SLR - July 2019 - Sharif AbdelFattah
Reference: Barbera F1, Lorenzetti F2, Marsili R2, Ragoni M2, Lisa A3, Zampa V4, Pantaloni M2. MRI Anatomical Preoperative Evaluation of Distally Based Peroneus Brevis Muscle Flap in Reconstructive Surgery of The Lower Limb. J Plast Reconstr Aesthet Surg. 2017 Nov;70(11):1563-1570. doi: 10.1016/j.bjps.2017.06.018. Epub 2017 Jun 27.Scientific Literature Review
Reviewed By: Sharif AbdelFattah, DPM
Resident Program: East Liverpool City Hospital – East Liverpool, OH
Podiatric Relevance: Peripheral neuropathy is an immense complicating factor in the development and healing of ulcerations in the lower extremity. When conservative management (including orthobiologics, primary wound closure, split thickness skin grafts and free flaps) fails, the next step in the reconstructive ladder is ascended to in the attempt to achieve complete and timely wound closure. Muscle flaps have proven to be a valuable tool for surgeons to have in their armamentarium in the management of chronic ulcerations of the lower extremity. Muscle flaps are versatile and time tested modality of providing bulk in order to obliterate dead space, provides vascular supply to the recipient site for antibiotic delivery while providing a surface to promote a healthy granular base for definitive coverage with grafting. Additionally, when muscle flaps are involved there is more rapid collagen deposition and greater tissue in growth. The reverse distal peroneus brevis muscle flap is advantageous in that it can be manipulated to cover small to medium sized defects at the anterior, lateral and- within reason- the medial aspect of the ankle as well. That being said, there is a good amount of variability in the size of the peroneus brevis muscle belly depending on patient factors. The purpose of this journal article was to evaluate the capability of MRI to measure the muscle belly to assess the size preoperatively.
Methods: The journal article describes a series of 32 patients between 2008 and 2017 that underwent preoperative MRI to measure the peroneus brevis length. All of these patients subsequently underwent reconstruction with the peroneus brevis. The muscle belly was measured intraoperatively during the procedure and then the results were compared. MRI length was measured to be 9 to 21 cm and intraoperatively the measured range was from 9 to 20 cm (variation = +/- 1 cm, r= 0.92, p= 0.002).
Results: The results of the study showed statistical significance in direct correlation of the muscle belly measured by MRI and intraoperatively. Part of the work up for these muscle flaps in vascularly compromised patients is 3D CT angiography with the possibility of intervention in attempts to improve quality of the procedure. However, peroneus belly is rarely assessed for adequate size for the amount of coverage and bulk necessitated by the wound. This flap is well designed in that the vascular supply is rich in the properly selected patient, however due to patient factors the muscle belly may have atrophied and be inadequate for complete coverage of the wound. In this study, the researchers suggest that MRI should become part of preoperative work up before preforming a peroneus brevis flap procedure.
Conclusions: With the growing prevalence of diabetes mellitus and subsequent neuropathy the management of longstanding wounds needs to be addressed with aggressive modalities if we are going to continue the trend of limb salvage in the podiatric field. Based on this study, use of preoperative MRI for Peroneus Brevis muscle transfer may help to prevent intraoperative complications and the possibility of need for further operative management as a result of improper surgical planning.