Zusammenfassung
Operationsziel
Defektrekonstruktion durch Transposition von gut vaskularisiertem Muskelgewebe als Muskellappenplastik oder mit Fibulaknochen als osteomuskuläre Lappenplastik.
Indikationen
Kleine und mittlere Integumentdefekte im Bereich des Rückfußes, des Sprunggelenks und des distalen und mittleren Unterschenkeldrittels, Rekonstruktion von kombinierten kleinen und mittleren Integument- und Knochendefekten.
Kontraindikationen
Läsionen der proximalen A. tibialis anterior (proximal gestielter Lappen), Läsion der distalen A. peronea bei gleichzeitiger Läsion des Ramus communicans cum arteriae tibialis posterior (distal gestielter Lappen); vorliegende Schädigung oder Lähmung des M. peroneus longus bei funktionsfähigem Sprunggelenk.
Operationstechnik
Distal gestielte Lappenplastik: Stumpfes Lösen des M. peroneus brevis von M. peroneus longus, subperiostales Lösen des Muskels von der Fibula, Isolation an einem distalen septokutanen Ast aus der A. peronea. Zur Verbesserung der Durchblutung kann der proximal durchtrennte Ast der A. tibialis anterior im Empfängergebiet mikrochirurgisch mit einem adäquaten Gefäß reanastomosiert werden. Proximal gestielte Lappenplastik: Abtrennung des distalen sehnigen Anteils des M. peroneus brevis und subperiosteales Ablösen nach proximal unter Ligatur der segmentalen Gefäße aus der A. peronea und Belassung der proximalen Versorgung aus der A. tibialis anterior. Für osteomuskulären Lappen Mitnahme eines Fibulasegments auf Höhe des Muskelursprungs unter Schonung der engen periostealen Verbindung.
Weiterbehandlung
Vollständige Immobilisation für 5 Tage und Elevation über Herzhöhe, anschließend Orthostasetraining der Extremität über 10 Tage unter postoperativer standardisierter Kompressionstherapie, evtl. kombiniert mit Narbentherapie (Silicon Sheet).
Ergebnisse
Zuverlässige, ausgezeichnete funktionelle und ästhetische Ergebnisse. Sehr niedrige Spendermorbidität.
Abstract
Objective
Soft tissue defect reconstruction by transposition of well-vascularized muscle tissue with a muscle flap and as an osteomuscular flap together with a fibular bone segment for combined skeletal and soft tissue defects.
Indications
Small- and medium-sized defects of the hindfoot, around the ankle and the distal and middle third of the lower leg, skeletal reconstruction of underlying small- and medium-sized bone defects.
Contraindications
Lesions of the proximal anterior tibial artery (proximal pedicled flap), combined lesions of the distal peroneal artery including the communicating branch with the posterior tibial artery (distal pedicled flap); lesion or paralysis of the peroneus longus muscle in an intact ankle joint.
Surgical technique
Distally pedicled flap: blunt separation between the peroneus longus and brevis muscle, subperiosteal release with isolation on a distal septocutaneous branch of the peroneal artery. To increase perfusion, the proximally released branch of the anterior tibial artery may be re-anastomosed in the recipient site. Proximally pedicled flap: dissection of distal peroneus brevis muscle tendon and subperiosteal release in a proximal direction with ligation of the segmental peroneal artery branches until the flap is isolated on its proximal anterior tibial artery branch. For an osteomuscular flap, simultaneous harvest of a fibula segment underneath the muscle origin with preservation of the intimate periosteal relationship between muscle and bone.
Postoperative management
Complete immobilization and elevated leg position for 5 days, followed by successive orthostatic training for 10 days. Postoperative standardized compression garments for 6 months, eventually combined with silicone sheet scar therapy.
Results
Reliable, excellent functional and aesthetic results with very low donor site morbidity.
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Giessler, G., Schmidt, A. Die Musculus-peroneus-brevis-Lappenplastiken. Oper Orthop Traumatol 25, 131–144 (2013). https://doi.org/10.1007/s00064-012-0202-7
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DOI: https://doi.org/10.1007/s00064-012-0202-7