CLINICAL ARTICLE

The Role of Less Commonly Used Local Muscle Flaps for Soft Tissue Coverage of Complex Lower Extremity Wounds Rohit Jaiswal, MD, MPH, and Lee L.Q. Pu, MD, PhD, FACS Introduction: Lower extremity reconstructions may be pursued by adhering to established algorithms primarily based on the area of injury and the extent of missing tissue and wound. Certain flaps—either local or free—have been relied on as workhorse flaps for soft-tissue reconstruction of the lower extremity. However, when these flaps are unavailable or contraindicated, alternative options can be considered for reconstruction of relatively small wounds in the lower extremity. Methods: We report 2 cases of complex lower extremity wounds that were the result of complications from orthopedic procedures after traumatic injuries. In case 1, an exposed Achilles tendon (7  3 cm) after wound infection and breakdown after orthopedic fixation was performed using a distally based peroneal brevis muscle flap with split thickness skin grafting. The same patient also had a previous free anterolateral thigh flap for the coverage of his medial tibial wound in the distal third of the leg with success. In case 2, a middle lateral leg wound (5  3 cm) with exposed tibia as a result of hematoma and wound breakdown after orthopedic debridement was reconstructed with a distally based tibialis anterior muscle flap with split thickness skin grafting. Results: Full soft tissue coverage of the defects was achieved using these distally based local muscle flaps. There was complete healing of each complex wound in the lower extremity without complications, thus a microvascular free flap reconstruction for those patients was avoided. Aesthetic appearance of the reconstructions was closely matched to the native skin. Functional status was acceptable over long-term follow-up in both patients. Conclusions: For complex lower extremity wounds, less commonly used local muscle flaps that are distally based may successfully reconstruct certain relatively small defects in the lower extremity. Knowledge of these flaps and illustration of their success allow the reconstructive surgeon to confidently add them to the reconstructive armamentarium. Key Words: muscle flaps, local flaps, lower extremity, wounds (Ann Plast Surg 2015;74: S22–S24)

L

ower extremity wounds needing coverage are a domain that reconstructive surgeons may often be called upon as the primary expert in an acute setting. Thus, a thorough knowledge of reconstructive options and techniques is essential to successfully solve lower extremity wound problems. Commonly encountered consultations may include defects resulting from trauma, oncologic resection, poorly healing wounds, chronic infection, exposed vascular grafts, or orthopedic hardware needing sturdy coverage. The goals of a lower extremity reconstruction include coverage of vital structures (exposed bone, tendon, vessels/grafts, or hardware), restoration of the patient's premorbid level of functioning if possible, and an aesthetically pleasing result. Therefore, reconstructive strategies should aim to accomplish these objectives to achieve a successful outcome. Received August 29, 2014, and accepted for publication, after revision, January 22, 2015. From the Division of Plastic Surgery, Department of Surgery, University of California, Davis, Sacramento, CA. Conflicts of interest and sources of funding: none declared. Reprints: Lee L.Q. Pu, MD, PhD, Division of Plastic Surgery University of California at Davis 2221 Stockton Blvd., Suite 2123 Sacramento, CA 95817. E-mail: [email protected]. Presented at the 64th Annual Meeting of California Society of Plastic Surgeons, Newport Beach, CA, May 24–26, 2014. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7401–S022 DOI: 10.1097/SAP.0000000000000492

S22

www.annalsplasticsurgery.com

Algorithms have previously been published to assist in decision making regarding suitable coverage options for lower extremity wounds, particularly after a traumatic injury.1,2 Following the reconstructive ladder, wounds may be closed by numerous techniques ranging from simple primary closures to complex solutions using free tissue transfer. The reconstructive surgeon should have comfort in executing a broad array of operations, including free flaps for large or distal wound coverage. Smaller defects, however, may not require free tissue transfer but may still require a creative strategy to obtain the goals of lower extremity reconstruction. Therefore, knowledge of alternative local reconstructive options may be of great utility for reconstructive surgeons—especially those who practice in a nontertiary setting. We report 2 cases of lower extremity wounds with exposed vital structures because of complications from orthopedic procedures after traumatic injury. Both wounds were successfully covered with a combination of the distally based local muscle flap and skin grafting, thus avoiding the necessity of free tissue transfer.

PATIENT REPORTS Case 1 is a 42-year-old man who sustained a right lower extremity closed type C pilon fracture. He underwent multiple procedures, including an open reduction internal fixation of a fibular fracture, as well as the pilon fracture. Incisions used by the orthopedic surgeons included a laterally based incision over the fibular shaft, a posterolateral incision in the Achilles tendon region, and an anteromedial incision over the ankle. He was followed up in the orthopedics clinic and noted to have wound infections requiring irrigation and debridement in the operating room with purulent fluids within the wounds. He developed an exposed fracture site in addition to hardware as well as an area of 7  3 cm exposed Achilles tendon (Fig. 1A) as a result of orthopedic debridements. A free anterolateral thigh flap was done for coverage of the exposed fracture and hardware wound in the distal third of the medial leg. The exposed Achilles tendon was not considered to be of major significance at the time of the initial operation, thus wound care was done over this site using negative pressure wound therapy. However, this failed to improve the wound. A separate operation was undertaken 4 weeks later for coverage of the exposed Achilles tendon. A free-style pedicled perforator flap was planned initially but, intraoperatively, no good perforators were identified for such a flap reconstruction. Therefore, the decision was made to proceed with a distally based peroneal brevis muscle flap. The proximal portion of the muscle was identified and dissected freely from the fibular attachment. A few perforators along the distal portion of the muscle were identified, and 1 perforator was served as a pivot point for the flap turnover. (Fig. 1B) The exposed Achilles tendon was completely covered with the distally based peroneal brevis muscle (Fig. 1C). A meshed split thickness skin graft was used to cover the flap (Fig. 1D). At follow up, the patient had full survival of the flap and complete take of the skin graft. Lower extremity function remained intact and a fairly good aesthetic result was achieved (Fig. 1E). Case 2 is a 29-year-old man who had developed heterotopic ossification of his right tibia and fibula after a previous soft tissue injury. This was resected with a resulting complication of hematoma and overlying skin breakdown along the area of incision. The evacuation of hematoma and debridement of necrotic tissue were performed by the orthopedic surgery team with a resultant 5  3 cm area of exposed tibia in the middle third requiring Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015

Role of Less Commonly Used Local Muscle Flaps

FIGURE 1.

coverage (Fig. 2A). Surrounding skin was noted to be of poor quality, thereby precluding the use of a local bi-pedicled fasciocutaneous flap. The decision was made to cover the wound with a distally based tibialis anterior muscle flap. Under tourniquet control, the tibialis anterior muscle was identified and dissected free proximally from the extensor hallucis longus muscle (Fig. 2B). Proximally, the tibialis anterior muscle was divided and then turned over into the wound in a reverse fashion. Attention was made to only dissect adequate length of the

muscle for flap turnover (Fig. 2C). The anterior fascia overlying the muscle was scored to enhance the arch of the flap turnover. A meshed split thickness skin graft was then placed over the muscle for final coverage (Fig. 2D). Complete coverage of the exposed tibia was achieved. Complete viability of the flap and take of the skin graft were demonstrated at follow-up with an acceptable aesthetic result (Fig. 2E). The patient's functional status was at his baseline premorbid state.

FIGURE 2. © 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.annalsplasticsurgery.com

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

S23

Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015

Jaiswal and Pu

DISCUSSION Reconstruction of lower extremity defects can be approached via an algorithmic format. Traditionally, approaches to reconstructive strategies are based on variables, such as location within the extremity, assessment of exposed structures, presence of infection that may require muscle-based coverage for assistance with eradication, and defining the zone of injury. Perhaps just as important, a thorough analysis and discussion should be held between treating teams as well as the patient regarding the decision to pursue limb salvage versus amputation. Free tissue transfer can achieve excellent coverage of lower extremity defects and allow the patient to achieve an acceptable functional status.3 However, these operations require a number of preconditions including a relatively stable medical status to undergo a major operation, appropriate equipment and staff for microsurgical reconstruction, and an extended hospital stay for flap monitoring and physical therapy (at our institution, lower extremity free flap patients are not discharged until they have tolerated dangling and been cleared by physical therapists). In addition, the aesthetic result may be limited and require additional operations for improvement in appearance. Free flaps are therefore advocated for distal leg circumferential large defects, open fractures/Gustilo IIIb/c fractures, exposed joint or tendons, or inability to use local flaps.4 Smaller defects, especially in the mid or distal portions of the leg, may require alternative solutions. Although many uncomplicated wounds can be closed with primary advancement or rotation flaps, or delayed coverage with vacuum assisted therapy followed by skin grafting, more complex wounds with exposed structures, such as bone, tendon, or hardware, may require more robust coverage. Muscle coverage of infected tissues or hardware may help eradicate infection by bringing in healthy, vascularized tissue to the wound.5–8 The peroneus brevis muscle is a type II muscle located in the lateral compartment of the leg. It originates from the lower third of the lateral fibula below the peroneus longus muscle and inserts via a relatively long tendon onto the fifth metatarsal. The muscle functions in foot dorsiflexion and eversion and is innervated by the superficial peroneal nerve. The dominant pedicle is the muscular branch of the peroneal artery that enters on the deep surface of the proximal portion of the muscle. The muscular branch of the anterior tibial artery serves as a minor pedicle and enters the muscle on its deep surface in the distal portion. The skin overlying the territory receives its supply from septocutaneous perforators of the peroneal artery, though a cutaneous component of this flap is not often used. The distally based flap is raised by separating the proximal origins of the muscle from the fibula as well as the neighboring peroneus longus and flexor digitorum longus muscles. The minor pedicle is identified, and the muscle can be rotated to cover a lower third lateral leg defect. Lyle and Colborn9 described their success with using the peroneal brevis muscle flap for small defects of the distal third of the leg. Their technique involved a proximally based flap and division of distal pedicles to allow an adequate arc of rotation for fibular coverage. The use of the flap based on its distal pedicle in a turnover fashion was not described by these authors, but has recently been successfully illustrated by others.10–12 Using the flap in this fashion may allow complete coverage of exposed Achilles tendon. Basing a type II flap on its minor pedicle only may be considered a risky endeavor; however, it is illustrated successfully here. The anterior tibialis muscle is a type IV muscle located on the lateral aspect of the tibia. It originates on the lateral tibial condyle as well as the upper lateral surface of the tibia and inserts onto the base of the first metatarsal. The muscle is innervated by deep branches of the peroneal nerve and functions to dorsiflex and invert the foot. It is not ordinarily an expendable muscle unless the peroneal nerve has already been damaged. The arterial supply is between 8 and 12 major segmental pedicles from the anterior tibial artery that will pierce the muscle on its deep

S24

www.annalsplasticsurgery.com

and lateral surface. The flap may be used in coverage of small defects of the middle and lower third of the leg. Various descriptions of the muscle for coverage include a standard proximally based flap, segmental flap, sagittal split flap, and longitudinal split muscle flap.13–15 Using the flap based on the distal segmental supply and insetting in a turnover fashion— as performed here—has not been as well described. This case serves as an illustration to the success of using this strategy. Although each patient had a distally based muscle flap without complications, partial or even total muscle flap loss may certainly be possible. Therefore, familiarity with each muscle flap and its unique vascular anatomy and possible arches of flap movement is key. In addition, each flap can only be used for a small soft tissue defect—less than 20 cm2 in the middle or distal third of the leg—and such a limitation should be fully recognized by the reconstructive surgeon. If tip necrosis of the flap does occur, the necrotic portion of flap can be debrided and readvancement of the flap performed.

CONCLUSIONS Lower extremity defects needing soft tissue coverage require the expertise of the reconstructive surgeon. Knowledge of a multitude of options will allow for the appropriate selection of reconstructive technique. Although free tissue transfer is useful for a variety of lower extremity defects, there are numerous drawbacks and may not be required for certain wounds. Smaller defects, in particular, can be closed using distally based local muscle flaps that are less commonly used. Knowledge of these flaps and illustrations of their success can allow the reconstructive surgeon to confidently add them to his or her armamentarium. REFERENCES 1. Hong JP. Reconstructive surgery: lower extremity coverage. In: Neligan PC, ed. Plastic Surgery. 3rd ed. Volume 4. New York, NY: Elsevier Saunders; 2013: 128–150. 2. Kasabian AK, Karp NS. Lower Extremity Reconstruction. In: Thorne CH, ed. Grabb and Smith’s Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007:676–688. 3. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma. 1989;29:1086. 4. Hollenbeck ST, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg. 2011;128:551e. 5. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1986; 77:785–794. 6. Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg. 1982;70:1–10. 7. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg. 1982;69:815–829. 8. Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment. Plast Reconstr Surg. 1991;88:311. 9. Lyle WG, Colborn GL. The peroneus brevis muscle flap for lower leg defects. Ann Plast Surg. 2000;44:158–162. 10. Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg. Plast Reconstr Surg. 2001;107:1443–1448. 11. Bach AD, et al. The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg. 2007;58: 397–404. 12. Bajantri B, et al. Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects. Indian J Plast Surg. 2013;46:48–54. 13. Mathes SJ, Nahai F. Tibialis Anterior Flap. In: Reconstructive Surgery: Principles, Anatomy, and Technique. New York, NY: Churchill Livingstone; 1997: 1501–1512. 14. Hirschowitz B, et al. External longitudinal splitting of the tibialis anterior muscle for coverage of compound fractures of the middle third of the tibia. Plast Recon Surg. 1986;79:407–414. 15. Hallock GG. Sagittal split tibialis anterior muscle flap. Ann Plast Surg. 2002;49:39–43.

© 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

The role of less commonly used local muscle flaps for soft tissue coverage of complex lower extremity wounds.

Lower extremity reconstructions may be pursued by adhering to established algorithms primarily based on the area of injury and the extent of missing t...
10MB Sizes 0 Downloads 10 Views