Redefining the vascular anatomy of the peroneus brevis muscle flap

The use of peroneus brevis in lower limb reconstruction-What we have learned from 49 cases

INTRODUCTION

There are many suitable techniques for the treatment of soft tissue defects of the lower limb. Older subjects often with multiple comorbidities, presenting with a laterally located and complex defect, can be challenging to treat. This cohort are often unsuited to long procedures or multi-stage reconstruction and so one is faced with a paucity of options. In such instances, we use the peroneus brevis (PB) muscle flap as a single stage procedure.

METHODS

We performed a retrospective study evaluating the use of PB flaps in lower limb injury. Subjects were collated using a database and multiple variables were assessed including: patient demographics, comorbidities, defect size, peri-operative timings, time in theatre, use of inotropes / blood transfusion, mean hospital stay, patient morbidity / mortality, flap survival.

RESULTS

During 2015-2023, 49 patients underwent lower limb reconstruction using PB muscle flaps. 42 cases involved PB and skin graft alone whilst seven were more complex requiring additional local and free tissue techniques. The most common indication (n = 28) was infection after closed fracture fixation, followed by open trauma (n = 21). Median patient age was 59 (20-93 years), and ASA grade 3. Median defect size was 4 × 7 cm (2-18 cm) and time from admission to definitive closure 4 days (0-21 days) with median time in theatre 120 min (45-520 min). 17 patients required inotropes and 13 had blood transfusion. Median length of hospital stay was 12 days (0-58 days), one patient (aged 90) died. 100 % of flaps survived and median Enneking score was 65. Heterotopic ossification was not identified in the post-operative imaging within the first year.

DISCUSSION

Our experience highlights the benefits and risks of using the PB flap and advocates it as a reliable, cost-effective, 1-stage technique for reconstructing small lateral defects in the distal third of the lower limb.

Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study

BACKGROUND

The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA).

METHODS

A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin.

RESULTS

A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%).

CONCLUSIONS

This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.

Limitations of Computed Tomography Angiography in Preoperative Planning of Peroneus Brevis Rotational Flap

The distally based peroneus brevis (PB) rotational flap has been shown to be a reliable method of coverage of distal third tibial wounds. The flap is perfused via retrograde flow from distal PB perforators located within 8 cm of the lateral malleolus. The ability to assess patency of these vessels preoperatively facilitates surgical planning, and computed tomography angiography (CTA) has been used for perforator assessment of other lower extremity flaps. The purpose of the present study is to establish the potential utility of standard CTA for locating distal PB perforators by examining uninjured lower extremities.

Methods

Twenty-five patients who underwent bilateral lower extremity CTAs using standard lower extremity protocol were retrospectively identified. Axial two-dimensional images were scanned craniocaudally using our institution's standard CT image viewing software, Merge Radsuite (Merge Healthcare, Hartland, Wis.).

Results

The average location of distal-most PB perforators identified on CT angiogram was 13.1 ± 5.1 cm proximal to the distal fibula, or 34.5% ± 13.5% of total fibular length. Standard CTA was only able to locate a pedicle within 8 cm of the lateral malleolus (20.9% of fibular length) in three of 25 patients (12%).

Conclusions

Previous studies have described a reliable pedicle within 8 cm of the distal fibular tip upon which to design a distally based PB rotational flap. The absence of such perforators in the CT angiogram suggests that standard CT angiogram is not a reliable technique for identifying the patency of such perforators when evaluating the utility of a distally based PB flap.

Distally Based Peroneus Brevis Muscle Flap for Lower Extremity Defect Reconstruction in Severely Ill Multimorbid Patients

BACKGROUND

Reconstruction of lower extremity soft tissue defects is an exceptional surgical challenge, especially in multimorbid, elderly and severely ill patients with their thin and tense local soft-tissue conditions and increased perioperative risk. The distally based peroneus brevis muscle flap (DPBM), a local flap based on the muscular branches of the fibular artery, could pose a pragmatic solution. The objective of this study was to evaluate and quantify DPBM defect reconstruction in the lower leg, especially in elderly, multimorbid and severely ill patients.

MATERIAL AND METHODS

The DPBM as a surgical option in defect reconstruction in multimorbid, elderly, severely ill patients (inclusion criteria: at least 3 pre-existing comorbidities, patient age: at least 55 years, ASA status: at least III) was evaluated in a retrospective single-centre study from 01 April 2014 to 31 December 2019. The electronic SAP health records (EHR) were analysed according to 18 criteria, including patient details, extent of multimorbidity, defect characteristics, clinical outcome, and complications.

OUTCOME

Ten patients with a mean age of 72.6 years, a mean number of 8.5 pre-existing comorbidities and a mean ASA status of 3.1 met the inclusion criteria. The leading causes of defects, each with exposed tendons, bones, joint capsule, or joint, were chronic ulcers (n = 5) and soft tissue defects resulting from fractures (n = 3). In case of DMPB the success rate was 100% (no partial or total loss) with a short operating time (mean: 103 min) and a brief postoperative length of stay (mean: 11 d). In 2 patients (20%), DPBM surgery had to be discontinued intraoperatively and an alternative technique of defect reconstruction had to be adopted. The reasons included impaired muscle perfusion and fatty degeneration of the peroneus brevis muscle.

CONCLUSION

The DPBM flap allows straightforward, fast and safe defect reconstruction in the lower extremity, particularly in elderly, multimorbid and severely ill patients at risk. In patients with inadequate peroneal brevis muscle, however, DMPB surgery should be discontinued intraoperatively and the defect reconstructed using alternative techniques.

Surgical Outcome of Distally Based Peroneus Brevis Flap: A Retrospective Study

Background: This study aimed to evaluate the surgical outcomes of distally based peroneus brevis muscle flap in post-traumatic lower leg defects.

Methods: This is a retrospective analysis conducted from February 2017 to May 2019 including six patients who had sustained post-traumatic lower leg critical soft tissue defects and were treated with distally based peroneus brevis muscle flap and primary skin grafting.

Results: In five cases, the flap was successful in providing excellent soft tissue cover to the defects addressed. Partial flap loss was seen in one patient. Skin graft partial loss was seen in three of the six patients. There was no significant donor site morbidity.

Conclusions: The distally based peroneus brevis muscle flap is a safe, easy, and reliable flap option for coverage of lower leg defects. The muscle flap also thins with time to provide a good aesthetic outcome.

MRI anatomical preoperative evaluation of distally based peroneus brevis muscle flap in reconstructive surgery of the lower limb

BACKGROUND

The distally based peroneus brevis muscle flap has proved to be a simple solution for small- to moderate-sized wounds of the lower limb. The length of the muscle belly suitable for coverage is a crucial parameter. In this study, we evaluated the capability of 3D MRI of the lower limb to measure it preoperatively.

METHODS

Between 2008 and 2017, 32 patients with lower limb defects underwent preoperative MRI to measure the peroneus brevis muscle length. All patients underwent reconstruction, and the muscle was measured again intraoperatively during surgical dissection. Surgical measurements were then compared to the MRI ones.

RESULTS

MRI measures of the peroneus brevis muscle belly ranged from 9 to 21 cm (μ = 14.44 ± 3.43 cm), and intraoperative measures ranged from 9 to 20 cm (μ = 14.2 ± 2.3 cm). Thirty of 32 intraoperative measures corresponded to the MRI ones (variation = ± 1 cm, r = 0.92, p = 0.002). One patient showed an intraoperative muscle length 3 cm shorter than the MRI measure, and another patient had intraoperative muscle length 3 cm longer than the MRI one. All flaps survived, and no secondary local flap coverage was required, with no flap-related complication, limited donor site morbidity, and acceptable patient discomfort.

CONCLUSIONS

The reverse peroneus brevis muscle flap is a versatile alternative to free flap reconstruction in small- to moderate-sized defects of the lower limb. Preoperative 3D MRI is accurate to evaluate the anatomy of the muscle when performed by an expert radiologist. In our experience, it should become part of preoperative workup before performing a peroneus brevis flap procedure.

Postoperative negative pressure therapy significantly reduces flap complications in distally based peroneus brevis flaps: Experiences from 74 cases

BACKGROUND

The distally based peroneus brevis muscle flap is a valuable therapeutic option for coverage of tissue defects around the ankle and the distal lower leg. However, the rate of postoperative flap complications requiring revisional surgery is high due to an impaired venous drainage and oedema formation. The purpose of this study was to evaluate if postoperative negative pressure therapy is able to reduce flap complications.

METHODS

From April 2010 until March 2014, we treated 74 patients with distally based peroneus brevis muscle flaps for defect coverage at the lower leg. In four cases, an osteomuscular composite flap has been used to treat partly stability-relevant bone defects. In 43 cases, negative pressure therapy (75mmHg, continuous) with a circular dressing was initiated after the flap procedure for 7 days. In 31 cases no negative pressure therapy was initiated. We retrospectively analysed those two groups of patients. The primary endpoint was the incidence of flap complications with a need for revision surgery, which were classified in three grades.

RESULTS

The group treated with negative pressure therapy had significantly less flap complications when compared to the control group (p<0.0001). Concerning the single grades of complication, the negative pressure therapy-group had a significantly smaller rate of skin graft necrosis (Grade 1; p=0.014) and partial flap loss (Grade 2; p=0.002) compared to the control group. There were no statistically significant differences concerning complete flap loss (Grade 3) between both groups.

CONCLUSION

Postoperative negative pressure therapy for 7 days reduces flap complications in distally based peroneus brevis flaps.

Redefining the Vascular Classifications of the Lateral Supramalleolar Flap

BACKGROUND

The blood supply of the lateral supramalleolar flap (LSMF) generally comes from the perforating branch of the peroneal artery. However, the cutaneous branch may also receive blood from the anterior tibial artery. The main objective of the present study was to clarify the vascular anatomy of the LSMF.

METHODS

Anatomical dissections were performed on 28 perfused fresh cadaver legs. The cutaneous branches of LSMF were identified, and the anatomic relationship between the cutaneous branches and the peroneal and anterior tibial arteries was analyzed.

RESULTS

The vascular supply for LSMF was divided into 2 main types. A collateral inferolateral branch from the anterior tibial artery anastomosed with the perforating branch of the peroneal artery around the inferior tibiofibular angle, and the main cutaneous branch of the flap arose from this arterial anastomosis in 20 of 28 limbs (71.4%). The collateral inferolateral branch was absent or very small in the other 8 of 28 dissections (28.6%), and the cutaneous branches solely arose from the perforating branch of the peroneal artery. The anastomosis of the descending branch of the peroneal artery and anterior lateral malleolar artery was always (100%) found around the tibiotalar joint.

CONCLUSIONS

In addition to the perforating branch of the peroneal artery, the LSMF may also receive blood from the anterior tibial artery through the collateral inferolateral branch. New modified proximally based flaps could be designed, and caution is warranted for these variations when a distally based flap is performed.