Soleus Muscle Flap Research Articles

Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft

The role of internal fixation and local muscle flaps for open tibial fractures is still not specifically determined. We describe the integration of internal fixation and soleus muscle flap for open fractures complicated with soft tissue loss of the tibial shaft. Twenty-seven patients with Gustilo IIIB open fractures of the tibial shaft were operated on by internal fixation and soft tissue coverage by soleus muscle flaps and variances. Data were collected on types of implants, types of flaps, union time, postoperative complications, and objective clinical measurement. Regarding implants for fixation, plates and screws were selected in 22 patients, and intramedullary nails in 5. Proximally based soleus flap was used in 17 patients, hemisoleus in 6, and reversed hemisoleus in 4. All flaps survived and all fractures were united with a mean union time of 21.8weeks (range 14-30). One patient had unplanned reoperations due to delayed union and equinus deformity of the ankle. All patients had good-to-excellent Puno functional score results. Internal fixation and soft tissue coverage, frequently referred to as 'fix and flap', by a local soleus muscle flap is safe and effective for open fractures accompanied with small-to-medium size soft tissue defect of the tibial shaft.

The Masquelet technique combined with the muscle flap for use in emergency management of acute Gustilo type III trauma of the lower limb with segmental bone loss:Case series.

Gustilo-Anderson type III traumas have been described as high-energy injuries with severe bone defects and extensive soft tissue damage, which remain a challenging entity, due to an inherent risk of infection, nonunion and even amputation. The emergency management of such severe trauma presents additional difficulties. Our study attempts to retrospectively evaluate the Masquelet technique combined with the muscle flap for the management of Gustilo type III trauma of the lower limb with segmental bone loss in emergencies and assess key points of success in this technique. From June 2014 to December 2017, 17 patients of Gustilo type IIIA/B/C trauma of lower limb with segmental bone loss, were recruited for our studies. All the cases experienced thorough debridement, stabilization of fracture and antibiotic-impregnated cement spacer insertion. When necessary, muscle flap surgeries were performed immediately. After wound healing, cement spacers were removed, and cancellous bone was filled to repair bone defects. Procedures were performed by two experienced orthopedic surgeons. Among the patients studied, retrograde translocations of the medial head of the gastrocnemius were performed in 5 cases, medial hemimuscular flaps of soleus in 3 cases, and medial head of the gastrocnemius combined with medial hemimuscular flaps of soleus in 4 cases. One patient developed a necrotic soleus flap and was treated with the cross-leg flap. Using a mean 28.2 months of follow-up, results were analyzed radiologically and clinically. Failures (include infection and nonunion) were not noted. And all the patients returned to full weight bearing without pain. According to the Paley fracture healing score, 15 patients showed excellent results and 2 patients displayed good results regarding bone outcomes. When considering functional outcomes, 14 patients exhibited excellent results and 3 patients displayed good results. The muscle flap is synergistic with the Masquelet technique in the emergency management of severe complex fractures. The combination of both techniques in emergency surgery demonstrates an alternative option for the treatment of acute Gustilo type III trauma of the lower limb with segmental bone loss, which can effectively prevent bone infection and amputation. We also demonstrate that firm fixation is key to the Masquelet technique.

Soft tissue coverage techniques for management of open fractures of tibia (type IIIB)

<p class="abstract"><strong>Background:</strong> Open fractures are surgical emergencies; incidence of open fractures is increasing with more high-energy road traffic accidents. The tibia is exposed to frequent injury because of its location. The need for aggressive debridement, adequate fracture fixation, and early flap coverage in reducing the morbidity cannot be over emphasized.</p><p class="abstract"><strong>Methods:</strong> Treatment of open fracture by immediate debridement and anatomical fracture reduction using external fixator device. Gastrocnemius muscle flap done in upper 1/3 open fractures (type IIIB) with larger defects along with split thickness skin graft (STSG). In middle and lower 1/3 open fractures (type IIIB), fasciocutaneous and soleus muscle flaps done with relatively smaller soft tissue defects and exposed bone with STSG.<strong></strong></p><p class="abstract"><strong>Results:</strong> The study included 15 patients with open tibia fracture Gustillo Anderson type IIIB classified after the initial debridement. Excellent flap takes up was seen in all cases. 11 cases (73.3%) achieved union at the end of 6 months follow-up while 4 cases (26.7%) showed delayed union which required additional procedures like BMI or bone graft.</p><p class="abstract"><strong>Conclusions:</strong> Soft tissue coverage techniques like fascicutaneous flap, gastrocnemius and soleus muscle flap had a definitive role in the management of open fractures of tibia (type IIIB).</p>

Soft tissue reconstruction in the leg by orthopedic surgeons: Practices at an African trauma center

IntroductionSoft-tissue coverage is a crucial step when treating open tibial fractures, which is often performed by orthopedic surgeons in a low resource setting. The objective of this study was to analyze the use of non-microsurgical flaps to treat such injuries in a West African trauma center. HypothesisPedicled flaps are reliable procedures that can be used by any orthopedic surgeon for soft-tissue coverage in the leg. MethodsA retrospective study was conducted including patients treated between 2007 and 2011 for open tibial fractures or posttraumatic sequelae requiring flap coverage. Early flap necrosis and skin viability at the last follow-up were evaluated. ResultsFifty-five patients with mean age 34 years were included. They had 57 soft-tissue defects requiring flap reconstruction, 36 of which were infected. In total, 62 pedicled flaps were performed: 12 muscular flaps and 50 fasciocutaneous flaps, including 40 rotational flaps and 10 island flaps. The short-term result was successful in 55 flaps (89%). Seven flaps had partial or complete necrosis, including three soleus flaps and three lateral supramalleolar rotational flaps. At the average follow-up of 9 months, skin viability was inferior in the posttraumatic sequelae group and seemed to be altered by primary bone infection. ConclusionSoft-tissue coverage in the leg can be reliably achieved by orthopedic surgeons using simple and robust flaps that do not require pedicle dissection. Surgeon training in basic flap surgery is essential and still inadequate in emerging countries. Level of evidenceIV, Retrospective study.

Human cadaveric Study of Soleus Muscle arterial blood supply and its Application in peri-ankle Reconstruction

Introduction: Soft tissue defects of the lower limb are a formidable challenge to the plastic surgeon but a soleus muscle flap often provides the solution. Aim of the work: study the anatomy of the various patterns of arterial supply to soleus muscle based on cadaveric dissection for its application as a pedicle flap for lower leg and peri-ankle reconstruction. Methodology: The study included 8 adult lower limbs from the Department of Anatomy at Faculty of medicine Al-Azhar University. The study duration was from May 2018 to May 2019. The branches of popliteal, posterior tibial and peroneal arteries were traced till their point of entry into the soleus muscle.These were considered as extra muscular branches(EMB) to the soleus. Results: Popliteal artery supplies the muscle by 1 perforator at 2 samples , 2 perforator branches at 3 samples and absent at 3 samples .Posterior tibial artery: supplies the muscle by not less than 4 perforators at 8 samples. Peroneal artery: supplies the Soleus muscle by 2 to 4 perforators according to our study 2 samples were supplied by 2 perforators , 4 samples were supplied by 3 perforators and 2 samples were supplied by 4 perforators Conclusion: The proximal 25 % of length of soleus received EMB from all the three arteries and hence a proximally based soleus muscle flap is better than distally based muscle flap. Recommendations: Doppler ultrasonography and angiography are useful for detection the actual location and size of soleus perforators.

Best Local Flaps for Lower Extremity Reconstruction.

The ideal reconstruction of lower limb defects should replace like with like and minimize morbidity to the donor site, achieving the best possible esthetic and functional outcome. The goal is to obtain stable healing and to resume daily life in an efficient manner. Although the classical local flaps such as gastrocnemius, soleus muscle flap, and the reverse sural flap have allowed to achieve those goals, perforator flaps are now added on to the armamentarium in lower extremity reconstruction using local flaps. A perforator-based local flap, such as a propeller or keystone flap, has made reconstruction efficient while further reducing donor-site morbidity. This article aims to provide a useful review of the best available local flaps for lower limb defects.

Reverse peroneal artery flap with soleus flap for the treatment of calcaneal osteomyelitis

Reverse peroneal artery flap with soleus flap for the treatment of calcaneal osteomyelitis

Functional donor-site morbidity after soleus muscle-flap procedure in the treatment of lower limb severe injuries.

The gastrocnemius and soleus muscle flaps are the most commonly used transfer flaps to treat lower limb severe lesions. The use of the muscle as coverage tissuemay incur in functionality loss and motor control deficits. The aim of this study is to assess whether functional deficits are present during gait, posture and heel rise test (HRT). From 2008-2013 we treated 9 patients suffering from complex injury of the lower third of the leg (Gustilo III B). A population of 9 patients (group A) was examined after reconstruction with a soleus muscle flap. The results were compared with a control population (group B: 9 patients). Each patient performed at least 3 gait tests at a fast pace, 2 posture tests and 2 HRT on an inclined plane. Gait parameters for group A: Spatio-temporal parameters such as step length, cadence were reduced compared to the homolateral leg (p < 0.05). The initial double support phase was shorter in relation to the final phase and the first peak in the vertical ground reaction component was reduced compared to the contralateral leg.Posture for the group A: the mediolateral excursion (during open- and closed-eyes test) and the related mean velocity (in the open-eyes test) were significantly lower compared to the control group (p < 0.05).HRT for group A: the number of rises and relative height and angular excursion were reduced in the operated leg in relation to the control group (p < 0.05) and to the contralateral leg. The patients treated with the soleus muscle used as tissue defect coverage completely recovered the ability to walk but showed some deficits in kinetic parameters during the body weight-loading phase. During gait prolonged muscle activity compared to controls was observed. The absence of soleus (group A) revealed no significant alterations in postural control. However, the HRT remained the most relevant test to measure patients' performance when treated with soleus flap in relation to the control group.

The double muscle gastrocnemius-soleus flap in resurfacing large lower limb defects: Modifications and outcomes

IntroductionLarger soft tissue defects over critical areas of the lower limb involving the knee and proximal two thirds of the tibia present a challenge to the reconstructive surgeon. Options include a large free flap or pedicled local flaps. The gastrocnemius or soleus flap alone is not sufficient. Combined gastrocnemius-soleus flaps can be used adequately without the need to resort to free flaps. We review the use and outcomes of the combined pedicled gastrocnemius and hemi-soleus double muscle flap to cover large defects of the leg and discuss our technique. Material and methodsA retrospective review of the patients who underwent the pedicled double muscle (gastrocnemius and soleus) flap for wound resurfacing in our institution between 2008 and 2013 was performed. The patients’ case notes were analyzed and data collected included their age, comorbidities, wound characteristics, surgical procedures and post-operative outcomes and complications. ResultsThere was a total of ten double flaps in ten patients; eight due to trauma and two due to infection. Mean follow up period was 12 months. All flaps achieved primary healing without major complications. There were two cases of minor complications: flap tip necrosis and superficial infection. Nine patients were able to achieve ambulation without aid at final follow up. ConclusionThe combined pedicled gastrocnemius and hemisoleus double muscle flap is a useful alternative for reconstruction of large critical soft tissue defects around the knee and leg.

An analysis of post traumatic leg and foot defects

Background: Management of lower extremity trauma with bone and soft tissue injury is a challenging task with the aim of giving early recovery and durable good quality skin cover according to the skin defect and analyze various reconstructive options at various levels of injury. Our aim of the study is to analyze various reconstructive options for traumatic skin loss involving lower limbs especially knee and below knee, and analyze the incidence of age, sex and etiology of traumatic defects.Methods: Prospective study in our plastic surgery department in the period of 24 months, with all the cases of traumatic defects of leg and foot where included. All age and sex patients were included.Results: Most common cause for traumatic leg and foot defects are road traffic accidents followed by accidental fall and others, most commonly in males amounting 73%, children 10% and females 17%, among the skin and soft tissue defects upper and lower 1/3 leg defects are predominant. Among the soft tissue coverage split thickness skin graft dominating about 60% of cases, flaps 30% of cases, among the flaps 70% are fasciocutaneous flaps predominantly inferiorly based and 30% are muscle and musculocutaneous flaps, among the muscle predominantly soleus muscle flap was used to cover the defect.Conclusions:Road traffic accidents dominating the cause for leg and foot defects , males are more commonly affected and upper one third leg defects are predominant for soft tissue coverage split thickness skin graft are commonest procedures followed that cutaneous and muscle flaps.

Application of muscular flap and induced membrane technique in the emergency treatment for limb salvage for Gustilo type III B and III C open fracture of lower leg

Objective To investigate the clinical effectivity of the muscular flap transposition and induced membrane technique in the emergency treatment for the limb salvage of Gustilo type III B/C open fracture of lower leg. Methods From July, 2015 to December, 2017, 10 cases of Gustilo type III B/C fracture of lower leg with bone defects were performed limb salvage surgery. Induced membrane technique was used to fill the bone defects in the emergency room. The gastrocnemius and/or soleus muscular flaps were transposed to cover the bone cement or exposed bone simultaneously in emergence treatment. After the wound healed completely, traditional bone grafting was used to repair the bone defects. There were 4 cases of Gustilo type III B and 6 cases of Gustilo type III C. The average length of bone defect was (5.25±1.70) cm ranging from 3.0 cm to 11.0 cm. The gastrocnemius medial head flaps were performed in 5 cases, the combined application with the gastrocnemius medial head flaps and the medial hemimuscular flaps of soleus were performed in 2 cases, and medial hemimuscular flaps of soleus were transposed in 3 cases. Results The wounds in 6 cases were healed at one stage, but 2 cases healed by dressing because the exudate after skin grafting. In 1 case, the cross-leg flap was used to cover the exposed bone cement due to the necrosis of soleus flap. The other 1 was performed the transposition of the lateral gastrocnemius flaps because the exposure of bone cement after the necrosis of the upper and lateral muscles in lower leg. In the second-stage, the bone defects were reconstructed by traditional bone grafting. The average healed time of bone was 7.2 months ranging from 5 months to 9 months. At the last followed-up time, all patients recovered their function of weight-bearing. The Paley's score of the adjacent joints: excellent in 8 cases and good in 2 cases. Conclusion The combination with induced membrane technique and local muscular flap transposition in emergency surgery is an effective method to limb salvage for the Gustilo type III B/C open fracture of lower leg. Key words: Gustilo type III, Gustilo type; Open fracture of lower leg; Induced membrane technique; Muscular flap; Emergency treatment

Soleus Muscle Flap Application for Reconstruction of the Middle Third of the Leg

Introduction: Lower limb injuries are common in emergency rooms and surgery services. Many are extensive wounds and have complicated and extended treatment. A good option for reconstruction is the use of muscle flaps. Purpose: The aim of this study is to analyze a case series of wounds in the middle third of the leg, using soleus muscle flap for reconstruction and evaluating its effectiveness. Methods: Seven patients with wounds in the middle third of the leg were selected to demonstrate its reconstruction using soleus flap. The procedures occurred between 2015 and 2017. Results: In six cases, the cause of the injuries was trauma, with bone exposure in all of them. One patient had osteomyelitis as the cause of the lesion. Partial skin graft from the flap was performed after two weeks. There was one case of infection, with no necrosis of flaps or suture dehiscence, neither systemic complications. None of them needed new surgical intervention. All patients had good evolution. Conclusions: Soleus muscle flap is a reliable flap and it is valuable for closing the defects in the middle third of the leg.

The Soleus Muscle Flap: An Overview of Its Clinical Applications for Lower Extremity Reconstruction.

Lower extremity reconstruction often poses several challenges for the reconstructive surgeon. Because of limited local tissue options, patients who sustain extensive middle to distal third tibia fractures used to be at higher risk of limb loss without adequate soft tissue coverage. The traditional principle of reconstructing middle and distal third leg wounds with free tissue transfer is being challenged by advances in understanding of local muscle flap anatomy and surgical techniques to improve the efficacy of local flaps. In this article, we examine contemporary considerations, developed by the authors, for the appropriate indications of free tissue transfer versus use of local flaps such as the soleus muscle flap. We review the versatility and reliability of the soleus muscle as a local muscle option once the technique is mastered on how to safely and effectively design and execute this flap. We highlight the importance of an algorithmic approach to soft-tissue reconstruction of the lower extremity based on the best surgical option for the patient. This includes factors such as medical history, appropriate surgical candidacy, as well as the size and mechanism of injury to decide the most viable option for lower extremity reconstruction. We show that the medial hemisoleus muscle flap is a reliable local option, both by itself or in conjunction with other local flaps, to reconstruct less extensive wounds in the middle to distal third of the leg. Ultimately, such a local muscle flap must be mastered by the reconstructive surgeon to augment his or her armamentarium to provide a well-rounded reconstructive plan in managing the soft-tissue wound, while minimizing donor-site morbidity and potentially be more cost-effective in nature.

Microsurgical Limb Reconstruction Utilizing Truelok TL External Fixator: A Case Report

Coverage of lower extremity wounds, especially those in the distal leg, present challenges to the reconstructive surgeon. The present case illustrates a surgical technique utilizing a distally based reverse soleus muscle flap for coverage of an anterior leg wound deficit with exposed bone. The wound failed conservative wound care and was at risk of a below the knee amputation. The wound was first debrided to healthy bleeding tissue. The Truelok TL External Fixator was then applied for stabilization of the muscle flap. The medial portion of the soleus muscle was dissected with care to preserve its vascular supply and transposed to cover the wound defect. This was followed by utilization of the Integra Bi-Layer Matrix to control the vapor loss of the wound, act as a bacterial barrier, and provide a scaffold for cellular invasion and capillary growth. A wound VAC was applied to promote granular tissue formation. Following post-operative wound care, a split-thickness skin graft was later applied. The limb was salvaged and wound closure was achieved within three months. The patient began ambulating in a patella tendon bearing orthosis within four months. The reverse soleus muscle flap provides a viable option for ankle wound and anterior leg coverage, especially in medically frail patients. Due to a high degree of versatility, reliability, 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. It should be considered in the reconstruction of soft tissue defects about the ankle, especially when the surgeon has exhausted all other conservative and surgical options.

Repair soft-tissue defect in forefoot with reversed lateral soleus muscle flap

To summarize clinical application results of repair soft tissue defect in forefoot with a reversed lateral soleus muscle flap on peroneal artery pedicle. From January 2005 to January 2013, 8 patients with soft-tissue defect on forefoot were underwent reconstruction with a reversed lateral soleus muscle flap on peroneal artery pedicle. There were 6 males and 2 female, aged from 16 to 48 years with an average of 26.8 years old. The reversed lateral soleus muscle flap was transposed to the forefoot defect area, then immediate coverage of the muscle flaps were performed by a meshed split-thickness free skin graft. The donor site was closed directly. The muscle flap survey was observed after the repair of the forefoot. All muscle flaps had survived completely. No clinical vascular deficiency was found on muscle flaps postoperatively. One case occurred recipient area sustained insignificant superficial infection, one patient developed distal muscle flap small skin graft necrosis, and spontaneous heal by 2 weeks' change dressing. Follow-up period was ranged form 2.5 to 5.5 years with an average of 3.5 years postoperatively. A good contour was confirmed at the recipient area. According to Cedell questionnaire, 6 patients obtained good results and 2 fair. When the local skin flap or muscle flap application is limited, lateral soleus muscle flap survey is satisfactory after repair and very suitable for repair of soft tissue defect of forefoot.

Management of Soft Tissue Complications Associated with Leg Bone Injuries by Local Muscle Pedicle Flap

Background : Subcutaneous nature of tibia and poor blood supply to leg bone area causes increased complications and poor wound healing which can be managed by applying principles of plastic surgery Aims & objectives: To evaluate the use of gastrocnemius, soleus and sural flap by orthoapedic surgeon in management of complications of open leg bone fractures i.e. exposed implants, soft tissue defects. Material & methods: We prospectively studied 20patients with soft tissue complications in patients having both bone leg fracture. Out of which12 patients were managed by gastrocnemius flap,5 patients by soleus flap & 3 patients were treated by sural flap according to the location of the wound. Patients with age between 18-60 years with no or minimal infection, size of wound <50cm 2 for middle leg and <9×12cm for lower leg were included in study. The mean follow up was of 6 months. Results: Only two sural flap and one soleus flap had marginal necrosis. Hypoaesthesia over lateral border of foot was noted in two patients of sural flap which was not troublesome. Not any patient had developed significant functional loss. All flaps resulted in a good wound coverage with early healing. Conclusions: Local muscle flap is efficient and easy method of treating wound defects over leg and allows an orthopaedician to manage the compound fractures comprehensively.

髄内釘の露出した下腿感染創を持続陰圧洗浄とヒラメ筋弁側方移動術で温存し得た 1 例

髄内釘の露出した下腿感染創を持続陰圧洗浄とヒラメ筋弁側方移動術で温存し得た 1 例

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.

下腿皮膚欠損創に対しヒラメ筋弁・内側腓腹筋弁・遠位茎の内側腓腹筋弁を用いて再建を行った 3 例

下腿皮膚欠損創に対しヒラメ筋弁・内側腓腹筋弁・遠位茎の内側腓腹筋弁を用いて再建を行った 3 例