Tag Archives: muscle flap

Utilization of a peroneus brevis muscle flap for calcaneal fat pad atrophy secondary to radiation treatment: A case report and treatment course

Posted on June 30, 2019 | Comments Off on Utilization of a peroneus brevis muscle flap for calcaneal fat pad atrophy secondary to radiation treatment: A case report and treatment course

by Amanda Kamery DPM1*, Byron Hutchinson DPM FACFAS2

It has been well-documented that peroneus brevis muscle flaps are an excellent option for coverage of small to medium sized soft tissue defects of the distal lateral lower extremity. They are widely used due to their reliable blood supply, minimal donor site morbidity and lower technical demand as compared to other lower extremity muscle flaps. To our knowledge, no study has evaluated the efficacy of the use of a peroneus brevis muscle flap for an intractable calcaneal scar tissue. We present a unique case in which the peroneus brevis muscle flap was used to assist with eliminating pain from an intractable calcaneal scar secondary to radiation treatment.

Keywords: Muscle flap, rear foot, lower extremity, reconstructive surgery

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0002

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Research Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author- akamery@kent.edu

Peroneus brevis muscle flaps are widely used for distal lateral lower extremity soft tissue defects due to their reliable blood supply, minimal donor site morbidity and lower technical demand as compared to other muscle flaps [1-3]. The efficacy and utility of this muscle flap has been well-documented in the literature. Since the first discussion of a distally based peroneus brevis flap in 1997, the indications for this flap have vastly expanded and the technique has since been simplified into 5 steps [4]. It has been documented that partial or full flap necrosis is a common complication, with an occurrence of up to 41% [4]. However, with advancements in postoperative dressings and wound care modalities, this complication can be well managed [3,4]. In this case report, we present a patient with a unique indication for a distally based peroneus brevis flap.

Case Report

The patient is a 40-year-old male who presented with a painful lateral calcaneal scar after removal of clear cell sarcoma and subsequent radiation treatment years ago (Figure 1). The patient complained of significant pain to the area with activity and irritation from shoe gear. He had undergone numerous conservative treatment options without relief of symptoms. He was unable to perform duties required of his job due to pain. His goal was for pain reduction to help return to normal activity levels at work. 

A staged procedure was planned. The index procedure included scar excision, a peroneus brevis muscle flap and application of an external fixator to allow for stability of the flap and to allow full flap incorporation (Figure 2). A secondary procedure, performed 7 weeks later, included external fixator removal and skin graft application (Figure 3).   

Figure 1 Pre-operative clinical picture.  

Figure 2 Intraoperative picture of muscle flap after placement.

Intra-operatively adequate bulk and length from the peroneus brevis muscle to cover the calcaneus and aid in scar revision (Figure 2). Slight distal tip necrosis was seen at 2 weeks post-index procedure, but was managed adequately with serial in-office debridements and local wound care. 

Following the secondary procedure, epithelialization was seen over the majority of the muscle flap. Complete muscle flap incorporation and donor site closure with 90% epithelialization was noted at 6 months post-index procedure. At 12 months post-index procedure, a small soft tissue defect with granular base remained on the plantar lateral aspect of the calcaneus (Figure 4). This small soft tissue defect closed at 16 months postoperatively. The patient reports significant improvements in pain scores, subjective ambulatory tolerance, ability to return to work at full capacity and improved quality of life. 

Figure 3 Intraoperative picture of skin graft placement.

Figure 4 Twelve-month post-index procedure clinical picture.

Discussion

The traditional applications for the peroneus brevis muscle flap are well-recognized and utilized. Painful calcaneal cicatrix is a less commonly seen pathology; however, when assessing these patients the peroneus brevis muscle flap should be considered as a viable option to eliminate intractable scar, relieve pain and improve patient function. Our case example demonstrates successful use of the peroneus brevis muscle flap for this novel indication.

References

  1. Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg. Plast Reconstr Surg. 2001;107(6):1443-8.
  2. 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(4):397-404.
  3. Lorenzetti F, Agostini T, Pantaloni M, Lazzeri D. The versatility of the distally based peroneus brevis muscle flap. Plast Reconstr Surg. 2011;127(4):1751-2.
  4. Troisi L, Wright T, Khan U, Emam AT, Chapman TWL. The Distally Based Peroneus Brevis Flap: The 5-Step Technique. Ann Plast Surg. 2018;80(3):272-276.

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Staged treatment of plantar midfoot ulceration with use of a Hemisoleus Muscle Flap, application of external fixation and split-thickness skin graft

Posted on December 31, 2018 | Comments Off on Staged treatment of plantar midfoot ulceration with use of a Hemisoleus Muscle Flap, application of external fixation and split-thickness skin graft

by Stephanie Oexeman, DPM1*; Mallory J. Schweitzer, DPM, MHA2; Craig E. Clifford  DPM, MHA, FACFAS, FACFAOM3

The Foot and Ankle Online Journal 11 (4): 2

Muscle flaps are a versatile option for limb salvage that can provide coverage for chronic ankle and foot defects that fail to heal from other conservative and surgical treatments. We discuss the use of a medial hemisoleus muscle flap for treatment of a chronic foot ulcer following dehiscence of an intrinsic pedicled muscle flap. Hemisoleus muscle flaps are utilized for soft tissue defects of the distal third of the lower extremity but are not commonly utilized for coverage of defects on the plantar foot.

Keywords: wound care, muscle flap, lower extremity, hemisoleus muscle flap, medial hemisoleus muscle flap

ISSN 1941-6806
doi: 10.3827/faoj.2018.1104.0002

1 – Resident Physician, PGY-1, Franciscan Foot & Ankle Institute, Federal Way, WA,
2 – Resident Physician, PGY-2, Franciscan Foot & Ankle Institute, Federal Way, WA,
3 – Residency Director, Franciscan Foot & Ankle Institute, Federal Way, WA
* – Corresponding author: s.oexeman@gmail.com

We discuss the use of a medial hemisoleus (MHS) flap for treatment of a chronic foot ulcer following dehiscence of an intrinsic pedicled muscle flap. This case study presents our treatment of a chronic wound that failed to heal despite local wound care and several attempts at primary closure. We present our surgical technique for mobilizing the MHS flap and recommend concomitant use of external fixation to decrease motion of the flap on the wound bed, allowing for neovascularization and full incorporation.

Case Study

A case is presented of a fifty-seven-year-old male who underwent a plantar fasciotomy with a subsequent postoperative soft tissue infection. This resulted in a chronic, painful wound to the plantar medial left foot after the infection resolved. Non-invasive vascular studies and clinical vascular examination were normal. He failed conservative therapy including local wound care and offloading and elected to undergo primary closure eight months after the plantar fasciotomy. A fissure developed along the incision six weeks postoperatively and persisted for nine months despite continued wound care. A second attempt at primary closure was made and approximately three weeks later the incision partially dehisced. Progressive healing was achieved for three months, but the patient fell at this time which resulted in the wound reopening. An MRI was obtained and ruled out osteomyelitis or presence of a foreign body. The patient then elected to undergo scar excision with the placement of an abductor hallucis muscle flap. The patient had an uneventful postoperative course and was transitioned to heel weight bearing at twelve weeks postoperatively. At four months postoperatively, the incision partially dehisced and became a chronic ulcer (Figure 1).

Figure 1 Preoperative (A) Chronic ulceration to plantar medial left foot (B) Ellipsoid excision of the ulcer.

At this time, the patient was given the option of a  below-knee amputation and he declined. After five months of additional conservative therapy with no improvement  in appearance of the wound, another attempt at closure was made by performing a medial hemisoleus flap. The decision was made to utilize an  external fixator to minimize motion of the flap within the wound bed. Three weeks later a split-thickness skin graft (STSG) was applied and the external fixator was removed at this time. The incisions healed and the graft and flap had completely incorporated at ten weeks postoperatively (Figure 4). The patient is ambulatory in accommodative shoe gear and has not had a recurrence of the soft tissue defect after twenty-three months of follow-up.

Surgical Technique

The patient was brought to the operating room and placed on the operating room table in the supine position. A tourniquet was not utilized during the procedure. An elliptical incision was made to encompass the wound (Figure 1). Due to previous surgeries, a significant amount of scar tissue was encountered that extended to the level of the plantar musculature. Attention was directed to the tarsal tunnel and dissection was carried through the flexor retinaculum. The wound was irrigated with copious amounts of normal saline and all nonviable soft tissue was excised; leaving a large soft tissue defect (Figure 2).

Figure 2 Intraoperative (A) Excision of Chronic Wound (B) Incision and dissection of medial soleus (C) Closure with application of External Fixation for ankle motion and flap protection.

The decision was made to transpose a medial hemisoleus muscle flap for coverage of the defect. Continuing the incision from the tarsal tunnel, a longitudinal incision was made over the medial aspect of the calf. The incision was carried down to the crural fascia. The fascia was incised longitudinally allowing exposure to the gastroc-soleus muscle complex. The soleus muscle belly was identified and the medial portion of the muscle was transected proximally and freed from lateral muscle belly along the central raphe down to the level of the tarsal tunnel.  An intraoperative doppler was utilized during this dissection to identify perforators of the muscle. With sharp dissection, the epimysium was excised. The muscle was transposed through the tarsal tunnel and placed within the plantar soft tissue defect. 3-0 nylon was used to secure the flap in the proper position, with no tension on the flap. The medial incision was closed in layers and the skin was closed with staples. Vessel loops in a zig-zag pattern were used to reduce tension to the edges of the incision.

Figure 3 Intraoperative (A) status post 3 weeks from muscle flap (B) Fenestrated STSG applied to debrided muscle flap.

An external fixator consisting of a tibial block with two full rings and a distal block with a full ring was used to encompass the forefoot. Opposing olive wires were inserted using standard techniques.

Three weeks following the frame application, the patient was brought back to the operating room for debridement of the muscle flap and application of a split-thickness skin graft (STSG). The external fixator was removed and extremity was prepped and draped in a sterile manner. The muscle flap was debrided of eschar tissue, leaving a mixture of bleeding granular and muscular tissue (Figure 3). The muscle flap measured 3cm x 9cm. The site was covered with an intermediate STSG harvested from the proximal left thigh with use of a dermatome. The skin graft was meshed and sutured in place using 3-0 Monocryl. The skin graft was covered with a sterile dressing and a wound VAC was applied. The STSG was fully incorporated after 10 weeks of local wound care (Figure 4).

Discussion

MHS flap reliability has been questioned due to variability in vascularity, but successful coverage of distal lower extremity defects have been reported. Our use of a MHS flap for plantar foot defects is a novel application.

The performing surgeon should have an in-depth knowledge not only of the muscular but also of the vascular anatomy. There are many classifications within the literature discussing mapping the vasculature of the lower leg.

Figure 4 Clinical images (A) healing STSG five weeks postoperatively and (B)  fully incorporated split thickness skin 10 weeks graft.

Angiosomes should always be acknowledged throughout the surgical planning and intervention. Angiosomes are a unit consisting of the skin, subcutaneous tissue, fascia, muscle, and bone being supplied by a source artery. The human body has forty angiosomes, with six being located in the foot and four located within the lower leg [1,2]. Mathes and Nahai’s classification divides muscle flaps accordingly to their blood supply. The soleal muscle flap is a type II flap, meaning it has one major pedicle and several minor pedicles [2,3]. Its dominant  pedicle is the posterior tibial artery and the perforating branches of this artery are the secondary pedicles [2,4-7].  The vascular supply of the medial soleus muscle body is mainly from the posterior tibial artery (PTA) via multiple minor pedicles [4,5,8]. The medial soleus has perforators from the PTA extending the length of the muscle [9,10].  

Ward, et al. state that perforators can be found on the posterior border of the tibia roughly 5 cm, 10 cm, and 15 cm proximal to the ankle joint [11].  Similarly, Raveendran, et al. report the distal perforating arteries of the PTA averaged 6.5 cm, 11.6 cm, and 16.8 cm from the medial malleolus [12].

When planning for coverage, the entire soleal muscle can cover defects approximately 26 cm2 [2]. However, the MHS has an extended arc of rotation compared to a full soleal flap which allows a greater percentage of coverage [6,7,13,14]. The medial soleus belly averages 25.4 cm in length, 6.9 cm in width, and has a mean surface area of 87.5 cm2 [15]. Techniques, such as excising the epimysium, can also increase the flap’s range by 20% [4].

Prior to incision, perforators should be marked appropriately along the posterior border of the tibia [9,11]. For the surgical approach, we prefer a medial incision overlying the posterior compartment. Preserving the saphenous neurovascular bundles can be achieved and blunt dissection can be utilized to separate the gastrocnemius from the soleus [2,11]. It is highly encouraged to use intraoperative doppler examination throughout the surgery to confirm the major pedicle is viable and only minor perforators are being ligated [2]. The medial body of the soleus should be dissected from the lateral portion at the “C-point”, or the perforator located approximately 15 cm from the ankle joint [11].  Bourdais-Sallot et al. reported the pivot point for MHS is 14.5 cm from the top of the medial malleolus or 32.5% of the tibial length [15].  The lateral soleal muscle body is left intact to help maintain plantar-flexion at the ankle [9,2].

Conclusion

To our knowledge, the use of a MHS flap for coverage of a plantar foot soft tissue defect has not been previously described. MHS flaps have been used to cover defects in the proximal and distal lower extremity [7,10]. Techniques can be used to extend the range of coverage of the medial soleus in order to reach the plantar foot.  With careful and proper planning, the MHS flap is an option for coverage of soft tissue defects of the plantar foot.

The goal of our staged procedure was to heal the chronic ulceration and provide a functional lower extremity for ambulation. Within ten weeks of MHS flap with external fixator and STSG, the patient was able to ambulate with a well adhered and fully incorporated graft. No dehiscence has occurred in twenty-three months.

References

  1. Brodmann, Marianne. “The Angiosome Concept in Clinical Practice.” Endovascular Today, May 2013.
  2. Dockery, G. and Crawford, ME. Lower Extremity Soft Tissue & Cutaneous Plastic Surgery. Saunders Elsevier, 2012, pp. 269–288.
  3. Banks, AS, and McGlamry, ED. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Lippincott Williams & Wilkins, 2001, Pp 1513-1519.
  4. Hallock, GG. “Getting the Most from the Soleus Muscle.” Annals of Plastic Surgery, vol. 36, no. 2, 1996, pp. 139–146.
  5. Klebuc, M and Menn, Z. “Muscle Flaps and Their Role in Limb Salvage.” Methodist DeBakey Cardiovascular Journal, vol. 9, no. 2, 2013, pp. 95–98.
  6. Pu, Lee LQ. “Soft-tissue reconstruction of an open tibial wound in the distal third of the leg: a new treatment algorithm”.  Plastic and Reconstructive Surg. 2007;58(1): 78-83. 4.
  7. Pu, Lee LQ. “ Successful soft-tissue coverage of a tibial wound in the distal third of the leg with a medial hemisoleus muscle flap”. Plastic and Reconstructive Surg. 2005;115(1):245-51.
  8. Tobin, CR. “Hemisoleus and Reversed Hemisoleus Flaps.” Plastic and Reconstructive Surgery, vol. 76, no. 1, 1985, pp. 87–96.
  9. Sayed, AT. “Distally Based Medial Hemi-Soleus Muscle Flap Based on the Posterior Tibial Vessels”. AAMJ, Department of Plastic and Reconstructive Surgery, Faculty of Medicine Al-Azhar University; Vol.7,N.1, January 2009.
  10. Schmidt, I. “The Proximally and Distally Pedicled Hemisoleus Muscle Flap as Option for Coverage of Soft Tissue Defects in the Middle Third of Lower Leg.” Trauma and Emergency Care, vol. 2, no. 6, 2017.
  11. Ward, KL, et al. “Cadaveric Atlas for Orthoplastic Lower Limb and Foot Reconstruction of Soft Tissue Defects.” Clinics in Surgery, vol. 3, 28 June 2018.
  12. Raveendran, SS, and Kumaragama, KGJL. “Arterial Supply of the Soleus Muscle: Anatomical Study of Fifty Lower Limbs.” Clinical Anatomy, vol. 16, no. 3, 2003, pp. 248–252.
  13. Pu, Lee LQ. “The Reversed Medial Hemisoleus Muscle Flap and its Role in Reconstruction of an Open Tibial Wound in the Lower Third of the Leg”. Ann Plast Surg 2006 Jan;56(1):59–63.
  14. Pu, Lee LQ. “Further Experience with the Medial Hemisoleus Muscle Flap for Soft-Tissue Coverage of a Tibial Wound in the Distal Third of the Leg.” Plastic and Reconstructive Surgery, vol. 121, no. 6, 2008, pp. 2024–2028.
  15. Bourdais-Sallot, A, et al. “Distally Based Medial Hemisoleus Muscle Flap: Anatomic and Angiographic Study of 18 Lower Limbs”. Annals of Plastic Surgery, vol. 79, no. 1, 2017, pp. 73–78.
  16. Houdek, MT, et al. “Reverse Medial Hemisoleus Flaps for Coverage of Distal Third Leg Wounds.” Journal of Orthopaedic Trauma, vol. 30, no. 4, 2016.

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Application of the distally pedicled peroneus brevis: Technique, case study, and pearls

Posted on August 31, 2016 | Comments Off on Application of the distally pedicled peroneus brevis: Technique, case study, and pearls

by Chad Seidenstricker DPM1, Megan L. Wilder DPM2, Byron L. Hutchinson DPM, FACFAS3pdflrg

Soft tissue defects of the distal leg and hindfoot are difficult to eradicate. Avascular structures become exposed through seemingly superficial wounds rather quickly. The present case describes a surgical technique for the peroneus brevis muscle flap for coverage of a postoperative lateral heel wound following a lateral extensile approach for ORIF of a calcaneal fracture. Nonoperative and operative wound care modalities failed over the course of several years, and a peroneus brevis rotational flap was attempted for wound coverage. Although several minor complications occurred, the wound had successful epithelialization at 3 months. The distally pedicled peroneus brevis muscle flap offers a good option at wound coverage in difficult to heal wounds of the distal leg and hindfoot.  

Key words: muscle flap, peroneus brevis, soft tissue defect, ankle, foot

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0003

1 – Podiatry Resident at Swedish Medical Center PGY-3, Seattle, WA
2 – The Everett Clinic, Marysville, WA
3 – Director, Franciscan Foot and Ankle Institute; Medical Director, Foot & Ankle Service, CHI Franciscan Health, Federal Way, WA.
* – Corresponding author: chaddpm14@gmail.com

Soft tissue defects of the foot and ankle present a significant challenge. There is little soft tissue coverage and exposed tendon and bone can easily occur following elective reconstruction or trauma, requiring surgery. Skin grafting is often not an option in this region as bone and tendon are not suitable as a recipient bed. Rotational muscle flap techniques for foot and ankle wound closure are gaining popularity and have proven effective. Muscle flaps offer pliability and can eradicate dead space, can overcome residual bacterial infection in bone, improve blood flow, and will provide a vascular recipient bed for split thickness skin grafting [1]. While negative pressure wound therapy devices are excellent at promoting expedited closure of deep wounds, they should not be placed directly over bone or tendon and especially not in the setting of residual infected tissue.

Indications for rotational muscle flap wound closure may include exposed bone with osteomyelitis, traumatic wounds, non-healing wounds over the lateral ankle and hindfoot after Achilles tendon procedures, surgical wound dehiscence recalcitrant to nonoperative therapies after calcaneal fractures, ankle fractures, and total ankle arthroplasty. In a systematic review, Yu et al, demonstrated a wound complication rate of 13.5% in calcaneal fractures after ORIF [2]. There has been a movement toward minimally invasive techniques, but the lateral extensile incision is still routinely utilized. Raikin et al demonstrated an 8.5% incidence of wound complications following TAR with anterior midline incisional approach that required at least one secondary visit for surgical wound debridement [3]. Wound dehiscence after TAR requires immediate definitive treatment to avoid catastrophic deep space infection.

The distally pedicled peroneus brevis muscle flap offers a relatively simple, reproducible and reliable option for wound closure with complication rate equal or reduced compared to other techniques. In general the muscle flap should not be used as a first line procedure, but is used in limb salvage situations and has very little downside. The peroneus brevis muscle flap also has the advantage of low donor site morbidity and heals with minimal scar.  Lower extremity surgeons can easily perform the peroneus brevis flap closure if it is acceptable in the foot and ankle specialist’s region to perform this type of procedure.

Rationale & Background

Attinger described the role of various intrinsic muscle flaps for small wound closure of the foot and reported a 96% success rate [4]. The abductor hallucis muscle flap has been reported to provide excellent outcomes in plantar heel defects [4,5]. While intrinsic flaps have proven efficacy for small wounds about the foot, they are not sufficient for larger wounds of the hindfoot, ankle and lower leg. Larger wounds in the distal third of the leg and hindfoot are amenable to the peroneus brevis flap. The peroneus brevis muscle is classified as a type IV muscle flap by Mathes and Nahai, which represents a muscle flap with segmental blood supply provided by branches of equal importance (Table 1) [6]. Ensat et al evaluated the blood supply of the peroneus brevis muscle flap identifying constant blood supply by segmental branches of the peroneal and tibial arteries and also supported Yang’s finding of the most distal pedicle being provided between 4-5 centimeters proximal to the tip of the fibula [7,8]. Ensat also recommended a pivot point at least 6-cm above the tip of the fibula to assure there is an intact vascular pedicle, however, this should always be evaluated intraoperatively [7]. The muscle length available for rotation is close to 20-cm, but due to distal flap necrosis, the most proximal 2-cm should always be removed, providing a muscle approximately 18-cm in length [9,10,11].

 

Table 1: Mathes & Nahai [6] classification of muscle and myocutaneous flaps
Type I: One vascular pedicle
Type II: Dominant pedicle(s) and minor pedicle(s)
Type III: Two dominant pedicles
Type IV: Segmental vascular pedicles (ie Peroneus Brevis)
Type V: One dominant pedicle and secondary segmental pedicles

The arc of rotation is determined by the most distal vascular pedicle, which should allow an average of 12-cm from the pivot point.

We present a case in which a chronic lateral heel wound following ORIF of calcaneus was treated successfully with a distally pedicled peroneus brevis flap. Our scenario is similar to Rodriguez who recently reported success of the peroneus brevis flap following wound dehiscence after ORIF of a lateral malleolar fracture with subsequent surgical wound dehiscence [12].

Case report

In this case report, a 63 year old male non-smoker sustained a closed intra-articular calcaneal fracture. The records from previous surgeons were not retrieved so the exact timeline is unknown but the following events occurred over the course of several years prior to his definitive operation and closure. The patient had an ORIF through a lateral extensile approach with dehiscence at the apex of the incision which never fully healed.  He had hardware removal and local wound care which failed. He then had a small rotational flap which failed, followed by an advancement flap which resulted in re-opening of the sinus tract and a chronically draining wound with exposed bone. He presented to a local plastic surgeon for consultation who felt a free flap was not a good option. He then presented to the author’s clinic for a preoperative evaluation.  On arrival to clinic the patient had a small wound at the apex with a sinus tract and suspected osteomyelitis of the lateral calcaneal wall, which was draining minor amounts of serous fluid (Figure 1). A distally pedicled peroneus brevis rotational flap was planned.

1

Figure 1 Chronic lateral hindfoot wound recalcitrant to several operative debridements, antibiotics, local wound care, and local skin flaps.

2

Figure 2 Lateral incision over the fibula, with the peroneus longus retracted inferiorly and the peroneus brevis muscle belly and tendon origin exposed.

Surgical technique

After skin preparation, and exsanguination of the limb, a pneumatic thigh tourniquet was inflated to 350mmHg. An incision was made overlying the lateral heel wound in a curvilinear fashion extending a few centimeters proximally and a few distal to the wound. The scar tissue was bluntly dissected through down to calcaneus, and the skin was elevated in a single layer as a flap. There was a loose portion of cement that was noted in the lateral wall of the calcaneus which had been left from a prior surgery and this was removed.

3

Figure 3 Peroneus longus in the right hand, and peroneus brevis muscle belly held in the left.

4

Figure 4 Peroneus brevis muscle belly being elevated off the fibula, moving proximally.

The calcaneus was debrided to good, healthy bleeding bone that appeared without signs of infection. Attention was then directed to the lateral leg where a standard incision was made as described by Eren [13]. The incision connected with the lateral heel wound incision. The crural fascia overlying the peroneals was incised (Figure 2). The peroneus brevis was followed up its muscle belly proximally until the origin was released (Figure 3,4,5). Segmental pedicles were ligated from proximal to distal until approximately 6-cm proximal to the lateral malleolus.

5

Figure 5 The free peroneus brevis flap, with distal vascular pedicles still in tact.

6

Figure 6 Intraoperative doppler to assure the pedicle is patent to provide blood supply to the brevis muscle.

7

Figure 7 The peroneus brevis muscle flap rotated down, showing adequate length to reach the lateral heel wound.

8

Figure 8 Closure of the harvest site, demonstrating easy closure of the harvest site.

Utilizing ultrasound, a vascular pedicle was identified at this level (Figure 6). Care was taken to not violate the pedicle. The peroneus brevis was folded from proximal to distal into the wound and overlying the exposed calcaneal wound (Figure 7). It was loosely secured in place overlying the lateral wall of the calcaneus. The wound was then closed in layers proximally, leaving the distal wound overlying the lateral wall of the calcaneus open with the muscle flap secured within the wound (Figures 8,9).

An Integra bilayer wound matrix was then placed and trimmed to the appropriate size overlying the muscle flap (Figure 10). It was secured in place around the rim of the wound utilizing staples with a single staple in the middle of the flap. The membrane was then fenestrated to allow drainage. The site was then dressed with negative pressure wound therapy (Figure 11). A monorail external fixator was applied to the medial calcaneus and medial tibia with half pins to establish stability while being able to access the wound for local wound assessment and care in the early wound healing phase (Figure 12). Proper alignment was confirmed under fluoroscopy. Sterile dressings were then applied. Tourniquet was deflated.

9

Figure 9 Closure of the incision along the lateral leg down to the original defect site. The original defect site should be left open, and ideally is covered with a biologic dressing.

10

Figure 10 Securing an Integra graft over the exposed peroneus brevis in the chronic wound site with staples.

11

Figure 11 Wound vac secured over the Integra graft after fenestrating the integra graft.

12

Figure 12 Unilateral External fixator applied to the medial tibia for stabilization of the muscle and the wound to allow for incorporation.

13

Figure 13 Application of STSG roughly 3 weeks after the Integra graft was placed. The silicone layer was removed and the wound was carefully debrided and cleansed prior to application. STSG secured with staples.

14

Figure 14 Healed lateral foot wound.

Follow up care

About 2 weeks later, he presented to the emergency department with fever and chills and was noted to have a pin tract infection, requiring removal of one of the pins in the ED. The following week he returned to the operating room for removal of the external fixator and debridement of a small portion of muscle flap necrosis.  Following debridement, the split-thickness skin graft (STSG) was secured with staples and negative pressure wound therapy was applied (Figure 13). The patient presented to clinic for follow-up seven days post-skin graft application and negative pressure wound therapy was removed. Four days later he returned to clinic and reported a visit to the ED for fever and previous talar pin site irritation and pain with two centimeter diameter of surrounding erythema. He was started on IV rocephin for a few days and then transitioned to a two week course of Keflex. He had resolution of infection. His donor site incision healed without incident. He was discharged with instructions to remain NWB to his surgical limb until complete incorporation of graft, about two months. At final three-month follow-up he had completely healed (Figure 14).

Discussion

There are several key points to discuss regarding this case report. First, there was partial flap necrosis, which required repeat debridement in the OR. For the case presented, the most proximal aspect of the peroneus brevis muscle belly was not debrided, which has been recommended by multiple authors [9,10,11]. Other potential ways to improve wound closure may include the use of bilayer membrane which, after it takes, will provide a superior surface for a STSG. Negative pressure wound therapy can be applied at 50-125mmHg [12]. It has been proposed that higher vacuum settings may be damaging to skin grafts, but this theory was not upheld [13].

Recently it was found that wound vac application at 75mmHg applied for seven days post-operatively significantly reduced partial flap necrosis and skin graft necrosis, and they concluded that prolonging the period of wound vac application may further reduce complications by eliminating shear force, improving neovascularization of the muscle, and reducing edema and venous congestion [14]. There is debate whether to perform the transfer of the brevis through a subcutaneous tunnel or whether to connect the harvesting incision to recipient site. It is not absolutely necessary to connect the incision with the recipient site, but there should not be excessive tension within the subcutaneous tunnel as this may obstruct venous outflow resulting in flap failure. If there is question, one should connect the recipient bed with the donor site incision.  

A few other obstacles occurred which can be avoided. While pin tract infections are common when using external fixators, rarely catastrophic infection develops. Minor infections can be managed with local wound care and oral antibiotics oftentimes. As long as there is not failure at the bone-pin interface with loosening, fracture with nonunion or malunion, or chronic osteomyelitis,  it should not compromise your end result. Placing a unilateral fixator to stabilize the extremity offers several advantages. It offers stability to the extremity and the wound bed in the immediate postoperative phase while also permitting wound care and wound observation for the first few weeks after index surgery. The external fixator can be removed at the three week mark as this is when you can return to the operating room, remove the silicone layer from the bilayer membrane, and harvest and apply the STSG. Other options include applying a posterior splint for immobilization, but this doesn’t offer an easily accessible portal for wound evaluation and wound care and, makes continued care with a wound vac particularly difficult. If the recipient site is prone to shear forces, ie lateral malleolus, be sure to utilize a bulky soft dressing to protect the graft site. Although several publications [14,15] have advocated for single stage procedure, it is prudent to wait for application of the STSG until muscle flap viability is assured. This prevents unnecessary repeat skin grafting.

It has been demonstrated that the peroneus brevis muscle flap provides a reliable means for treating bone infections, providing blood supply, and a suitable recipient bed for skin grafting [1]. Preoperatively the patients should be evaluated for vascular insufficiency. As foot and ankle experts, sacrificing the primary evertor of the foot may seem uncouth, but these are limb salvage situations. One can perform a tenodesis of the the peroneus brevis to the longus to enhance eversion power if it is possible. However, it has been shown that eversion and plantarflexion are maintained following the procedure even without ancillary procedures and patients do not report lateral ankle instability [16]. The donor site is rarely problematic, and can be closed primarily without issue [10-12,16-18].

The peroneus brevis has a consistent blood flow [7,16,17]. The maximum number of vascular pedicles should be maintained as possible, but one can elect to ligate all pedicles leaving only the most distal intact approximately 6-cm proximal to the tip of the fibula. To ensure adequate blood supply will be provided by each successive pedicle, a vascular clip can be placed temporarily to ensure the next pedicle maintains adequate perfusion. Ensat et al demonstrated in a cadaveric model that there were an average of 5.1 segmental branches to the muscle. This included branches from both the peroneal and the anterior tibial artery, however, most branches were derived from the peroneal artery [7]. The most distal vascular branch was derived from the peroneal artery in 100% of cadavers at a distance about 4.3cm proximal to the tip of the lateral malleolus. There is also retrograde flow provided from the posterior tibial artery [7]. This is important in gaining a muscle flap with the most potential length. The pivot point should be at least 6-cm proximal to the lateral malleolus to ensure there is a vascular pedicle attached distally to supply the muscle when performing rotational flaps. The diameter of the pedicle must be at least 0.5mm, while the average size pedicle is 1.1mm this is rarely a problem [7]. The average length of the muscle is 19.8cm, but the most proximal 2-cm should be resected as this area of the graft is expected to undergo necrosis.

In conclusion, many studies have found reliability in this muscle flap. It offers great utility to cover defects in the distal leg and hindfoot. It can cover defects of the anterior ankle, lateral ankle and hindfoot. Despite some authors reporting an unfavorable success rate, the majority of reports found high rates of success and this should be considered in the reconstructive ladder for complex lower extremity wounds [10,11,18,19].

References

  1. Anthony JP, Mathes SJ. Update on chronic osteomyelitis. Clin Plast Surg 1991;18:515-523. PubMed
  2. Yu X, Pang QJ, Chen L, Yang CC, Chen XJ. Postoperative complications after closed calcaneus fracture treated by open reduction and internal fixation: a review. Jour Int Med Research 2013; 42(1):17-25. PubMed
  3. Raikin SM, Kane J, Ciminiello ME. Risk factors for incision-healing complications following total ankle arthroplasty. J Bone Joint Surg 2010; 92 (12):2150-2155. (PubMed
  4. Attinger CE, Ducic I, Cooper P, Zelen CM. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg  2002;110(4):1047-1054. PubMed
  5. Ortak T, Ozdemir R, Ulusoy MG, Tiftikcioglu YO, Karaaslan O, Kocer U, Sensoz O. Reconstruction of heel defects with a proximally based abductor halluces muscle flap. J Foot Ankle Surg 2005; 44(4): 265-270.  PubMed
  6. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchill-Livingstone: 1997.
  7. 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 2015;35:39-44. PubMed
  8. Yang YL, Lin TM, Lee SS, Chang KP, Lai CS. The distally pedicled peroneus brevis muscle flap anatomic studies and clinical applications. J Foot Ankle Surg 2005;44:259-264. PubMed
  9. Hu X, Du W, Chen Z, Li M, Wang C, Shen Y. 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 Lower Ext Wound 2013;12(1):53-62. PubMed
  10. Ng YH, Chong KW, Tan GM, Rao M. Distally pedicled peroneus brevis muscle flap: a versatile lower leg and foot flap. Singapore Med J 2010; 51(4):339-342. PubMed
  11. Schmidt AB, Giessler GA. The muscular and the new osteomuscular composite peroneus brevis flap: experiences from 109 cases. Plast Reconstr Surg 2010; 126:924-932. PubMed
  12. Rodriguez Collazo ER, Bibbo C, Mechell RJ, Arendt A. The reverse peroneus brevis muscle flap for ankle wound coverage. J Foot Ankle Surg 2013;52:543-546. PubMed
  13. Timmer MS, Le Cessie S, Banwell P, Gukema GN. The effect of varying degrees of pressure delivered by negative-pressure wound therapy on skin perfusion. Ann Plast Surg. 2005;55(6):665-71. PubMed
  14. Erne H, Schmauss D, Schmauss V, Ehrl D. Postoperative negative pressure therapy significantly reduces flap complications in distally pedicled peroneus brevis flaps: experiences from 74 cases. Injury 2016;47:1288-1292. PubMed
  15. Ensat F, Hladik M, Larcher L, Mattassich G, Wechselberger G. The distally based peroneus brevis muscle flap – clinical series and review of the literature. Microsurgery 2013;34:203-208. PubMed
  16. Eren S, hofrani A, Refenrah M. The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg. Plastic Recon Surg 2001;107:1443-1448. PubMed
  17. 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 limb: postoperative ankle function and stability evaluation. J Plast Reconst Aesthet Surg 2010;63:1523-1533. PubMed
  18. 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 lower leg. Ann Plast Surg 2007;58:397-404. PubMed
  19. Barr ST, Rowley JM, O’Neill PJ, Barillo DJ, Paulsen SM. How reliable is the distally based peroneus brevis muscle flap. Plast Reconstr Surg 2002;110(1):360-362. PubMed

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