The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg

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.     

小腿前外侧的皮瓣及筋膜瓣的临床应用

目的介绍小腿前外侧的皮瓣筋膜瓣的应用解剖、手术方式、方法及临床应用。方法在１４侧成人下肢标本及１条断腿上,观察了腓浅血管的起始部位、行程及皮支的分布情况,设计了小腿前外侧组织瓣的４种术式。１９８８年以来,临床应用２６例。结果术后皮瓣筋膜瓣全部成活,切口Ⅰ期愈合２３例,Ⅱ期愈合３例,２０例随访４个月到５年,情况稳定良好,无复发。结论手术操作简单、安全可靠,对供区影响小,是修复小腿及对侧踝及跟部后方创面及治疗胫骨慢性骨髓炎的一种可供选用的方法。     

小腿前外侧的皮瓣及筋膜瓣的临床应用

目的 介绍小腿前外侧的皮瓣筋膜瓣的应用解剖、手术方式、方法及临床应用。方法 在１４侧成人下肢标本及１条断腿上,观察了腓浅血管的起始部位、行程及皮支的分布情况,设计了小腿前外侧组织瓣的４种术式。１９９８年以来,临床应用２６例。结果 术后皮折筋膜全部成活,切口Ⅰ期愈合２３例,Ⅱ期愈合３例,２０例随访４个月到５年,情况稳定良好,无复发。结论 手术操作简单、安全可靠,对供区影响小,是修复小腿及对侧踝及跟部     

Skin and muscle flaps to cover and fill chronic open osteitis of the tibia. Results with 10 cases

Chronic osteomyelitis is a severe long-term bone infection which retains its mechanical qualities. The authors report 10 cases of osteomyelitis of the tibia treated by muscular and fascio-cutaneous flaps and reviewed at one year follow-up. Four cases concerned the third upper part of the tibia, 3 the middle and 3 the lower third. Two total failures at the third lower part and three complications which finally healed with delay were observed. The results of this small series compared with the reports in the literature suggest the value of large excision with coverage by a well vascularized flap and the need for antibiotics. The choice of flap is related to type and site of the bone defect. Another question should be raised concerning the surgical strategy in one--or two--stage management and the duration of antibiotic therapy.     

逆行腓肠神经营养血管蒂带薄层肌肉岛状皮瓣修复胫骨慢性骨感染缺损创面

目的探讨逆行腓肠神经营养血管蒂带薄层肌肉岛状皮瓣修复胫骨慢性骨感染缺损创面的方法及临床疗效。方法应用腓肠神经营养血管蒂岛状筋膜肌皮瓣逆行转位修复12例胫骨慢性骨髓炎后骨缺损并骨外露患者,皮肤软组织缺损为9~16 cm~2。结果 12例均获得随访,时间16~72个月。12例转移肌皮瓣均一期存活,伤口愈合时间14~21 d。1例肌皮瓣静脉回流障碍,行网状打孔并以肝素钠溶液冲洗网孔1周后皮瓣成活;1例皮瓣边缘部分坏死,经换药3周后愈合;所有感染均治愈。结论应用腓肠神经营养血管蒂岛状筋膜肌皮瓣逆行转位修复胫骨慢性骨髓炎后骨缺损并骨外露疗效理想。     

The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap

BACKGROUND: Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a 180-degree propeller flap, an excellent esthetic result and direct closure of the donor site can be achieved, with minimal morbidity. METHODS: Eight patients with defects in the malleolar region were treated with 180-degree propeller flaps based on perforators from the tibial and peroneal vessels. RESULTS: One partial flap loss was encountered in an insulin-dependent diabetic. Partial superficial epidermolysis was encountered in 2 cases and healed without further interventions. No other complications were encountered. All patients returned to full ambulation within 8 weeks. CONCLUSION: The 180-degree propeller flap is an elegant and versatile method to achieve soft tissue coverage with local tissue in defects of the distal tibia. Contrary to other local perforator flaps, this specific design facilitates direct closure of the donor site. As only local, thin tissue is used, no interference with normal shoe wear occurs. Even in older patients, this flap has proven to be a reliable option.     

游离腓动脉远端穿支腓肠神经营养血管皮瓣修复上肢皮肤缺损

目的 介绍游离腓动脉远端穿支腓肠神经营养血管皮瓣修复上肢皮肤缺损的手术方法.方法 2006年6月-2007年8月,应用游离腓动脉远端穿支腓肠神经营养血管筋膜蒂皮瓣修复上肢皮肤缺损6例,其中缝合皮神经4例.结果 术后6例皮瓣全部存活.随访时间为4个月至1.5年.皮瓣与供区皮肤外观基本一致,厚薄适中,弹性、质地好,外观满意;4例缝合皮神经的皮瓣感觉恢复至S2以上,余2例皮瓣恢复保护性感觉.结论 游离腓动脉远端穿支腓肠神经营养血管皮瓣是修复上肢软组织缺损的有效方法.     

小隐静脉-腓肠神经逆行筋膜瓣的临床应用

目的 探讨应用小隐静脉-腓肠神经筋膜瓣联合全厚皮片移植修复小腿远段及足踝部软组织缺损的临床疗效. 方法 在小腿后侧设计小隐静脉-腓肠神经的筋膜瓣联合全厚皮片移植治疗小腿远段及足踝部单纯软组织缺损12例,软组织缺损伴胫骨骨髓炎3例、跟骨骨髓炎2例,皮肤缺损范围3cm×5 cm～9 cm×13 cm,切取筋膜瓣最大13 cm×18 ca.供筋膜瓣区保留皮肤及髂腹股沟取皮区皮肤均直接缝合. 结果 术后17例筋膜瓣联合全厚植皮均完全成活,成功治愈软组织缺损及骨髓炎,筋膜瓣供区、受区以及髂腹股沟取皮区均一期愈合,所有病例获得随访,随访时间为6～12个月,平均9个月,外形平整美观,供区保留皮肤感觉正常. 结论 带小隐静脉-腓肠神经筋膜瓣联合全厚皮片移植既能充分治愈小腿远段及足踝区软组织缺损以及骨髓炎,同时也能最大程度保护患肢功能及整体外观.     

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects.Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle.All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction.Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.     

Proximally Based Split Abductor Hallucis Turnover Flap for Medial Hindfoot Reconstruction: A Case Report

Limited reconstructive options exist for soft tissue defects of the foot and ankle because of a lack of surrounding tissue. Although microsurgical free flaps have become a popular treatment modality for this anatomic region, pedicled muscle flaps can provide robust coverage of small foot wounds with significantly less donor site comorbidity. One such muscle is the abductor hallucis, which can be used as a proximally based turnover flap to cover medial hindfoot defects. However, complete distal disinsertion of the muscle may lead to loss of support over the medial arch and first metatarsophalangeal joint, leading to pes planus and hallux valgus. In this case report, we describe a modified technique of a split abductor hallucis turnover flap for a young patient with a chronic, traumatic medial heel wound complicated by calcaneal osteomyelitis. By preserving part of the muscle's distal tendinous attachment, this technique allows for adequate soft tissue coverage while maintaining long-term biomechanical function.     

Utility of both muscle and fascia flaps in severe lower extremity trauma

BACKGROUND: The evolving technology in trauma management today permits salvage of many severe lower extremity injuries previously even considered to be lethal. An essential component for any such treatment protocol must be adequate soft tissue coverage that often will use vascularized flaps. Traditionally, calf muscles have been used proximally and free flaps for the distal leg and foot. The reintroduction of reliable local fascia flaps has challenged this dictum, proving to be a simpler and yet versatile option. MATERIALS AND METHOD: The role of both muscle and fascia flaps in lower extremity injuries has been retrospectively reviewed from a 2-decade experience. Soft tissue deficits requiring some form of vascularized flap occurred in 160 limbs in 155 patients. The frequency of use of flap types, specific complications and benefits, effect of timing of wound closure, and rate of limb salvage were compared. RESULTS: Initial coverage after significant lower extremity trauma in these 160 limbs required 60 local muscle flaps, 50 local fascia flaps, and 74 free flaps. These flaps had been selected on a nonrandom basis according to wound location, its severity, and flap availability. Complications were directly related to the severity of injury, and for free flaps as a group (39%), although these were not independent variables. Local muscle (27%) or fascia flaps (30%) were similar with regard to this morbidity. Healing was more likely to be uneventful if coverage were accomplished during the acute period after injury, regardless of flap type. Muscle flaps were still used in two thirds of all cases, with the soleus muscle used as often for the distal leg as the mid-leg. Local fascia flaps were most valuable for smaller defects, especially in the distal leg or foot, and often as a reasonable alternative to a free flap. CONCLUSION: The traditional role of the gastrocnemius muscles for flap coverage of knee and proximal leg defects and the soleus muscle for the middle third of the leg was reaffirmed. The soleus muscle often also reached distal leg defects as could local fascia flaps, where classically, otherwise, a free flap would have been necessary. The largest or most severe wounds, irrespective of limb location, required free flap coverage. Local fascia flaps proved to be a valuable alternative.     

小腿前外侧的皮瓣及筋膜瓣的临床应用

目的介绍小腿前外侧的皮瓣筋膜瓣的应用解剖、手术方式、方法及临床应用。方法在14侧成人下肢标本及1条断腿上,观察了腓浅血管的起始部位、行程及皮支的分布情况,设计了小腿前外侧组织瓣的4种术式。1988年以来,临床应用26例。结果术后皮瓣筋膜瓣全部成活,切口Ⅰ期愈合23例,Ⅱ期愈合3例,20例随访4个月到5年,情况稳定良好,无复发。结论手术操作简单、安全可靠,对供区影响小,是修复小腿及对侧踝及跟部后方创面及治疗胫骨慢性骨髓炎的一种可供选用的方法。     

Wound coverage considerations for defects of the lower third of the leg

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm² size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author''s practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.KEY WORDS: Free flaps, perforator flaps, lower leg defects     

Pearls and tips in coverage of the tibia after a high energy trauma

Coverage of soft-tissue defects in the lower limbs, especially open tibial fractures, is currently a frequently done procedure because of the high incidence of high-energy trauma, which affects this location. The skilled orthopedic surgeon should be able to carry out an integral treatment of these lesions, which include not only the open reduction and internal fixation of the fracture fragments but also the management of complications such as local wound problems that may arise. There is a wide variety of muscular or pedicled flaps available for reconstruction of lower limb soft-tissue defects. These techniques are not commonly used by orthopedic surgeons because of the lack of familiarity with them and the potential for flap failure and problems derived from morbidity of the donor site. We present a coverage management update for orthopedic surgeons for complications after an open tibial fracture. We choose and describe the most adequate flap depending on the region injured and the reliable surgical procedure. For proximal third of the tibia, we use gastrocnemius muscle flap. Middle third of the tibia could be covered by soleus muscle flap. Distal third of the tibia could be reconstructed by sural flaps, lateral supramalleolar skin flap, and posterior tibial perforator flap. Free flaps can be used in all regions. We describe the advantages and disadvantages, pearls, and tips of every flap. The coverage of the tibia after a major injury constitutes a reliable and versatile technique that should form part of the therapeutic arsenal of all the orthopedic surgeons, facilitating the integral treatment of complex lower limb injuries with exposed defects.     

Modified retrograde‐flow medial plantar island flap for reconstruction of distal dorsal forefoot defects—Two case reports

Soft tissue reconstruction of the distal forefoot and toes poses a difficult problem. Skin grafts are not suitable when deep structures are exposed. Local flaps are not available, particularly for defects of the toes. Free flaps are spared for larger defects. Medial plantar flap has been widely used for plantar defects, especially weight‐bearing surface of the heel. Distally based retrograde‐flow design of this flap allows the transfer of the pedicled flap distally and provides coverage of soft tissue over the metatarsal heads. In this report, we further modified the retrograde‐flow medial plantar island flap to extend its use for distal dorsal forefoot defects. The technique and outcomes of two patients are presented. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Lower-Extremity Local Flaps

Some soft-tissue defects of the lower extremities can be covered reliably with local flaps. Five such flaps--the tensor fascia lata, gastrocnemius, soleus, posterior tibial artery fasciocutaneous, and dorsalis pedis flaps--are described. If the indications for each flap are understood and the vascular pedicle is carefully preserved, these flaps can be used to provide relatively simple and reliable coverage of selected soft-tissue defects on the lower extremities. However, the indications must not be overextended in an attempt to avoid a free-tissue transfer. The gastrocnemius flap is most often used. It reliably covers common defects about the knee and the proximal tibia. A skin graft is required for the gastrocnemius flap, as well as the soleus flap, which covers the midportion of the tibia. The soleus requires deeper dissection of the calf for elevation. The tensor fascia lata flap and the more recently described posterior tibial artery fasciocutaneous flap are relatively easy to raise, but there are fewer orthopaedic indications for their use. The dorsalis pedis cutaneous flap is technically more demanding, but it can be used to cover difficult defects around the ankle.     

Reconstruction of composite tibial defect with free flaps and ipsilateral vascularized fibular transposition

Composite defects of the tibia following open fractures are among the most challenging of clinical problems. The aim of this study is to report the results of treatment using a free flap procedure followed by ipsilateral vascularized fibular transposition (IVFT) for reconstruction of composite tibial defects. Ten patients underwent a free flap procedure followed by IVFT and plating. The mean size of the flaps was 12.1 × 6 cm(2). The mean length of bone defect was 5.35 cm. IVFT were performed 4.3 months following the free flap. Patients were followed for an average of 3.4 years. All flaps survived. The average time to union of the proximal and distal ends was 5.2 and 6.7 months, respectively. There were neither stress fractures of the transferred fibula nor recurrent infections. One patient demonstrated a medial angulation of 8° in the reconstructed tibia but experienced no difficulties in activities of daily living. At the last follow-up time point, all patients were able to walk without an assist device and were satisfied with the preservation of the injured lower extremity. Free flap procedures followed by IVFT for the treatment of composite tibial defects may reduce complications at the recipient site and infections, such as osteomyelitis. The plating technique combined with IVFT allowed bone union without additional operations or stress fractures in our series. We suggest that staged free flap and IVFT is useful for the treatment of composite segmental tibial defects.     

Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb

We present in this work, our experience with the sural fasciocutaneous flap to treat coverage defects following a lower limb posttraumatic lesion. This paper is a review of these flaps carried out in different centres between 2000 and 2005. The series consists of 14 patients, 12 men and 2 women with an average age of 38 years (23-54) and with a medium follow-up time of 2 years (12-48 months). In all of the cases, aetiology was a lower limb injury or its complications, most frequently a distal tibial fracture (eight patients), followed by sequelae from Achilles tendon reconstruction (two patients), fracture of the calcaneus (two patients) and osteomyelitis of the distal tibia secondary to an open fracture (two patients). Associated risk factors in the patients for performing the flap were diabetes (one case) and cigarette smoking (four cases). The technique is based on the use of a reverse-flow island sural flap with the superficial sural artery dependent on perforators of the peroneal arterial system. The anatomical structures which constitute the pedicle are the superficial and deep fascia, the sural nerve, short saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin. The flap was viable in 13 of 14 patients. Only one flap failed in, a diabetic patient. No patient showed signs of infection. Slight venous congestion of the flap occurred in two cases. No further surgical intervention of the donor site was required. In two cases partial necrosis of the skin edges occurred which resolved satisfactorily with conservative treatment. The sural fasciocutaneous flap is useful for the treatment of complex injuries of the lower limbs and their complications. Its technical advantages are: easy dissection with preservation of more important vascular structures in the limb, complete coverage of the soft tissue defect in just one operation without the need of microsurgical anastomosis. All this results in a well vascularised cutaneous islet and thus a reliable flap.     

应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.     

Long-term results of multiple-stage treatment for posttraumatic osteomyelitis of the tibia

BACKGROUND: The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment. METHODS: We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998. RESULTS: Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured. CONCLUSION: Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.