Versatility of the Peroneus Brevis Muscle Flap for Distal Leg, Ankle, and Foot Defects: A Comprehensive Review.

Soft tissue defects of the distal third of the leg are challenging and management with simple split thickness skin graft or conservative measures is often difficult. The peroneus brevis muscle flap is well described in the literature to cover such defects. The aim of our study was to review the different applications and potential complications of the peroneus brevis muscle flap. A comprehensive review of all existing evidence on the use of peroneus brevis muscle flaps for coverage of defects in the distal third of the leg in adult populations was performed. Two hundred forty-eight records were identified in the literature search, among which 15 met the PICOS (Patient, Intervention, Comparison, Outcome and Study design) criteria. All selected studies were retrospective. Overall, 222 patients who received peroneus brevis muscle flaps were analyzed. Indications for reconstruction were post-traumatic defects, infected wounds, and chronic wounds. The overall complication rate was 21% (46/222) with the most commonly reported complication being skin graft loss. We observed 2 cases of partial flap loss, 17 cases of skin graft loss, 2 cases of post-operative hematoma, 2 cases of recurrent infection, 12 cases of partial flap necrosis, 3 cases of skin graft necrosis, and 8 cases of delayed wound healing. Overall, 16 patients (7%) required revision surgery. No cases of donor site morbidity were described. The current review shows that the peroneus brevis muscle flap is a versatile and reliable option for the coverage of small to medium sized defects of the distal leg, ankle, and foot with low complication rates and donor site morbidity.

Empirical Evidence on the Reliability of Lateral Supramalleolar Flap over Reverse Sural Flap for Local Soft Tissue Coverage of Dorsum of the Foot and Ankle Defects.

Background Soft tissue coverage of the distal foot and ankle region has been an area of debate due to the paucity of local flap options. To provide empirical evidence on the reliability of an underreported local alternative for foot and ankle defects, we aim to compare the lateral supramalleolar flap (LSMF) to the reverse sural flap (RSF). Methods During 2016-2019, 48 patients were divided randomly into two equal groups, LSMF and RSF groups respectively. The patients' demographic, surgical, and clinical outcome details were recorded and analyzed. Results Flap necrosis was found in five patients in the group treated with RSF and none in the LSMF group. The mean total number of stages in RSF group was significantly higher than in LSMF group ( p < 0.05). The mean operative time for patients in LSMF group was 85.8 ± 18.5 and 54.2 ± 11.2 in RSF group ( p < 0.05). Five patients in the RSF group needed additional procedures following flap complications. Nine patients in the LSMF group reported satisfaction outcomes to be "excellent," five patients reported "good" whereas, in the RSF group, 14 patients reported "excellent," 5 reported "good," 3 reported "fair," and 2 reported "poor" outcomes. Compared to the RSF (46.4 ± 4.3) group, the LSMF group had significantly better foot function indices (34.03 ± 3.9). Conclusion The lateral supramalleolar flap for foot and ankle defects offers better results, reduced complications as well a lesser number of stages and secondary procedures over the traditionally used reverse sural flap.

Angioleiomyoma in a 54-year-old Female: A Case Report of Distal Leg Tumor and Review of the Literature.

Introduction: Angioleiomyomas are rare benign tumors originating from smooth muscle cells of blood vessels. Although they can occur in various anatomical locations, angioleiomyomas of the distal leg are relatively uncommon. Due to its clinical resemblance to other soft-tissue tumors, misdiagnosis can occur leading to inadequate treatment. Case Report: We present a case of angioleiomyoma in a 54-year-old female who presented with a palpable mass in her distal leg. The tumor was surgically excised, and histopathological examination confirmed the diagnosis of angioleiomyoma. In this article, we discuss the clinical presentation, diagnostic evaluation, and management of angioleiomyoma, with a focus on distal leg tumors. Furthermore, we provide a comprehensive review of the existing literature on angioleiomyomas, emphasizing findings and treatment outcomes reported in previous studies. Conclusion: Angioleiomyomas are uncommon soft-tissue tumors that can mimic other more common lesions such as ganglion cysts. Hence, diagnosis requires a high index of suspicion. Surgical excision is the treatment of choice for angioleiomyoma. Complete resection is generally curative, with a low rate of recurrence.

Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects-Anatomical Study and Clinical Application.

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases-anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm2 (mean 28.2 ± 23.8 [range 6-120] cm2) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.

A case report of a reverse sural flap for posterior ankle soft-tissue defect following an injury in a patient from Tanzania.

In the treatment and management of severe wounds, microsurgical repair remains the gold standard. However, it is difficult to transfer free tissue from a Tanzanian perspective due to donor site morbidity, longer operational times, bulky forms, recipient vessel stress, sophisticated surgical expertise, and high costs of the equipment. Meanwhile, the reverse sural flap has been considered as the ultimate tissue restoration technique. This study reviews a case of a 35-year-old man who was admitted at Mbeya Zonal Referral Hospital in the Department of Orthopaedics, Trauma, and Neurosurgery in Mbeya, Tanzania. The patient had a 9-day injury to the rear of his right ankle due to a cut he suffered after tripping over a toilet seat in the washroom. After the diagnosis, the plan involved surgical debridement, tendon repair, and reverse sural flap rotation. Despite the difficult working environment requiring advanced learning experience, our patient fully recovered after 3 weeks. Proving that reverse sural flap is one of the few available possibilities in the protection of vital structures such as bone or tendons, in the distal areas of the leg, ankle, and foot especially when the medical treatment facility lacks a strong microsurgery team and equipment.

Reverse Dermis Flap for Coverage of Distal Leg and Ankle Defects.

Soft tissue defects of the distal third of the leg and ankle, which frequently expose tendon, bone or osteosynthesis material, are difficult to cover and pose a major challenge to the plastic surgeon. Traditional reconstructive options for this region usually require complex flaps which made them unsuitable for elderly patients or those with multiple comorbidities. We hereby present the reverse dermis flap as an easy and reliable choice to cover this type of wounds and refer our experience in 9 cases in which clinical, operative, and follow-up data were recorded. Of the 9 flaps performed, 8 survived completely and 1 presented a partial flap necrosis, requiring additional surgery. No other operative procedure was required. In conclusion, the reversed dermis flap is a simple, quick, noninvasive, and safe technique for coverage of noble structures such as tendon or bone in the distal third of the leg that every plastic surgeon should incorporate in his surgical armamentary.

Clinical Study of the Lateral Supramalleolar Flap in the Soft Tissue Reconstruction around the Ankle Region.

Objective The purpose of this study is to present the efficiency of the lateral supramalleolar flap which is a very useful and yet underutilized in the soft tissue reconstruction of the regions extending from the distal leg, ankle, and foot. Methods Over a period of 3 years, 20 flaps were used in the reconstruction of soft tissue defects in the region extending from the distal leg, ankle, and foot. The location of the defects, the etiology, possible alternative flaps, outcome, and the complications were studied and presented. Results The follow-up period of the cases was from 1 month to 18 months after surgery. Seventeen flaps survived and three were lost. All the three lost flaps were those used over the tendocalcaneal region. The lost flaps were later replaced with split skin graft after the wound was debrided and was later covered with granulation tissue. Conclusion The lateral supramalleolar flap is a very useful flap in the regional soft tissue reconstruction around the ankle except in the tendocalcaneal region.

Simultaneous soft tissue coverage of both medial and lateral ankle wounds: Sural and rotational flap coverage after revision fixation in an infected diabetic ankle fracture.

AIMS: To describe a case of simultaneous medial and lateral soft tissue coverage for exposed orthopaedic implants in the setting of revision fixation of a non-united ankle fracture. This was achieved using a sural flap as well as a propeller flap. METHODS: Case report. RESULTS: Both the sural and posterior tibial artery based rotational propeller flap healed without incident. The underlying fracture healed successfully and the patient returned to normal shoe wear. CONCLUSIONS: The sural flap in conjunction with the posterior tibial artery based rotational flap is effective in providing simultaneous medial and lateral soft tissue coverage to the ankle.

Modified distally based sural adipofascial flap for reconstructing of leg and ankle.

BACKGROUND: While free flaps can be used in many cases to cover soft tissue defects in the distal leg and ankle in a single stage, factors such as diabetes and advanced age can interfere with success of vascular anastomoses. METHODS: Twenty-five patients with deep tissue exposure of the distal leg and ankle underwent reconstruction with a modified reverse sural adipofascial flap. Seventeen cases were due to trauma (13 due to high velocity trauma). All 17 had anterior tibial soft tissue defects without significant rear calf soft tissue injury. Eight patients had iatrogenic soft tissue defects due to orthopaedic surgeries for fractures. The flap is raised through two small incisions (3-5 cm) in the posterior aspect of the leg and the subcutaneous fat is split such that some is preserved with the skin. Once the flap is in place, it is covered by a full-thickness skin graft and the donor site is closed primarily. RESULTS: Twenty-one flaps survived. Four had partial loss of the skin graft on the flap, which healed spontaneously without secondary resurfacing. Anatomic contour was obtained in the recipient sites of all 25 patients. All donor sites healed primarily with the preservation of protective sensation in the calf and acceptable aesthetic appearance. Numbness in the lateral dorsal foot improved gradually and only minor residual numbness was noted at 1 year postoperatively. CONCLUSIONS: The modified reverse sural adipofascial flap preserved the sensation of the donor site and the anatomic contour of both recipient and donor sites.

Fascial versus fascio-cutaneous pedicled sural flaps in the reconstruction of distal leg, ankle and foot soft tissue defects

BACKGROUND: The coverage of soft tissue defects of the distal leg, ankle or foot poses several challenges to the reconstructive surgeon. Reconstructive procedures may range from simple skin grafting to complicated free tissue transfers. The reverse sural flap has been one of the most dependable methods for soft tissue coverage of such complex wounds. The purpose of this paper was to compare the clinical results of reverse sural flaps harvested with a fascial versus a fasciocutaneous pedicle. METHODS: A retrospective cohort of twenty-six patients who underwent a reverse sural flap procedure for complex wounds of the distal lower extremity was examined from January 1, 2003 to December 31, 2009, with a minimum follow-up of one month. Fifteen patients had a fascial pedicled flap, while eleven patients had fasciocutaneous pedicled flaps with a minimum of one month follow-up. The primary outcome was flap-related complications. Fisher's exact test was used to determine the differences between the two groups and the level of significance was set at p?0.05. RESULTS: All flaps survived. Flap-related complications were more common in the fascial pedicled flap (6/15) compared with the fasciocutaneous pedicled flap (1/11). The difference was not significant (p=0.09). In terms of cosmetic acceptability, 11 patients (11/15) in the fascial pedicle group and five patients (5/11) in the fasciocutaneous pedicle group expressed that the sural flap was acceptable. CONCLUSION: Reverse sural flap was a reliable reconstructive procedure for coverage of soft tissue defects of the distal leg, ankle or foot. There was no significant difference in terms of complication rates for those with fascial compared with those with fasciocutaneous flaps. Cosmetic acceptability was higher for the fascial pedicled flap.