Gastrocnemius Flap Research Articles

Dorsalis Pedis Artery-based Flap to Cover Nonhealing Wounds Over the Tendo Achillis—A Case Series: 用足背動脈蒂皮瓣來覆蓋非癒合的跟腱手術傷口—系列病例報告

Background/PurposeSoft tissue necrosis after the repair of a ruptured tendo Achillis is a difficult problem commonly encountered by orthopaedic surgeons. Such wounds are difficult to manage because of the tenuous blood supply and the characteristic anatomical features of the area. Flaps such as the reverse sural flap, medial plantar flap, gastrocnemius flap and free flaps cover such wounds with a good success rate. The aim of our study was to investigate the use of a dorsalis pedis artery (DPA)-based flap to cover a wound over the tendo Achillis insertion area. MethodsWe report a series of 11 patients in whom wounds over the tendo Achillis insertion area were covered with a DPA-based flap. Between 1995 and 2012, 11 patients (nine men and two women), who were referred to us with a nonhealing wound over the tendo Achillis because of soft tissue necrosis after the open repair of a ruptured tendon, were selected for soft tissue coverage of the wound by using a DPA-based flap. ResultsThe average follow-up period was 2.4 years (range, 1–6 years). The mean operative time was 1.7 hours (range, 1.5–2.0 hours). At the latest follow-up examination, the flaps had survived in all patients. ConclusionA DPA-based flap is a good and relatively less complex procedure to use to cover defects over the tendo Achillis with minimum donor site morbidity.

V-Y ADVANCEMENT OF MEDIAL GASTROCNEMIUS MUSCLE FLAP FOR REPAIRING SOFT TISSUE DEFECTS IN MIDDLE AND LOWER SEGMENTS OF ANTERIOR TIBIA

To investigate the effectiveness of V-Y advanced medial gastrocnemius muscle flap to repair soft tissue defects in the middle and lower segments of the anterior tibia. Between March 2008 and March 2014, 8 patients with skin and soft tissue defects of the anterior tibia were treated, including 6 males and 2 females with an average age of 36.2 years (range, 28-47 years). The soft tissue defects located at the left leg in 5 cases and at the right leg in 3 cases. The causes included traffic accident injury in 6 cases, and heavy pound injury in 2 cases. Three cases had simple soft tissue defects, and the disease course was 5 hours, 6 days, and 14 days, respectively. Five cases had soft tissue defects and fractures, including 1 case of Pilon fracture, and 4 cases of middle and distal tibial fracture; open reduction and internal fixation were performed in 3 cases, the implementation of external fixation in 2 cases; 1 case had chronic osteomyelitis at 11 months after operation, and 4 cases had skin necrosis and wound infection at 1 to 2 weeks after operation; the duration was 1-12 months (mean, 3.4 months). The skin and soft tissue defect area was 5.2 cm×2.5 cm to 13.0 cm×5.5 cm. Debridement was given, and vacuum sealing drainage was used in 6 cases, and then V-Y advancement of medial gastrocnemius muscle flap was used to cover the wound. Because of light wound contamination, the wound was repaired by the flap after emergency debridement in 1 case; 1 patient with osteomyelitis underwent flap repair at immediate after sensitive antibiotics use and debridement. The size of medial gastrocnemius muscle flaps ranged from 15 cm×6 cm to 26 cm×15 cm. The donor site was sutured in 3 cases or repaired with skin graft in 5 cases. One case had tension blisters in the distal flap, which was cured after symptomatic treatment. The flap and skin graft survived, and primary healing was obtained in the other cases. Seven patients were followed up 6-18 months (mean, 9 months). The texture and appearance of the flaps were satisfactory. At 6 months after operation, two-point discrimination ranged from 12 to 18 mm (mean, 16 mm). The plantar flexion was weaker than that of normal side, but the patients could normally walk and had normal gait. The V-Y advancement of medial gastrocnemius muscle flap is recommendable to repair soft tissue defects in the middle and lower segments of the anterior tibia for the advantages of reliable blood supply, simple operation, high survival rate of the flap, and satisfactory appearance.

Achilles Tendon Open Repair Augmented With Distal Turndown Tendon Flap and Posterior Crural Fasciotomy.

The aim of the present study was to investigate the outcomes after open repair of Achilles tendon rupture augmented with a distal turndown gastrocnemius flap and deep posterior crural fasciotomy based on the modified Lindholm technique. Twenty-three patients with acute Achilles tendon injury underwent open end-to-end tendon repair augmented with a distal turndown gastrocnemius flap and deep posterior compartment fasciotomy. The concentric and eccentric muscle strength was measured using a functional squat system, and dynamic balance was assessed using the Y-balance test with anterior, posteromedial, and posterolateral reach distances. Jump performance was assessed using the vertical jump and 1-leg hop tests. All patients returned to their preinjury activity level, and their mean American Orthopaedic Foot and Ankle Society hindfoot scale score was 98.2±2.3 after surgery. No significant difference was found between the involved and uninvolved extremities in terms of concentric and eccentric muscle strength (p=.82 and p=.53, respectively). In addition, no significant differences were seen between legs in the vertical jump (p=.16), one-leg hop (p=.15), and balance (p>.05) tests. Open end-to-end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complications. Functional performance of the involved leg after recovery was similar to that of the uninvolved leg. The modified Lindholm surgical technique described in our report appears to be a useful intervention for acute Achilles tendon rupture.

Reconstruction of neglected achilles tendon ruptures with gastrocnemius flaps: excellent results in long-term follow-up.

Repair of the neglected achilles tendon ruptures can be challenging due to retraction of tendon stumps. Different repair and augmentation techniques were described. This study aims to investigate long-term results of neglected achilles tendon rupture repair with gastrocnemius flaps. Between 1995 and 2005, 21 neglected achilles tendon rupture reconstructions were performed with using gastrocnemius fascial flaps. Mean age was 32.1years. Mean period between rupture and operation was 8.4weeks. Ankle range of motion, calf circumference, heel raise test, Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and Foot and Ankle Disability Index (FADI) scores were checked. The average gap length was 6.4cm. Mean follow-up was 145.3months. Median dorsiflexion/plantar flexion values for operated and uneffected sides were 18°/30° and 19°/30°, respectively. The mean values for AOFAS and FADI scores were 98.5 points and 98.9%, respectively. VAS score was 0 point for all patients. With the numbers available, no significant difference could be detected in terms of ankle range of motion, calf circumference measures and dynamometric analysis. Mean time for return to daily activities was 11.1 (8-16) weeks after surgery. Prerupture activity level was achieved 14.1months postoperatively. All patients were able to perform heel raise test. Repair of neglected achilles tendon ruptures with gastrocnemius flaps has satisfactory long-term results.

Medial Gastrocnemius Flap for Reconstruction of the Extensor Mechanism of the Knee Following High-Energy Trauma. A minimum 5 year follow-up

IntroductionThe purpose of this study was to assess the medium-term results of reconstruction of the extensor mechanism using the medial gastrocnemius while also providing soft tissue coverage. Materials and methodsThis retrospective review consisted of a consecutive series of four patients (age 28–40 years) with complex high energy traumatic injuries to lower extremity including both soft tissue loss and disruption of the knee extensor mechanism. The medial gastrocnemius rotational flap was used to reconstruct the patellar tendon and restore soft tissue coverage simultaneously. Range of motion and extensor lag; functional recovery was judged by return to work and sports activity. Validated measures included the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and the modified Cincinnati Score. ResultsAt the final follow up was 61.5 (57–66) months after reconstruction, the mean SF 12 physical component score ranged from 21.7 to 56.8 with a median of 55.3; the mental component from 42.8 to 60.7 with a median of 58.6. The KSS knee score ranged from 50 to 78 with a median of 68; the function score from 65 to 90 with a median of 85. The Oxford knee score ranged from 22 to 45 with a median of 33.5. The KOOS ranged from 28 to 82.7 with a median of 73.7 and the modified Cincinnati score from 38 to 82 with a median of 76.5. Knee range of motion ranged from 0 to 120°. Of the four patients three returned to working fulltime in their profession and returned to sports, including mountain biking and fitness training. ConclusionsFor severe traumatic knee injuries with the combination of soft tissue defects and disruption of the extensor mechanism, the medial gastrocnemius flap provides an excellent reconstructive option to address both problems simultaneously. The results of this small case series support the use of this limb salvage technique.

Open Achilles tendon defects: reconstructive surgeries and long term follow-up

Objective To explore the reconstructive surgeries for open Achilles tendon defects and their long term outcomes. Methods A retrospective review was performed on 31 patients with open Achilles tendon defects treated at our center. There were 19 males and 12 females with an average age of 23.1 years (range, 4-55 years). There were 7 cases on left side and 24 on right. The injury causes included spoke injuries (18 cases), crash injuries (6 cases), machine injuries (6 cases), and cut injuries (1 case). The defect lengths of the Achilles tendons in the study ranged from 1 to 11cm and the soft tissue defects ranged from 3 cm×3 cm to 12 cm×10 cm. There were 10 cases with calcaneus fractures. Surgeries for Achilles tendon defects included sliding the Achilles tendon stump down with the sliding gastrocnemius musculocutaneous flap (15 cases), suture at the plantar flexion (10 cases), tendon flap turndown (1 case), hamstring tendon autograft (1 case), fascia lata muscle reconstruction (1 case) and tendon allograft (3 cases). Free flaps (7 cases) and non-free flaps (24 cases) were used for the coverage of concomitant skin defects. The calcaneus fractures were fixed with screws (6 cases) or K-wires (4 cases). The treatment protocols were based on the defect length of the Achilles tendon. Results The follow up period was 1-6 years (average, 1.8 years). There was no total flap failure or tendon re-rupture, while 7 cases who had partial flap loss 2-4 days after the surgeries. In the latest follow-up, all the cases had regained full walking abilities: 19 cases (61.3%, 19/31) even had regained the heel raising by the reconstructed foot while 12 cases (38.7%) cannot. Compared with the contralateral side, 31 cases' (100.0%) reconstructed ankles had the maximum plantar flexion, while 21 cases (67.7%) had the maximum dorsal extention. Ten cases (32.2%) lost their maximum dorsal extension ranging from 5° to 25°. Conclusion There are many reconstructive surgeries available for open Achilles tendon defects, however, the optimal choice should be based on the defect length of the Achilles tendon: those within 4 cm could be reconstructed with tendon reattachment and local flaps; those between 4 cm and 11 cm could be best treated with sliding gastrocnemius flap; and those over 11 cm should be reconstructed with free anterolateral thigh perforator flap with tendon autograft. The long term follow-up showed the strength and elasticity of the reconstructive Achilles tendon was satisfactory. Key words: Achilles tendon; Wounds and injuries; Surgical flaps

A Case Report on Bilateral Knee Coverage Following Septic Arthritis: Lateral Distal Thigh Island Flap and Medial Head Gastrocnemius Flap Methods

Introduction: Septic arthritis is the rheumatological and orthopedic emergency that causes the most difficulties with joints–especially knee and hip joints. The clinical symptoms include pain, swelling, inflammation, stiffness, and a limited range of motion in both active and passive joints. Debridement of the necrotic tissue is one beneficial method for septic arthritis treatment, although soft tissue defects around joints are a challenging issue for surgeons. Our purpose was to investigate the consequences of two flap surgery methods undertaken to repair soft tissue damaged during knee joint debridement caused by septic arthritis. Case Presentation: This is a case report concerning a patient who had septic arthritis in the knee area and so underwent soft tissue surgery. The reconstruction methods were not the same for both knees as the lateral distal thigh island flap reparation method was used on the left knee and the medial head gastrocnemius flap method was utilized on the right. We then investigated the results and outcomes of the surgery three months later. Conclusions: Lower extremity movement extent was carefully evaluated and, in respect to muscle strength, the patient was able to walk independently three months after the surgery. The patient’s balance was studied and the results showed moderate levels of stability.

Reconstruction of Chronic Achilles Tendon Rupture by V-Y Gastrocnemius Flap and Peroneus Brevis Transfer

Purpose: Reporting the outcome of the modified peroneus brevis (PB) transfertechnique in treating 26 patients with chronic rupture of Achilles tendon (AT). Methods: The diagnosis was neglected acute AT rupture in ten patients, ten with achronic rupture, re-rupture of the tendon in four cases, and Achilles xanthoma in two cases. The gap after debridement was 6 cm in average (range 4-8). The technique was V-Y gastrocnemius flaps of the ruptured AT in addition to peroneus brevis transfer. AOFAS score and isokinetic evaluation were used for functional assessment of ankle plantar flexion torque deficit in average 36 months follow up period (range 24-54 months). Results: Significant improvement of the AOFAS score at latest follow up. No re-rupture nor major complication, particularly of wound healing, was observed, isokinetic testing at 30 degrees/second and 120 degrees/second revealed a significant average decrease of 28 ± 11% and 36 ± 4%, respectively, in plantar flexion peak torque. Although strength deficit persisted at latest follow up, functional improvement was significant without morbidity due to (PB) harvesting. Conclusion: The surgical technique of V-Y myotendinous advancement of gastrosoleus tendon augmented by modified PB transfer for the treatment of chronic or neglected ruptures of AT with a gap of 6 cm length or more is a successful technique leading to high percentage of repair site healing and achieved excellent functional outcome.

Cadaveric study using radio-opaque contrast to determine arterial communication between the two bellies of gastrocnemius muscles.

Introduction:Gastrocnemius muscle is a workhorse flap to cover upper third tibial defects but has a limitation in covering middle one-third tibial defects. The inferiorly based hemi gastrocnemius muscle flap can be useful for reconstruction of the middle third of the leg. The arterial communication between the gastrocnemius muscle heads has been demonstrated, the consistent location, however, was not studied in large specimens.Materials and Methods:This study was conducted on sixty specimens of gastrocnemius muscles harvested from thirty fresh cadavers to determine arterial communication between two heads of gastrocnemius muscle using radio-opaque contrast with future application of taking one head of muscle distally based for coverage of middle third defect of tibia. A total of 60 specimens were obtained from thirty fresh cadavers. In thirty specimens, medial sural artery ligated and divided and 20 ml iohexol (350) given through popliteal artery. In remaining thirty specimens lateral sural artery ligated and divided and 20 ml iohexol (350) given through popliteal artery. Digital X-rays of gastrocnemius muscle specimens were taken, and collaterals between two bellies in lower half were noted and the distance of collaterals from the muscles top edge was also noted.Results:We found the communications between both bellies of the gastrocnemius muscle in all specimens in both legs. The mean distance of communications from the upper edge of the medial belly was 15.88 cm and from upper edge of the lateral belly was 14.72 cm in the right leg, respectively. The mean distance of communications from upper edge of the medial belly was 16.01 cm and from upper edge of the lateral belly was 13.78 cm in the left leg. The distal communications between gastrocnemius bellies were not constant in their location, but all the connections were present in distal 3.79 cm of raphe.Conclusion:This study supports the future application of inferior-based hemigastrocnemius muscles flap to cover defects of middle third leg. When distally based hemigastrocnemius flap is planned roughly 1/3rd of distal attachment or distal 3.79 cm of connection between raphe should be maintained to preserve the vascular communications between the two bellies.

Versatility of the medial gastrocnemius muscle flap in reconstructing lower limb soft tissue lesions

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

CORR Insights®: What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

CORR Insights®: What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

Assessing safety of negative-pressure wound therapy over pedicled muscle flaps: A retrospective review of gastrocnemius muscle flap

The use of negative-pressure wound therapy (NPWT) for management of open wounds and immobilization of split-thickness skin grafts (STSGs) over wounds has been well described. However, there is a concern for potential compromise of flap viability when NPWT is used for skin grafts over pedicled muscle flaps. We have used NPWT to immobilize STSGs in eight patients who underwent a pedicled gastrocnemius muscle flap operation in our department. We applied a negative pressure of -75mmHg on the muscle flaps for 5 days postoperatively. All wounds healed successfully, with a 97.5±5.5% mean STSG uptake. No flap necrosis was observed. In our series, the use of NPWT for fixation of STSGs over pedicled gastrocnemius muscle flap was effective and had no negative impact on flap viability.

What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

Soft tissue defects after TKA are a potentially devastating complication. Medial gastrocnemius flaps occasionally are used to provide soft tissue coverage, most commonly with a periprosthetic joint infection. We asked: (1) What were the rates of persistent or recurrent infection, implant survivorship, flap-related complications, and reoperation for patients who underwent medial gastrocnemius flap reconstruction for soft tissue coverage after TKA? (2) What were the Knee Society clinical and functional scores for patients who underwent medial gastrocnemius flap reconstruction for soft tissue defects after TKA? (3) What were the risk factors for failure of medial gastrocnemius flap reconstruction after TKA, with failure defined as recurrent or new periprosthetic joint infection or inability to reimplant the TKA prosthesis? Between 2003 and 2011, four surgeons at one institution performed 31 medial gastrocnemius flaps for soft tissue coverage over an infected TKA. Of those, 27 (87%) were available for followup at a minimum of 2 years (mean, 4 years; range, 2-6 years), although patients experiencing complications or treatment failures before two years were included. The study group consisted of 15 men and 12 women with a mean age of 61 years at the time of surgery (range, 36-86 years). The general indication for using a gastrocnemius flap in this setting was full-thickness soft tissue deficiency over the anterior knee during the course of treatment for concomitant deep infection. Six flaps were performed at prosthetic explantation and antibiotic spacer placement, eight at a spacer exchange, eight at second-stage TKA prosthesis reimplantation, and five at débridement with polyethylene exchange. The decision regarding when during staged treatment to place the flap was based solely on when the soft tissues were deemed insufficient, and not based on a belief that placement at one stage versus another was advantageous. Failure was defined as inability to undergo reimplantation of a TKA prosthesis or recurrence of periprosthetic joint infection. Patient and procedural characteristics were tested for association with failure. Survivorship was calculated by Cox proportional hazards modeling. Outcomes scores were drawn from a longitudinal institutional registry. Fourteen of 27 (52%) patients had a persistent or recurrent infection; survivorship of the TKA prosthesis at 4 years was 48% (95% CI, 31%-66%). Although there were no flap-related complications, 12 patients had a total of 19 reoperations during the study period. Overall, the mean (± SD) Knee Society knee (38 ± 18 vs 65 ± 20; p < 0.001) and function (20 ± 22 vs 37 ± 25; p = 0.002) scores were improved at most recent followup. No factors were identified as associated with failure when a Bonferroni correction was applied. Gastrocnemius flaps were used to address difficult soft tissue defects in this series, in the presence of deep infections; the high proportion of patients experiencing persistent or recurrent infections reflects the case complexity and not necessarily a problem with the flaps. However, this series highlights the need to continue to explore alternative approaches to managing this difficult clinical problem. Future studies should aim to establish an evidence-based reconstructive algorithm, focusing on host, wound, and timing characteristics that may maximize outcomes. Level IV, therapeutic study.

Tissue flap repair strategy for severe defects of skin and soft tissue around the knee joints

To explore selection and method of tissue flaps for the repair of severe defects of skin and soft tissue around the knee joints. Fifty-four patients with wounds around the knee joints, all accompanied by exposure or necrosis of tendon or bone and exposure of prosthesis, were hospitalized in our burn center from June 2008 to December 2014. Five of them were with knee joint injury. After thorough debridement or tumor resection, the wound area ranged from 5 cm × 5 cm to 46 cm × 22 cm. Three patients were repaired with free latissimus dorsi myocutaneous flaps, 7 were repaired with modified sartorius myocutaneous flaps, 8 were repaired with gastrocnemius myocutaneous flaps, one was repaired with gastrocnemius muscle flap, two were repaired with posterior leg flaps combined with gastrocnemius muscle flaps, one was repaired with femoral biceps muscle flap combined with gastrocnemius muscle flap, 13 were repaired with reverse anterolateral thigh island flaps, two were repaired with reverse anterolateral thigh island flap combined with gastrocnemius myocutaneous flaps, two were repaired with superior lateral genicular flaps, 4 were repaired with reverse posterior thigh island flaps, 11 were repaired with saphenous artery flaps. Patellar ligament was reconstructed in 4 patients. The tissue flap size ranged from 5 cm × 5 cm to 38 cm × 19 cm. Some donor sites were sutured directly, and the others were closed by split-thickness skin grafting obtained from ipsilateral or contralateral legs. Among 59 tissue flaps of 54 patients, 55 tissue flaps of 50 patients survived, while necrosis of the distal part was observed in 4 tissue flaps, including one saphenous artery flap, two reverse anterolateral thigh island flaps, and one free latissimus dorsi myocutaneous flap. Among them, 3 flaps with necrosis at the distal part healed after debridement followed by skin grafting, one myocutaneous flap healed by transplanting gastrocnemius myocutaneous flap. During the follow-up period of 6 to 36 months, the tissue flaps were in good appearance and texture, and knee joint function was good in most cases. In 4 patients the knee joint function was satisfactory after patellar ligament reconstruction, while stiffness was observed in 4 out of 5 patients with knee joint injury. Free latissimus dorsi myocutaneous flaps are preferred to repair extensive defects around the knee joints. Reverse anterolateral thigh island flaps followed by saphenous artery flaps are preferred to repair wounds around the anterior knee. Wounds of the lateral knee are mainly repaired with reverse anterolateral thigh island flaps, and for small wounds the use of the superior lateral genicular flaps may be considered. Wounds of the medial knee can be repaired with modified sartorius myocutaneous flaps or saphenous artery flaps. Wounds of the posterior knee can be repaired with reverse posterior thigh island flaps or superior lateral genicular flaps. Wounds with severe infection or large space can be repaired with gastrocnemius myocutaneous flaps or muscle flaps or modified sartorius myocutaneous flaps. Anterolateral thigh flaps and gastrocnemius myocutaneous flaps are preferred in cases with indication of patellar ligament reconstruction.

To further improve the techniques for repair and reconstruction of skin and soft tissue defects around the knee joints

This article briefly summarizes the techniques for repair of skin and soft tissue defects around the knee joints as reported in 5 papers in this issue, including how to choose the skin flap, muscle flap, myocutaneous flap, and vascular anastomosis in recipient site. It is found that the anterolateral femoral flap, latissimus dorsi myocutaneous flap, and gastrocnemius flap are widely used in clinic with high survival rates, and they can be used for the repair of large soft tissue defects as well as the reconstruction of the knee joint function.

Versatility of the Medial Sural Artery Perforator Flap

INTRODUCTION: The medial sural artery perforator (MSAP) flap was first described in 2001.1,2 Having constant anatomy, long pedicle, and pliable soft tissue, the flap was shown to be a good alternative option for soft tissue reconstruction.3,4 The aim of this study was to report our experience with this flap for reconstruction throughout the body, highlighting its potentially increasing role as a workhorse flap for multipurpose reconstruction. PATIENTS AND METHODS: Between March 2006 and July 2014, the MSAP flap was used for reconstruction in 200 cases. The flap was transplanted as free (n=189) and pedicled (n=11). The sites of reconstruction included head and neck (n=129), upper extremity (n=47), and lower extremity (n=24). Patients’ charts were reviewed retrospectively. Indications, flap design, flap survival, and complications were analyzed. We further compared survival rate and complications between the three different reconstruction sites. RESULTS: In head and neck group, flap survival rate was 95.3%. There were fifteen re-explorations (venous congestion: 10, arterial occlusion: 4, both: 1) with 6 total failures due to unsalvageable congestion. The donor site was closed primarily in 85.3% of the cases. In upper extremity group, flap survival rate was 95.7%. There were five re-explorations (venous congestion: 2, arterial occlusion: 2, both: 1) with 2 total failures. The donor site was closed primarily in 76.6% of the cases. In lower extremity group, flap survival rate was 100% in free MSAP subgroup compared with 90.9% in pedicled MSAP subgroup. There was one re-exploration due to venous congestion salvaged successfully in free MSAP subgroup. Partial necrosis occurred in 2 pedicled MSAP flaps and managed by debridement and skin grafting. The donor site was closed primarily in 45.8% of the lower extremity cases. Versatile designs of the flaps included chimeric flaps with the gastrocnemius muscle (n=11) and split flaps (n=2). The plantaris tendon was transferred with the flap in 20 cases for composite reconstruction. CONCLUSION: The MSAP flap is an alternative workhorse flap for reconstruction of the head/neck and extremities. The flap can be harvested as free or pedicled. Multiple tissue components can be included with the flap for multipurpose reconstruction. A small to medium size flap should be harvested to ensure primary closure at the donor site, maximizing cosmesis and decreasing morbidity.

The Use of Gastrocnemius Muscle Flap in Reconstruction of Pretibial Defects

Background: In Western part of Nepal the post traumatic lower leg and bone injuries with infected, open wound is common occurrence.Aim: It was to find out whether Gastrocnemius muscle flap is a viable option for pretibial defects. However variations in vascular anatomy of pedicle, use of reverse flow soleus muscle flap based on posterior tibial artery, leads to high failure rate and sacrificing major leg vessels.Method: Use of soleus muscle flap supported by perforating arteries, branches of posterior tibial vessels is option to cover small defects. The flap with careful newer modification to preserve vascularity, is used in 32 cases of pretibial defects.Observation: All 32 flaps survived with two cases in post operative phase, needing a flap elevation debridement of underlying bone and other skin grafting.Result: None of the case showed any vascular insufficiency, graft muscle loss or any functional loss. Use of muscle flap a viable option in pretibial defects.Journal of Nepalgunj Medical College Vol.12(1) 2014: 2-5

Effectiveness of the Gastrocsoleous Flap for Coverage of Soft Tissue Defects in Leg with Emphasis on the Distal Third.

The standard methods for reconstruction of soft tissue defects in the leg include gastrocnemius flap for proximal third defects, soleus flap for middle third and free flap in the distal third. However, there are problems with the use of free flap, like increased operative time, damage of major vessels and the need for experienced microsurgeon. This prospective study was undertaken on 23 patients (20 male and 3 female) with the mean age 32.13 years (14 to 65). This group consisted of all of the patients referred to Dr Bahonar Hospital, Kerman with soft tissue defects between April 2011 and April 20012 and would give informed consent for participation in the study and treatment of the defect with muscle flaps. 8 patients with proximal third defects were treated with were treated with gastrocnemius flap, 4 with middle third defects with soleus flap and 3 with reverse soleus flap and 8 with distal third defects with reverse soleus flap. The patients were followed up for at least 1 year. Finally the results were analyzed by SPSS 16. In patients with soft tissue defect in proximal and middle third of leg repair was successful in all. In 5 patients with soft tissue defect in distal third of leg repair was complete but in 3 of them flap failure was seen. Overall success rate for reverse soleous flap was 72.7%. The success rate of the flap for the upper and lower thirds was similar to other studies and seems that this is the standard method. In the distal third defects the reverse soleous flap failed in 3 cases and it seems that preoperative investigations such as angiography must be performed before embarking on such a procedure.

Surgical Model for Analysis of Signal Transfer Through Biologic and Synthetic Materials.

High-fidelity volitional control of bioengineered prosthetic limbs with multiple degrees of freedom requires the implantation of multiple recording interfaces to detect independent control signals. However, interface utilization is complicated by interfering electrophysiological signals originating from surrounding muscles and nerves, leading to equivocal signal detection. We developed and validated a surgical model to characterize signal propagation through various biomaterials to identify insulating substrates for use in implantable interfaces. The identification of these insulating materials will facilitate the acquisition of noncontaminated prosthetic control signals, thus improving manipulation of advanced prosthetic limbs. Using a rat hindlimb model, 4 groups (n = 8/group) were tested. A medial gastrocnemius muscle flap was elevated, leaving the neurovascular pedicle intact. The flap was rotated into a chamber and secured to a silicone base. A stainless steel electrode was affixed to the surface of a muscle and encircled by 1-layer small intestinal submucosa (SIS), 4-layer SIS, silicone elastomer, or nothing (uninsulated). A superimposing electrode was attached, and an external silicone layer was wrapped around the construct and sutured in place. Electromyographic studies were then performed. This model was found to correspond with expected signal isolation characteristics of the nonconductive silicone group, electrically inert single and multilayer SIS group, and the uninsulated group. Signal isolation of compound muscle action potential amplitude at stimulation threshold was significantly greater using silicone (51.4%) compared with the 1-layer SIS (-6.8%), 4-layer SIS (-3.3% ), or uninsulated groups (1.2%) (P = <0.001). Isolation of the maximum compound muscle action potential peak-to-peak amplitude was also greater with silicone (56.7%) versus the 1-layer SIS (1.5%), 4-layer SIS (1.1%), or uninsulated groups (-0.7%) (P = <0.001). This study demonstrates and validates a novel surgical model to characterize in vivo signal propagation and subsequently identify insulating materials for use in implantable interface systems currently in development. Improved signal isolation through the utilization of these materials stands to greatly improve control fidelity of neuroprosthetic limbs.

Pedicled chimeric gastrocnemius-medial sural artery adipofascial flap for reconstruction of anterolateral defects of the knee.

A medial gastrocnemius muscle flap is useful for soft tissue reconstruction of the knee and proximal tibia but insufficient to cover defects involving the lateral aspect of the knee. The purpose of this report is to present the results of the use of a pedicled chimeric gastrocnemius-medial sural artery adipofascial flap for reconstruction of defects of the knee and lateral aspect of the knee. Six patients underwent soft tissue reconstruction of the knee by means of the described procedure. Patients included one female and five males. The mean age of the patients was 48 years. The cause of soft tissue defects was open fractures in three cases and infection in three cases. The mean size of soft tissue defects was 9.3 × 7 cm (range: 6 × 3 to 18 × 14 cm), and the mean size of adipofascial components was 6.8 × 3.8 cm (range: 6 × 3 to 10 × 6 cm). Medial knee defects were covered by the medial gastrocnemius muscle component and lateral knee defects were covered by the medial sural artery adipofascial component. All flaps survived in the six cases. Soft tissue reconstruction and infection control were successful without any additional surgical procedures. A pedicled chimeric gastrocnemius-medial sural artery adipofascial flap may be considered effective for soft tissue reconstruction of the knee as it reduces scars at the donor site and reconstructs the lateral knee defects not covered by the medial gastrocnemius muscle flap. © 2015 Wiley Periodicals, Inc. Microsurgery 37:206-211, 2017.