Sunday, October 10, 2004

Peroneus brevis muscle flap for reconstruction of pediatric ankle and foot

Sandeep Munjal, MD, Jerald R Sultz, MD, Robert Galpin, MD, FRCS, and Dougals Armstrong, MD, FRCS.

Purpose: Motor vehicle and lawn mower injuries of distal lower extremity in pediatric population seen in trauma centers are often open and associated with significant soft tissue loss. Although reconstruction of soft tissue defects has been studied extensively in adults, the subject has been rarely evaluated in pediatric population. Peroneus brevis muscle flap has been reported as a method of covering soft tissue defects around ankle in adults but has not been reported in pediatric population. The purpose of this study is to review and report the results of peroneus brevis muscle flap in children. Methods: Two children with open ankle injuries and soft tissue defects were treated with distally pedicled peroneus brevis flap after primary debridement, fracture fixation and preservation of viable tissues. First patient was a six year old girl who was run over by a pick up truck and sustained open ankle joint, distal tibia epiphysis and talar body fracture extensor tendon injury with loss of anterolateral skin and soft tissue. Second patient was a two year old girl who sustained lawn mower injury with open distal tibial epiphysis injury and soft tissue defect posteromedially with exposed tendoachilles and heel. Wound debridement was performed on date of injury and second look debridement was performed forty eight hours later. For the first patient a free flap was planned for the coverage of the anterolateral defect which was approximately 5cm 4cm with exposed ankle joint and distal tibia, however we were able to harvest and rotate the peroneus brevis flap to cover this defect and did not need a free flap. For second patient the flap was planned during the second look debridement and we were successfully able to predict the area which can be covered by the peroneus brevis flap. The distally pedicled peroneus brevis muscle flap was done on day 5 for both patients; split skin graft was used to cover the flap. No more surgeries were needed. Both patients were discharged five days after surgery after first dressing change. Clinical follow up was obtained consisting of physical examination and radiographs. Results: Follow up of these patients is from 6 18 months. Both patients healed successfully with functional plantigrade ankles. They were allowed weight bearing at 3-4 weeks from the injury, largely dictated by the bony injury. They did not require any further procedures. The donor site morbidity was limited to the harvest site scar. Conclusion/Significance: Reconstruction of soft tissue defects of the ankle and foot is a challenging problem, injuries to this area commonly cause significant wounds that if not properly treated can lead to progressive deformity and disability. Aim of treating such injuries is to achieve durable, permanent painfree and aesthetically satisfying defect coverage. The reconstruction often requires free tissue transfer and/or local flaps. Microsurgery has solved some of these problems although can be technically difficult with variable results in children. The simplest appropriate technique for the injured foot that is likely to produce the best outcome should be selected. Our study patients involved complex soft tissue defects. The distally pedicled peroneus brevis muscle flap represents a local and simple method of covering soft tissue in this area. With the help of this flap defects upto 20 cm 4cm can be covered in adults, in our younger 2 year old patient we were able to elevate flap approx 8cm 2.5 cm. Both patients healed successfully and did not require any secondary procedures.