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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1369-1374

Reconstruction of the middle third of the leg by distally based hemigastrocnemius muscle flap


1 General Surgery Department, Faculty of Medicine, Menoufia University, Kafr El-Sheikh, Egypt
2 Plastic Surgery Department, Faculty of Medicine-Menoufyia University, Kafr El-Sheikh, Egypt
3 Resident of Plastic Surgery at El-Obour Hospital, Kafr El-Sheikh, Egypt

Date of Submission04-Apr-2017
Date of Acceptance23-Apr-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Mohammad K Bassam
Kafr El-Sheikh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_249_17

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  Abstract 


Objective
The aim of this study was to evaluate coverage of middle third leg soft tissue defects using distally based hemigastrocnemius muscle flap regarding advantages, disadvantages, and rate of complications.
Background
Skin defects of the leg still present a reconstructive problem particularly if associated with complicated orthopedic lesions, which is why coverage of the soft tissue defects of the middle third leg is a challenge to plastic surgeons
Patients and methods
This study was done at the Department of Plastic and Reconstructive Surgery, Menoufia University Hospitals, from January 2015 to January 2017, with a follow-up period of 12 months. The study included 20 patients – 15 males and five females – and their ages ranged between 22 and 65 years. Patients presented with posttraumatic pretibial defects, and the main cause was motorcycle accidents. Some patients were associated with fracture of the tibia or both bones of the leg. All defects were covered by the distally based hemigastrocnemius muscle flap.
Results
Early complication included graft rejection in two (10%) patients, partial flap necrosis in two (10%) patients, wound infection in one (5%) patient, postoperative hematoma in one (5%) patient, and delayed graft take in one (5%) patient. Late results during follow-up showed one (5%) patient with hypertrophic scar of the donor area and one (5%) patient with hyperkeratosis. All postoperative complications were managed conservatively, and flap provided stable reconstructive option.
Conclusion
The distally based hemigastrocnemius muscle flap can be used for reconstruction of the middle third leg soft tissue defects.

Keywords: graft rejection, hematoma, leg, surgical flaps


How to cite this article:
Gad SS, Kishk TF, Elkashty SM, Bassam MK. Reconstruction of the middle third of the leg by distally based hemigastrocnemius muscle flap. Menoufia Med J 2018;31:1369-74

How to cite this URL:
Gad SS, Kishk TF, Elkashty SM, Bassam MK. Reconstruction of the middle third of the leg by distally based hemigastrocnemius muscle flap. Menoufia Med J [serial online] 2018 [cited 2024 Mar 28];31:1369-74. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1369/252034




  Introduction Top


The standard of surgical management of lower extremity trauma has advanced from that of amputation during World War I and II to one of extremity salvage by progression in debridement techniques, fracture fixation (and later bone lengthening/transport), and soft tissue coverage via local, regional, and free tissue transfers[1].

The progression in limb salvage started with the presentation of microsurgery from the 1960 onward. This advance allowed the use of vascularized tissue to cover and repair soft tissue defects[2].

In some centers, which claim relatively restricted facilities, alternative methods such as the cross-leg flap[3] or the reversed dermis flap[4] are advanced as similarly adequate and dependable. In most publications, there is usually no direct comparison between the different methods available, but there are exceptions[5].

The customary reconstructive ladder presented by Mathes and Nahai in 1982 to cover tissue defects beginning with secondary intention closure, direct wound closure (primary or delayed primary closure) of wounds followed by autologous skin grafting, regional and local pedicled flaps, tissue expansion, and free tissue transfer were further strides[6].

Many reconstructive techniques have been published to repair soft tissue defects in the middle third of the leg, like proximally based fasciocutaneous flaps based on the posterior tibial or peroneal perforators and a distally based fasciocutaneous flap based on the lower posterior tibial perforator[7].

The soleus muscle is used for the reconstruction of defects of the middle third of the leg based on its major pedicle. Nonetheless, the use of the soleus muscle in a reverse manner, based on its secondary pedicles, has been reported by several authors for the proper coverage and repair of defects of the lower third of the leg as another option to use microsurgical flaps[8].

The aim of our work was to evaluate distally based hemigastrocnemius muscle flap being an option for coverage of middle third leg soft tissue defects regarding advantages, disadvantages, and rate of complications.


  Patients and Methods Top


This study was done at the Department of Plastic and Reconstructive Surgery, Menoufia University Hospitals, from January 2015 to January 2017, with a follow-up period of 12 months. The study was approved by ethical committee of Menoufia Faculty of Medicine. All subjects gave written informed consent before inclusion into the study. The study included 20 patients – 15 (75%) male and five (25%) female – and the mean age of the patients was 38.8 years. All patients presented with posttraumatic pretibial medium-sized defects, with mean size of the defects of 7.45 × 7.67 cm. The main causes of the defects were motorcycle accidents [Figure 1] and [Figure 2], postburn ulcer, and post-tumor excision [Figure 3]. Some patients were associated with fracture of the tibia or both bones of the legs and were fixed with either external or internal fixations by orthopedic surgeons, and the patients were referred to our Plastic Surgery Department for soft tissue coverage.
Figure 1: Operative steps using distally based hemigastrocnemius muscle flap. (a) Preoperative photograph of right leg with defect; (b) midline skin incision with dissection of the pedicel; (c) division of the medial sural neurovascular pedicle; (d) identification of the first communicating arteriole in the raphe between the two heads; (e) the distally based medial head was delivered through a wide subcutaneous tunnel; (f) the muscle fascia was scored, and the muscle flap was sutured to the edge of the defect; (g) the muscle flap was covered by a split thickness skin graft; (h) 3 months postoperatively.

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Figure 2: A 31-year-old male patient with history of road traffic accident had leg defect in the middle third of the right leg with tibial fracture, and external fixator was done by orthopedic surgeons. (a) Intraoperative photograph of right leg with a defect at the junction of the middle and distal thirds with segmental loss of tibia after debridement by orthopedic surgeons; (b) radiography of the right leg showed fracture of tibia and fibula with segmental loss of the tibia; (c) separation of the medial head off the lateral head along the raphe down to the intercommunicating vessels; (d) the medial head detached from its origin down along the raphe with criss-cross scoring of the muscle fascia; (e) medial head was delivered via a wide subcutaneous tunnel into defect with graft coverage; (f) a 6-month postoperative photograph after bone grafting of the segmental tibial loss and Ilizarov fixation.

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Figure 3: A 38-year-old male patient with past history of soft tissue tumor removed by general surgery and grafted at the time presented with ulcer in the middle third tibia underwent distally based medial head gastrocnemius. (a) Preoperative defect in the upper middle third; (b) marking the thirds and the defect; (c) midline skin incision with dissection and separation of the muscle head; (d) distally based muscle marked 8 cm proximal to musculotendoneous junction with release of origin; (e) after transposition of distally based flap to the defect; (f) late postoperative result with full graft takes.

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Methods

Inclusion criteria

The inclusion criteria were as follows: all patients presented with posttraumatic mid third leg defects, aged between 10 and 65 years old, and fit for surgery.

Exclusion criteria

Patients unfit for surgery; patients with peripheral vascular diseases and suspected vascular injury of the limb, children younger than 10 years, and elderly patients aged more than 65 years were excluded.

Patients were subjected to following:

Full history taking, clinical examination including general examination of the patient, local examination of (site-size) of the defect, motor status–sensory status of the affected leg, and assessment of distal circulation.

  • All our patients subjected to routine laboratory investigations such as complete blood picture, liver profile, kidney function test, prothrombin time and activity, international normalized ratio, fasting blood sugar, and hepatitis markers
  • Radiography of the injured limb to rule out underlying fracture and osteomyelitis.


Operative technique

The operative technique was performed under spinal anesthesia in most of cases; however, some were performed under general or epidural anesthesia with tourniquet control, which was placed in the thigh of the limb to be operated. The patients were positioned supine at first for debridement of necrotic or unstable tissues, and the recipient area was covered with a saline-soaked gauze bandage. Then, the patients were moved in the lateral decubitus position, with the operated leg upward for ease of access. A longitudinal skin incision was made in the middle of the upper calf region down to the deep fascia, starting from the popliteal crease proximally to be ended at the lower end of the gastrocnemius distally. Thereafter, the muscle was dissected and separated from the underlying soleus and other muscles. The sural neurovascular pedicle originating from the popliteal vessels and the posterior tibial nerve for the selected head of the muscle to be used was dissected, isolated, and divided. Then, the selected head was disinserted from its origin of the femoral condyle and separated down from the other head along the intermuscular raphe. Caution must be taken for preserving the most distal third of the raphe to preserve the vascular communications between the two heads. After flap elevation scoring of the muscle fascia was done for increasing its surface area and deflation of tourniquet with good hemostasis and observation of viability of the muscle flap fibers and the debridement of nonviable fibers if any was done down to bleeding points of the muscle fibers, then subcutaneous tunnel was created between the donor site of the flap and the defect by finger blunt dissection and then flap sliding through the tunnel into the defect by using long retractor. Fixation of the muscle flap was done to the periphery of the defect by transverse mattress sutures using vicryl 2.0 to be overlapped by the undersurface of the normal skin. Finally, a split thickness skin graft was attached over the muscle and fixed by staples or simple interrupted sutures by vicryl 4.0. Calf incision was closed by direct suture over a suction drain number 16, which was mandatory to obliterate the dead space created by the elevation of the flap, as it is evacuated daily, and the color and amount of suctioned fluid were documented. When the fluid was serous and less than 50 ml for 2 days, the drain was removed. A piece of Vaseline gauze can be placed directly on the graft and covered with layers of gauze. Following this, a well-padded posterior plaster splint, from above the knee to the toes, was placed and not removed until the fifth postoperative day, at which time the gauze was removed and appropriate rehabilitation instituted [Figure 1].

For all of our patients, the following hospital data were obtained: operative details; operative time; photographs (preoperative, intraoperative, and postoperative); and operative complications, including wound infections, hematoma, seroma, and function loss, with study of flap survival, graft take, and aesthetic outcome.

Statistical analysis

All data were collected, tabulated, and statistically analyzed. The descriptive measures of central tendency (mean and median) and measures of dispersion (range, SD, minimum and maximum), besides frequency and percentage, were calculated by SPSS 20 statistical software package (SPSS Inc., Chicago, Illinois, USA).


  Results Top


This study included 20 patients, with 15 (75%) male and five (25%) female. All presented with posttraumatic middle third leg defects. Some patients were associated with fractures of tibia or both bones, representing 60% [Figure 1] and [Figure 2], and other 40% did not have any fractures [Figure 3]. The mean length of defect was approximately 7.45 cm, with mean defect width of 7.67 cm. The leg defects were located in the middle third of the leg alone by 85%, in the middle third with lower portion of the upper third by 10%, and at the middle third with upper portion of the lower third by 5% [Table 1]. All defects were reconstructed by distally based hemigastrocnemius muscle flap. Mean follow-up was 12 months. Early complications showed 10% of them had graft rejection, 10% had partial flap necrosis, 5% had wound infection, 5% had hematoma, and 5% had delayed graft take, whereas the late results of complications showed only 5% of patients with hypertrophic scar of the donor site and 5% of the patients with hyperkeratosis [Table 2]. Regarding donor site morbidity, no functional deformity was reported. Because of the thinness of the flap, no defattening procedure had to be performed, and the subjective esthetic result, according to the patients, was satisfactory in 90% of the patients. No recurrence of ulceration was noticed during follow-up.
Table 1: Preoperative data of the studied patients

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Table 2: Postoperative complications among the studied patients

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  Discussion Top


Open injuries and deformities in the lower extremity result from trauma, tumor resection, and chronic diseases such as peripheral vascular disease and diabetes; these wounds need reconstruction for some reasons. Initially, any uncovered bone that is not secured by vascularized soft tissue is at risk for osteomyelitis, bone necrosis, and sepsis. Osteomyelitis is a noteworthy reason for amputation in patients after leg trauma or patients with systemic illness, most commonly diabetes[9],[10],[11]. Second, open injuries cause chronic pain, inability to ambulate, significant therapeutic costs, and unemployment. Uncovered tendons become dry and necrotic, and exposed blood vessels are at hazard for rupture.

Careful debridement is imperative for the effective result of the treatment of lower limb trauma[12].

Reconstruction of the injury ought to be performed as effectively as could reasonably be expected. Once the wound is clean and well vascularized, reconstruction alternative is chosen from the reconstructive ladder[13].

Primary closure and delayed closure, in addition to wound coverage with a graft, are well documented alternatives and should be attempted in simple wound, in those where expedited recovery is required, or where more complex reconstructive failure would be disastrous[14].

Tissue loss of the middle third of the leg can be covered with the soleus flap[15]. However, the defect will be covered by the least vascularized part of the flap, and the volume of the flap is frequently too little to fill the defect, plus an unsatisfactory donor site scar.

The split tibialis anterior muscle flap can be additionally used; however, its use is constrained by its little size, restricted mobility, and injury liability by fractured tibia, making it perfect for limited and narrow longitudinal pretibial defects[16].

Local random-pattern skin flaps have random perfusion pattern, limited size and arc of rotation, and the need for skin grafting of the donor site. The reversed sural flap is an another option but is plagued by the sensory loss at the lateral foot, the ugly grafted donor site, especially in females, and the high complication rate if there is comorbid diseases such as diabetes mellitus and peripheral vascular diseases[17],[18].

The cross-leg flaps have stood the test of time ever since its first description by Hamilton in 1854 It has always found an important place in the surgeon's armamentarium in reconstructive surgeries of the lower limb even in the era of microsurgery and supermicrosurgery. The cross-leg flap has the disadvantage of long-term immobilization and several operative stages[19],[20].

Muscle flaps, by virtue of their excellent intrinsic blood supply and moldable nature that fills in the irregular cavities of the bone, are the best solution for such defects[21]. The medial head of the gastrocnemius muscle in adult measures 15–20 cm in length and 8 cm in width. The corresponding skin territory of each head measures 23 cm in length and 10 cm in width. The area of potential wound closure is greater for the myocutaneous flap than for the muscle flap alone[22].

In our study, males represents 75% and females 25%, and this shows how much males are more prone to having leg defects in Egypt. This is coincident with that 70% of studied patients were trauma patients as they are more involved in the road traffic accidents especially the motorcycles as it is a main method of transport in Menoufia and males are the main labor category and there were another causes for leg defects as chronic leg ulcers (10%) that resulting after burn and did not respond to normal care by dressing or grafting and need more advanced reconstructive options so we decided to use distally based gastrocnemius flap for treating such defects. Moreover, leg defects after exposed prosthesis secondary to wound infection over the prosthesis represented 5% of our study. Additionally, 10% had osteomyelitis with soft tissue loss over the infected bone, and finally, we reconstructed one case (5%) that showed defect that resulted after sarcoma excision and failure of graft coverage done by general surgeons after cycle of radiotherapy.

We had the following distribution of cases in our study with leg defects: 85% were isolated middle third tibia, whereas the rest 15% involved additional parts of the middle third, as either middle third of tibia with lower portion of proximal third (10%) or middle third of tibia with upper portion of distal third (5%). Moreover, an extensive tibial wound of the leg is commonly associated with orthopedic trauma, and the successful soft tissue coverage of the open fracture site provides a critical means for primary or secondary healing of the tibial fracture and subsequent limb salvage. In this study, 60% of the patients were associated with fracture of the tibia or both bones of the legs.

Bashir[23] described an inferiorly based muscle flap of the medial head. This flap was supplied exclusively by the lower most communicating vessel between the two gastrocnemius heads.

Tarek[24] successfully used the distally based hemigastrocnemius flap in covering the middle third leg defects in 19 patients and concluded that the flap was useful for reconstruction of the middle third of the leg.

Magdy[25] successfully used the distally based medial head hemigastrocnemius muscle flap based on the blood supply through communicating arteries with the lateral head to cover the defects in the middle third of the leg in seven cases. There was no flap necrosis or failure, one case lost graft and need re grafting, one case had hematoma in the donor site, and one case had wound dehiscence, which was healed by local wound care. The author concluded that the flap was a simple technique allowing rapid, durable, and reliable coverage of these defects without sacrificing a nerve or a major vessel.


  Conclusion Top


The distally based hemigastrocnemius muscle flap based on the vascular bundles between the two heads can be useful for reconstruction of the middle third of the leg. There are many related advantages of this flaps such as being a simple technique allowing full tissue coverage in a one-stage operation, and it is present in the dissection field. Full tissue coverage, functional recovery, and good esthetic results are achieved with minimum damage to the donor site. In addition, the surgical procedure is relatively short and easy to perform, and it does not require microsurgical skills and instruments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Saint-Cyr M, Schaverian MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy and use in reconstruction (CME). Plast Reconstr Surg 2007; 123:132e–145e.  Back to cited text no. 1
    
2.
Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr Surg 2010; 125:582–588.  Back to cited text no. 2
    
3.
Ambroggia G, Oberto E, Teich-Alasia S. Twenty years' experience using the cross leg flap technique. Ann Plast Surg 1982; 9:152.  Back to cited text no. 3
    
4.
Thatte RL. One stage random pattern de-epithelialized 'turn over' flaps in the leg. Br J Plast Surg 1982; 35:287.  Back to cited text no. 4
    
5.
Serafin D, Georgiada NG, Smith DH. Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot. Plast Reconstr Surg 1977; 59:492.  Back to cited text no. 5
    
6.
Knobloch K, Vogt PM. The reconstructive sequence of the 21st century-the reconstructive clockwork. Chirurg 2010; 81:441–446.  Back to cited text no. 6
    
7.
Barklay TL, Cardoso E, Sharpe DT, Crockett DJ. Repair of lower leg injuries with fasciocutaneous flaps. Brit J Plastsurg 1982; 35:127–132.  Back to cited text no. 7
    
8.
Pu LL. The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg. Ann Plast Surg 2006; 56:59–63.  Back to cited text no. 8
    
9.
Harris AM, Althausen PL, Kellam J, Bosse MJ, Castillo R. Lower Extremity Assessment Project (LEAP) Study Group. Complications following limb-threatening lower extremity trauma. J Orthop Trauma 2009; 23:1–6.  Back to cited text no. 9
    
10.
Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008; 122:1796–1805.  Back to cited text no. 10
    
11.
Scher KS, Steele FJ. The septic foot in patients with diabetes. Surgery 1988; 104:661–666.  Back to cited text no. 11
    
12.
Olerud S, Karlstrom G, Danckwardt-Lilliestrom G. Treatment of open fractures of the tibia and ankle. Clin Orthop 1978; 136:212–224.  Back to cited text no. 12
    
13.
Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg 2006; 117:193S–209S.  Back to cited text no. 13
    
14.
Oganesyan G, Jarell AD, Srivastava M, Jiang SI. Efficacy and complication rates of full-thickness skin graft repair of lower extremity wounds after Mohs micrographic surgery. Dermatol Surg 2013; 39:1334–1339.  Back to cited text no. 14
    
15.
Arnold PG, Yugueros P, Hanssen AD. Muscle flaps in osteomyelitis of the lower extremity: a 20-year account. Plast Reconstr Surg 1999; 104:107.  Back to cited text no. 15
    
16.
Nikhil P, Parag S, Ganesh P, Ajay C, Rajendra D, Lalit R. The split tibialis anterior muscle flap: a simple solution for longitudinal middle third tibial defects. Indian. J Plast surg 2012; 45:53.  Back to cited text no. 16
    
17.
Touam C, Rosoucher P, Bhatia A, Oberlin C. Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one fourth of the leg, the ankle and the foot. Plast Reconstr Surg 2001; 107:383.  Back to cited text no. 17
    
18.
Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstur Surg 2003; 112:129.  Back to cited text no. 18
    
19.
Topalan M. A new and safer anastomosis technique in cross-leg flap procedure using the dorsalis pedis arterial system. Plast Reconstr Surg 2000; 105:710–713.  Back to cited text no. 19
    
20.
Atiyeh BS, Al-Amm CA, El-Musa KA, Sawwaf AW, Musharafieh RS. Distally based sural fasciocutaneous cross-leg flap: a new application of an old procedure. Plast Reconstr Surg 2003; 111:1470–1474.  Back to cited text no. 20
    
21.
Agarwal P, Dawar R, Yadav P. The segmental gastrocnemius muscles' flap. A cadaveric study. J Plast Reconstr Surg Aesth Surg 2011; 64:1202–1206.  Back to cited text no. 21
    
22.
Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. New York: CV Mosby Company Publishers; 1982. pp. 514–524.  Back to cited text no. 22
    
23.
Bashir AH. Inferiorly-based gastrocnemius muscle flap in the treatment of war wounds of the middle and lower third of the leg. Br J Plast Surg 1983; 3:307–309.  Back to cited text no. 23
    
24.
Tarek K. Reconstruction of the middle third of the leg by distally based hemigastrocnemius muscle flap. Egypt J Plast Reconstr Surg 2010; 34:181–186.  Back to cited text no. 24
    
25.
Magdy Ahmed AA Gastrocnemius muscle flap for middle third leg defects. Egypt J Plast Reconstr Surg 2014; 38:197–204.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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