Hemisoleus Flap Research Articles

Hemisoleus muscle flap in the reconstruction of exposed bones in the lower limb

To evaluate the efficacy of soleus muscle flap for covering complex defects of the middle and lower leg. The study also outlines functional gain after the reconstructive procedure, the donor site morbidity and the technical details of the operative procedure. This prospective study consists of a total of 40 patients with middle and lower third defects with exposed bone present in the leg. In all cases, a proximally-based hemisoleus flap was used. All patients were between 15-65 years of age. Depending upon the position of the defect and ease of rotation, either the medial or lateral hemisoleus was used to cover the defects. In 7 patients with large defects, both the hemi-gastrocnemius and hemisoleus flap were used. Most of the patients studied (52.5%) had defects in the middle third of their leg. A further 12(30%) patients had defects over the upper part of the lower third of the leg and 7(17.5%) cases involved large defects exposing bones comprising both the middle and lower thirds of the leg. All the flaps survived well except 5 which developed partial skin graft loss, and 1 where complete flap loss was observed. Out of 5 patients who developed partial graft loss, 3 patients achieved complete healing by regular dressings and 2 required regrafting. The patient who developed complete flap loss required below knee amputation. No donor site morbidity was observed, except minimal depression in the posterior leg. Due to a high degree of reliability, versatility, minimal donor site morbidity, less operating time, low cost and good functional gain, this procedure is highly suitable for the treatment of complex middle and lower leg defects. There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Knee extensor loss and proximal tibial soft tissue defect managed successfully with simultaneous medial gastrocnemius flap, saphenous fasciocutaneous flap and medial hemisoleus flap: a case report

IntroductionOpen fractures of the proximal tibia often pose serious challenges to the treating orthopedic surgeon. Management of these complex injuries becomes difficult if they are associated with damage to the extensor mechanism and an exposed knee joint. The scenario becomes more difficult to manage when the soft tissue defect extends to the middle third of the leg. We report a case where we used an extended medial gastrocnemius flap in combination with a saphenous artery fasciocutaneous flap and a medial hemisoleus flap for treatment of an infected proximal tibia fracture with loss of the extensor mechanism and soft tissue defect. To the best of our knowledge, combined use of these three flaps for the management of such injuries has not been reported elsewhere to date.Case presentationA 28-year-old Indian man presented to our Out-patient Department with complaints of pain and pus discharge from his left proximal leg for four weeks. He had sustained an open fracture of his left proximal tibia in a road traffic accident five weeks ago and had been operated on elsewhere. He had a stiff, painful knee with an infected wound of 4×4cm over the proximal third of his leg exposing infected, necrotic patellar tendon. He was successfully managed with debridement and simultaneously elevated flaps as described.ConclusionsThis procedure avoids the donor site morbidity associated with free flaps harvested from sites distant from the site of injury, and also does not need the expertise of microvascular reconstruction. To the best of our knowledge, this is also the first report of the combined use of three local flaps for knee extensor reconstruction and soft tissue coverage around the knee.

An anatomical study of the blood supply of the soleus muscle in humans

IntroductionThe soleus muscle is a powerful plantar flexor of the ankle joint and receives its blood supply from several different sources. AimThis study was done to describe the distribution of the arterial supply of the soleus muscle. Materials and methodsThe study was carried out at the Faculty of Medicine, University of Alexandria. Forty limbs were dissected, which included specimens from both male and female cadavers. The pattern of arterial supply of the soleus muscle and the distribution of the perforators were studied. ResultsThe soleus muscle is supplied by perforators of the popliteal, posterior tibial and peroneal arteries, the posterior tibial artery gave 38.80% of total perforators while the peroneal artery gave 33.30% of total perforators and the popliteal artery gave 27.80% of total perforators. Perforators of popliteal artery were larger; 12.9±2.07cm in length and 2.55±0.214mm in diameter while those of the posterior tibial artery had a length of 5.1±0.99cm and a diameter of 1.93±0.25mm and perforators of the peroneal artery had a length of 3.8±0.98cm and a diameter of 1.49±1.03mm. ConclusionThe soleus muscle is richly supplied by many arterial pedicles and can be used safely as a free flap, hemisoleus flap or composite flap to cover defects in the lower limb.

Improving Outcomes of the Distally Based Hemisoleus Flap: Principles of Angiosomes in Flap Design

The reliability of the distally based pedicled hemisoleus flap for coverage of relatively small medial distal third leg wounds has been continuously debated among reconstructive surgeons. Whereas some authors report that the distally based hemisoleus can be elevated safely, other authors argue that the flap's retrograde blood supply is problematic. The authors believe that application of angiosome principles may help surgeons to better design the distally based hemisoleus flap such that outcomes are optimized. Seventeen patients received a distally based hemisoleus flap for coverage of a small distal third leg wound. Flaps were designed to capture one full angiosome and only a portion of the adjacent angiosome. Reliable soft-tissue coverage and wound healing were achieved in all patients. Mean operative time of 130 minutes reflected the relative technical ease and efficiency of the surgery. Only one patient suffered distal tip flap necrosis, which did not compromise soft-tissue coverage and ultimately resulted in a healed wound and fracture. The distally based hemisoleus flap is an efficacious method of treating small distal third medial tibial wounds. Flap design based on vascular perforator angiosome principles may help surgeons improve the reliability of this flap.

The island hemisoleus flap on distal vascular pedicle: anatomical bases and clinical applications

The coverage of skin defects of the ankle and of the distal fourth of the leg remains a difficult problem despite progress in reconstructive surgery. The aim of our study was to establish an arterial map of the lateral head of the soleus muscle, to compare it with the existing data in order to investigate the possibility of raising a fibular artery-based pedicle island reverse flow flap. It has the theoretical advantage over its medial counterpart of sparing the main arterial axis of the leg and foot. The anatomical study was undertaken on 15 fresh cadavers, 8 left and 7 right randomly chosen lower extremities from different subjects. For each calf, the following measurements were obtained: fibular length from the fibular head to the tip of the lateral malleolus; length of the lateral head of the soleus from its most proximal insertion point on the fibula to the most proximal part of the ending of the muscle belly on the Achilles tendon; width of the lateral head of the soleus; distance between the origin of the fibular artery and the tip of the fibular head; number and height of the pedicles for the lateral soleus, taking as reference their origin from the fibular artery. The mean dimensions of the muscle belly of the lateral soleus were 218 mm in length (between 160 and 270) and 73 mm in width (58-95). In all the examined lower extremities, we found a main pedicle for the lateral soleus emerging from the fibular artery; and in all cases the blood supply of the proximal part of the muscle was of a segmental distribution by way of multiple branches originating from the fibular artery. Then the flaps were raised with a distal pivot point represented by the perforating branch of the fibular artery. In all the cases, the flap would have covered an ankle or a dorsal foot defect up to the metatarsal heads.

The laterally extended medial hemisoleus flap for reconstruction of a tibial wound in the distal third of the leg

A soleus flap as a local reconstructive option for soft-tissue coverage of a tibial wound in the distal third of the leg has never been well recognized. In a 2-year period, seven patients underwent reconstruction of a less extensive tibial wound (4 × 3 to 10 × 4 cm) in the distal third of the leg after orthopedic trauma with the laterally extended medial hemisoleus flap. The flap was elevated with emphasis on the preservation of the most distal perforators from the posterior tibial vessels to the flap as possible while allowing adequate rotation of the flap to cover the exposed tibia and/or hardware and on the possible preservation of foot planter flexion by reconstruction of the proximal Achilles’ tendon. In this series, there was no total or partial flap loss. All patients healed their tibial wounds primarily with reliable soft-tissue coverage, evidenced fracture healing, and good cosmetic outcome during follow-up. Thus, the laterally extended medial hemisoleus flap described by the author can be a reliable option for soft-tissue coverage of a less extensive tibial wound in the distal third of the leg. It offers a more cost-effective approach for managing this unique problem and can be performed by most reconstructive surgeons without microsurgical expertise.

Arterial supply of the soleus muscle: anatomical study of fifty lower limbs.

Soft tissue defects of the lower limb are a formidable challenge to the plastic surgeon but a soleus muscle flap often provides the solution. Various types of soleus muscle flap have been described, based mainly on the vascular supply. The arterial blood supply of the soleus muscle was studied in 50 cadaveric lower limbs. The blood vessels and their branches to the muscle were dissected. The distance of the origin of the perforators was measured from fixed bony landmarks. Branches of the popliteal artery trunk, the posterior tibial artery, and the peroneal artery supplied the soleus muscle. The number of branches to the soleus muscle from these main arteries were analyzed. The medial part of the muscle was supplied throughout its length by perforators arising from the posterior tibial artery. This constant feature makes the medial part of the muscle reliable as a proximally or distally based flap. The average distances of the lower perforators arising from the posterior tibial artery were 6.5 cm, 11.6 cm, and 16.8 cm from the medial malleolus. The branches of the peroneal artery were mostly distributed in the upper half of the muscle. These large pedicles allow a composite transfer of the soleus muscle with the fibula. Lower perforators were demonstrated to arise from the peroneal artery in 60% of the limbs but the scarcity of perforators in this region limits the clinical usefulness of an inferiorly based lateral hemisoleus flap. The study demonstrates the distribution of arteries entering the soleus muscle and how the information may be used in the design of soleus muscle flaps. The average numbers of the perforators arising from the vessels and their distribution have been highlighted.

Getting the most from the soleus muscle.

The bipennate soleus muscle has properly become entrenched as the muscle flap of choice for coverage of the middle third of the leg. Yet its potential versatility in fulfilling many other indications has been understated. With minor alterations in the methodology for transfer, often the reach of the muscle can be extended to more proximal or even distal defects in lieu of more complex solutions. Function preservation with hemisoleus flaps, the possibility of a cutaneous version, and use as a dynamic muscle demonstrate the diversity of additional alternatives. The merit of several techniques for augmenting circulation to the unreliable "reversed" soleus flap further prove the limitations of this option. Recognizing that we can often "get more" from the soleus muscle than traditionally considered deserves reemphasis.

Distal vascular pedicle-hemisoleus to tibial length ratio as a main predictive index in preoperative flap planning.

The management of severe compound tibial fractures is aimed at obtaining osseous consolidation, proper cutaneous and muscular cover, absence of infection and restoration of limb function. A knowledge of the cutaneous and muscular vascularisation allows the surgeons to use many flaps in a rational and predictable manner. One of the most commonly used flaps is the soleus muscular flap. This may be used as a proximally or distally based muscular flap and the use of a hemisoleus flap has also been described. A morphometric analysis of the relation between tibial length and soleus vascular pattern provides a simple and reliable method for planning this flap preoperatively. The study was performed on fresh and preserved cadavers.

ANATOMIC VARIATIONS OF THE BLOOD SUPPLY OF THE SOLEUS MUSCLE

A total of 36 cadaver and fresh amputation specimens were studied by dissection. Two vascular patterns were identified--a segmental posterior tibial artery (Type 1) and a proximally dominant posterior tibial artery (Type 2). Type 1 was seen in 77.8% of cases, and Type 2 in 22.2%. Injection studies in five fresh specimens demonstrated numerous cross-connections between the two halves of the muscle. A distally based hemisoleus flap should not be performed when a Type 2 vascular pattern is encountered. Also, vascular cross-connections between the two halves of the soleus muscle should be preserved, when possible.