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Nava CM, Martineau J, Suva D, Kalbermatten DF, Oranges CM. Distally based peroneus brevis flap: Reconstruction of complex soft-tissue defects with bony infection of the lateral malleolus. J Plast Reconstr Aesthet Surg 2024; 95:207-215. [PMID: 38936331 DOI: 10.1016/j.bjps.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/02/2024] [Accepted: 06/06/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Managing wounds of the lateral malleolus is challenging owing to limited nearby tissues and possibly injured or inadequate vessels for free flaps, especially in case of underlying infections. Moreover, free flaps require specialized skills and are not suitable for every patient. Therefore, identifying reliable local alternatives is crucial. This retrospective study investigated the efficacy and safety of the distally based peroneus brevis muscle flap in treating complex and infected soft-tissue defects of the lateral malleolus. MATERIALS AND METHODS A retrospective medical chart review of all patients who underwent a distally based peroneus brevis muscle flap reconstruction in the context of an infected lateral malleolus defect at Geneva University Hospitals between October 2020 and January 2024 was performed. RESULTS Ten patients underwent lateral malleolus reconstruction using a distally based peroneus brevis muscle flap primarily to address post-traumatic infections. Flap coverage was performed within 4 weeks of infection onset for post-traumatic cases, alongside antibiotic treatment. The defects were moderate in size, with a median width of 2.5 cm and length of 5.5 cm. There were no complete or partial flap failures. All patients regained the ability to walk within 5 days after surgery. CONCLUSIONS The distally based peroneus brevis muscle flap was efficient in managing complex and infected soft-tissue defects of the lateral malleolus, with control of infection in all patients and minimal donor-site morbidity.
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Affiliation(s)
- Caterina M Nava
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland; Department of Surgery, HFR Fribourg Cantonal Hospital, 1708 Fribourg, Switzerland
| | - Jérôme Martineau
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Domizio Suva
- Department of Orthopaedic Surgery, Bone Infection Unit, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland
| | - Carlo M Oranges
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, 1205 Geneva, Switzerland.
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Antúnez M, Huyen C, Neiman R. Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects. J Orthop Trauma 2024; 38:e105-e110. [PMID: 38158599 PMCID: PMC10868666 DOI: 10.1097/bot.0000000000002751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/16/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments. METHODS DESIGN Retrospective review. SETTING Rural outpatient surgical facility in Honduras. PATIENT SELECTION CRITERIA Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot. OUTCOME MEASURES AND COMPARISONS Flap healing, complications, and reoperations. RESULTS Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication. CONCLUSIONS The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Merlin Antúnez
- Holy Family Surgery Center, One World Surgery, Tegucigalpa, Honduras; and
| | - Cormac Huyen
- Holy Family Surgery Center, One World Surgery, Tegucigalpa, Honduras; and
| | - Rafael Neiman
- Holy Family Surgery Center, One World Surgery, Tegucigalpa, Honduras; and
- Sutter Roseville Medical Center, Trauma Services, Roseville, CA
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Giunta G, Kapila A, Brussaard C, Nistor A, De Baerdemaeker R, Zeltzer A, Hamdi M. Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study. J Plast Reconstr Aesthet Surg 2023; 83:165-171. [PMID: 37276735 DOI: 10.1016/j.bjps.2023.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Gabriele Giunta
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Ayush Kapila
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Carola Brussaard
- Department of Radiology, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alexandru Nistor
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Assaf Zeltzer
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Moustapha Hamdi
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
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Limitations of Computed Tomography Angiography in Preoperative Planning of Peroneus Brevis Rotational Flap. Plast Reconstr Surg Glob Open 2023; 11:e4774. [PMID: 36776596 PMCID: PMC9911208 DOI: 10.1097/gox.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 02/05/2023]
Abstract
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.
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Schubert CD, von Freyhold-Hünecken J, Bittrich T, Onken ML, Tomala L, Montenegro V, Elsner J. Distally Based Peroneus Brevis Muscle Flap for Lower Extremity Defect Reconstruction in Severely Ill Multimorbid Patients. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:422-430. [PMID: 33873224 DOI: 10.1055/a-1373-6564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Cornelius Dieter Schubert
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Asklepios Hospital Harburg, Hamburg, Germany
| | | | - Thomas Bittrich
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Asklepios Hospital Harburg, Hamburg, Germany
| | - Marie Luise Onken
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Asklepios Hospital Harburg, Hamburg, Germany
| | - Laura Tomala
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Asklepios Hospital Harburg, Hamburg, Germany
| | - Vladan Montenegro
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Asklepios Hospital Harburg, Hamburg, Germany
| | - Jörg Elsner
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Asklepios Hospital Harburg, Hamburg, Germany
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Jose J, Parameswaran SC, Rajappan A, Prameela LN. Surgical Outcome of Distally Based Peroneus Brevis Flap: A Retrospective Study. Cureus 2022; 14:e26329. [PMID: 35911317 PMCID: PMC9314270 DOI: 10.7759/cureus.26329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/05/2022] Open
Abstract
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.
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Irvine E, Cochrane E, Harwood P, Taylor DM, Bhat W, West C. Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle. Strategies Trauma Limb Reconstr 2022; 16:176-178. [PMID: 35111258 PMCID: PMC8778725 DOI: 10.5005/jp-journals-10080-1540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ankle fractures are a common presentation to orthopaedic surgeons, with the lateral malleolus involved in 86% of cases. A soft tissue injury can be a concomitant feature of these injuries as a result of the primary injury or following secondary wound breakdown. The peroneus brevis muscle flap provides a reliable and robust option to cover the distal third of the lower limb. With an understanding of the anatomy and cautious dissection during periosteal elevation, the perforating vessels supplying the peroneus brevis can be preserved ensuring that a valuable reconstructive option is available.
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Affiliation(s)
- Esmee Irvine
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom
- Esmee Irvine, Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom, Phone: +07814912790, e-mail:
| | - Elliott Cochrane
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Paul Harwood
- Department of Orthopaedic and Trauma Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - David M Taylor
- Department of Orthopaedic and Trauma Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Waseem Bhat
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Chris West
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom
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Yang YF, Gao XS, Liu ZL, Huang JW, Wang JW, Xu ZH. Repair of Small-Size Wound With Achilles Tendon Exposure With Proximal Pedicled Cutaneous Neurovascular Flap. Ann Plast Surg 2021; 87:457-460. [PMID: 33512822 DOI: 10.1097/sap.0000000000002730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the clinical outcomes associated with repairing of small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap in the dorsolateral foot. METHODS After thorough debridement, 16 cases with small-sized wounds of Achilles tendon exposure were repaired by proximal pedicled cutaneous neurovascular flap of the dorsolateral foot, and their clinical outcomes were observed. RESULTS All the flaps in the 16 cases survived completely, excluding the marginal part necrosis in 1 case, and all the wounds were healed. The 2-point discrimination of the flaps was 14.53 ± 1.55 mm (range, 12-17 mm) in patients without sural nerve injury after 3 to 18 months follow-up. No discomfort was felt in wearing normal shoes by all the 16 patients. CONCLUSIONS It is reasonable to repair the small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap of dorsolateral foot due to its effective repair of the wound, relatively uncomplicated surgery, and had satisfactory healing recovery.
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Affiliation(s)
- Yun-Fa Yang
- From the Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, P.R. China
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Hanna J, Ma R, Jansen S. Peroneus brevis flap in vascular surgical treatment of diabetic lower limb infection. ANZ J Surg 2021; 91:E640-E641. [PMID: 33629422 DOI: 10.1111/ans.16668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/31/2021] [Accepted: 02/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph Hanna
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Robert Ma
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Curtin University Medical School, Perth, Western Australia, Australia.,Heart and Vascular Research Institute, Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
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Somasundaram J, Wallace DL, Cartotto R, Rogers AD. Flap coverage for necrotising soft tissue infections: A systematic review. Burns 2021; 47:1608-1620. [PMID: 34172327 DOI: 10.1016/j.burns.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/05/2020] [Accepted: 01/20/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas. METHODS A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate. RESULTS After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%. CONCLUSION Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.
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Affiliation(s)
- J Somasundaram
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - D L Wallace
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - R Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - A D Rogers
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
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Distally-based Peroneus Brevis Turnover Muscle Flap in the Reconstruction of Soft Tissue Defects. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3290. [PMID: 33425602 PMCID: PMC7787294 DOI: 10.1097/gox.0000000000003290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/30/2020] [Indexed: 11/27/2022]
Abstract
Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area. Methods The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention. Results The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up. Conclusion The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.
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Abstract
Chronic ulcerations of the lower extremity centered around the lateral malleolus, medial malleolus, Achilles tendon, or anterior ankle are complex and difficult to heal with conventional treatment modalities. With the evolution of orthoplastics and microsurgery techniques, the peroneus brevis muscle flap has been shown to be simple, versatile, and effective in management of small to medium-sized soft tissue defects that may or may not have exposed bone, tendon, or both. This article reviews the peroneus brevis muscle flap in lower extremity reconstruction and presents pertinent real-world cases of its applications as a tool for limb salvage and orthoplastic reconstruction.
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Affiliation(s)
- Phuoc V Bui
- Department of Podiatric Surgery, TriHealth - Bethesda North Hospital, Montgomery, OH, USA
| | - Dominic A Rizzo
- Department of Podiatric Surgery, TriHealth - Bethesda North Hospital, Montgomery, OH, USA; Cincinnati Lower Extremity Reconstructive Institute, Foot and Ankle Specialists of Cincinnati.
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Vaienti L, Cottone G, Zaccaria G, Rampino Cordaro E, Amendola F. One-Step Approach for Infections After Achilles Tendon Open Repair: The Distally Based Peroneus Brevis Muscle Flap. INT J LOW EXTR WOUND 2020; 21:436-442. [PMID: 32844700 DOI: 10.1177/1534734620951540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Luca Vaienti
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | - Giovanna Zaccaria
- Policlinico di Modena Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
| | - Emanuele Rampino Cordaro
- Presidio Ospedaliero Universitario Santa Maria della Misericordia, Piazzale Santa Maria della Misericordia, Udine, Friuli-Venezia Giulia, Italy
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14
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Abstract
Soft tissue defects of the distal leg, ankle, and hindfoot pose challenges for orthopaedic surgeons. The distally based peroneus brevis muscle flap is a viable local muscle rotation flap to cover defects in these challenging circumstances, and can be learned and performed by most orthopaedic surgeons without the need for microvascular techniques. This video demonstrates the technique for a peroneus brevis rotation flap in a patient with a lateral ankle defect and exposed bone.
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Distally based peroneus brevis muscle flap: A single centre experience. Chin J Traumatol 2019; 22:108-112. [PMID: 30975508 PMCID: PMC6487458 DOI: 10.1016/j.cjtee.2018.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 09/21/2018] [Accepted: 10/05/2018] [Indexed: 02/04/2023] Open
Abstract
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.
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Nguyen T, Rodriguez-Collazo ER. Healing Heel Ulcers in High-Risk Patients: Distally Based Peroneus Brevis Muscle Flap Case Series. J Foot Ankle Surg 2019; 58:341-346. [PMID: 30583837 DOI: 10.1053/j.jfas.2018.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to demonstrate use of a distally based peroneus brevis muscle flap in high-risk patients with diabetes and peripheral vascular disease for limb salvage of nonhealing heel ulcerations. Seventeen patients were referred for a below-knee amputation because of nonhealing heel ulcerations and peripheral vascular disease. As a last resort, 17 distally based peroneus brevis muscle flaps were elevated in 17 patients with full-thickness heel ulcerations measuring an average defect size of 14.11 cm2. All flaps were supplemented with concentrated bone marrow aspirate, negative pressure wound therapy, bilayer wound matrix, and static external fixation for an average time of 10.3 weeks. Split-thickness skin graft was delayed by an average of 17.5 days. All procedures were performed on patients diagnosed with diabetes, advanced peripheral arterial disease and a nonhealing heel ulcer present >1 year. All flaps survived at 1.5 years follow-up. The average time to healing was 10.3 weeks. No major amputations were performed to date. Partial tip necrosis occurred in 2 patients and healed uneventfully with local wound care. Distally based peroneus brevis muscle flaps in patients with diabetes and peripheral vascular disease offer a reliable alternative to limb salvage for full-thickness heel ulcerations measuring up to 7 × 6 cm. Combinatorial procedures are necessary to improve outcomes in high-risk patients whose alternative is a major amputation.
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Affiliation(s)
- Tea Nguyen
- Podiatrist, Department of Surgery, Watsonville Community Hospital, Watsonville, CA.
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Troisi L, Wright T, Khan U, Emam AT, Chapman TW. The Distally Based Peroneus Brevis Flap. Ann Plast Surg 2018; 80:272-276. [DOI: 10.1097/sap.0000000000001224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The Peroneus Brevis Flap is a described option for the soft tissue coverage and for small bone gap reconstruction in the lower third of the lower leg, where few other local flaps are available and reliable. We analysed retrospectively a case series of 11 consecutive patients whose age ranged from 31 to 87 years (mean 56), who underwent a reconstruction with a PB flap in the treatment of post-traumatic bone infections from October 2010 to February 2012. In our series, only one patient at a 3 year minimum follow-up showed recurrence of the bone infection and required further surgical treatment. Main complications were partial flap necrosis or overlying skin graft necrosis, but without the need of secondary surgery. In our experience, the PB flap is a reliable option for soft tissue coverage in the treatment of distal leg and ankle osteomyelitis.
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Barbera F, Lorenzetti F, Marsili R, Ragoni M, Lisa A, Zampa V, Pantaloni M. MRI anatomical preoperative evaluation of distally based peroneus brevis muscle flap in reconstructive surgery of the lower limb. J Plast Reconstr Aesthet Surg 2017; 70:1563-1570. [PMID: 28720406 DOI: 10.1016/j.bjps.2017.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 06/11/2017] [Accepted: 06/18/2017] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Federico Barbera
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy; Scuola Superiore Sant'Anna di Studi Universitari e Perfezionamento, Pisa, Italy.
| | - Fulvio Lorenzetti
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
| | - Ricccardo Marsili
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
| | - Matteo Ragoni
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
| | - Andrea Lisa
- Humanitas Research Hospital, University of Milan, Italy
| | - Virna Zampa
- Diagnostic Radiology Department, University of Pisa, Italy
| | - Marcello Pantaloni
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
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Distally based peroneus brevis flap: a reliable and versatile flap to cover the lateral foot and ankle. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000422] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Erne H, Schmauss D, Schmauss V, Ehrl D. Postoperative negative pressure therapy significantly reduces flap complications in distally based peroneus brevis flaps: Experiences from 74 cases. Injury 2016; 47:1288-92. [PMID: 26980646 DOI: 10.1016/j.injury.2016.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/18/2016] [Accepted: 02/23/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- H Erne
- Department for Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, BG Trauma Center Murnau am Staffelsee, Germany; Department for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, Germany.
| | - D Schmauss
- Department for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - V Schmauss
- Department for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - D Ehrl
- Department for Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, BG Trauma Center Murnau am Staffelsee, Germany
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Open-book Splitting of a Distally Based Peroneus Brevis Muscle Flap to Cover Large Leg and Ankle Defects. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 3:e572. [PMID: 26893997 PMCID: PMC4727681 DOI: 10.1097/gox.0000000000000560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 10/09/2015] [Indexed: 11/08/2022]
Abstract
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.
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Ceran C, Demirseren M, Aksam E, Cicek C, Demiralp C. Lateral malleolar region defects with exposed implants: proximally based peroneus brevis muscle flap. J Wound Care 2015; 24:372-7. [DOI: 10.12968/jowc.2015.24.8.372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C. Ceran
- Ataturk Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - M.E. Demirseren
- Ataturk Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - E. Aksam
- Akhisar State Hospital, Department of Plastic, Reconstructive and Aesthetic Surgery, Manisa, Turkey
| | - C. Cicek
- Ataturk Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - C.O. Demiralp
- Ataturk Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey
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Bipedicled Flap for the Reconstruction of Soft Tissue Defects of the Achilles Tendon. Ann Plast Surg 2015; 74:484-7. [DOI: 10.1097/sap.0b013e3182a1e508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ovaska MT, Madanat R, Tukiainen E, Pulliainen L, Sintonen H, Mäkinen TJ. Flap reconstruction for soft-tissue defects with exposed hardware following deep infection after internal fixation of ankle fractures. Injury 2014; 45:2029-34. [PMID: 25458066 DOI: 10.1016/j.injury.2014.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/27/2014] [Accepted: 10/06/2014] [Indexed: 02/02/2023]
Abstract
The aim of the present study was to determine the outcome for patients treated with flap reconstruction following deep ankle fracture infection with exposed hardware. Out of 3041 consecutive ankle fracture operations in 3030 patients from 2006 to 2011, we identified 56 patients requiring flap reconstruction following deep infection. Thirty-two of these patients could be examined at a follow-up visit. Olerud-Molander Ankle (OMA) score, 15D score, Numeric Rating Scale (NRS), and clinical examination were used to assess the outcome. A total of 58 flap reconstructions were performed in 56 patients with a mean age of 57 years (range 25–93 years) and mean follow-up time of 52 months. The most commonly used reconstruction was a distally based peroneus brevis muscle flap with a split-thickness skin graft. A microvascular free flap was required in only one patient. 22 (39%) patients required subsequent surgical interventions because of a flap-related complication. With flap reconstruction, hardware could eventually be salvaged in 53% of patients with a non-consolidated fracture. The mean OMA score was fair or poor in 53% of the patients, and only 56% had recovered their pre-injury level of function. Half of the patients had shoe wear limitations. The 15D score showed a significantly poorer health-related quality of life compared to an age-standardised sample of the general population. The mean pain NRS was 2.1 (range 0–6), and the mean satisfaction NRS was 6.6 (range 0–10). Our study showed that successful treatment of a soft-tissue defect with exposed hardware following ankle fracture infections can be achieved with local flaps. Despite eventual reconstructive success, complications are common. Patients perceive a poorer health-related quality of life, have shoe wear limitations, and only half of them achieve their pre-injury level of function.
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Ensat F, Weitgasser L, Hladik M, Larcher L, Heinrich K, Skreiner A, Russe E, Fuerntrath F, Kamp J, Cotofana S, Wechselberger G. Redefining the vascular anatomy of the peroneus brevis muscle flap. Microsurgery 2014; 35:39-44. [DOI: 10.1002/micr.22294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 06/27/2014] [Accepted: 07/07/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Florian Ensat
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Laurenz Weitgasser
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Michaela Hladik
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Lorenz Larcher
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Klemens Heinrich
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Anna Skreiner
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Elisabeth Russe
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Frank Fuerntrath
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Jonas Kamp
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
| | - Sebastian Cotofana
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
- Department of Anatomy; Paracelsus Medical University; Salzburg Austria
| | - Gottfried Wechselberger
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg, Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 5020 Salzburg Austria
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[Muscular and osteomuscular peroneus brevis flaps]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 25:131-44. [PMID: 23512179 DOI: 10.1007/s00064-012-0202-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Ensat F, Hladik M, Larcher L, Mattiassich G, Wechselberger G. The distally based peroneus brevis muscle flap-clinical series and review of the literature. Microsurgery 2013; 34:203-8. [DOI: 10.1002/micr.22172] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 07/11/2013] [Accepted: 07/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Florian Ensat
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg; Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 Salzburg 5020 Austria
| | - Michaela Hladik
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg; Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 Salzburg 5020 Austria
| | - Lorenz Larcher
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg; Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 Salzburg 5020 Austria
| | - Georg Mattiassich
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg; Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 Salzburg 5020 Austria
| | - Gottfried Wechselberger
- Department of Plastic and Reconstructive Surgery; Krankenhaus Barmherzige Brüder Salzburg; Teaching Hospital of the Paracelsus Medical University; Kajetanerplatz 1 Salzburg 5020 Austria
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Bajantri B, Bharathi R, Ramkumar S, Latheef L, Dhane S, Sabapathy SR. Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects. Indian J Plast Surg 2013; 46:48-54. [PMID: 23960305 PMCID: PMC3745121 DOI: 10.4103/0970-0358.113706] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Babu Bajantri
- Departments of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Rodriguez Collazo ER, Bibbo C, Mechell RJ, Arendt A. The reverse peroneus brevis muscle flap for ankle wound coverage. J Foot Ankle Surg 2013; 52:543-6. [PMID: 23583580 DOI: 10.1053/j.jfas.2013.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Indexed: 02/03/2023]
Abstract
Coverage of lower extremity wounds, especially those in the ankle region, presents a challenge to the foot and ankle surgeon. The present case illustrates a surgical technique for the use of the reverse (distally based) peroneus brevis muscle flap for coverage of a postoperative ankle wound with exposed bone. The reverse peroneus brevis muscle flap provides an option for wound coverage in the ankle region in limb salvage cases in medically frail patients.
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Hu XH, Du WL, Chen Z, Li M, Wang C, Shen YM. 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. INT J LOW EXTR WOUND 2013; 12:53-62. [PMID: 23446372 DOI: 10.1177/1534734613479381] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Xiao-hua Hu
- Beijing Jishuitan Hospital, Beijing, P R China
| | - Wei-li Du
- Beijing Jishuitan Hospital, Beijing, P R China
| | - Zhong Chen
- Beijing Jishuitan Hospital, Beijing, P R China
| | - Ming Li
- Beijing Jishuitan Hospital, Beijing, P R China
| | - Cheng Wang
- Beijing Jishuitan Hospital, Beijing, P R China
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Gosau M, Schoeneich M, Koyama K, Jung EM, Fanghänel J, Prantl L. Ultrasound analyses, anatomical considerations, and clinical experience with the peroneus brevis muscle flap. Ann Anat 2012; 195:183-8. [PMID: 23123186 DOI: 10.1016/j.aanat.2012.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 08/16/2012] [Accepted: 08/21/2012] [Indexed: 11/25/2022]
Abstract
This ultrasound study investigated the frequency, location, and diameter of segmental blood supply of 34 lower legs in relation to muscle size. Furthermore, we investigated the possibilities and constraints of distally pedicled peroneus brevis muscle flaps, which allow defect coverage down to the medial as well as the lateral ankle. In the proximal part of the peroneus brevis muscle, blood is supplied by branches from the anterior tibial artery that perforate the anterior intermuscular septum; in the distal part of the muscle, blood is supplied by branches from the peroneal artery that perforate the posterior intermuscular septum. All lower legs showed at least one perforating vessel penetrating the posterior intermuscular septum. In all, 32.4% of the legs showed two perforators and 17.6% three perforators. The average position of the most distal perforator was 4.8cm proximal to the tip of the malleolus lateralis. Based on this blood supply, muscle tissue measuring up to 15-20cm can be harvested and rotated by 180° to cover defects of the lower ankle. Our ultrasound study is supplemented by an anatomical dissection and two clinical cases of successful defect coverage with the distally pedicled peroneus muscle flap.
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Affiliation(s)
- Martin Gosau
- Department of Cranio-Maxillo-Facial Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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Tharayil J, Patil RK. Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique. Indian J Plast Surg 2012; 45:45-52. [PMID: 22754152 PMCID: PMC3385397 DOI: 10.4103/0970-0358.96584] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases. Materials and Methods: Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years. Results: Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management. Conclusions: RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.
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Affiliation(s)
- Jose Tharayil
- Department of Plastic and Reconstructive Surgery, Lakeshore Hospital, Cochin, Kerala, India
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Kneser U, Brockmann S, Leffler M, Haeberle L, Beier JP, Dragu A, Unglaub F, Bach A, Horch RE. Comparison between distally based peroneus brevis and sural flaps for reconstruction of foot, ankle and distal lower leg: An analysis of donor-site morbidity and clinical outcome. J Plast Reconstr Aesthet Surg 2011; 64:656-62. [DOI: 10.1016/j.bjps.2010.09.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 08/25/2010] [Accepted: 09/21/2010] [Indexed: 11/30/2022]
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The Muscular and the New Osteomuscular Composite Peroneus Brevis Flap: Experiences from 109 Cases. Plast Reconstr Surg 2010; 126:924-932. [DOI: 10.1097/prs.0b013e3181e3b74d] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lorenzetti F, Lazzeri D, Bonini L, Giannotti G, Piolanti N, Lisanti M, Pantaloni M. Distally based peroneus brevis muscle flap in reconstructive surgery of the lower leg: Postoperative ankle function and stability evaluation. J Plast Reconstr Aesthet Surg 2010; 63:1523-33. [DOI: 10.1016/j.bjps.2009.08.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 06/14/2009] [Accepted: 08/09/2009] [Indexed: 10/20/2022]
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Abstract
The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 x 6 cm to 25 x 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.
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Reconstruction of Soft Tissue Defects Overlying the Achilles Tendon Using the Super Extended Abductor Hallucis Muscle Flap. ACTA ACUST UNITED AC 2008; 65:1459-62. [DOI: 10.1097/ta.0b013e31815ede2f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gruber S, Michlits W, Papp C. The new distal soleus adiposal pull-through composite flap for reconstruction of defects overlying the Achilles tendon: The anatomy and clinical experience. Surgery 2008; 143:441-6. [DOI: 10.1016/j.surg.2007.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 10/24/2007] [Accepted: 10/25/2007] [Indexed: 10/22/2022]
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Experience With the Distally Based Sural Neurofasciocutaneous Flap Supplied by the Terminal Perforator of Peroneal Vessels for Ankle and Foot Reconstruction. Ann Plast Surg 2007; 59:526-31. [PMID: 17992146 DOI: 10.1097/01.sap.0000258969.13723.68] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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El-Khatib HA. The split peroneus muscle flap: a new flap for lower leg defects. J Plast Reconstr Aesthet Surg 2007; 60:898-903. [PMID: 17616365 DOI: 10.1016/j.bjps.2007.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 01/15/2007] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Hamdy A El-Khatib
- Plastic and Reconstructive Surgery, Hamad Medical Corporation, Al-Omran Street, Doha, Qatar.
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Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. The Versatility of the Distally Based Peroneus Brevis Muscle Flap in Reconstructive Surgery of the Foot and Lower Leg. Ann Plast Surg 2007; 58:397-404. [PMID: 17413882 DOI: 10.1097/01.sap.0000239842.24021.e4] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Alexander D Bach
- Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany.
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