The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg

The usefulness of a reversed hemisoleus muscle flap as a local reconstructive option for soft-tissue coverage of an open tibial wound in the lower third of the leg has never been acknowledged. Over the past 2 years, 8 patients underwent soft-tissue reconstruction of an open tibial wound (3 x 3 to 10 x 6 cm) in the lower third of the leg with the reversed medial hemisoleus muscle flap modified by the author. The flap was dissected with attention to preserve several critical perforators from the posterior tibial vessels to the flap as possible while allowing adequate turnover of the flap to cover the exposed tibia or hardware. There was no total flap loss, and limb salvage was achieved in all patients. Only 2 patients developed insignificant distal flap necrosis, and they were treated subsequently with debridement and flap readvancement. All patients had reliable healing of their tibial wounds, with good reconstructive and cosmetic outcomes of their flap reconstructions during follow-up. Therefore, the author believes that the reversed medial hemisoleus muscle flap can be a good choice for soft-tissue coverage of a sizable open tibial wound in the lower third of the leg and may be used successfully to replace free tissue transfer in selected patients.     

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.     

Soft-tissue reconstruction of an open tibial wound in the distal third of the leg: a new treatment algorithm

Over the past 4 years, a total of 33 patients, each with an open tibial wound in the distal third of the leg, underwent a skin-grafted muscle flap reconstruction according to the new treatment algorithm developed by the author. When the size of the soft-tissue defect was less than 50 cm, a pedicled medial hemisoleus muscle flap was used for the soft-tissue coverage (n = 20). If the soleus muscle was traumatized, a small free muscle flap (ie, gracilis) was then used (n = 3). When the size of the soft-tissue defect was greater than 50 cm, a larger free muscle flap (ie, rectus abdominis or latissimus dorsi) was selected (n = 10). All patients were followed for up to 4 years. Three patients with a medial hemisoleus muscle flap developed insignificant distal flap necrosis and were treated subsequently with debridement and flap advancement. Five patients with a free muscle flap required an additional operation, and 2 patients had a subsequent debulking procedure of the flap for contour improvement of the leg. Reliable soft-tissue coverage with a well-healed tibial wound, evident fracture healing, and good contour of the leg were achieved in all 33 patients during follow-up. Following this new treatment algorithm, a selected option for an open tibial wound in the distal third of the leg can provide reliable soft-tissue coverage for different sizes of open tibial wounds and may offer a more cost-effective approach for managing such a complex clinical problem.     

Medial hemisoleus muscle flap: a reliable flap for soft tissue reconstruction of the middle-third tibial wound

Although the medial hemisoleus muscle has been considered a local reconstructive option for soft-tissue reconstruction of the middle-third tibial wound, its reliability and usefulness has been debated among plastic surgeons. This study reports one surgeon's experience with medial hemisoleus muscle flaps and shows their application for soft tissue reconstruction of middle-third tibial wounds. Over the past 2 years, 10 patients underwent soft tissue reconstruction of a middle-third tibial wound with a medial hemisoleus muscle flap and skin graft. The flap was elevated with emphasis on the preservation of as many perforators to the flap as possible while allowing adequate arch rotation of the flap to cover the exposed tibia and/or hardware. All patients were followed for up to 2 years. There was no total flap loss, and limb salvage was achieved in every patient in this series. Only two patients with peripheral vascular disease developed small partial but insignificant distal flap necrosis and were treated with debridement and flap advancement. The tibial wounds of all patients subsequently healed with excellent cosmetic outcome during follow-up. The results from this study indicate that the medial hemisoleus muscle flap is reliable for soft-tissue reconstruction of a middle-third tibial wound. Meticulous flap elevation with the preservation of perforators to the flap is the key for such success.     

Reconstruction of an extensive tibial soft-tissue defect with multiple local muscle flaps for limb salvage when free-tissue transfer was not an option

The use of microvascular free-tissue transfer for stable soft-tissue coverage has all but replaced the use of local muscle flaps to provide for reliable soft-tissue coverage of an extensive tibial wound. However, free-tissue transfer may not be an option of choice for patients with an extensive tibial defect for various reasons. We present two cases of extensive tibial soft-tissue defect that were managed successfully by multiple local muscle flaps with skin grafts. Both patients had complete healing of their wounds with only minimal complications. These cases demonstrate that an extensive tibial soft-tissue defect can be reconstructed with innovative use of multiple local muscle flaps. This approach is a good alternative to free-tissue transfer for limb salvage, and should be offered to patients with an extensive tibial wound when free-tissue transfer is not an option.     

吻合血管的游离肌肉瓣加网状皮片移植修复胫骨骨折合并骨外露及感染创面

目的介绍应用吻合血管的游离肌肉瓣加网状皮片移植修复胫骨骨折合并骨外露及感染创面的新方法。方法26例胫骨骨折合并骨外露及感染创面患者依伤情选择手术时机,5例采用一期吻合血管的游离肌肉瓣加网状皮片移植覆盖骨外露创面；6例急诊清创术后2周行二期修复；其余15例入院前胫骨远端感染严重,均采用二期肌肉瓣加网状皮片移植覆盖骨外露创面。结果26例中22例术后肌肉瓣及皮片全部成活；2例皮片部分坏死,2例创口延迟愈合,经换药均二期愈合。随访10～24个月(平均18个月),皮片色泽、质地、弹性均良好,无瘢痕挛缩。骨折均已愈合。结论肌肉瓣血运丰富,是修复胫骨远端感染及骨外露创面的理想方法,比较适合覆盖大面积软组织损伤合并骨外露创面和小腿远端慢性窦道及慢性骨髓炎骨外露创面。     

腓肠肌内侧头岛状肌瓣修复胫骨上端感染创面

目的：总结腓肠肌内侧头岛状肌瓣修复胫骨上端感染创面的临床应用结果。方法：胫骨上端感染创面9例,男7例,女2例;年龄21～60岁,平均34岁。应用改进的腓肠肌内侧头岛状肌瓣修复,供区均选用同侧小腿。肌瓣表面行Ⅰ期中厚网状游离植皮,供区直接缝合。结果：仅1例术后发生表浅感染,经换敷料逐渐愈合。所有患者肌瓣和其上植皮全部成活。术后随访13个月～4年,平均21个月,供区愈合良好,未发现明显功能障碍。结论：腓肠肌内侧头岛状肌瓣以腓肠内侧动脉为血供,具有血供丰富,血管解剖恒定,血管蒂长,以及肌瓣较薄的优点,带蒂移植适宜修复胫骨上端软组织缺损。     

Repair of soft-tissue defect close to the distal perforating artery using the modified distally based medial fasciocutaneous flap in the distal lower leg

In this study, we modified distally based posterior tibial artery perforator flaps for repair of soft-tissue defects close to the distal perforating artery in the distal lower leg. The flap was designed along the axial network around the saphenous nerve. Flap transfer was performed in 45 cases. The size of the defects after debridement ranged from 4 × 3 cm to 20 × 8 cm (mean, 13 × 5.5 cm). Flap size ranged from 9 × 3 cm to 25 × 10 cm (mean, 16 × 7 cm). In this series, 41 flaps survived completely. Venous congestion was not observed. At a mean follow-up of 16.5 months, all flaps matched the recipient sites in color, texture, and thickness. Donor site morbidity was minimal. The modified distally based posterior tibial artery perforator flap is a reliable and useful option for coverage of the soft-tissue defect close to the distal perforating artery in the distal lower leg.     

Reconstruction of limited soft-tissue defect with open tibial fracture in the distal third of the leg: a cost and outcome study

This study was conducted to analyze the cost and outcome of free-tissue transfers versus local muscle flaps for reconstruction of limited soft-tissue defects associated with tibial fractures in the distal third of the leg. Twelve adult patients underwent either free (n = 6) or local muscle (n = 6) flap reconstruction were retrospectively reviewed. Total operative time for local muscle flap reconstruction was 215 +/- 47 minutes compared with 450 +/- 90 minutes (P < 0.0002) for free-muscle transfer. Median length of hospital stay after reconstruction was 7 days for local muscle flap compared with 9 days for free-muscle transfer. Total cost of the local muscle flap procedure was US dollars 11,729 +/- US dollars 4460 compared with US dollars 19,989 +/- US dollars 3295 (P < 0.0004) for free-flap reconstruction. Five of 6 patients in each group had excellent soft-tissue contours. Fracture healing was evident in all patients of each group. Thus, a local muscle flap for reconstruction of a limited distal tibial wound appears to be more cost-effective than free-tissue transfer because of equivocal outcomes achieved but at approximately half of the cost.     

骨外固定加压治疗胫骨骨折内固定失败的疗效观察

目的:评估胫骨骨折内固定失败后骨外固定的疗效.方法:43例胫骨骨折内固定失败后采用骨外固定治疗.骨外交叉穿针时,伤口感染应先彻底清创,取出已松动内固定物.稳定性骨折可直接加压固定,不稳定性骨折可借助外固定器连接螺杆牵伸使骨周组织产生一定张力能维持骨折对位、对线,同时也将骨折达到稳定固定.小腿上段软组织缺损选用腓肠肌皮瓣或腓肠肌内侧头转位,中下段用邻近筋膜皮瓣覆盖.结果:43例中32例伤口Ⅰ期愈合(79%),骨折愈合时间为4～6个月(平均5.5个月).结论:骨外穿针骨折固定牢固,方法简便,对骨端血供干扰小,能早期功能锻炼,有利于骨愈合.同时,也便于术后对伤口观察和处理.     

Experience with the distally based posterior tibial island flap

A series of ten patients is presented to demonstrate the use of the distally based posterior tibial island flap with or without a muscle component for reconstruction of the foot. Six patients had defects due to a road traffic accident, two had defects due to a work accident, one had extensive scar contractures after a deep burn and advanced Buerger’s disease in another. There was complete survival of all the flaps but one. Four flaps were fasciocutaneous and six myofasciocutaneous, including the medial hemisoleus muscle. This flap is very useful in lower extremity reconstruction, particularly in the lower third of the leg and foot due to its long vascular pedicle, availability of skin and muscle and ease of elevation. All the island flaps were based on the anastomosis between posterior tibial and peroneal arteries above the medial malleolus. Received: 16 December 1997 / Accepted: 1 July 1998     

The posterior tibial artery perforator flap: an alternative to free-flap closure in the comorbid patient

Wounds of the distal third of the leg with exposed bone traditionally require free flaps for coverage. Although this often provides good results, patients with multiple comorbidities cannot undergo the long operating times and multiple surgical sites required for these complex procedures. We reviewed the use of posterior tibial (PT) perforator flaps as an alternative to free flaps for distal leg wound coverage in ill patients. Six patients (mean age, 53 years) with multiple comorbidities that precluded free-flap closures were treated with PT perforator flaps to cover complex distal leg wounds. The most common comorbidity was cardiac disease. Five patients had Gustilo grade IIIB open tibial fractures and one had a chronic wound. Mean flap size was 8x5.5 cm with a mean of one perforator per flap. Mean operating room time was 103 minutes. Four flaps were done without general anesthesia. There were no perioperative cardiopulmonary events. With a mean follow-up of 15 months, all flaps survived and all patients were ambulatory. There were no cases of malunion, nonunion, infection, wound breakdown, or partial flap loss. The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free-flap closure.     

Die Musculus-soleus-Lappenplastik

Objective

Defect coverage especially in exposed bone of the lower leg by pedicled muscle flaps in association with a split-thickness skin graft. Defect coverage oropharyngeal or at the upper extremity by free soleus flaps.

Indications

Defects of the proximal and middle thirds of the anterior lower leg for the proximally pedicled soleus flap; defects of the middle and distal third of the anterior lower leg for the distally pedicled soleus flap. The free flap is almost ubiquitously useable.

Contraindications

Primary diseases that makes a 2-h operation impossible, relevant affection of supplying vessels (the posterior tibial artery and/or the peroneal artery). Inadequate perfusion of the lower leg due to angiopathy, extensive soft-tissue infection, and wound contamination.

Surgical technique

Medial, longitudinal incision, slightly posterior to the tibia, according to the desired flap elevation (distally or proximally pedicled). Preparation of relevant vessels, mobilization of the muscle and transposition into local defects or use as a free graft. The pedicled flaps usually need a split-thickness skin graft to cover.

Postoperative management

Close monitoring of blood flow, temperature and swelling situation (hourly). Pressure-free wound-dressing of the leg, no circular or constricting dressings. Bedrest for 10 days, then start of flap training with intermittent circular compression, thrombosis prophylaxis, nicotine abstinence, physiotherapy, which depends on the bony situation, compression stocking after 3 weeks.

Results

Reliable results achieved at the middle and distal lower leg.     

Der distal gestielte M.-peroneus-brevis-Lappen zur Defektdeckung am Unterschenkel

BACKGROUND: Defects of the lower leg with exposed tendons or bone require either a local or free flap coverage. The distally pedicled peroneus brevis muscle flap has been proven to be a sufficient local flap alternative. MATERIAL AND METHOD: Using this technique the muscle is perfused by the non dominant distal perforators. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split skin graft. Between 2000 and 2004 12 patients with defects of the lower leg in the distal lower third have been treated by using this muscle flap. The defects were located over the tibial bone, the extensor tendons, the achilles tendon and the lateral malleolar region. RESULTS: All muscles healed primarily, 4 patients had minor wound healing complications of the skin graft, which in all cases healed conservatively. The muscle and skin graft remained stable. Donor site morbidity is restricted to the scar in the lateral lower leg. Pronation of the foot is not impaired. CONCLUSION: These cases show that the distally based peroneus brevis muscle has a wide range of coverage and even allows a closure down to the calcaneal tuberosity. Additionally, a local flap management with a safe muscle transposition is an economic procedure with short operation time and decreased hospital stay. If the muscle does not cover the wound sufficiently, free flap surgery can still be performed.     

Fasciocutaneous flap closure of a grade III lower third tibial fracture: an alternative to free flap coverage

We present a patient who sustained a close-range shotgun wound resulting in a grade III fracture of the lower tibia. The wound was debrided on several occasions and, on day 4, was closed with a flexor digitorum muscle and pedicled fasciocutaneous flap. Grades III and IV lower one-third tibial fractures generally require a free flap to accomplish stable soft-tissue coverage. Free-tissue transfer, however, remains a tedious and lengthy procedure. Occasionally a fasciocutaneous flap may be available to facilitate wound closure and spare the patient a lengthy procedure and distant donor site. The established principles of compound tibial coverage must be adhered to when choosing a local fasciocutaneous flap.     

Pearls and tips in coverage of the tibia after a high energy trauma

Coverage of soft-tissue defects in the lower limbs, especially open tibial fractures, is currently a frequently done procedure because of the high incidence of high-energy trauma, which affects this location. The skilled orthopedic surgeon should be able to carry out an integral treatment of these lesions, which include not only the open reduction and internal fixation of the fracture fragments but also the management of complications such as local wound problems that may arise. There is a wide variety of muscular or pedicled flaps available for reconstruction of lower limb soft-tissue defects. These techniques are not commonly used by orthopedic surgeons because of the lack of familiarity with them and the potential for flap failure and problems derived from morbidity of the donor site. We present a coverage management update for orthopedic surgeons for complications after an open tibial fracture. We choose and describe the most adequate flap depending on the region injured and the reliable surgical procedure. For proximal third of the tibia, we use gastrocnemius muscle flap. Middle third of the tibia could be covered by soleus muscle flap. Distal third of the tibia could be reconstructed by sural flaps, lateral supramalleolar skin flap, and posterior tibial perforator flap. Free flaps can be used in all regions. We describe the advantages and disadvantages, pearls, and tips of every flap. The coverage of the tibia after a major injury constitutes a reliable and versatile technique that should form part of the therapeutic arsenal of all the orthopedic surgeons, facilitating the integral treatment of complex lower limb injuries with exposed defects.     

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.     

Salvage of a through-knee amputation level using a free fillet of sole flap

A young adult male sustained a compound crural fracture with a 15 cm defect of tibia and fibula, and an extensive soft-tissue loss of the lower leg and knee joint. A free fillet of sole flap was raised on the amputated foot and transferred to the soft-tissue defect around the femoral condyles in order to prevent an above-knee amputation. Intact vascularisation and sensation of the flap were secured by microsurgical anastomoses of the popliteal and posterior tibial vessels and the sciatic and tibial nerves. The patient was rehabilitated rapidly with a prosthesis. At the 12-month follow-up, he demonstrated excellent ?foot”? sensibility, stable soft-tissue coverage of the stump, and an optimal functional result. © 1993 Wiley-Liss Inc.     

Utility of both muscle and fascia flaps in severe lower extremity trauma

BACKGROUND: The evolving technology in trauma management today permits salvage of many severe lower extremity injuries previously even considered to be lethal. An essential component for any such treatment protocol must be adequate soft tissue coverage that often will use vascularized flaps. Traditionally, calf muscles have been used proximally and free flaps for the distal leg and foot. The reintroduction of reliable local fascia flaps has challenged this dictum, proving to be a simpler and yet versatile option. MATERIALS AND METHOD: The role of both muscle and fascia flaps in lower extremity injuries has been retrospectively reviewed from a 2-decade experience. Soft tissue deficits requiring some form of vascularized flap occurred in 160 limbs in 155 patients. The frequency of use of flap types, specific complications and benefits, effect of timing of wound closure, and rate of limb salvage were compared. RESULTS: Initial coverage after significant lower extremity trauma in these 160 limbs required 60 local muscle flaps, 50 local fascia flaps, and 74 free flaps. These flaps had been selected on a nonrandom basis according to wound location, its severity, and flap availability. Complications were directly related to the severity of injury, and for free flaps as a group (39%), although these were not independent variables. Local muscle (27%) or fascia flaps (30%) were similar with regard to this morbidity. Healing was more likely to be uneventful if coverage were accomplished during the acute period after injury, regardless of flap type. Muscle flaps were still used in two thirds of all cases, with the soleus muscle used as often for the distal leg as the mid-leg. Local fascia flaps were most valuable for smaller defects, especially in the distal leg or foot, and often as a reasonable alternative to a free flap. CONCLUSION: The traditional role of the gastrocnemius muscles for flap coverage of knee and proximal leg defects and the soleus muscle for the middle third of the leg was reaffirmed. The soleus muscle often also reached distal leg defects as could local fascia flaps, where classically, otherwise, a free flap would have been necessary. The largest or most severe wounds, irrespective of limb location, required free flap coverage. Local fascia flaps proved to be a valuable alternative.     

腓肠肌远端岛状肌瓣修复膝和小腿上2/3软组织缺损

目的 探讨应用腓肠肌远端岛状肌瓣修复膝关节周围和小腿上2/3软组织缺损的临床效果.方法 2003年5月至2009年5月,应用腓肠肌远端岛状肌瓣修复18例膝关节周围和小腿上2/3软组织缺损,其中腓肠肌内侧头远端岛状肌瓣12例,腓肠肌外侧头6例.肌瓣表面以中厚网状皮片修复,供区直接缝合.结果 18例患者的肌瓣和其上所植皮片均成活,仅有2例术后创缘表浅感染,但经换药后逐渐愈合.术后随访8个月至4.8年,平均3.5年,供区愈合良好,仅有一纵行手术切口痕迹.患肢膝关节屈、伸与小腿内、外旋,以及足的跖屈与站立时上提足跟的肌力强度与功能,与健肢相比无明显差异,未见明显的功能障碍.受区肌瓣质地、厚薄及颜色均较好.结论 腓肠肌远端岛状肌瓣血供丰富,血管解剖恒定,血管蒂长,肌瓣较薄,适宜修复膝关节周围和小腿上2/3软组织缺损.