevis muscle flap is a reliable and simple method for routine management of soft tissue defects in the fibular region by the traumatologist.     

Die Musculus-peroneus-brevis-Lappenplastiken

Objective

Soft tissue defect reconstruction by transposition of well-vascularized muscle tissue with a muscle flap and as an osteomuscular flap together with a fibular bone segment for combined skeletal and soft tissue defects.

Indications

Small- and medium-sized defects of the hindfoot, around the ankle and the distal and middle third of the lower leg, skeletal reconstruction of underlying small- and medium-sized bone defects.

Contraindications

Lesions of the proximal anterior tibial artery (proximal pedicled flap), combined lesions of the distal peroneal artery including the communicating branch with the posterior tibial artery (distal pedicled flap); lesion or paralysis of the peroneus longus muscle in an intact ankle joint.

Surgical technique

Distally pedicled flap: blunt separation between the peroneus longus and brevis muscle, subperiosteal release with isolation on a distal septocutaneous branch of the peroneal artery. To increase perfusion, the proximally released branch of the anterior tibial artery may be re-anastomosed in the recipient site. Proximally pedicled flap: dissection of distal peroneus brevis muscle tendon and subperiosteal release in a proximal direction with ligation of the segmental peroneal artery branches until the flap is isolated on its proximal anterior tibial artery branch. For an osteomuscular flap, simultaneous harvest of a fibula segment underneath the muscle origin with preservation of the intimate periosteal relationship between muscle and bone.

Postoperative management

Complete immobilization and elevated leg position for 5 days, followed by successive orthostatic training for 10 days. Postoperative standardized compression garments for 6 months, eventually combined with silicone sheet scar therapy.

Results

Reliable, excellent functional and aesthetic results with very low donor site morbidity.     

Tissue Coverage and Functional Reconstruction Outcomes With Use of Serratus Osteomusculocutaneous Free Flap in Lateral Malleolar Reconstruction: A Case Report

Currently, there is no ideal method defined in the repair of complex lateral malleolar defects, and the existing methods (i.e., bone repair, soft tissue or free flap closure) are far from producing functional results in terms of the ultimate recovery of ankle movements. Herein, an operative technique for soft tissue, ligamentous, and osseous reconstruction of fibular defect, using a free vascularized serratus anterior osteomusculocutaneous flap for reconstruction of a fibular deficit and the sixth costa for soft tissue coverage, was described in relation to tissue coverage and functional reconstruction outcome in a 31-year-old male patient with soft tissue and distal fibula defects in the lateral malleolus region caused by a traffic accident. Ankle movement was regained to almost full extent. No complications requiring further intervention was encountered in the donor site or ankle. In conclusion, the described operative technique enabled the repair of functional ligaments of the ankle joint in addition to repair of the soft tissue, lateral malleolus bone and skin defects in one session without the need for further additional operative intervention. Hence, the use of serratus osteomusculocutaneous free flap as a lateral malleolar reconstruction method seems to enable not only the tissue coverage but also to assist with functional reconstruction.     

The relationship between tears of the peroneus brevis tendon and the distal extent of its muscle belly: an MRI study

BACKGROUND: Anomalous distal insertion of the peroneus brevis muscle belly has been implicated as a possible etiology of tears of the peroneus brevis tendon. The purpose of this study was to assess whether patients with operatively confirmed tears of the peroneus brevis tendons have a more distally located musculotendinous junction. METHODS: A retrospective review was done to identify all patients in whom direct inspection of the peroneal tendons was done between 1999 and 2004. The operative reports were evaluated, and all in whom a peroneal tendon tear was confirmed were included in the study group, Group I (29 patients). Group II represented an operative control group and consisted of all patients who had operative inspection of the peroneal tendons but did not have a tear (30 patients). Group III represented a radiographic control group and consisted of patients who had MRI of the ankle for reasons unrelated to lateral ankle symptoms (30 patients). For each patient, the vertical distance from the musculotendinous junction of the peroneus brevis tendon to the tip of the fibula was measured on sagittal MRI. The role of gender also was examined. The average distance between the musculotendinous junction of the peroneus brevis tendon to the distal fibula was calculated solely for men and women in all three groups. Statistical comparison of the groups was performed using the Mann-Whitney test. Interobserver reliability was determined by calculating Cronbach's Alpha coefficient. RESULTS: The average distance from the musculotendinous junction to the tip of the fibula was 33.1 cm, 41.2 cm, and 46.3 cm in Groups I, II, and III, respectively. The average distance in Group I was statistically significantly lower than the average distance in both Groups II and III (p < 0.05). Interestingly, the difference in the distance between Groups II and III also was statistically significant (p < 0.05). The average distances in both men and women were statistically significantly different (p < 0.05) among the three groups. CONCLUSION: It has been hypothesized that tears of the peroneus brevis tendon result from distal insertion of the peroneus brevis muscle belly. This study provides radiographic support for this hypothesis.     

Reconstruction of the form and function of lateral malleolus and ankle joint

Soft-tissue reconstruction alone cannot obtain normal ankle function in patients with large defects in the area of the lateral malleolus. The authors report a functional reconstructive method for the lateral malleolus, utilized in a male patient whose osteosarcoma in the fibula was resected with surrounding soft tissue. In order to reconstruct the lateral malleolus, the remaining half of the fibula at the knee was removed, and the fibular head was fixed with the tibia at the ankle joint. Ligaments were reconstructed with tendon grafts. Skin and soft-tissue defects were reconstructed with a combined composite flap comprised of a latissimus dorsi myocutaneous flap and a serratus anterior muscle flap. Dead space around the bone graft was filled with the serratus anterior muscle flap that was divided into two portions. The surface was covered with the latissimus dorsi myocutaneous flap. The patient regained almost normal function of the ankle joint. This technique would be a useful functional reconstructive method for patients with large defects in the area of the lateral malleolus.     

足背多叶皮瓣联合肌腱移植修复手部多指皮肤及肌腱缺损

目的 总结应用足背多叶皮瓣联合肌腱移植术修复手部多指皮肤及肌腱缺损的临床应用的经验.方法 在显微应用解剖研究的基础上,设计以胫前动脉为主干,分别以内踝前、足背动脉、外踝前血管为分支,构建成足内侧、足背、足外侧多叶皮瓣并携带(足母)短伸肌腱和第5趾固有伸肌腱,修复多指皮肤及肌腱缺损.结果 临床应用共12例,皮瓣完全成活11例,1例皮瓣远端小部分坏死,经换药后愈合.结论 足背多叶皮瓣移植是修复多指皮肤及肌腱缺损的较好方法.     

足背多叶皮瓣联合肌腱移植修复手部多指皮肤及肌腱缺损

目的 总结应用足背多叶皮瓣联合肌腱移植术修复手部多指皮肤及肌腱缺损的临床应用的经验.方法 在显微应用解剖研究的基础上,设计以胫前动脉为主干,分别以内踝前、足背动脉、外踝前血管为分支,构建成足内侧、足背、足外侧多叶皮瓣并携带(足母)短伸肌腱和第5趾固有伸肌腱,修复多指皮肤及肌腱缺损.结果 临床应用共12例,皮瓣完全成活11例,1例皮瓣远端小部分坏死,经换药后愈合.结论 足背多叶皮瓣移植是修复多指皮肤及肌腱缺损的较好方法.     

足背多叶皮瓣联合肌腱移植修复手部多指皮肤及肌腱缺损

目的 总结应用足背多叶皮瓣联合肌腱移植术修复手部多指皮肤及肌腱缺损的临床应用的经验.方法 在显微应用解剖研究的基础上,设计以胫前动脉为主干,分别以内踝前、足背动脉、外踝前血管为分支,构建成足内侧、足背、足外侧多叶皮瓣并携带(足母)短伸肌腱和第5趾固有伸肌腱,修复多指皮肤及肌腱缺损.结果 临床应用共12例,皮瓣完全成活11例,1例皮瓣远端小部分坏死,经换药后愈合.结论 足背多叶皮瓣移植是修复多指皮肤及肌腱缺损的较好方法.     

Soft tissue coverage of the distal third of the tibia with fasciocutaneous propeller flaps

BACKGROUND: The distal third of the tibia is often only amenable to free tissue transfer to cover exposed bone, tendons and neurovascular structures. Using relatively constant perforators of the tibial and peroneal vessels, soft tissue coverage can be achieved with so-called propeller flaps. METHODS: 8 patients presenting with post-traumatic defects over the lateral malleolus and the Achilles tendon were included in this study. A propeller flap based on perforators from the peroneal or tibial artery was used to cover the defect. RESULTS: One case of partial flap necrosis was encountered in a diabetic patient. Transient venous congestion of the flap tip was witnessed in two instances, which resolved without further intervention. No other complications occurred. All patients were fully ambulatory within 8 weeks, except for 1 patient, who required a below-knee amputation. CONCLUSION: The propeller flap has proven to be a versatile and elegant method to obtain soft tissue coverage with local tissue. Contrary to conventional rotation flaps, direct closure of the donor site is possible. Patients are not impaired by bulky flaps and may wear normal shoes. Even in the elderly, this flap was successful.