Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects

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.

Medial Femoral Condyle Free Flap for Persistent Osseous Nonunion of the First Metatarsophalangeal Joint: A Preliminary Report of a New Surgical Indication for the Medial Femoral Condyle Free Flap

Background

Recalcitrant or persistent nonunions of the metatarsophalangeal (MTP) joint occur following failed MTP surgery for MTP fusion, failed MTP prosthesis, for hallux rigidus or due to infection and erosion. A deficient soft tissue envelope and compromised vascular supply of tissues in this region compound further attempts to salvage the great toe and preserve function. The medial femoral condyle (MFC) free flap provides vascularized corticocancellous bone and periosteum and has been successfully used for a variety of complex hindfoot and ankle pathologies. We present an additional indication with a small cohort study demonstrating its use in persistent nonunions of the first MTP joint.

Methods

A retrospective review was completed of all MFC flaps used for revision of failed first MTP joint fusion from January 2019 to November 2022. Demographic information, comorbidities, as well as clinical and radiologic follow-up was obtained from the patient charts.

Results

Three patients were included with MTP nonunion and an average of 7.5 (range, 5-11) failed prior surgeries. Mean age at index surgery was 50 (range, 46-57) years. An osseous union was achieved in all patients after 82 (range, 75-88) days. Hardware removal was possible after 81 (range, 55-98) days. Mean follow-up was 17 (range, 5-31) months. We note a 100% flap success rate without returns to the operating room. The lengths of the bone flaps were 2 to 4 cm, the volumes were 8 to 12 cm3. Fixation was performed with 1 intramedullary K-wire. The recipient vessel in all patients was the dorsalis pedis artery or a tributary thereof. All arterial anastomoses were performed under the operating microscope.

Conclusion

The MFC free flap is a reasonable option for salvage of complex recalcitrant or persistent nonunions of the first MTP joint. More prospective long-term studies with functional outcomes are necessary to confirm these findings.

Level of Evidence

Level IV, retrospective case series.

Combined Orthoplastic Approach in Fracture-Related Infections of the Distal Tibia

This series reports on the treatment of distal tibia (DT) fracture-related infections (FRI) with a combined orthoplastic approach. Thirteen patients were included. In eight patients with extensive bone involvement and in those with a non-healed fracture, the DT was resected (“staged approach”). In five cases, the DT was preserved (“single-stage approach”). A wide debridement was performed, and the cavity was filled with antibiotic-loaded PerOssal beads. All patients had a soft-tissue defect covered by a free vascularized flap (anterolateral thigh perforator flap in eight cases, latissimus dorsi flap in five). At the final follow-up (mean 25 months, range, 13–37), no infection recurrence was observed. In one patient, the persistence of infection was observed, and the patient underwent a repeated debridement. In two cases, a voluminous hematoma was observed. However, none of these complications impacted the final outcome. The successful treatment of FRI depends on proper debridement and obliteration of dead spaces with a flap. Therefore, when dealing with DT FRI, debridement of infected bone and soft tissues must be as radical as required, with no fear of the need for massive reconstructions.

A case of infection and severe soft tissue loss of the elbow. Planning surgical treatment in compliance with good clinical-care practices and medico-legal implications

Soft tissue loss around  the elbow, with tendons, nerves and bone exposure,  represents a challenging condition, often requiring a complex and accurate surgical reconstruction. Inadequate repair of soft tissue defects may in fact compromise further reconstructive orthopedic procedures, including  osteosynthesis and joint replacement. A correct reparative sequence of these lesions usually starts with an appropriate debridement and removal of all non-viable and infected tissues, followed by soft tissues management through plastic and reconstructive techniques. Here we present a case report, showing a successful surgical solution, using a local muscular flap. The results are discussed in light of their functional and medico-legal implications, considering the frequent occurrence of partial functional recovery, the disabling impact on social and work activities and the aesthetic sequelae of these lesions, even in spite of a successful treatment.

Orthoplastic Management of Open Midfoot Injuries: Is Functional Limb Salvage Possible?

High energy open midfoot injuries are uncommon but devastating injuries. A combination of complex fracture dislocations and soft tissue injury patterns render reconstruction challenging. The aim of this study was to assess the surgical and patient reported outcomes following orthoplastic management of open midfoot injuries in a Major Trauma Center. A retrospective review of all open midfoot fractures admitted to our unit between January 2015 and December 2016 was undertaken. Demographics, operative details, complications, additional surgeries, and patient reported outcomes in the form of EQ-5D and Enneking scores were collected. Fifteen patients were identified (13 male, mean age 39.2 years). One patient underwent amputation at initial debridement and 8 required additional debridement. Of these 8 patients, 3 had an amputation during their index admission. In the limb salvage group (11 patients), definitive soft tissue cover involved free flaps in 6 patients, split skin graft in 3 patients, and delayed primary closure in 2 patients. Definitive orthopedic treatment was internal fixation in 8 and external fixation in 3 patients. Two patients required a Masquelet procedure for bone loss. One patient had a toe amputation and 1 had a below knee amputation for deep infection. The median EQ-5D score was 66 (interquartile range 43), and the median Enneking score was 20.5 (interquartile range 9). Limb salvage following open midfoot fractures is technically possible in most cases, however this often involves multiple procedures and the outcomes are variable and difficult to predict. Patients should be carefully counseled, and amputation considered in all such cases.

Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency

Introduction: Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. Methods and Results: One-hundred sixty patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 47 patients. Of these, six presented with extensor apparatus deficiency. One patient underwent primary arthrodesis and five patients underwent reconstruction of the extensor apparatus. The principle to reconstruct missing tissue 'like with like' was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and two patients who did not qualify for free flap surgery received a pedicled medial sural artery perforator gastrocnemius flap. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo arthrodesis because of recurrent infection and one patient was lost to follow-up. Conclusion: These results show that PJI of the knee and extensor apparatus deficiency is a dreaded combination with a poor long-term outcome. Standardization of surgical techniques for a defined PJI problem and consensus on study variables may facilitate interinstitutional comparisons of outcome data, and hence, improvement of treatment concepts.

Open fractures with soft-tissue loss: Coverage options and timing of surgery

Open fractures with soft-tissue loss remain challenging injuries to treat. These often high-energy fractures are at a higher risk of delayed healing and at much higher risk of infection than open fractures with less significant soft-tissue injury. The initial management of the open wound, flap coverage options, and the timing of definitive coverage all remain areas of controversy, which will be discussed in this article.

A Review on the Orthoplastic Approach to Lower Limb Reconstruction

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

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

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.