ArticlePDF Available

The gastrocnemius muscle flap for coverage of soft tissue defect of the proximal third of lower leg

Authors:
I. Schmidt at Not affiliated (Private Practice / Trauma-Orthopaedic-Hand and Trauma-related Plastic Surgeon)
I. Schmidt
  • Not affiliated (Private Practice / Trauma-Orthopaedic-Hand and Trauma-related Plastic Surgeon)
Download full-text PDF
Read full-text
Download citation

Figures

Figures - uploaded by I. Schmidt
Author content
All figure content in this area was uploaded by I. Schmidt
Content may be subject to copyright.
Content uploaded by I. Schmidt
Author content
All content in this area was uploaded by I. Schmidt on Jan 26, 2017
Content may be subject to copyright.
International Journal of Case Reports and Images, Vol. 8 No. 2, February 2017. ISSN – [0976-3198]
Int J Case Rep Images 2017;8(2):168–170.
www.ijcasereportsandimages.com
Schmidt 168
LETTERS TO THE EDITOR PEER REVIEWED | OPEN ACCESS
The gastrocnemius muscle flap for coverage of soft tissue
defect of the proximal third of lower leg
Ingo Schmidt
To the Editor,
Postoperative soft tissue defect with exposure
of relevant structures such as bone with or without
osteosynthesis plates of the proximal third of lower leg
represents a challenging problem. A 57-year-old male
presented with a highly comminuted open fracture of
the proximal right tibia (Figure 1A). First, the fracture
was stabilized by knee joint-bridging external fixation.
After four debridements and negative-pressure vacuum
assisted closure (VAC) therapies including incorporation
of polymethyl methacrylate (PMMA) beads containing
gentamycin (Figure 1B), the pre-tibial soft tissue defect
could be covered with a medial gastrocnemius muscle
flap and additional splitted skin grafts (Figure 1C). Then,
the fracture was definitively treated with open reduction
and internal fixation (ORIF). After eight weeks of injury,
there was uncomplicated fracture and wound healing
with complete restoration of knee joint function (Figure
1D–E), and 12 weeks after injury the patient could be
mobilized with full weight-bearing on the affected leg.
The use of local flaps for coverage of soft tissue
defects of the proximal third of lower leg and knee is
an option for treatment in patients who are not willing
or healthy enough to undergo free microvascular tissue
transplantation, and do not require microsurgical
expertise. The use of the gastrocnemius muscle flap is
one method of choice for reconstruction [1]. There is
only one vasculonervous pedicle for each of both muscle
heads composed of a sural artery and one or two veins,
Ingo Schmidt
Affiliation: SRH Poliklinik Gera GmbH, Straße des Friedens
122, 07548 Gera, Germany.
Corresponding Author: Dr. Ingo Schmidt, SRH Poliklinik
Gera GmbH, Straße des Friedens 122, 07548 Gera, Ger-
many; Email: schmidtingo62@googlemail.com
Received: 01 July 2016
Accepted: 11 November 2016
Published: 01 February 2017
and is classified as type I according to the classification of
Mathes and Nahai [2]. It is possible to divide the muscle
in two sections longitudinally according to the needs.
However, the lateral head has to be rotated around the
proximal fibula, therefore, it has a lower rotation angle
than the medial head. There is an option to safely harvest
a skin paddle overlying the muscle [3]. The gastrocnemius
muscle flap is probably one of the safest flap, however,
muscle flaps for reconstruction of legs are generally not
free of any complications. Neale et al. [4] reported on
major and minor complications in 32% of a total of 95
muscle flaps and they agreed that the causes were mainly
technical errors, inadequate debridement, use of diseased
and traumatized muscle, and unrealistic objectives. When
Figure 1: (A) Posteroanterior radiograph demonstrating highly
comminuted fracture of proximal tibia, (B) Clinical photograph
showing soft tissue defect at the ventral aspect of proximal tibia
with incorporated polymethyl methacrylate beads, (C) Clinical
photographs showing the harvest and transposition after skin
grafting of the medial gastrocnemius head, (D) Posteroanterior
and lateral radiographs demonstrating fracture healing after
open reduction and internal fixation, (E) Clinical photographs
showing uncomplicated wound healing and complete
restoration of knee joint function.
International Journal of Case Reports and Images, Vol. 8 No. 2, February 2017. ISSN – [0976-3198]
Int J Case Rep Images 2017;8(2):168–170.
www.ijcasereportsandimages.com
Schmidt 169
a gastrocnemius muscle flap is not indicated, the use of
random pattern skin transposition flaps is one salvage
option [5].
Keywords: Gastrocnemius muscle flap, Proximal third
lower leg, Soft tissue defect
How to cite this article
Schmidt I. The gastrocnemius muscle flap for coverage
of soft tissue defect of the proximal third of lower leg. Int
J Case Rep Images 2017;8(2):168–170.
Article ID: Z01201702LE10024IS
*********
doi:10.5348/ijcri-201708-LE-10024
*********
Author Contribution
Ingo Schmidt – Substantial contributions to conception
and design, Acquisition of data, Analysis and
interpretation of data, Drafting the article, Revising
it critically for important intellectual content, Final
approval of the version to be published
Guarantor
The corresponding author is the guarantor of submission.
Conflict of Interest
Author declare no conflict of interest.
Copyright
© 2017 Ingo Schmidt. This article is distributed under
the terms of Creative Commons Attribution License which
permits unrestricted use, distribution and reproduction in
any medium provided the original author(s) and original
publisher are properly credited. Please see the copyright
policy on the journal website for more information.
REFERENCES
1. Le Nen D, Hu W, Liot M, Moineau G, Gerard
R. Gastrocnemius medial flaps. Interact Surg
2007;2(2):118–27.
2. Mathes SJ, Nahai F. Classification of the vascular
anatomy of muscles: Experimental and clinical
correlation. Plast Reconstr Surg 1981 Feb;67(2):177–
87.
3. McCraw JB, Fishman JH, Sharzer LA. The versatile
gastrocnemius myocutaneous flap. Plast Reconstr
Surg 1978 Jul;62(1):15–23.
4. Neale HW, Stern PJ, Kreilein JG, Gregory RO, Webster
KL. Complications of muscle-flap transposition for
traumatic defects of the leg. Plast Reconstr Surg 1983
Oct;72(4):512–7.
5. Haroon-Ur-Rashid, Hafeez K, Abbas K. Use of distally
based random flap in the management of soft tissue
defects in upper two thirds of leg. J Pak Med Assoc
2014 Dec;64(12 Suppl 2):S15–8.
ABOUT THE AUTHOR
Article citation: Schmidt I. The gastrocnemius muscle flap for coverage of soft tissue defect of the proximal third
of lower leg. Int J Case Rep Images 2017;8(2):168–170.
Ingo Schmidt is a surgeon in the Department of Traumatology SRH Poliklinik, Waldklinikum
Gera GmbH, Germany. From 1983 to 1989, he studied human medicine at the Friedrich-Schiller-
University in Jena (Germany). From 1990 to 1999, Dr. Schmidt graduated his training for general
surgery, traumatology, orthopaedics, and hand surgery at the University hospital in Jena. In 1994, he
successfully defended his scientic work to gain the title as a medical doctor. He has published more
than 20 scientic articles. His areas of interest include hip replacement, coverage of soft tissue defects,
and hand surgery with special focus on total wrist replacement and arthroplasties of all other joints of
the hand.
International Journal of Case Reports and Images, Vol. 8 No. 2, February 2017. ISSN – [0976-3198]
Int J Case Rep Images 2017;8(2):168–170.
www.ijcasereportsandimages.com
Schmidt 170
Access full text article on
other devices
Access PDF of article on
other devices

Supplementary resource (1)

Z01 2016070179 LE prov (complete correct, proved by the author Nov 24.)
Data
November 2016
I. Schmidt
... The new generation of MCPJ arthroplasty is unconstrained surface replacement either with pyrocarbon prostheses [8,31,32] or prostheses with a metal-on-polyethylene (PE) articulation [33,34]. The goal of these prostheses is that they are low profile, anatomically designed implants limit the amount of bone removed [35]. ...
View
... Highly comminuted fractures or fracture-dislocation injuries with concomitant severe closed or open soft tissue injuries especially at the critical distal third of lower leg, ankle and hindfoot where the bradytrophe bony tissue is not surrounded by well vascularized defending muscles ( Figure 8A) represent a challenging therapeutic problem [11]. In general, surgical treatment typically involves the three-stage management both at the upper and lower extremities without any differences that is based on the fundamental knowledge by Gustilo and Anderson in the late 70th's to prevent bony infection [7,[12][13][14][15]. The first stage includes CREF, first applied in 1843 by Malgaigne and later modified in 1902 by Lambotte, to restore length of bone and alignment of its axis, and joint congruency by ligamentotaxis with or without additional percutaneous pinning ( Figures 4A, 5B, 6A, 7B and 8B) [16][17][18][19]. ...
View
... An unacceptable failure leading to loss of flap is when the vascular pedicle was selceted too short and no sufficient arterial supply exists [15]. Local muscle flaps, first reported by Stark in 1946, became an established procedure for coverage of soft tissue defects of the lower leg with exposure of bone with or without osteosynthesis plates, joints with or without total knee or total ankle arthroplasties in the absence of deep infect, tendons, and can provide as well as prevent shortening of the tibial bone [6,[15][16][17][18][19][20]. Muscle flaps promotes better capillary circulation leading to a decrease of bacterial load, hence, muscle flaps are not contraindicated when superficial bacterial wound contamination is present. ...
View
Use of distally based random flap in the management of soft tissue defects in upper two thirds of leg
Article
Full-text available
  • Dec 2014
  • J Pakistan Med Assoc
Objective: To assess the results of cases with complex wounds exposing tibia who were managed with distally based random flaps. Methods: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and Dow University Hospital, Karachi and comprised data between February 2000 and March 2013of patients who had been admitted with a recent or prior history of trauma with a soft tissue defect in upper two-thirds of tibia and who had undergone coverage procedure using distal based flap. Results: The mean age of the total 21 patients in the study was 29±9 years, and 20(95%)were male. Road traffic accident was the most common mechanism of injury in 13(62%). Tibia was exposed in all the 21(100%) cases requiring soft tissue coverage. There was associated fracture of tibia in 18(86%) patients. Mean flap length was 12±1.7 cm and width was 5.3 ±0.86 cm. Maximum size for the flap dissected was 15x7cm. Donor site was covered with split thickness skin graft in 19(90.5%) patients. Flap survival rate was 100%. Only 2(9.5%) patients developed partial flap necrosis. Clinical outcome was graded as good in 19(90.5%) patients and fair in 2(9.5%). Superficial infection was observed in 2(9.5%) patients. Conclusion: Distal based flap appeared to be an effective solution for the coverage of soft tissue defects in upper two-thirds of leg.
View
Gastrocnemius medial flaps
Article
Full-text available
  • Apr 2012
With reference to the data reported in the literature and to the anatomical vascular basis, the authors expose different techniques and maneuvers used for dissection of gastrocnemius flaps. The use of muscular and myocutaneous gastrocnemius flaps and some modifications of the standard surgical technique aiming to gain more versatility are described. So that, the range of these flaps can be planned to cover the greatest part of the lower extremity of the leg.
View
View
The versatile gastrocnemius myocutaneous flap. Plast Reconstr Surg 62: 15-23
Article
  • Aug 1978
  • PLAST RECONSTR SURG
The medial and lateral gastrocnemius myocutaneous flaps are described. Their usefulness, as direct flaps without a delay, in reconstruction of the lower extremity is described. In our practice, this flap has supplanted the cross-leg flap for most reconstructions in the lower extremity.
View
Complications of Muscle-Flap Transposition for Traumatic Defects of the Leg
Article
  • Nov 1983
  • PLAST RECONSTR SURG
A careful study of 95 consecutive muscle-flap procedures performed on 71 patients with traumatic soft-tissue defects of the leg was carried out. Although there were only 5 cases of total muscle-flap necrosis, major and minor complications were found in 31 patients, requiring additional surgery for coverage. Technical errors resulted in partial split-thickness skin-graft loss or hematoma and were responsible for the 10 minor complications. Inadequate debridement of necrotic soft tissue and bone, the use of diseased or traumatized muscle, and unrealistic objectives for the muscle-flap coverage were the source of 21 major complications. We feel fewer complications would result with more careful preoperative evaluation and surgical planning, adequate debridement of bone and soft tissue, and the transfer of healthy, nontraumatized muscle.
View
Classification of the Vascular Anatomy of Muscles: Experimental and Clinical Correlation
Article
  • Mar 1981
  • PLAST RECONSTR SURG
Five patterns of muscle circulation, based on studies of the vascular anatomy of muscle, are described. Clinical and experimental correlation of this classification is determined by the predictive value of the vascular pattern of each muscle currently useful in reconstructive surgery in regard to the following parameters: arc of rotation, skin territory, distally based flaps, microvascular composite tissue transplantation, and design of muscle-delay experimental models. This classification is designed to assist the surgeon both in choice and design of the muscle and musculocutaneous flap for its use in reconstructive surgery.
View
The versatile gastrocnemius myocutaneous flap
  • Jan 1978
  • 15-23
  • Jb Maccraw
  • Jh Fishman
  • La Sharzer
MacCraw JB, Fishman JH, Sharzer LA. The versatile gastrocnemius myocutaneous flap. Plast Reconstr Surg 1978; 62(1):15-23.
Article citation: Schmidt I. The gastrocnemius muscle flap for coverage of soft tissue defect of the proximal third of lower leg
  • Jan 2017
  • 168-170
  • About The
ABOUT THE AUTHOR Article citation: Schmidt I. The gastrocnemius muscle flap for coverage of soft tissue defect of the proximal third of lower leg. Int J Case Rep Images 2017;8(2):168–170.
ABOUT THE AUTHOR Article citation: Schmidt I. The gastrocnemius muscle flap for coverage of soft tissue defect of the proximal third of lower leg
  • Jan 2017
  • 168-170
ABOUT THE AUTHOR Article citation: Schmidt I. The gastrocnemius muscle flap for coverage of soft tissue defect of the proximal third of lower leg. Int J Case Rep Images 2017;8(2):168-170.
he successfully defended his scientific work to gain the title as a medical doctor. He has published more than 20 scientific articles. His areas of interest include hip replacement, coverage of soft tissue defects
  • Jan 1994
  • Srh Traumatology
  • Waldklinikum Poliklinik
  • Germany Gera Gmbh
Ingo Schmidt is a surgeon in the Department of Traumatology SRH Poliklinik, Waldklinikum Gera GmbH, Germany. From 1983 to 1989, he studied human medicine at the Friedrich-Schiller-University in Jena (Germany). From 1990 to 1999, Dr. Schmidt graduated his training for general surgery, traumatology, orthopaedics, and hand surgery at the University hospital in Jena. In 1994, he successfully defended his scientific work to gain the title as a medical doctor. He has published more than 20 scientific articles. His areas of interest include hip replacement, coverage of soft tissue defects, and hand surgery with special focus on total wrist replacement and arthroplasties of all other joints of the hand.