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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00940-4
10.1016/j.ijscr.2024.110159
110159
Case Report
Re-innovation of split lateral gastrocnemius muscle flap for complicated proximal tibia open fracture: Case report
Yassin Amin M.
Mohamed Momen Momen.m.ibrahim@gmail.com
⁎
Mohammed Maany
Dirar Mohamed
Ahmed Muhnnad
Salah Musab
Department of plastic surgery, Alsrorab hospital, Khartoum, Sudan
⁎ Corresponding author at: Department of plastic surgery, Alsrorab hospital, Khartoum, Sudan. Momen.m.ibrahim@gmail.com
13 8 2024
9 2024
13 8 2024
122 11015922 6 2024
8 8 2024
10 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Maintaining mobility and hence the productivity of individuals depends on the preservation of lower limb integrity. Increasing violence, mainly triggered by weapons, inversely impacts limb functionality, and the resulting wounds require proper care.

Case presentation

A 47-year-old African man without any previous medical conditions experienced an injury to his right leg from a high-speed accident, resulting in an open fracture in the upper third of the tibia with missing tissue. At first, he received care from orthopedic surgeons and had debridement done along with the use of an external fixation device to stabilize his limb. Two weeks later, he was referred to the plastic surgery unit and was preparing for urgent surgery. A split lateral gastrocnemius muscle flap was used to reconstruct him after a surgical debridement.

Clinical discussion

Proximal leg trauma can be managed successfully by rearrangement of local tissue, resulting in a perfect outcome with less donor site morbidity and a long, complex surgery compared to free tissue transfer. Gastrocnemius muscle or myocutaneous flap, is a gold standard for proximal leg trauma, mainly when a cavity exists, and it is able to create satisfactory reconstruction.

Conclusion

The split lateral gastrocnemius muscle flap is an effective modification of the flap, resulting in greater surface area coverage, less bulk and shape distortion, and reliable blood supply. Furthermore, it is easy to harvest and apply, deferring the need for step-curve microsurgical procedures.

Highlights

• Lower limb injuries are common and promoting management requires collaboration between plastic and orthopedic surgeries aiming to preserve ambulatory function of limbs.

• The gastrocnemius muscle flap remains a popular choice for reconstructing proximal leg wounds, favored over free tissue transfer for its reputation of being simple and dependable.

• The ability of the lateral gastrocnemius muscle flap to spread over a larger surface area is enhanced by its splitting.

Keywords

Leg injury
Lower limb reconstruction
Lateral gastrocnemius muscle flap
Split lateral gastrocnemius muscle flap
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pmc1 Introduction

Traumatic lower limb injuries induced by high-speed weaponry result in difficult wounds that carry a high morbidity and necessitate the collaboration of orthopedic and plastic surgery departments for immediate reconstruction. An injury in the upper portion of the tibia requires urgent attention in order to preserve joint integrity and function. Deep infection is the main opponent, which can distract locally and spread to cause a catastrophic wound. This condition existed in the vast majority of open fracture victims with delayed presentation [1,2].

The objective of therapy for a lower limb open fracture is debridement and obliteration of the lesion with viable tissue. Local tissue is usually sufficient to cover minor to moderate defects, eliminating the requirement for distant and free tissue transfer. For upper leg defects, the gastrocnemius muscle flap is the workhorse method of reconstruction, especially when the defect requires a considerable quantity of tissue to conceal dead space [3,4,5].

The lateral head of the gastrocnemius muscle is less commonly utilized than the medial head, although it can cover lateral proximal leg and knee wounds with less complications and functional limitations. Modifications to this flap increase its value, and the split lateral gastrocnemius muscle flap is not a popular variety of flap, despite its ability to cover a larger area than the standard approach.

This article describes using a split lateral head of gastrocnemius muscle flap for the reconstruction of complicated defects at proximal leg.

2 Case presentation

A 47-year-old man-African with no known significant medical background. He presented to plastic surgery unit with right upper leg wound resulted from the explosion. He was initially admitted to the orthopedic department on the same day of the trauma, where he was undergoing initial assessment and management. He also underwent surgical debridement and subsequent stabilization of the proximal third tibia fracture. After two weeks, he was directed to a plastic surgery department. The delay in arrival can be attributed to various factors, such as being admitted to the orthopedic department in a different hospital, financial constraints, and the challenge of transferring between two hospitals located in a conflict zone. His arrival was delayed because the medical facilities related to the war were inaccessible. On arrival at the plastic surgery department, the patient was systematically examined and found to have only injured his right leg.

On examination, the right leg was supported by an external fixator and had a wound of approximately 5 × 6 × 4 cm on the anterior LEG with a skin defect distal to the edge of the hole (Fig. 1). Unfortunately, the wound was complicated by infection and pus discharge, but examination of the remaining part of the limb revealed no abnormalities. In addition to routine dressing changes, the microbiologist analyzed wound secretions for microbiological testing and antibiotic treatment.Fig. 1 Pre-operative: Right lateral leg wound with cavity extended deep to tibia.

Fig. 1

He was scheduled for urgent surgical debridement and wound cover. At operating room, after application of spinal anaesthesia and a tourniquet, all necrotic tissue was being excised result in expanded wound about 8 ∗ 10 ∗ 6 cm (Fig. 2). Lateral head of gastrocnemius muscle became exposed after debridement and was chosen to reconstruct defects. Incision was extended distal to 10 cm above lateral mallulous, and then lateral head of gastrocnemius muscle was isolated from overlying skin and underlying soleus muscle. Distal insertion of muscle was divided from Achilles tendon, then dissection continued proximal toward origin, lateral sural artery was exposed and this the end point of proximal dissection (Fig. 3). Deep peroneal nerve was identified and secured to prevent iatrogenic injury and compression by flap transposition. Following the main trunk, the lateral sural artery dissection progressed distally through the muscle until it divided into superficial and deep branches. The muscle was then split into two parts, each receiving a vascular branch (Fig. 4). The superficial segment was utilized to seal the cavity at inferolateral aspect of knee, while the deeper segment was used to cover the remaining wound area over exposed bone and anchored to the subdermal layer of skin at the medial edge of the wound. Flap was not covered with a skin graft to facilitate flap monitoring. Wound was closed with semi-occlusive wound dressing (Fig. 5, Fig. 6).Fig. 2 Intra-operative: Lateral aspect of right leg after debridement.

Fig. 2

Fig. 3 Diagram showing intra-operative step: isolation of lateral head of muscle and detached distal insertion from Achilles tendon.

Fig. 3

Fig. 4 Diagram showing intra-operative step: division of lateral head of muscle into to segment each have its dependent blood supply from lateral sural artery.

Fig. 4

Fig. 5 Diagram showing intra-operative step: application of the superficial part of muscle into cavity proximally, while the deep part was used to resurface exposed tibia anteriorly.

Fig. 5

Fig. 6 Intra- operative: after application of split lateral head of gastrocnemius muscle flap.

Fig. 6

Partial necrosis at edge of deeper portion was observed about 1-2 cm, but the rest of flap healed nicely and infection was not encountered (Fig. 7). Split thickness skin graft was used to resurface flap in separate operation. Over the course of four consecutive months, the follow-up period progressed seamlessly and without any complications. Nonetheless, the follow-up was halted due to the patient's relocation to another city.Fig. 7 2-Weeks follow up post-operative.

Fig. 7

This work is under SCARE guideline [6].

3 Discussion

The lower extremities are human ambulatory tools, with the ortho-plastic team's efforts focused on maintaining skeletal stability and favorable coverage. Most lower extremity injuries cause significant morbidity and negative effects on the individual, while also exhausting the health care system. It is recommended to have a team of vascular, orthopedic, and plastic surgeons provide definitive coverage for lower extremity injuries within days of injury. Unfortunately, this case does not apply to worldwide or conflict areas like Sudan.

Traumatic injury by war weapons usually contaminated and a delayed in presentation of patient double risks of infection which convert wound into challenging one. Temporal management with negative pressure wound therapy accompanied by implanted antibiotics was reported to treat open leg fracture, but long hospitalisation and multiple sessions for dressing changes promoted toward flap coverage. The emerging trend in reconstruction involves the use of advanced surgical methods such as free flap and supermicrosurgical procedures, which entail anastomosing the recipient's perforator to those of the flap to circumvent major vessels. Although these techniques offer superior outcomes compared to other approaches, their intricate nature poses challenges in developing countries with limited resources and inadequate training for such complex surgeries. Furthermore, conducting these procedures in hospitals situated in conflict zones is not advisable [7].

Large intricate wounds are commonly reconstructed using a free flap or multiple local flaps, such as the gastrocnemius and soleus, leading to successful outcomes. Given that the primary approach is unsuitable in our case, the secondary option involves sacrificing a major muscle for foot flexion. Nevertheless, modifying the lateral head of the gastrocnemius can effectively treat the wound with reduced morbidity [8].

The use of fasciocutaneous, muscle or mycocutaneous flap for complicated wound is still debatable and many researches reveled no superiority of one over another. In our case, muscle was needed to provide bulky tissue with generous blood supply to obliterate cavity. Also, local flap is easy, reliable with less donor site morbidity comparing with free tissue reconstruction. Gastrocnemius muscle flap proves effectiveness for reconstruction of defects around knee joint and proximal leg, and consider the most salvageable tool for complicated knee replacement procedures. Lateral head of gastrocnemius muscle is not commonly used flap because it has less bulk and limited arc of rotation, and some report mentioned post-operative personal neuropathy. Deposit these withdrawal effects, the lateral head able to manage complex wound at lateral aspect of knee and the leg [9,10].

Various studies have detailed different versions of the gastrocnemius flap, showcasing impressive results. Among these variations is the myocutaneous gastrocnemius flap, which can effectively treat complex wounds by filling cavities with muscle while the cutaneous part covers the surface of the wounds. However, in our specific case, this flap is not suitable for covering a wound with two components - a cavity and exposed bone - both in opposing directions [11].

Splitting of lateral head of gastrocnemius muscle flap is not a new modification but also is not commonly used although it is a fabulous method to increase the total surface area of flap while providing durable bulk for small cavity. Lateral sural artery divided into superficial and deep branches makes splitting of flap into two parts achievable, and both segments can be used either simultaneously or separately. In our case, using of this method facilitated obliteration of proximal cavity while another segment was recruited to resurface the upper anterior side of the tibia [12,13]. Split-thickness skin grafts are commonly employed concurrently with muscle flaps to improve graft acceptance and reduce the need for additional surgical procedures. However, in our particular situation, split-thickness skin grafts were not utilized due to the necessity of debridement in the event of flap necrosis, which would result in the wastage of skin grafts. Furthermore, if the infection is not effectively treated, the graft is unlikely to survive. Within two-week flap healed beautifully with adorable shape without excessive bulk or disfiguring leg shape. Marginal necrosis did not affect outcome significantly, and other complication such as hematoma, the infection and neuropathy did not develop.

We encountered a variety of obstacles, including the non-availability of an orthoplastic team, the location of a medical facility in a conflict zone, delays in patient presentation, and the loss of long-term follow-up due to patient relocation. Additionally, the inadequate setup for complex surgical procedures limits the possibility of employing a superior reconstruction option. Moreover, there is a dearth of studies that have examined this methodology, which, despite its usefulness, is not widely adopted.

4 Conclusion

The lateral gastrocnemius flap is a powerful tool for knee and proximal leg reconstruction if wisely used in the management of selected patients, although it is associated with many complications. Splitting of the gastrocnemius head robust utility of flap and increase total surface area covering with reliable predictable outcome.

Consent

written consent was obtained by patient to be part of this job and provide permission for publication includes photography. A copy of consent available but written in Arabic to allow patient to understand purpose of study.

Ethical approval

Patient confidentiality maintained and data collected after full explanation of research project and aim of it, then written informed consent was obtained. Ethical approval is not need and written consent was taken from patient for publication.

Funding

No Fund received.

Author contribution

I confirm that all the authors have made a significant contribution to this manuscript, have seen and approved the final manuscript and have agreed to its summation. Also I accept full responsibility for the work and the conduct of study, have access to data, and controlling the decision of publishing.

Guarantor

Dr. Momen Mahmoud Ibrahim Mohamed.

Research registration number

No trial or experiment involved human subjects.

Conflict of interest statement

No conflict of interest.

Acknowledgement

We hereby acknowledge Dr. Eltahir Elhadi Ibrahim for his exceptional expertise and assistance in producing diagrams that effectively illustrate the intra-operative steps, significantly improving the overall value of our article.
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