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

Ortho-plastic approaches to fracture related infection (FRI)

When a plastic surgery opinion is sought to support orthopaedic colleagues, invaluable contributions to decision-making in fracture-related infection (FRI) can be made. We summarise the plastic surgeon's perspective on the most pertinent questions which are relevant when assessing infections as a sequelae of fractures: 1.) How to define the soft tissues involved. 2.) Local & free tissue cover: options & outcomes. 3.) What to do when flaps fail. 4.) When simple dressings are an option.

One-Step Approach for Infections After Achilles Tendon Open Repair: The Distally Based Peroneus Brevis Muscle Flap

The aim of this single-center, retrospective study is to demonstrate the effectiveness of distally based peroneus brevis muscle flap as first therapeutic option for infections after Achilles tendon open repair. We retrospectively analyzed 14 consecutive patients with complete Achilles tendon rupture and developing surgical site infection after an attempt of open surgical repair. Every patient was reconstructed with distally base peroneus brevis muscle flap. The primary outcome was the return to work and the initiation of full weight-bearing. Secondary outcomes were complication rate and time needed to return to work. A review of the literature was conducted to better define the actual standard treatment. Each patient returned to work. No flap necrosis occurred. Two minor healing delays and one hematoma were reported. Median time to wound healing was 17 days (interquartile range [IQR] = 13-20). Median time to full weight-bearing was 52 days (IQR = 47-55). Median follow-up (FU) was 21 months. Distally based peroneus brevis flap is a safe treatment for surgical site infections after Achilles tendon rupture repair. Patients regained full weight-bearing after a median time of 52 days from the surgical reconstruction. No major complications were observed. This flap clearly emerges as first reconstructive option for complications after surgery of Achilles tendon region.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.

Open-book Splitting of a Distally Based Peroneus Brevis Muscle Flap to Cover Large Leg and Ankle Defects

Background:

Large soft-tissue defects in the lower leg and ankle are a major problem for plastic surgeons. Many local flaps that are either proximally or distally based have been previously described to cover small defects. Larger defects may require a distant flap that is either pedicled or free. The peroneus brevis muscle flap is a well-known distally based safe flap that is used to cover a small defect.

Methods:

Ten distally based peroneus brevis muscle flaps were elevated in 10 patients (8 males and 2 females) with major lower third leg and ankle defects that were 6–12 cm in length and 6–10 cm in width, with open-book splitting of the proximal portion of the muscle to cover these large defects.

Results:

Flap survival was excellent, and partial skin graft loss in two cases healed with dressing. The average flap length was 10 cm, ranging between 6 and 12 cm. The average flap width was 8 cm, ranging between 6 and 10 cm. The donor site also healed uneventful.

Conclusions:

Open-book splitting of the distally based peroneus brevis muscle flap is ideally suited for moderate to large defects in the distal third of the lower leg and ankle. This modification of the distally based peroneus brevis muscle flap offers a convincing alternative for covering large defects of up to 12 × 10 cm in the distal leg and ankle region.

Reconstruction of the lateral malleolus and calcaneus region using free thoracodorsal artery perforator flaps

Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 × 5 cm(2) to 12 × 16 cm(2), and the flaps from 3 × 5 cm(2) to 10 × 15 cm(2). Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral malleolus and calcaneus region.

The Application of Distally Pedicled Peroneus Brevis Muscle Flaps and Retrograde Neurocutaneous Accompanying Artery Flaps for Treatment of Bony and Soft-Tissue 3-Dimensional Defects of the Lower Leg and Foot

To investigate the clinical effect of distally pedicled peroneus brevis muscle flaps and retrograde neurocutaneous flaps on treatment of bone and soft-tissue 3-dimensional defects of the lower leg and foot, the authors retrospectively studied all the patients admitted in their center in 3 consecutive years with bone and soft-tissue defects from March 2008 to February 2011; 21 patients suffering from traumatic and osteomyelitis were treated with peroneus brevis muscle flaps, for obliterating the hole-shaped bony defects after osteomyelitis debridement, and neurocutaneous flaps, for repairing associated soft-tissue defects. After thorough debridement, the average size of soft-tissue defects was 2 cm × 2 cm to 13 cm × 9 cm and that of bony defects was 2 cm × 2 cm × 2 cm to 6 cm × 3 cm × 3 cm. Neurocutaneous flaps completely survived in 20 cases, and the wounds healed at stage I; 1 case developed necrosis in the distal part of the peroneus brevis muscle flap and sural nerve flap, and the wound healed with a saphenous nerve flap. The flaps maintained good texture and shape during a follow-up of 6 to 24 months. Recurrence of osteomyelitis was not observed in any of the patients. In conclusion, distally pedicled peroneus brevis muscle flaps and retrograde neurocutaneous flaps are simple, safe, reliable, and suitable for clinical treatment of hole-shaped bony defects and reconstruction of soft-tissue defects within a single stage, especially when the 2 defects are located in different 3-dimensional spaces.