Gastrocnemius Flap Research Articles

Calcaneal insufficiency fracture in a child with osteosarcoma after chemotherapy and limb-sparing surgery

We report a rare case of a calcaneal insufficiency fracture in an 11-year-old boy with an osteosarcoma of the right proximal tibia. After one course of neoadjuvant chemotherapy for 4 months, we performed limb-sparing surgery. The knee joint was replaced with a custom-made endoprosthesis and the knee extensor mechanism was reconstructed with a medial gastrocnemius muscle flap. Seven months postoperatively, he complained of pain in the right foot and a plain radiograph revealed a calcaneal insufficiency fracture. Osteoporosis induced by chemotherapy and change of forces transmitted to the calcaneus after reconstruction with a gastrocnemius muscle flap might contribute to this fracture. It is important to be aware of the rare clinical entity of insufficiency fracture for making an early diagnosis and for differentiating them from pathological fractures associated with malignancy.

Wound Problems in Total Knee Arthroplasty

Wound problems can often be prevented with careful planning. When transverse incisions are used for knee surgery many years prior to any anticipated knee arthroplasty, no major problems are typically encountered with a conventional, anterior longitudinal incision. We recommend lateral incisions (eg, after a previous lateral tibial plateau fracture) be reused for TKA. When confronted with multiple previous incisions, surgeons would best use the most recently healed or the most lateral. We prefer soft tissue reconstruction with expanders or a gastrocnemius flap if there are multiple incisions, if the skin and scar tissue are adherent to underlying tissue, or if wound healing seems questionable. Deep infection must be determined by aspiration. When present, we believe treatment must include irrigation, débridement, polyethylene exchange if acute, and resection arthroplasty if chronic. Poor wound healing is a potentially devastating complication that may result in multiple reconstructive procedures and even amputation. Early recognition followed by expeditious débridement and soft tissue reconstruction should be used for managing wound complications after TKA.

The Segmental Gastrocnemius Muscle Flap: Anatomical Study and Clinical Applications

The versatility of the gastrocnemius muscle for reconstruction of defects in the knee region from the upper third of the calf to the lower third of the thigh is well known. Possible limitations of this flap include difficulties in covering multiple separate wounds in the same area as well as contour deformity because of the flap bulkiness. The findings in this study extend the versatility of the gastrocnemius muscle flap by splitting each head into two segments allowing for the closure of multiple defects. Studied was the vascular anatomy of 15 fresh cadaveric lower extremities. Contrast material was injected into the sural artery and this showed the bifurcation of the pedicle in the upper third of the muscle. A constant intramuscular vascular pattern represented by two main longitudinal branches permitted the safe division of each head. Based on these anatomic studies, segmentation was performed of the gastrocnemius muscle flap in 29 patients. In 13 cases were used, one or two muscle segments and in 16 cases, three muscle segments were transposed. All of the flaps survived. Minor complications, such as wound dehiscence, cellulitis, or hematoma, were encountered in seven patients. Except for one patient with persistent drainage from osteomyelitic bone, all the wounds closed successfully. The authors report the safe splitting of the distal gastrocnemius muscle in 29 patients based on vascular anatomic studies. The advantages of gastrocnemius segmentation include the possibility of covering multiple defects with less contour deformity.

Reconstruction of Segmental Bone Defects Due to Chronic Osteomyelitis with Use of an External Fixator and an Intramedullary Nail

Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation.

RECONSTRUCTION OF SEGMENTAL BONE DEFECTS DUE TO CHRONIC OSTEOMYELITIS WITH USE OF AN EXTERNAL FIXATOR AND AN INTRAMEDULLARY NAIL

Background: Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical débridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience with distraction osteogenesis performed with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb-shortening resulting from radical débridement of chronic osteomyelitis. Methods: Thirteen patients who ranged in age from eighteen to sixty-three years underwent radical débridement to treat a nonunion associated with chronic osteomyelitis of the tibia (seven patients) and femur (six patients). The lesions were classified, according to the Cierny-Mader classification system, as type IVA (nine) and type IVB (four). The resulting segmental defects and any limb-length discrepancy were then reconstructed with use of distraction osteogenesis over an intramedullary nail. Two patients required a local gastrocnemius flap. Free nonvascularized fibular grafts were added to the distraction site for augmentation of a femoral defect at the time of external fixator removal and locking of the nail in two patients. At the time of the latest follow-up, functional and radiographic results were evaluated with use of the criteria of Paley et al. Results: The mean size of the defect was 10 cm (range, 6 to 13 cm) in the femur and 7 cm (range, 5 to 10 cm) in the tibia. The mean external fixator index was 13.5 days per centimeter, the consolidation index was 31.7 days/cm, and the mean time to union at the docking site was nine months (range, five to sixteen months). At a mean follow-up of 47.3 months, eleven of the thirteen patients had an excellent result in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, the infection was controlled and the nonunions healed. Conclusions: This combined method may prove to be an improvement on the classic techniques for the treatment of a nonunion of a long bone associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. The earlier removal of the external fixator is associated with increased patient comfort, a decreased complication rate, and a convenient and rapid rehabilitation. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Cutaneous Island with V-Y Closure over a Gastrocnemius Muscle Flap

Cutaneous Island with V-Y Closure over a Gastrocnemius Muscle Flap

Medial Gastrocnemius Flap Coverage for Treatment of Skin Necrosis after Total Knee Arthroplasty

Skin necrosis after total knee arthroplasty is a rare complication that can rapidly lead to deep infection of the prosthetic components. The medial gastrocnemius transposition flap usually provides adequate soft tissue coverage to salvage the total knee arthroplasty. However, variations in defect location and excursion of the muscle flap can affect results. Twelve patients were treated with a medial gastrocnemius transposition flap after total knee arthroplasty. The skin defect that required flap coverage was located over the tibial tubercle or patellar tendon in eight patients (Group 1). The defect extended proximally to the patella or quadriceps tendon in four patients (Group 2). A functioning total knee arthroplasty was salvaged in 11 patients (92%). The medial gastrocnemius flap healed primarily in all patients in Group 1. Three patients in Group 2 required additional fasciocutaneous, lateral gastrocnemius, or free flap coverage, and one patient underwent above knee amputation. The medial gastrocnemius flap is most effective for coverage of distal defects over the tibial tubercle or patellar tendon. Defects that extend more proximally over the patella or quadriceps tendon are more likely to require additional procedures to achieve adequate soft tissue coverage. Therapeutic study, level IV (case series). See Author Guidelines for a complete description of levels of evidence.

Clinical application of distally based sural neurofasciocutaneous flap with muscle

目的 探讨带肌肉的远端蒂腓肠神经营养血管皮瓣修复特殊病例的踝足部软组织缺损.方法2004年2月以来应用带肌肉的远端蒂腓肠神经营养血管皮瓣修复踝足部软组织缺损7例,其中胫骨下段软组织缺损伴慢性骨髓炎1例,足后跟软组织缺损伴死腔3例,足底软组织缺损伴跟骨表层骨质缺失(长度为5～8 mm)3例,皮瓣切取的面积为16 cm×12 cm～10 cm×7 cm,切取的腓肠肌厚度为1～4 cm,肌瓣的面积比相应的皮瓣面积小.结果术中观察15～20 min,切取肌皮瓣的肌肉面活跃渗血,血液循环良好,皮瓣均成活,所有病例均经2～6个月以上随访,骨髓炎治愈,肌皮瓣外形满意,大部分恢复感觉,行走负重良好.结论带肌肉的远端蒂腓肠神经营养血管皮瓣可以成活,该手术操作简便,系特殊病例的踝足部软组织缺损需行肌皮瓣修复的良好供区。

Gastrocnemius muscle flap of both heads on a single vascular pedicle

We present a case of a muscle flap of both heads of gastrocnemius on a single vascular pedicle for reconstruction of a tibial defect. The flap was based on the medial sural vessels alone. The vascular supply to the lateral head was achieved through the anastomotic vessels along the gastrocnemial raphe.

Recurrent Basal Cell Carcinoma of the Lower Limb with Tibial Invasion

Basal cell carcinoma (BCC) is the most common skin malignancy and is most prevalent on the head and neck region, although BCC can occur in other sites, including the lower limbs. We report the case of an 85-year-old female patient who experienced recurrent BCCs in the lower limb with tibial invasion. Treatment consisted of wide skin excision, tibial osteotomy, intraoperative cryotherapy, and coverage with an internal gastrocnemius muscle flap. The computed tomographic scan showed local bone control of the BCC, with no recurrence, so we avoided limb amputation. The reported case is uncommon because of the site, the extent of bone infiltration, and local treatment with cryotherapy.

Management Of High Energy Tibial Fractures Using Ilizarov Apparatus

Forty-two high-energy tibial fractures (18 closed and 24 open) in 41 patients were treated with the Ilizarov apparatus between 1999 and 2004. Open wounds were debrided and tension free primary closure using interrupted nylon sutures was attempted wherever appropriate. In others, either split thickness skin grafting or local gastrocnemius flaps were used. Corticotomy and bone transport was instituted in patients with significant bone loss. Early weight bearing with range of motion exercises of ankle and knee joints were encouraged. Average fracture healing time was 5.3 months (range 3.5 8.5 months). Complications included pin site inflammation / infection (40.4 %), muscle transfixation (2 cases), shortening (3 cases), ankle joint stiffness (2 cases) and wire fracture (1 case). Based on Johner and Wruh's Criteria, there were 34 excellent, 6 good, 2 fair, and no poor results. The Ilizarov device provided early and definitive fixation for high-energy tibial fractures with good results.

Reconstructed Patellar Tendon Length after Proximal Tibia Prosthetic Replacement

A common problem after proximal tibia prosthetic reconstruction is insufficient extensor mechanism or extensor lag. Maintaining the reconstructed patellar tendon length is an important way to minimize extensor lag. We measured the patellar tendon length and extensor lag serially. From 1994-2003, seven consecutive patients with malignant bone tumors of the proximal tibia had prosthetic reconstruction. The extensor mechanism was reconstructed by reattachment of the patellar tendon to the prosthesis with a synthetic material and augmented by a gastrocnemius flap. The patellar tendon length was measured according to the Insall-Salvati ratio. The ratios at 30 degrees knee flexion decreased immediately postoperatively, and reverted to almost the same preoperative values within 18 months. The mean ratios at 60 degrees knee flexion are significantly greater than 30 degrees at 6 months postoperatively. These findings indicate that the patellar tendon stretched, whereas the extensor lag improved continuously for 12 months postoperatively. In the revision at 22 months postoperatively, although the patellar tendon was not reattached to the replaced prosthesis, the ratio and the extensor lag had not worsened. These results show that providing strong continuity of the patellar tendon, gastrocnemius flap, and leg extensors can decrease the extensor lag, although the patellar tendon stretches.

Tumeurs malignes osseuses du genou : exérèse et reconstruction

Both the distal femur and the proximal tibia are the preferential site of primitive malignant bone tumours, particularly adolescents' osteosarcomas. Total knee replacement is the gold standard when the tumour spreads to the epiphysis, when it is aggressive and extracompartimental. The prosthesis used in such case is the cemented press-fit of which the long centromedullar stems rest onto the healthy side of the isthmus. The joint is a hinge which may be rotational or not. In femoral lesions without joint invasion, in case of subtotal excision of the quadriceps, an extensor mechanism must be reconstructed, by transfer of the ischii and leg muscles. Surgery by antero-medial access allows controlling the vasculonervous pedicle. In tibial tumours, special attention must be paid to soft tissues, for the front prosthesis coverage (made using a medial gastrocnemius flap) and the extensor kinematization as well. If a part of the patellar ligament has been preserved, it is sutured on the biceps tendon after transferring both the osteotomized fibula and the medial gastrocnemius. If full excision of the patellar ligament has been performed, a combined composite prosthesis is used, that permits re-inserting the patient's extensor mechanism on the extensor mechanism of the allograft. In case of joint invasion, arthrectomy is necessary, using a total composite prosthesis with extensor allografting. After two decades of such reconstructive prostheses use, their long-lasting and satisfactory functional results following extensor reconstruction are confirmed and allow considering this therapeutic procedure even in young and active subjects. Biological reconstruction is recommended in patients with preserved epiphysis and joint (chondrosarcomas, metaphysis limited osteosarcomas). In femoral tumours, medial vascularized fibulas are used for reconstruction, with complementary lateral allografting. Plating is used for osteosynthesis. In tibial tumours, maintaining the allograft by a fixed nail may be effective. Arthrodeses are limited to some rare cases such as athletes, hard-working subjects, or major infectious risk. Today, prostheses are far more frequently used than arthrodeses. Owing to long-lasting effects, biological therapy is recommended provided it is compatible with satisfactory carcinologic excision. Such exeresis and reconstruction surgical procedures showed good oncologic and functional results, but interventions were complex, necessitating frequent resumptions. This surgery can be undertaken only by trained surgical teams, familiar with this type of prostheses, flap use, and vascularized bone transfers.

Prosthetic Survival and Functional Evaluation in Prosthetic Reconstruction of Malignant Bone Tumors of the Proximal Tibia

Purpose: This study retrospectively analyzed the prosthetic survival and functional results after a prosthetic reconstruction for malignant bone tumors of the proximal tibia. Materials and Methods: Thirty-five patients (32 osteosarcomas and 3 chondrosarcomas) were followedup for an average 72 months (24-167 months). A gastrocnemius flap was transferred in 12 patients and cement fixation of the stem was performed in 10. More than 40% of the bone length was resected in 12 patients. Results: Three patients had died of the disease at the time of the final follow-up. There were one local recurrence and five distant metastases. The major complications were infection (5), aseptic loosening (5) and periprosthetic fractures (1). Gastrocnemius flap affected the incidence of a deep infection in the proximal tibia (17.4% vs. 8.3%) but there were no statistical correlation. A resection of >40% of the involved tibia increased the incidence of aseptic loosening (p=0.002). The rate of prosthetic survival was 72% at 5 years and 58% at 10 years. The functional score at the final follow-up was 81% (43-93%). Conclusion: A prosthetic reconstruction in the proximal tibia showed acceptable oncologic and functional outcomes in patients at an intermediate term follow-up. Infection and loosening were the main factors threatening the survival of the prosthesis.

A case of referred pain following a pedicled medial gastrocnemius muscle flap

A case of referred pain following a pedicled medial gastrocnemius muscle flap

Medial Gastrocnemius Flap in the Reconstruction of Infected Total Knee Arthroplasty

Purpose: To evaluate the results of the medial gastrocnemius muscle flap to cover the wound necrosis and dehiscence caused by repeated surgery in the reconstruction of infected total knee arthroplasty (TKA). Materials and Methods: Out of forty three reconstructions of infected TKA performed between 1995 and 2002, eleven cases (25.6%) underwent medial gastrocnemius flap to cover the anterior skin defects at the time of reimplantation in two cases and in an average 3.3 weeks after reimplantation in seven cases. Two cases which refused reimplantation were treated by arthrodesis and delayed flap coverage and by flap surgery only resulting in pseudarthrosis respectively. They were five male and six female patients of 61 years (range, 56-77 years) of age in average. Clinical and radiological assessments were done for minimum two years of follow-up. Results: Nine cases (81.8%) maintained TK prostheses with less range of motion (in average) than ordinary TKAs of primary healing. Two patients refused TKA which resulted in one arthrodesis and one pseudarthrosis. There was no case of recurrence of wound dehiscence or infection. Conclusion: Medial gastrocnemius flap can salvage the prostheses by providing good soft tissue coverage for compromised operative wounds caused by infected TKA and repeated surgical interventions.

Management Of High Energy Tibial Fractures Using The Ilizarov Apparatus

Forty-two high-energy tibial fractures (18 closed and 24 open) in 41 patients were treated with the Ilizarov apparatus between 1999 and 2004. Open wounds were debrided and tension free primary closure using interrupted nylon sutures was attempted wherever appropriate. In others, either split thickness skin grafting or local gastrocnemius flaps were used. Corticotomy and bone transport was instituted in patients with significant bone loss. Early weight bearing with range of motion exercises of ankle and knee joints were encouraged. Average fracture healing time was 5.3 months (range 3.5 8.5 months). Complications included pin site inflammation / infection (40.4 %), muscle transfixation (2 cases), shortening (3 cases), ankle joint stiffness (2 cases) and wire fracture (1 case). Based on Johner and Wruh's Criteria, there were 34 excellent, 6 good, 2 fair, and no poor results. The Ilizarov device provided early and definitive fixation for high-energy tibial fractures with good results.

The Medial SuralMedial Gastrocnemius Perforator Local Flap

The medial sural(MEDIAL GASTROCNEMIUS) perforator flap has previously been described as a free flap distinguished by the potential for a large yet thin cutaneous flap that incorporates the calf skin territory. Its medial sural vascular pedicle can be tailored to allow reach extending from the popliteal fossa to the suprapatellar area also as a local flap without any need for microsurgery. Two variations presented are possible as either a broad-based peninsular or island flap. Both are alternatives to the more traditional medial gastrocnemius muscle flap and, because this is a true muscle perforator flap, function is always preserved.

Extended Medial Gastrocnemius Rotational Flap for Treatment of Chronic Knee Extensor Mechanism Deficiency in Patients with and without Total Knee Arthroplasty

Nine patients with chronic extensor mechanism disruption were treated with an extended medial gastrocnemius rotational flap reconstruction of the extensor mechanism. Seven patients previously had total knee arthroplasty and two patients had chronic infection of nonreplaced, native knees. Four patients previously had failed Achilles' tendon allograft reconstruction after total knee arthroplasty and two were complicated by infection. Infected arthroplasty patients had a staged procedure with placement of an antibiotic spacer after debridement and extended medial gastrocnemius rotational flap, followed by total knee arthroplasty replant 8 weeks later. The four infected arthroplasty patients had medical comorbidities that included a patient with HIV and hemophilia, and two with diabetes mellitus. Another patient with rheumatoid arthritis was severely malnourished as a result of dumping syndrome. Of the four patients treated by this two-stage procedure, one died in the early postoperative period from chronic medical issues after the second stage and another patient elected to have above-knee amputation after the first stage because of severe reflex sympathetic dystrophy. The final group of seven patients was studied at a mean followup of 21 months (range, 7-31 months), the average extensor lag was 13.5 degrees (range, 0-50 degrees ), and the average range of motion was 2 degrees to 93 degrees . The two patients with nonreplaced, native knees had extensor lags of 30 degrees and 10 degrees . All patients were able to regain sufficient extensor mechanism strength to return to independent ambulation, and all infections resolved after treatment. Two patients were able to ascend stairs foot over foot without support. In addition to the patient who had amputation, the other complication involved a wound breakdown that required a free flap at 13 months in a patient who had a failed Achilles' tendon allograft reconstruction after takedown of a knee fusion. Medial gastrocnemius flap reconstruction can provide successful salvage of a failed extensor mechanism allograft or an alternative to allograft reconstruction in patients with poor soft tissue coverage, previous infection, or a compromised immune system.

Long-term results of through-knee amputation with dorsal musculocutaneous flap in patients with end-stage arterial occlusive disease.

A modified technique of knee joint disarticulation using a dorsal musculocutaneous flap of the gastrocnemius muscle was first described in 1985. The operative results in 66 patients (33 women, 33 men; mean age 66.7 +/- 11.3 years, range 42-93 years) with gangrene due to peripheral vascular disease with 69 knee disarticulations are reported. After a mean survival period of 35.2 months (0-116 months), 88% ( n = 58) of the patients had died owing to cardiopulmonary reasons. The in-hospital 48-day mortality was 9%. Nine patients (14%) underwent reamputation at the above-knee level, and five patients underwent operative revision of the soft tissue. After discharge from the hospital, 35 of 60 patients (58%) were able to walk with the aid of a prosthesis. We conclude that knee disarticulation with the use of a myocutaneous gastrocnemius flap is a safe, functionally acceptable operative method in high risk vascular patients.