The use of peroneus brevis in lower limb reconstruction-What we have learned from 49 cases.

INTRODUCTION: There are many suitable techniques for the treatment of soft tissue defects of the lower limb. Older subjects often with multiple comorbidities, presenting with a laterally located and complex defect, can be challenging to treat. This cohort are often unsuited to long procedures or multi-stage reconstruction and so one is faced with a paucity of options. In such instances, we use the peroneus brevis (PB) muscle flap as a single stage procedure. METHODS: We performed a retrospective study evaluating the use of PB flaps in lower limb injury. Subjects were collated using a database and multiple variables were assessed including: patient demographics, comorbidities, defect size, peri-operative timings, time in theatre, use of inotropes / blood transfusion, mean hospital stay, patient morbidity / mortality, flap survival. RESULTS: During 2015-2023, 49 patients underwent lower limb reconstruction using PB muscle flaps. 42 cases involved PB and skin graft alone whilst seven were more complex requiring additional local and free tissue techniques. The most common indication (n = 28) was infection after closed fracture fixation, followed by open trauma (n = 21). Median patient age was 59 (20-93 years), and ASA grade 3. Median defect size was 4 × 7 cm (2-18 cm) and time from admission to definitive closure 4 days (0-21 days) with median time in theatre 120 min (45-520 min). 17 patients required inotropes and 13 had blood transfusion. Median length of hospital stay was 12 days (0-58 days), one patient (aged 90) died. 100 % of flaps survived and median Enneking score was 65. Heterotopic ossification was not identified in the post-operative imaging within the first year. DISCUSSION: Our experience highlights the benefits and risks of using the PB flap and advocates it as a reliable, cost-effective, 1-stage technique for reconstructing small lateral defects in the distal third of the lower limb.

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.

Surgeon-administered, intra-operative transversus abdominis plane block in autologous breast reconstruction: a UK hospital experience.

AIM: Perioperative Transversus abdominis plane (TAP) block has been well described in the literature as part of the multi-modal approach for management of postoperative pain in gynaecological and general surgery. The senior author started performing ultrasound-guided TAP block perioperatively in DIEP patients in January 2011. The role of surgeon-administered, intra-operative TAP block in abdominal based breast reconstruction surgery was investigated in terms of its efficacy, safety, ease of administration and impact on opioid-related usage and side effects profile. METHODS: Retrospective analysis of a single surgeon's experience of patients undergoing autologous breast reconstruction using abdominally-based free flaps who received intra-operative, surgeon-delivered TAP block (n=12) compared with a similar patient set not receiving TAP block (n=15). Data was analysed using Student's t-test and assessed for significance of results using p<0.05 as the threshold of significance. RESULTS: Patient's receiving TAP block had a significantly shorter length of stay (4.75 vs 7.00 days, p=0.002), lower usage of morphine (15.4 vs 71.4 mg, p=0.005), and fewer episodes of peri-operative nausea and vomiting (1 vs 6, p=0.03). CONCLUSION: Perioperative ultrasound guided TAP Block is an effective, cost effective and safe technique for postoperative pain management in abdominal based breast reconstruction.

Enteral vs total parenteral nutrition following major upper gastrointestinal surgery.

A best evidence topic in surgery was written according to a structured protocol. The question addressed was in patients undergoing elective major upper gastrointestinal surgery requiring post-operative nutritional support, does enteral feeding as compared to total parenteral feeding confer any clinical benefits. Thirty-two papers were identified by a search of the Medline and Embase databases, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study group, relevant outcomes and results of these papers were tabulated. All seven of these papers were randomised controlled trials which demonstrated enteral nutrition to be associated with shorter hospital stay, lower incidence of severe or infectious complications, lower severity of complications and decreased cost as compared to parenteral nutrition. For patients undergoing elective major upper gastrointestinal surgery requiring post-operative nutritional support, enteral feeding should be considered as the most desirable form of post-operative feeding.

Is routine postoperative enteral feeding after oesophagectomy worthwhile?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether, in patients undergoing an oesophagectomy for cancer, immediate postoperative enteral feeding (via percutaneous jejunostomy or nasojejunostomy) provides better patient outcomes as compared to waiting until oral feeding can be instituted. Four randomized controlled trials represented the best evidence to answer the clinical question. The first study randomized 25 patients into enteral feeding via jejunostomy (n = 13) versus a routine diet without jejunostomy (n = 12). The authors found no statistical difference in outcomes including length of stay, anastomotic complications and mortality. They did not report any catheter-related complications. A second study included patients undergoing an oesophagectomy or a pancreatodudenectomy, randomized to immediate postoperative jejunostomy feeding (n = 13) or remaining unfed for 6 days (n = 15). They reported one incident of detachment of the catheter from the abdominal wall. They also noted a statistically significant decrease in vital capacity and FEV1 in enterally fed patients. There was no difference in length of stay or anastomotic complications. They concluded that there was no indication for routine use of immediate postoperative enteral feeding in those patients without significant preoperative malnutrition. A third report randomized their post-oesophagectomy patients into enteral feeding via jejunostomy (n = 20) versus crystalloid only (n = 20). The also found no difference in length of stay, anastomotic leak rate or mortality. One catheter was removed due to concerns over respiratory function. They also concluded that there was no measurable benefit in early enteral feeding. The last of these 4 studies randomized patients into naso-duodenal feeding (n = 71) and jejunostomy feeding groups (n = 79). As in previous trials, they found no statistically significant difference between length of stay or anastomotic leak rates. Mortality was higher in the jejunostomy group, although the team did not attribute the deaths to the catheter. They found both methods equally effective in providing postoperative nutrition. In summary, all the trials concluded that routine postoperative enteral nutrition was feasible, but there was no evidence suggesting that it conferred any clinical benefits.