The Reverse Peroneus Brevis Muscle Flap for Ankle Wound Coverage

The Journal of Foot & Ankle Surgery 52 (2013) 543–546 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org The Reverse Peroneus Brevis Muscle Flap for Ankle Wound Coverage Edgardo R. Rodriguez Collazo, DPM 1, Christopher Bibbo, DO, DPM, FACFAS 2, R. Jordan Mechell, DPM 3, Adam Arendt, DPM 3 1 Director, Chicago Foot and Ankle Deformity Correction Center, Associate Director, St. Joseph Hospital/Chicago, IL PMSRþRRA Residency Program, Chicago, IL Chief, Foot and Ankle/Limb Preservation and Restoration Services, Department of Orthopaedics, Marshfield Clinic, Marshfield, WI 3 Postgraduate Year 3 Resident Physician, St. Joseph Hospital/Chicago, IL PMSRþRRA Residency Program, Chicago, IL 2 a r t i c l e i n f o a b s t r a c t Keywords: debridement external fixator fibula peroneal artery surgery tendon Coverage of lower extremity wounds, especially those in the ankle region, presents a challenge to the foot and ankle surgeon. The present case illustrates a surgical technique for the use of the reverse (distally based) peroneus brevis muscle flap for coverage of a postoperative ankle wound with exposed bone. The reverse peroneus brevis muscle flap provides an option for wound coverage in the ankle region in limb salvage cases in medically frail patients. Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved. Lower extremity wounds present a challenge for healing. In the ankle region, the paucity of muscle and thin subcutaneous tissues often require local rotation flaps, such as the reverse sural flap or free tissue transfer. In at-risk patients, these techniques can result in relatively high complication rates and significant donor site morbidity. The success of local tissue rotation flaps can be improved with supercharging techniques; however, just as with free tissue transfers, these techniques require specialized surgical skills. Furthermore, in many patients, these procedures are often not considered favorably. The reverse peroneus brevis muscle is a viable option in properly selected patients for coverage of wounds about the ankle. It poses lower donor site morbidity and less risk in medically frail patients (1–8) and is not as technically demanding as other flap techniques. We report a case of ankle coverage, with a reproducible step-by-step approach to the reverse peroneus brevis muscle flap. The patient had a history of a propensity for skin breakdown from external pressure sources. The physical examination demonstrated palpable dorsalis pedis and posterior tibial arteries pulses. Radiographs were taken and were negative for any radiographic signs of osteomyelitis. Arterial Doppler ultrasound showed triphasic wave forms of the dorsalis pedis, posterior tibial, and peroneal arteries. Disuse atrophy was noted in her extremity, involving all muscular compartments of the lower leg; her skin was thin and warm to the touch. The patient was neurosensory compromised, and although able to detect sharp and dull sensation, she was unable to discern vibratory, proprioception, or 2-point discrimination sensation. A chronic-appearing, full-thickness, anterior lateral right ankle wound, measuring 3.5  3.5  2-cm Case Report A 50-year-old, nondiabetic, paraplegic female was evaluated for a surgical wound of the anterior ankle with exposed hardware. Eight months previously, the patient had undergone surgical reconstruction of a rigid cavovarus foot. Previous to the surgery, she had been treated with local wound care, which had failed to result in wound closure. Her medical history was significant for a cerebral vascular accident, brain aneurysm, hypothyroidism, and stage II chronic kidney disease. Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Christopher Bibbo, DO, DPM, FACFAS, Chief, Foot and Ankle/Limb Preservation and Restoration Services, Department of Orthopaedics, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449. E-mail address: bibbo.christopher@marshfieldclinic.org (C. Bibbo). Fig. 1. Anterior lateral ankle wound with exposed hardware and bone in an elderly diabetic paraplegic female with a history of rapid skin breakdown from external pressure points. Note, devitalized skin edges and frail skin around the wound. 1067-2516/$ - see front matter Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2013.02.021 544 E.R. Rodriguez Collazo et al. / The Journal of Foot & Ankle Surgery 52 (2013) 543–546 Fig. 3. (A) The peroneus brevis muscle (shown held by forceps; white arrowhead) identified deep and slightly anterior to the peroneus longus muscle belly; the peroneal nerve was gently retracted by a vessel loop (yellow arrow). The peroneal artery (white/blue broken lines) was protected and left undisturbed. (B) The proximal muscle belly of peroneus brevis divided (shown held by forceps). The motor nerve was sacrificed, and the segmental vessels were ligated. The most distal segmental vessels feeding the muscle were kept intact. Fig. 2. External Doppler marking of distal segmental vessel to peroneus brevis. (A) This was corroborated with marking of the vessel intraoperatively. (B) A longitudinal skin incision was placed over the peroneal muscles from below the fibular neck (avoiding the common peroneal nerve) to a premeasured pivot point for the muscle flap. The incision can also extend to the wound, avoiding a subcutaneous tunnel for passage of the flap. Surgical Technique deep, with exposed bone and plate/screws was present (Fig. 1). The radiographs revealed healed bony regions with respect to the previous cavovarus reconstruction. A staged surgical approach was planned, consisting of debridement, flap coverage of the wound, and delayed skin grafting of the muscle flap. Fig. 4. Distally based peroneus brevis muscle was “reversed” (shown held by forceps), rotated 180 , and passed through a subcutaneous tunnel wide enough to accommodate the muscle flap and any anticipated swelling. The muscle flap was gently inset with fine-gauge absorbable suture on a taper needle. A Doppler examination was again performed to ascertain that the distal feeding vessels from the peroneal artery were not kinked or occluded (Inset). E.R. Rodriguez Collazo et al. / The Journal of Foot & Ankle Surgery 52 (2013) 543–546 545 Fig. 5. Closure in layers recommended, with drains placed as needed. An example of a vessel loupe technique, which can assist with easing tension of the skin suture line, is shown. In this case, a medical grade, processed amniotic membrane graft was used to cover the muscle flap during the observation period. First, the surgical wound was debrided, and all hardware was removed (Fig. 2). A bone specimen and swab cultures were obtained. The wound soft tissue cultures later grew moderate Staphylococcus aureus that was sensitive to oxacillin; the bone pathology sample was negative for osteomyelitis. Because of her history of skin breakdown from external pressure and to allow nursing care and mobilization of the patent while maintaining stability of the reconstructive site, an external fixator was constructed and applied to the limb (Fig. 2). This static Ilizarov external fixation device was formed using 3 half rings and 1 foot plate. The external fixator was secured to the patient’s extremity by half pins inserted into the medial distal tibia, the medial portion of the calcaneal tuber, and the lateral portion of the calcaneal tuber, with 2 placed in the midfoot. Next, the axis of the fibula was marked from the proximal head to the distal tip (Fig. 2). Under tourniquet control, an incision was made over the peroneal muscle bellies, from below the neck of the fibula to a premeasured pivot point for adequate wound coverage by the muscle flap. Under loupe magnification, the peroneus brevis muscle was separated from the peroneus longus muscle. After the proximal portion of the brevis muscle was detached from the fibula, dissection proceeded distally with ligation of the proximal branches of the peroneal artery to the muscle and the motor branch from the superficial peroneal nerve (Fig. 3). The tourniquet was then released, and the most distal segmental branches of the peroneal artery feeding the distal portion of the peroneus brevis were checked for a Doppler signal (Fig. 4). The proximal portion of the muscle belly was then divided, and a subcutaneous tunnel was created with blunt dissection in line with the muscle flap and exiting directly into the wound. The muscle was then passed through the tunnel; the patency of the distal pedicle was again assessed (Fig. 4). The muscle flap was gently inset into the defect with fine-gauge absorbable suture on a taper needle. Drains were placed depending on the hemostasis (recommended), and the donor site was closed (subcutaneous layer and skin). A vessel loupe technique can be used to relieve tension on the skin suture line (Fig. 5) but should only be used as needed. The inset muscle can be covered with a negative pressure dressing on a low setting (eg, 50 to 75 mm Hg pressure on intermittent suction). Alternatively, a synthetic covering (eg, Integra Bilayer, Integra LifeSciences, Plainsboro, NJ) or other growth-promoting membrane graft (eg, medical grade, processed amniotic membrane [Neox, Amniox Medical, Marietta, GA]) can be applied to the wound during an observation period of a few days. This will allow one to ascertain the muscle flap’s viability (Fig. 5). After 3 to 7 days, a split-thickness skin graft is applied and managed per surgeon preference. Complete Fig. 6. A split-thickness skin graft is applied either immediately if the muscle flap is quite robust, or, such as in the present case, 3 to 7 days after an observation period (A). It is imperative that the flap is not allowed to desiccate during the observation period. (B) Final appearance showing complete healing 4 weeks postoperatively. healing was achieved by 4 weeks postoperatively (Fig. 6), at which time the external fixator was removed, and the patient was fit for a custom ankle-foot orthosis for transfers and therapy for her paraplegia. Discussion The ankle poses a difficult region for coverage of soft tissue defects. Often, these wounds exist in either vascular compromised or medically frail patients. The most senior author (C.B.) has successfully used both local rotation flaps with venous supercharging and free tissue transfers to cover difficult ankle wounds. However, these techniques require considerable microsurgical skills and, in at-risk patients, considerable operative time and donor site morbidity Thus, in the medically frail (at-risk) patient, an alternate technique should be sought before microsurgical reconstruction, such as the reverse peroneus brevis muscle flap. The peroneus brevis muscle flap is simple and quick (average tourniquet time of 30 minutes) and results in limited donor site morbidity and limited functional deficit, if care is taken to perform tenodesis of the peroneus brevis tendon to the peroneus longus tendon. Previous investigators have described the use of muscle flaps for wound closure. In general, a flap should also be technically easy to 546 E.R. Rodriguez Collazo et al. / The Journal of Foot & Ankle Surgery 52 (2013) 543–546 harvest, should be reliable, and should have a high success rate, with minimal donor site morbidity. The distally based peroneus brevis muscle flap fits these criteria and has shown good results in covering defects in the distal leg (1–7). Hughes et al (9) also emphasized the importance of a good source of vascularity for flaps to achieve wound closure, particularly in cases in which bone is exposed. Gosau et al (8) performed an ultrasound analysis of 34 legs to investigate the vascularity and use of the peroneus brevis muscle. They determined that peroneus brevis muscle tissue measuring up to 15 to 20 cm can be harvested and rotated by 180 to cover defects and still maintain its blood supply. Another study performed by Yang et al (4) reported that an average of 5 pedicles (range 4 to 6) were found within the peroneus brevis muscle, suggesting good vascularity to the muscle flap. In conclusion, the distally based reverse peroneus brevis muscle flap provides a viable option for ankle wound coverage, especially in medically frail patients. This muscle flap is relatively simple and quick and has acceptable donor site morbidity; it should be considered in the reconstruction of soft tissue defects about the ankle. References 1. Eren S, Hofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg. Plast Reconstr Surg 107:1443–1448, 2001. 2. Bach A, Leffler M, Kneser U, Kopp J, Horch R. The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg 58:397–404, 2007. 3. Ng YH, Chong KW, Tan GM, Rao M. Distally pedicled peroneus brevis muscle flap: a versatile lower leg and foot flap. Singapore Med J 51:339–342, 2010. 4. 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 44: 259–264, 2005. 5. 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 leg: postoperative ankle function and stability evaluation. J Plast Reconstr Aesthet Surg 63:1523–1533, 2010. 6. Schmidt AB, Giessler GA. The muscular and the new osteomuscular composite peroneus brevis flap: experiences from 109 cases. Plast Reconstr Surg 126:924–932, 2010. 7. Arnold PG, Yugueros P, Hanssen AD. Muscle flaps in osteomyelitis of the lower extremity: a 20-year account. Plast Reconstr Surg 104:107–110, 1999. €nel J, Prantl L. Ultrasound 8. Gosau M, Schoeneich M, Koyama K, Jung EM, Fangha analyses, anatomical considerations, and clinical experience with the peroneus brevis muscle flap. Ann Anat Epub 2012 Oct 5. 9. Hughes LA, Mahoney JL. Anatomic basis of local muscle flaps in the distal third of leg. Plast Reconstr Surg 92:1144–1154, 1993. Erratum In the March/April 2013 issue (volume 52, issue 2, pp 235–238) of The Journal of Foot & Ankle SurgeryÒ, in the article “Early Results with Use of the Midfoot Fusion Bolt in Charcot Arthropathy,” the authors provided the incorrect second author for reference 13. The correct listing follows: 13. Wiewiorski M, Valderrabano V. Intramedullary fixation of the medial column of the foot with a solid bolt in Charcot midfoot arthropathy: a case report. J Foot Ankle Surg 51:379–381, 2012. DOI of original article: http://dx.doi.org/10.1053/j.jfas.2012.12.003. http://dx.doi.org/10.1053/j.jfas.2013.04.007