Gastrocnemius muscle flap combined with antibiotics loaded calcium sulfate in the treatment of postoperative infection and plate exposure of tibial plateau fracture in elderly patients / 中华显微外科杂志

Objective:To investigate the clinical efficiency of gastrocnemius muscle flap combined with antibiotics loaded calcium sulfate in the treatment of postoperative infection and plate exposure of tibial plateau fracture in elderly patients.Methods:From January, 2015 to May, 2019, 21 elderly patients with postoperative infection and plate exposure of tibial plateau fracture were treated, including 14 males and 7 females with an average age of 72.6 years, ranging from 61 to 82 years. The average course of disease was 22.7 days, ranging from 6 to 91 days. The site of wound infection was at medial in 8 cases, lateral in 9 cases and bilateral in 4 cases. The size of wound ranged from 2.0 cm×3.5 cm to 5.0 cm×12.0 cm. All wounds were implanted with antibiotics loaded calcium sulfate and repaired by gastrocnemius muscle flap combined with skin graft after debridement. Muscle flap survival, wound healing, inflammatory index, fracture healing and knee joint function were recorded. The curative effect was evaluated by McKee infection treatment criteria and the knee joint function was evaluated by HSS scoring criteria.Results:All 21 muscle flaps survived. In 1 case, skin graft necrosis occurred in a small area, and the wound healed well after dressing change. One case had exudation which was clear and the bacterial culturing was negative, and the wound healed after 2 weeks of dressing change. The other incisions were healed in stage I, and the healing rate was 90%. All patients were followed-up for an average of 28.7(16-39) months. The redness and swelling occurred in 1 case without exudation after 2 months which disappeared after anti-infection treatment and didn't recur again. The infection recurred in 1 case after 5 months, and it which was controlled after debridement and plate removal. According to McKee criteria, 19 cases were cured, 1 improved and 1 recurred with an effective rate of 95.2%. The fracture healing time was from 3 to 7 months, with an average of 4.6 months. According to HSS scoring criteria, the knee joint function was excellent in 12 cases, good in 7 cases and moderate in 2 cases.Conclusion:After thorough debridement, gastrocnemius muscle flap combined with antibiotic loaded calcium sulfate can effectively control the infection, repair the wound, promote fracture union and restore limb function in the treatment of postoperative infection and plate exposure of tibial plateau fracture in elderly patients.

The Cross-Leg Gastrocnemius Muscle Flap for Leg Reconstruction of the Difficult and Unfavorable Conditions

PURPOSE: In the cases of a vascular compromised condition in an injured lower extremity, soft tissue coverage with free tissue transfer presents a challenging problem to the reconstructive surgeon. For this reason, cross-leg flaps are still used in unusual circumstances. Advances in surgical technique has made the cross-leg free flap possible although it may require long operation time along with significant donor site morbidity. Therefore, a pedicled cross-leg muscle flap may be an alternative treatment modality when local flap or free flap is not possible. METHODS: Twelve patients(9 males and 3 females) underwent the operation from October 2001 to December 2008. The patients' age ranged from 6 to 82 years. The unusual defects included the regions such as the knee, popliteal fossa, distal third of the tibia, dorsal foot, and the heel. Indications for the cross-leg gastrocnemius flap are inadequate recipient vessels for free flap(in eight cases), extensive soft tissue injuries(in three cases) and free flap failure(in one case). The muscle flap was elevated from contralateral leg and transferred to the soft tissue defect on the lower leg while both legs were immobilized with two connected external fixator systems. Delay procedure was performed in 2 weeks postoperatively, and detachment was done after the establishment of the adequate circulation. The average period from the initial flap surgery to detachment was 32 days(3 to 6 weeks). Mean follow-up period was 4 years. RESULTS: Stable coverage was achieved in all twelve patients without any flap complications. Donor site had minimal scarring without any functional or cosmetic problems. No severe complications such as deep vein thrombosis or flap necrosis were noted although mild to moderate contracture of the knee and ankle joint developed due to external fixation requiring 3 to 4 weeks of physical treatment. All patients were able to walk without crutches in 3 months postoperatively. CONCLUSION: Although pedicled cross-leg flaps may not substitute free flap surgery, it may be an alternative method of treatment when free flap is not feasible. Using this modification of the gastrocnemius flap we managed to close successfully soft tissue defects in twelve patients without using free tissue transfers.

Early Resurfacing Using Gastrocnemius Muscle Flap Transposition for Degloving Injury with Exposure of Proximal Tibia

Degloving injuries result from the tangential force against the skin surface, with resultant separation of the skin and the subcutaneous tissue from the rigid underlying muscle and fascia. These injuries are associated with extensive soft tissue loss and occasionally with exposure of bone, and they require reconstructive modality for resurfacing and successful rehabilitation that considers the vascular anatomy and the timing of the operation. A 19-year-old male patient was transferred to our facility with degloving injury extending from the lower third of the right thigh to the malleolar area. The tibial bone was exposed to a size of 2x3.5 cm2 on the upper third of the lower leg at the posttraumatic third day. The exposed soft tissue was healthy, and the patient did not have any other associated disease. At the posttraumatic sixth day, one-stage resurfacing was performed with a medial gastrocnemius muscle flap transposition for the denuded bone and a split-thickness skin graft for the entire raw surface. The transposed gastrocnemius muscle attained its anatomical shape quickly, and the operating time was relatively short. No transfusion was needed. This early reconstruction prevented the accumulation of chronic granulation tissue, which leads to contracture of the wound and joint. The early correction of the gastrocnemius muscle flap transposition made early rehabilitation possible, and the patient recovered a nearly full range of motion at the injured knee joint. The leg contour was almost symmetric at one month postoperatively.

Reconstruction of Lower Extremity Soft Tissue Defect using Gastrocnemius Musculo-adipofascial Flap

UUse of the gastrocnemius muscle flap has proven to be highly effective in reconstruction of knee and lower leg defect due to its easy procedure, anatomical consistency, and less donor site morbidity.The gastrocnemius muscle is anatomically spindle shape, the volume of the distal part of the muscle for coverage is actually quite small and also even smaller when disuse atrophy is accompanied due to trauma. Although the defect is inside flap's arc of rotation, it is out of gastrocnemius muscle flap's indication when the defect size is extensive, and even though the defect is small, it is also out of indication when the defect is a bit out of arc of rotation. There has been a lot of modification to increase the flap's arc of rotation or dimension. However, it is difficult to achieve satisfactory results due to limitation and expense in clinical application. Authors used, for soft tissue reconstruction on broader area, gastrocnemius musculo-adipofascial flap, rather than classical gastrocnemius muscle flap, based on the fascial plexus of gastrocnemius muscle. We obtained a good result in lower extremity reconstruction of 7 cases from March 1999 to July 2000 and report this result with several cases.