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The tendons of the both peroneus longus and brevis muscles lie in the lateral compartment of the leg, enclosed in a fascial sheath. This sheath has been dissected off the tendons in three cases and opened longitudinally forming a sheet of vascularised fascia proximally based and continuous with the peroneal muscles. These sheets of 6×12 cm dimensions have been successfully transposed with split skin graft to cover an exposed Achilles tendon. In another case, the peroneus brevis muscle and the opened fascial sheath of the peroneus longus tendon forming one sheet was used to cover a defect over the Achilles tendon 10 cm above the heel. This ‘tenofascial flap’ offers regional tissue to solve the difficult lower third leg defects especially those of Achilles tendon exposure, as it is thin, pliable, allows gliding of the tendon underneath it and vascular enough to sustain a durable skin graft.
The leg is composed of three compartments. The lateral or peroneal one contains two muscles; the peroneus longus is superficial and higher than the peroneus brevis. Its muscle fibres end at the beginning of the lower third of leg with a tendon passing vertically downward behind the lateral malleolus to be inserted in the medial aspect of the foot. The peroneus brevis muscle is the deeper and lower muscle, hence its muscle fibres reach the lower third of the leg and its tendon continues deep to that of peroneus longus behind the lateral malleolus to be inserted in the lateral aspect of the foot. The two peroneal tendons are enclosed in a fascial sheath part of which contains synovium, which start approximately 4 cm proximal to the lateral malleolus and end at a similar distance distally. The sheath is single proximally and becomes doubled distally.
The exposed Achilles tendon following trauma, infection and failed repair often poses a problem for the plastic surgeon. Regional tissue especially vascularised fascial flaps is not always available to cover the exposed tendon. Many authors use free microvascular fascial flaps to cover this region.
This paper present a fascial flap dissected off the peroneal tendons and used to cover an exposed Achilles tendon in four cases, with successful outcome.
1. Patients and methods
Four cases with chronic ulcers over the Achilles tendon were treated in the year 2000. Table 1illustrates the cases.
2. Vertical skin incision at the lateral edge of the defect running up or downwards according to the site of the ulcer, over the peroneus longus tendon, 1–2 cm behind the lateral malleolus.
3. The deep fascia is opened in the incision line opening the peroneal compartment.
4. Release of the peroneal retinaculum with care not to injure the fascia over the tendons.
5. Dissection of the fascial flap:
(A) In three cases. Collar incision in the synovial sheath around the peroneal tendon at the tip of the lateral malleolus.
Splitting the tendon sheath deep to the peroneus brevis tendon, then dissection of the tendon sheath off the peroneal tendons, as one sheet continues from distal to proximal till the muscle fibres of the peroneus brevis muscle are reached, and are separated from the tendon in its lowermost fibres.
Now, the tendon sheath is dissected and split to form a sheet of vascularised fascia proximally pedicled with dimensions 6×12 cm as shown in Figure 2.
Figure 2Intra-operative photo showing the peroneal tendofascial flap of both peroneal tendons spreaded before transposition.
The flap of ‘peroneal tendofascia’ is transposed to cover the exposed Achilles tendon as shown in Figure 3.
Figure 3The fascial flap transposed to cover the Achilles tendon and peroneal tendons. Addison's forceps is shown to pass deep to the flap before the last suture.
After debridement and opening the peroneal compartment, dissection of the flap started at the same point by cutting the peroneus brevis tendon and its sheath, while the sheath of the peroneus longus only was cut.
Proximal dissection was continued by dissecting the tendon sheath of peroneus longus alone but attached as one sheet with peroneus brevis muscle which was separated from the periosteum of the fibula till the mid leg.
Now, a flap composed of peroneus brevis muscle and peroneal longus tendofascia is transposed to cover the exposed Achilles tendon as shown in Figure 7.
Figure 7(A–C) These diagrams illustrate the standard method of raising the flap described and transposing the fascial and synovial flap. (D) Shows the flap transposed with the peroneus brevis muscle (see text).
In the four cases, the fascial flap survived completely and the skin graft has taken.
The cases have been followed up for at least six months for the durability of the skin graft and motility of the ankle joint. Results are very promising as no breakdown of the skin graft had been noticed, also all the cases were ambulant two weeks after surgery with full range of movement along the follow-up period.
3. Discussion
The tendons of the peroneus longus and peroneus brevis muscles pass vertically downwards in the lower third of the lateral compartment of the leg, enclosed in a fascial sheath, the lower part of it contains synovium which splits into two separate sheathes distal to the lateral malleolus. The blood supply of this fascial and synovial sheath seems to come from the muscle proximally as it is continuous with its outer fascia and muscle fibres and the author did not notice any significant vessel cut during dissection of the four cases. In this work, the described fascial sheath was dissected off the tendon and opened longitudinally forming a sheet of vascularised fascia proximally based and of 6×12 dimensions. This fascial flap had been transferred to cover an exposed Achilles tendon with split skin graft over it with good results. In a higher and larger defect over the Achilles tendon, a flap of vascularised tissue of 7×13 composed of peroneous brevis muscle and split fascial sheath of peroneus longus tendon has been transposed and covered with split thickness skin graft resulting in complete healing of the ulcer. This fascial flap to the best of my knowledge was not described before and we refer to it as a peroneal tendofascial flap.
Dissection of this flap was easy with constant anatomy. Although this fascial flap is thin, it is vascular and strong enough to offer durable, sound coverage of the Achilles tendon without any functional motor deficit as proved during the follow-up period.
Fascial flaps are preferred in coverage of the Achilles tendon because they are pliable and thin, yet large enough to be wrapped completely around the tendon and interposed between it and the ankle joint if necessary.
Turnover distally based adipofascial flaps based on perforators of the posterior tibial or peroneal vessels are the available local fascial cover for Achilles tendon.
The aetiology behind tendon exposure either trauma, infection or burn may destroy the distal perforators around the tendon, hence directing the surgeon to use free microvascular fascial flap. This paper presents a local fascial flap expanding the armamentarium of the reconstructive surgeon to use local tissues to cover an exposed Achilles tendon with the following advantages:
1.
Minimal donor site morbidity as it lies within the vicinity of the defect (Fig. 8)
Figure 8Early post-operative result (2 week) showing complete graft take and donor site incision.
Highly dependable vascularity with constant blood supply
4.
Easy dissection and short operative time
5.
It lies in a deeper anatomical plane to that of both the fasciocutaneous and adipofascial flaps, as a result, it is not affected in most of the cases by the factors exposing the tendon.
6.
It can cover wide defects (7–8 cm in breadth) when combined with the peroneus brevis muscle which does not exceed 4 cm in breadth when used alone
Finally, this peroneal tendofascial flap can theoretically rotate anteriorly to cover defects located in the anterolateral aspect of the lower third of the leg.
4. Conclusion
The tendon sheath of both peroneal tendons in the lateral compartment of the leg was dissected off the tendons from distal at the lateral malleolus to proximal, resulting in vascularised fascial flap used to cover an exposed Achilles tendon in three cases and combined with peroneus brevis muscle in the fourth case. This fascial flap ‘peroneal tendofascial flap’ has the advantages of being thin, pliable, resilient, well vascularised to offer durable skin graft, easily dissected in short operative time and has constant proximal blood supply usually not affected by the various aetiologist factors exposing the tendo Achilles. This new flap may increase the capability of the reconstructive surgeon to cover the difficult lower third leg defects by regional tissue.
References
Williami P.L
Lawrence H.B
Martin M.B
et al.
Gray's Anatomy. 35 ed. Churchill Livingstone,
New York1995 (p. 856)
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