Tag Archives: Reconstructive surgery

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 correction of equinovarus in a diabetic patient: A case report

Posted on June 30, 2019 | Comments Off on Staged correction of equinovarus in a diabetic patient: A case report

by Amanda Kamery DPM1*, Byron Hutchinson DPM FACFAS2

The Foot and Ankle Online Journal 12 (2): 1

A rigid equinovarus deformity in the diabetic patient is a challenge for many surgeons. The utilization of a single stage, acute correction of the deformity can lead to soft tissue compromise and neurovascular complications. Using gradual correction by means of external fixation, with subsequent internal fixation for arthrodesis, provides a viable option for limb salvage in this difficult patient cohort.

Keywords: Reconstructive surgery, diabetes, external fixation, lower extremity 

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0001

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

The diabetic patient with a rigid equinovarus deformity subsequent to soft tissue contracture is a unique and challenging patient [1]. Limb salvage options for this patient population are limited and complex. The utilization of gradual correction with external fixation proves to be an adequate treatment option that has less complications and leads to a stable and functional foot in this at risk group [1]. Single stage acute correction is another viable option, however, this can lead to limb length discrepancy due to significant bone resection or neurovascular compromise [2,3]. Longstanding soft tissue contracture of the medial ankle can lead to a rigid equinovarus deformity, in this setting acute correction is not a viable option due to the risk of neurovascular compromise and the delicate soft tissue envelope [4].

Case Report

A 59 year-old female presented to the clinic with a rigid equinovarus deformity secondary to multiple medial malleolar wound debridement. The patient developed this deformity over several months of wound care, which resulted in soft tissue contracture to the medial ankle. She presented to our service non-ambulatory and unbraceable due to progression of the deformity (Figure 1). She subsequently developed a wound on the lateral malleolus. 

Staged surgical correction was planned due to severe contracture and questionable medial neurovascular and soft tissue compromise. It was felt that a single stage correction would not be ideal in this particular patient. A dynamic circular frame was placed for gradual correction (Figure 2). Five days post initial procedure, the patient was educated on how to perform distraction with a total of 2 degrees of angular correction daily. The patient was non-weight bearing during the correction process. 

After 42 days, approximately 84 degrees of correction was obtained (Figure 3). At this point, a clinical decision was made to proceed with a Tibio-talo-calcaneal (TCC) fusion. 

Figure 1 Pre-operative AP foot radiograph showing severe equinovarus deformity.

Figure 2 Intra-operative clinical picture.  

Figure 3 Clinical picture after 42 days of correction.

It was determined that enough correction had occurred to relax the medial soft tissue envelope. The patient was returned to the operating room for the secondary procedure. This included external fixator removal and TCC arthrodesis with an intramedullary nail.  The patient remained non-weight bearing for 6 weeks until bony consolidation was seen on x-ray (Figure 4). 

The patient was then transitioned to protected weight bearing for 2 weeks in a controlled ankle motion (CAM) boot. The patient eventually successfully transitioned into a Charcot restraint orthotic walker (CROW) (Figure 5). The patient has remained ambulatory in a CROW for 6 months.

Figure 4 Six-week post secondary procedure. 

Figure 5 Clinical picture six weeks post secondary procedure.

Discussion

The diabetic patient with a severe lower extremity deformity and soft tissue compromise presents a challenging case for foot and ankle surgeons. Staged correction of these deformities utilizing gradual correction by external fixation and subsequent internal fixation with arthrodesis proves to be a viable option to help with limb preservation in these patients. Our case presentation demonstrates the efficacy of staged correction in these challenging patients and that limb salvage and return to ambulation in a CROW can be obtained and maintained. 

References

  1. Cuttica DJ, Decarbo WT, Philbin TM. Correction of rigid equinovarus deformity using a multiplanar external fixator. Foot Ankle Int. 2011;32(5):S533-9.
  2. Mirzayan R, Early SD, Matthys GA, Thordarson DB. Single-stage talectomy and tibiocalcaneal arthrodesis as a salvage of severe, rigid equinovarus deformity. Foot Ankle Int. 2001;22(3):209-13.
  3. Paley, D., Herzenberg, JE. Ankle and Foot Considerations In: Principles of Deformity Correction. 2002. 571-646.
  4. Bellamy JL, Holland CA, Hsiao M, Hsu JR. Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device. Strategies Trauma Limb Reconstr. 2011;6(3):173-6.

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