The Reverse Peroneus Brevis Flap for Preventing Major Level Amputation in Multimorbid Patients

The use of free tissue transfers has overshadowed the much simpler approach of using simpler local rotation flaps for soft tissue coverage, especially in the foot and ankle. In this study, the authors aimed to examine the results of a single surgeon experience (CB) of the distally based reverse peroneus brevis muscle flap as the first line flap coverage for soft tissue coverage of the foot and ankle in medically high-risk patients who would otherwise require a major amputation.

All patients underwent Doppler examination only, prior to and intraoperatively prior to elevation of the distally based (reverse) peroneus brevis muscle flap; formal angiography or CT angiogram was not performed. The number of muscular perforators was documented intraoperatively as well as the defect size and location of flap inset. Patient demographics, medical risk factors for limb loss, mechanism of injury, the presence of soft tissue or bone infection, and wound size were recorded. The number of flap muscular perforators, flap complications, and donor site morbidity were recorded.

Complete flap survival was observed in 75% of patients, while 14% experienced partial flap necrosis. Minor donor site morbidity was seen in 11% of patients. Complete flap necrosis occurred in 11% of patients. Smoking demonstrated to a statistically significant influence for partial/full flap failure (P = 0.0383, Fisher's exact test). Additionally, among patients with diabetes, an abnormally elevated hemoglobin A1c, which was defined as ≥6.5, consistent with the standard for uncontrolled diabetes, demonstrated a statistical association for a flap-related complication (P = 0.0170, Fisher's exact test). Overall, at a mean follow-up of 6.9 years, an 83% limb salvage rate was achieved. Failed limb salvage resulting in amputation was not necessarily due solely to a flap complication.

These data demonstrate that the distally-based reverse peroneus brevis muscle flap may be considered as a first line option for foot and ankle soft tissue coverage in the high-risk, multimorbid patient who is otherwise facing a major level amputation. The novelty lies in the patient population examined, specifically, high-risk, multimorbid patients with medium or large-sized soft tissue defects of the lower leg, foot and ankle.