Healing Heel Ulcers in High-Risk Patients: Distally Based Peroneus Brevis Muscle Flap Case Series

Versatility of the Peroneus Brevis Muscle Flap for Distal Leg, Ankle, and Foot Defects: A Comprehensive Review

Soft tissue defects of the distal third of the leg are challenging and management with simple split thickness skin graft or conservative measures is often difficult. The peroneus brevis muscle flap is well described in the literature to cover such defects. The aim of our study was to review the different applications and potential complications of the peroneus brevis muscle flap. A comprehensive review of all existing evidence on the use of peroneus brevis muscle flaps for coverage of defects in the distal third of the leg in adult populations was performed. Two hundred forty-eight records were identified in the literature search, among which 15 met the PICOS (Patient, Intervention, Comparison, Outcome and Study design) criteria. All selected studies were retrospective. Overall, 222 patients who received peroneus brevis muscle flaps were analyzed. Indications for reconstruction were post-traumatic defects, infected wounds, and chronic wounds. The overall complication rate was 21% (46/222) with the most commonly reported complication being skin graft loss. We observed 2 cases of partial flap loss, 17 cases of skin graft loss, 2 cases of post-operative hematoma, 2 cases of recurrent infection, 12 cases of partial flap necrosis, 3 cases of skin graft necrosis, and 8 cases of delayed wound healing. Overall, 16 patients (7%) required revision surgery. No cases of donor site morbidity were described. The current review shows that the peroneus brevis muscle flap is a versatile and reliable option for the coverage of small to medium sized defects of the distal leg, ankle, and foot with low complication rates and donor site morbidity.

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.

Flaps for lower limb diabetic wound reconstruction: A systematic review and meta-analysis

BACKGROUND

The treatment of chronic diabetic wounds includes wound dressing, debridement, flap surgery, and amputation. For suitable patients with nonhealing wounds, locoregional flaps or free flaps may be used. This paper aims to review the outcomes of flap surgery and identify the risk factors for flap loss.

METHODS

MEDLINE, Embase, and Cochrane Library were searched. Articles reporting flap loss outcomes for flap surgery in lower limb chronic diabetic wounds were included. Case reports and case series with fewer than five patients were excluded. A subset of articles was used for revascularization subgroup analysis and another subset for meta-analysis of risk factors for flap loss.

RESULTS

In the free flap group, the total flap failure rate was 7.14% and partial flap failure rate was 7.54%. The rate of major complications requiring operative takeback was 19.0%. Early mortality was 2.76%. In the locoregional flap group, the total flap failure rate was 3.24% and partial flap failure rate was 5.36%. The rate of major complications requiring operative takeback was 13.3%. There was no early mortality. The rate of free flap loss was 18.2% with revascularization, significantly higher than 6.66% without revascularization.

CONCLUSIONS

Our findings concur with previously published studies on flap loss and complications in diabetic lower limb wounds. There is an increased risk of flap loss in patients who require free flap and revascularization compared to patients who only require free flap. This could be because of the fragile and fibrotic vessels found in diabetics with comorbid atherosclerosis.

The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis

INTRODUCTION

 Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades.

METHODS

 PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test.

RESULTS

 The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p < 0.001). Functional outcomes were more commonly reported between 1990 and 2012 (78.0 vs. 47.5%, p = 0.003); similarly, ambulatory status was reported more often in the previous review (70.0 vs. 40.0%, p = 0.004). This study solely examined the rate at which PCO were reported in the literature; the individual importance and effect on medical outcomes of each PCO was not evaluated.

CONCLUSION

 Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.

Lower Limb Muscle Flaps: The Reverse Peroneus Brevis Flap

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.

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.

Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?

BACKGROUND

 Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation.

METHODS

 A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol.

RESULTS

 Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes.

CONCLUSION

 The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible.