The Distally Based Peroneus Brevis Flap: The 5-Step Technique.

The peroneus brevis flap was first described as proximally based by Mathes et al (Surg Clin North Am. 1974;54:1337-1354) and later by Jackson and Scheker (Injury. 1982;13:324-330). A distally based version of this flap by Mathes and Nahai (Reconstructive Surgery: Principles, Anatomy and Technique. 1997:1437e46) was subsequently described in 1997. The first case series of distally based flaps was published by Eren et al (Plast Reconstr Surg. 2001;107:1443-1448). In our experience, the distally based flap is a useful muscle flap to reconstruct small defects in the lateral distal third of the leg. Initial interest and confidence in the use of this flap in our unit were hindered by lack of direct experience and descriptive detail in the literature. We have now developed a systematic approach to harvest the distally pedicled peroneus brevis muscle flap in 5 reproducible, safe steps. This has allowed the flap to become adopted as a standard technique of limb reconstruction in our unit with no cases of flap loss.

The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction.

BACKGROUND: The medial sural artery perforator (MSAP) flap provides a thin, pliable and durable soft tissue reconstruction with adequate pedicle length and low donor morbidity. It is an ideal choice for small-to-moderate defects of the lower extremity, although it does have limitations. We report our experience of the flap in a three-pronged anatomical, clinical and patient reported outcome-based study. METHODS: Cadaveric fresh frozen lower limbs (n = 10) were used for anatomical dissections to assess pertinent and clinically relevant findings. Data relating to MSAP flaps was collected from a prospectively maintained database over a 2-year period. Both clinical data and modified Enneking scores were analysed. RESULTS: Anatomical study: A mean of 2.1 ± 0.99 perforators arose from the medial sural artery, located 11.9 cm ± 2.07 along the line between the popliteal fossa and medial malleolus. The largest perforator was located 13.58 cm ± 2.01 from the popliteal artery. The distance from the dominant perforator to the first branching point within the gastrocnemius was 7.39 ± 1.50 (range 5-9.2 cm). The short saphenous vein was located on average 3.08 cm ± 0.77 from the dominant perforator. Clinical study: Twenty free and nine pedicled MSAPs were included (n = 29). Open lower limb fractures (n = 18, 62%) and infection (n = 10, 35%) were the most common aetiologies. Defects sites included: foot-and-ankle (n = 12, 55%), knee (n = 9, 31%) and anterior leg (n = 4, 14%). Four patients (14%) required SSG to for donor site coverage. Venous congestion was responsible for partial flap necrosis in 6.9%(n = 2) of patients. All wounds were healed at discharge. At 14 months, the mean Enneking score was 72.5%. All patients were ambulant, 96% returned to work and 87% were using pre-operative footwear. CONCLUSIONS: The MSAP provides robust foot-and-ankle reconstruction, whilst permitting glide when over the knee. Patient satisfaction and functional outcomes are excellent with careful patient selection. Care should be taken to avoid compression or kinking of the large, thin walled veins as the most commonly observed complication was venous congestion. We advocate MSAP as a first choice flap for small-to-moderate foot, ankle or knee defects.

A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly.

INTRODUCTION: Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding. METHODS: A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score). RESULTS: 33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation. DISCUSSION: These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.

Outcome of the management of open ankle fractures in an ortho-plastic specialist centre.

INTRODUCTION: We reviewed the functional outcome of 68 patients with open ankle fractures managed in an orthoplastic specialist centre. MATERIALS AND METHODS: Patients managed at Frenchay Hospital over a 6 year period were divided into 3 groups: group P were patients initially seen and managed at Frenchay Hospital (an orthoplastic specialist centre), group S were patients stabilised at a different unit and referred for definitive management, while group R were patients managed in a different unit and referred following complications. Injuries were graded using the AO score and outcome was measured using the Enneking score (both validated). RESULTS: 19 patients (group P, mean age: 43 years), 26 patients (group S, mean age: 41 years) and 23 patients (group R, mean age: 41.9 years) made the cohort. 82.4% patients required free tissue transfer. Mean AO scores of groups P, S and R were 11.5, 12.3 and 9.7 (p+0.03). Mean number of procedures for P, S and R were 2.6, 3.5 and 4.2 (p = 0.0006). Mean follow up time was 55.5, 61.0 and 57.0 weeks respectively (p = 0.72). Mean Enneking scores for groups P, S and R were 63.3, 74.8 and 73.5 (p = 0.16). CONCLUSION: Patients from groups S and R underwent more procedures. However, a similar outcome can be achieved, highlighting the importance of managing such injuries in an orthoplastic specialist centre.

Proximally pedicled medial plantar flap based on superficial venous system alone for venous drainage.

The proximally pedicled medial plantar flap is well described for coverage of wounds around the ankle and heel. This flap is usually based on the deep venae comitantes for venous drainage, with the superficial veins divided during dissection. Usually any disruption of the deep venous system of the flap would result in abandoning this choice of flap. Venous congestion is a recognised complication of medial plantar flaps. The patient described in this case report had a medial ankle defect with exposed bone, for which a proximally pedicled medial plantar flap was used. As we raised the flap, both venae comitantes of the medial planter artery were found to be disrupted. The flap was raised based on the superficial veins draining into the great saphenous, as the only system for venous drainage, with no evidence of venous congestion. The flap was successfully transposed into the defect and healed with no complications. The proximally pedicled medial plantar flap can safely rely on the superficial venous system alone for drainage. In addition, preserving the superficial veins minimise the risk of venous congestion in this flap. We recommend preservation of superficial venous system when possible.

Does vascular injury affect the outcome of open tibial fractures?

BACKGROUND: Consensus on the definition of a Gustilo grade IIIC injury was sought, and the influence of vascular injuries on outcome of severe open tibial fractures was investigated. METHODS: Three thousand three hundred fifty-one plastic and orthopedic surgeons were sent questionnaires to determine their interpretation of Gustilo grade IIIC injuries. Notes of patients with severe open tibial injuries reconstructed at Frenchay orthoplastic center with free tissue transfer between 2006 and 2010 were reviewed. Data were collected on patient demographics and vascular integrity. Outcome was measured using the Enneking score. RESULTS: Four hundred seventy-six plastic surgeons and 2875 orthopedic surgeons were contacted. Seven hundred fifty-three responses (22.5 percent) were received; 46.2 percent thought a grade IIIC injury was a devascularized limb, 24.2 percent felt it was a one- or two-vessel injury, 6.9 percent thought it represented any vascular injury, and 22.7 percent had no definite answer. Sixty-eight patients (50 men and 18 women; mean age, 42.7 years) were identified. Fifty had normal angiograms and 18 sustained vascular injuries. Forty-two percent of vascular injuries were to the anterior tibial artery, 37 percent were to the posterior tibial, and 27 percent were to the peroneal. Mean follow-up was 11.2 months. Mean Enneking score for patients without and with vascular injury was 29.8 and 24.4, respectively (p = 0.004). CONCLUSIONS: Vascular injury independently influences long-term limb function. The authors suggest a modification to the current classification to improve communication among surgeons, and advocate the use of preoperative angiography before free soft-tissue reconstruction of severe open tibial fractures.