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.     

远端蒂腓骨短肌瓣在修复小腿下1/3及足踝部软组织缺损中的应用

目的　探索一种简单有效的修复小腿下 1/3及足踝部软组织缺损的方法。　方法　设计远端蒂腓骨短肌瓣转位修复小腿下 1/3及足踝部软组织缺损创面 ,中厚皮片移植覆盖肌瓣。　结果　 16例小腿下 1/3及足踝部软组织缺损病例 ,缺损面积最大 5cm× 7cm ,最小 3cm× 4cm。术后伤口一期愈合 14例 ,二期愈合 2例 ,无 1例肌瓣完全坏死。　结论　远端蒂腓骨短肌瓣是修复小腿下 1/3及足踝部软组织缺损诸多方法中最简单、并发症最少、成功率较高的方法之一 ,尤其适合于中、小创面的修复。     

Interest of using muscle flaps in the coverage of small ankle and distal leg defects

The author reports his experience and the interest in using small pedicled muscle flaps in the coverage of small cutaneous size defects around the ankle and the distal leg. In such defects, the bad cutaneous status often precludes the use of fasciocutaneous flaps, and the use of wider muscle pedicled flaps or even free flaps is excessive. Because of their small sizes, the muscles used in our series, often considered as accessories, appear very useful.     

腓骨短肌肌瓣联合腓肠神经营养血管逆行岛状皮瓣治疗患者小腿远端及足部骨髓炎伴软组织缺损

目的 了解应用远端蒂腓骨短肌肌瓣联合腓肠神经营养血管逆行岛状皮瓣治疗患者小腿远端及足部骨髓炎伴软组织缺损的效果. 方法 2008年3月-2010年12月,笔者单位收治12例小腿远端及足部骨髓炎伴软组织缺损患者,其中7例为胫骨远端骨髓炎伴软组织缺损,1例为跟腱后侧慢性溃疡伴骨髓炎,4例为跟骨外侧软组织缺损伴骨髓炎及内固定物外露.彻底清创后,软组织缺损范围为4 cm×2 cm～13 cm×9 cm,骨缺损范围为3.0 cm ×3.0 cm ×3.0 cm～6.0 cm ×3.0 cm×4.0 cm.所有患者应用腓骨短肌肌瓣填充骨髓炎清创后形成的无效腔,腓肠神经营养血管逆行岛状皮瓣修复软组织缺损.手术切取皮瓣大小为5 cm×3 cm～14cm×10cm,肌瓣大小为11 cm ×3 cm～16 cm×4 cm.供瓣区直接缝合或植皮修复. 结果 11例皮瓣、肌瓣成活良好,创面均一次性愈合.1例皮瓣及肌瓣远端坏死,采用胫后动脉穿支肌皮瓣修复后愈合.随访6～ 24个月,皮瓣质地及外形良好,患者未复发骨髓炎. 结论 联合应用远端蒂腓骨短肌肌瓣与腓肠神经营养血管逆行岛状皮瓣移植,能有效治疗小腿远端及足部骨髓炎伴软组织缺损,操作简单、易行、安全可靠.     

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.     

Extensor digitorum brevis rotational muscle flap for lower leg and ankle coverage

BACKGROUND: Soft tissue reconstruction around the ankle has been a challenging problem. This article reports our experience using the extensor digitorum brevis muscle flap; some technical variations are discussed. METHODS: The extensor digitorum brevis muscle flap is vascularized by the well-defined lateral tarsal artery, a branch of the dorsalis pedis artery originating at the level of the inferior extensor retinaculum. This flap was used for coverage of soft tissue defects in the lower leg and the ankle in 10 patients with various injuries. RESULTS: All flaps survived completely. Complications included delayed healing of donor skin in two cases. Flap elevation was possible even in the traumatized donor foot. CONCLUSION: The advantages of this flap include constant and reliable blood supply, easy and rapid flap dissection, adequate bulk, and one-stage procedure. However, disadvantages include the small size of the flap and the sacrifice of the dorsalis pedis artery.     

An algorithm for reconstruction of soft tissue defects of the distal lower leg, ankle and heel

AIM: The purpose of the study was to establish an algorithm for the reconstruction of soft tissue defects of the distal lower leg, ankle and heel. METHOD: 81 patients presenting with soft tissue defects in these regions underwent flap coverage. The average age was 44.1 years. Small defects (up to 4 x 4 cm) were covered by local flaps. The neurovascular sural flap was the predominant flap procedure for medium size defects (up to 10 x 15 cm). Free flaps were used for larger defects or in cases of stenosis or occlusion of the peroneal artery. Femoro-crural bypasses were performed in three cases to improve peripheral arterial perfusion. RESULTS: The reconstructive goals were achieved in 95% of the cases by performing reconstruction according to the established algorithm. Minor complications occurred in 29.6% of the cases. CONCLUSION: The results appear to be very good considering a patient population with complex and predominantly contaminated wounds. A preoperative angiography represents an important part of the algorithm for flap reconstruction to detect abnormal arterial vascular conditions and thus to plan vascular reconstruction prior to or simultaneously with free flap coverage. Additionally, a non-patency of the peroneal artery represents a contraindication for sural flaps.     

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 random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel

Distally-based random pattern fasciocutaneous flaps were used to reconstruct defects of the lower third of the leg, the ankle and the heel in eight patients. Though a multi-staged procedure, this simplified fasciocutaneous flap design ensured safe transfer of tissue to defects in which it would otherwise have been very difficult to have obtained cover. This paper discusses the anatomical basis of the distally-based random pattern fasciocutaneous flaps and reviews the design, surgical technique, advantages, limitations and complications of these flaps.     

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BackgroundCovering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation.MethodsPatients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects.ResultsThe mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm² (range, 48–125 cm²). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation.ConclusionsThe propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.     

Skeletonised retrograde distal perforator island fasciocutaneous flaps for leg and foot defects.

Defects involving the distal leg and foot are frequently encountered following various aetiological factors. Paucity of local tissue causes surgeons to resort to the retrograde peninsular flap, the cross leg flap or the free flap. With specific knowledge of perforators, the fasciocutaneous flap from the calf area can be transferred to the defect in a single stage based on skeletonised distal perforators. The surgical anatomy, flap planning and procedure have been detailed. Nineteen patients were treated during the period 1995 to 2005. The perforators were identified preoperatively by audio Doppler. The flaps were marked and dissected proximal to the defect skeletonising the distal perforators under loupe magnification and transferred to the defect in a single stage. The donor site was skin grafted. Out of 19 cases, 16 flaps healed uneventfully, one flap necrosed completely and in two cases there was marginal necrosis. The cases were followed up for 2-10 years with an average of 6 years. With detailed knowledge of perforators one can safely reconstruct distal moderate-size defects of the lower limb in a single stage, thus having the benefits of free tissue transfer without resorting to microsurgery. This technique has proved to be an advancement in the reconstructive repertoire allowing flaps of non conventional dimensions to be perfused by skeletonised perforators.     

Repair of defects in the Achilles tendon with the peroneus brevis muscle (author's transl)

The authors report a dynamic plastic repair of the Achilles tendon in cases of neglected rupture: The peroneus brevis muscle is used to bridge the gap. The muscle remains intact at the proximal end, its tendon is dissected immediately above its insertion, then pulled through the calcaneus by a bore-hole and fastened to itself and to the ends of the Achilles tendon. If a plantaris tendon exists, it may be used to strengthen the defect by resecting it as far as possible proximally and then fanning it out to cover the gap. The distal end of the peroneus brevis tendon is sutured side-by-side to the peroneus longus tendon. This technique was first applied in 1968. During the last 5 years 8 patients underwent repair of the Achilles tendon by this method at the Department of Orthopaedic Surgery at the University of Kiel. In all cases the results obtained were good or excellent. The patients were very content and returned to a comparable level of preoperative activity. They were able to go as well on tip-toes as on the heels, though dorsal extension in several cases was slightly restricted. Calf atrophy up to 3 cm was found in several cases, which, however, was due partly to preoperational influences. In two cases wound healing complications occured without disturbing the functional results. The authors can recommend their technique, which seems to be superior to other methods especially in difficult cases with large gaps and unfavourably anatomic conditions.     

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.     

The use of local muscle flaps in foot and ankle reconstruction

Pedicled muscle flaps always should be considered as a reconstructive option when evaluating possible options to filling a defect around the foot and ankle. To gain confidence in using this option, multiple anatomic dissections with special attention to the vascular anatomy are necessary. These dissections also should give the surgeon a feel for the reach of the various flaps and their applicability in various circumstances. For optimal results, the interoperative dissections should be performed with loupes and the Doppler. This allows the surgeon to identify and protect the dominant pedicle. When insetting the flap, special attention is directed to avoid placing excessive torsion or tension on the pedicle so that the blood flow is not compromised. The flow, both arterial and venous, should be assessed after insetting the muscle with a Doppler. Pedicled muscle flaps offer a rapid and easy solution to difficult soft tissue problems around the foot and ankle. The operation can be performed with a regional block in under two hours. The postoperative stay is short, and the donor defect is minimal. Pedicled muscle flaps offer a great alternative to microsurgical free flaps, especially in the sick patient. They should be considered more often when looking at how to fill small defects with exposed bone or osteomyelitis around the foot and ankle.     

Propeller flaps for leg reconstruction.

Leg soft tissue defects with bone or tendon exposure need to be covered with a flap. Various local and free flaps with more or less consistent donor site defects have been described in the past. After the introduction of the perforator-based flap concept, new flaps have also been described for the leg. An evolution and simplification of the perforator flap concept, together with the 'free style' flap harvesting method, are the propeller flaps, i.e. local flaps, based on a perforator vessel, which becomes the pivot point for the skin island that can, therefore, be rotated up to 180 degrees . In this prospective study, six consecutive patients, having post-traumatic soft tissue defects of the leg or knee prosthesis infection, with bone or tendon exposure, were treated with propeller flaps. Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only cosmetic, donor site defect. No flap necrosis was observed, with the exception of a small superficial necrosis of the tip of one flap, due to the inclusion in the design of scarred tissue. In two cases, transient venous congestion was observed and resolved spontaneously. Mean operative time was 2 h (ranging from 60 min to 6 h when an orthopaedic procedure was also needed) and mean hospital stay after surgery was 10 days. Propeller flaps allow the coverage of wide defects, can be raised with a relatively simple surgical technique, have a high success rate and good cosmetic results without functional impairment. In the light of this they can be considered among the first surgical choices to resurface complex soft tissue defects of the leg.     

腓骨短肌肌瓣逆行转位修复外踝及跟腱软组织缺损

目的介绍一种简单有效的修复外踝及跟腱处软组织缺损的方法。方法设计腓骨短肌肌瓣逆行转位修复外踝及跟腱处软组织缺损创面。中厚皮片移植覆盖肌瓣。结果7例外踝及跟腱处软组织缺损合并骨、跟腱外露病例。缺损面积最大5cm×6cm,最小3cm×4cm。术后伤口Ⅰ期愈合,肌瓣全部成活。结论腓骨短肌肌瓣逆行转位修复外踝、跟腱处软组织缺损,此方法简单、并发症少、成功率较高,尤其适用于中小创面。     

Use of soleus muscle flaps for coverage of distal third tibial defects

The authors reviewed the outcome of 12 patients who underwent soleus flap reconstruction of distal third lower extremity defects. Nine of the 12 patients achieved a healed, stable wound; however, several flaps and multiple additional procedures were often required. One of the 12 patients experienced soleus flap loss and two of the patients required below-knee amputations. Failure of limb salvage was related to traumatic injuries or comorbid conditions such as peripheral vascular disease, smoking, and planned radiation. They conclude that these factors should be considered relative contraindications to the use of the soleus flap in the distal third of the leg, and that free flap coverage is the most reliable option for these high-risk patients.     

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.