Gastrocnemius Myocutaneous Flap for Coverage of Knee Defects in the injuries of popliteal artery: A clinical case report

doi:10.21203/rs.3.rs-4839940/v1

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Gastrocnemius Myocutaneous Flap for Coverage of Knee Defects in the injuries of popliteal artery: A clinical case report

https://doi.org/10.21203/rs.3.rs-4839940/v1

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Introduction

Reconstruction of defects caused by trauma and open fractures in knee is one of the important issues of reconstructive surgeries. The use of the gastrocnemius muscle flap has become an excellent choice for coverage of Knee Defects. But the surgical management Gastrocnemius Myocutaneous Flap in the injuries of popliteal artery remains a challenging therapeutic problem. The purpose of this article was to present a case of successful knee gastrocnemius flap in a patient with popliteal artery injuries.

Case report

In 2024, a 46-year-old woman with tibia fracture and popliteal artery injury went to the emergency room of Namazi Hospital. In the first stage, the external fixator of the tibia bone was performed to fix the fracture. Then popliteal artery anastomosis was performed. After two weeks, all internal implants were removed due to abscess. Four weeks later, the patient's skin developed necrosis and was repaired using Medial hemi Gastrocnemius Myocutaneous flaps (MHGMF).

Conclusion:

We present a case of the successful use of MHGMF for Coverage of Knee Defects in the injuries of popliteal artery.

Gastrocnemius Myocutaneous Flap

popliteal artery

Knee Defects

Reconstruction of defects caused by trauma and open fractures is vital for the injured person in terms of aesthetics, treatment and psychosocial issues (1). These defects can be caused by tumor, infection, or trauma, which, if left untreated, lead to pain, limited movement, and apparent dissatisfaction in people (2, 3). Since 1978, the gastrocnemius muscle flap has been introduced as a reliable and safe method in the reconstruction of soft tissue defects of the knee due to its good blood supply(4). In general, the gastrocnemius flap is performed in two ways, external and internal, as a Myocutaneous flap, usually when the soft tissue defect is so large that the patient's tendon and bone are visible, or the surgical incision is so deep that the two edges of the tissue are not closed (5, 6).

The transfer of one head of the gastrocnemius muscle in the flap technique not only does not lead to the dysfunction of the donor organ, but also leads to the improvement of the function of the recipient organ and the return of its beauty (3). Other advantages of this technique include high success rate, easy removal with minimal complications in the donor tissue, capacity to regenerate the removed tissue, and reducing the possibility of infection (2, 6). The gastrocnemius muscle is supplied with blood by the internal and external sural arteries and direct branches of the popliteal arteries (6). The sural arteries are large vessels that arise on each side of the popliteal artery to provide a vascular supply to the gastrocnemius, soleus and plantaris muscle. Both medial and lateral heads of gastrocnemius are supplied by the lateral and medial sural arteries, which are direct branches of the popliteal artery (7).

This good source of blood supply by helping to regenerate the muscle makes the gastrocnemius muscle flap an effective treatment method in large defects and traumas (2). Injury of the sural and popliteal vessels following trauma in the knee area disrupts the effectiveness of the gastrocnemius muscle flap technique and is considered as a contraindication for the use of this technique (5).

The purpose of this report is to introduce a case of gastrocnemius muscle flap for the reconstruction of the tissue defect in the knee area in the injury of the popliteal artery.

A 46-year-Female was brought to the emergency room of Namazi hospital (The largest medical center in the south of Iran) because of a car accident. The patient's left leg had an open fracture of Tibia plateau Type 6 Schatzker or type 5 Hohl and more classification along with popliteal artery injury along with pulseless. The patient's open fracture is type IIIc according to Gastilo-Anderson classification that have significant loss of tissue with an associated vascular injury.

Treatment

In the first stage, external fixator of tibial along with 2 cancellous screws (Close method) were performed to fix the fracture area in the orthopedic service. The use of screws was for the temporary reconstruction of the articular surface (Fig. 1).

In the next step, popliteal artery anastomosis was performed in the vascular surgery department through a medial knee incision. The patient was discharged from the hospital and after 6 weeks when the condition of the skin and soft tissue improved, the external fixator was removed in the operating room, and after 5 days using a lateral approach, the patient's fracture was repaired using a proximal lateral tibia locking plate and a butters plate was fixed.

After 2 weeks of surgery, an abscess between the medial incision (for popliteal artery repair) and lateral incision (for fracture fixation) with bone involvement was diagnosed by the doctor. By sending culture from Surgical site infection, MRSA (Methicillin-resistant Staphylococcus aureus) type of infection was diagnosed. At this stage, due to the spread of the infection deep into the bone, during a surgery, all internal implants (plates and screws) were removed, and after extensive washing of the surgical site during several stages in consecutive weeks and control of the infection (negative result of culture (SSI), Masquelet technique was performed for the patient. This technique involves the insertion of an antibiotic loaded polymethylmethacrylate (PMMA) bone cement spacer into the area of bone loss. The bone is stabilised by external fixation. The cement spacer stimulates a biological membrane to form around it (8).

Four weeks after this technique, the patient's skin was necrotic in an area of 4 x 10 cm and the patient's bone was exposed. At this stage, the patient's skin is repaired using MHGMF (Based on sural vascularity) and Split thickness skin graft was performed (Fig. 3). After 4 weeks, the flap is completely repaired (Figs. 4 and 5).

Figure4: Repaired flap after 3 and 4 weeks

One of the contraindications for using Medial hemi gastrocnemius is Active infection, Repair of popliteal artery, Popliteal anorism. In this case, despite the injury of the popliteal artery, the flap was repaired well.To complete the fixation of the patient's fracture at this stage, Bone Autograft graft (The tissue typically comes from the top of your hip bone (Iliac crest)) was used and placed instead of bone cement at the fracture site and external and final fixation with Elizarov fixator.

The gastrocnemius muscle is the most superficial muscle of the posterior calf. It has two heads, medial and lateral, which form the distal border of the popliteal fossa. Each head can be used as a separate muscle or musculocutaneous unit, based on its own pedicle. The medial head originates from the medial condyle of the femur and the lateral from the lateral condyle of the femur Both heads insert to the calcaneus through the Achilles tendon. The gastrocnemius muscle helps the plantar flexion of the foot. One or both heads of the muscle are expandable if the soleus muscle is intact (7).

Reconstruction of defects caused by tibial bone fracture along with popliteal artery damage is one of the important and challenging issues. It is necessary to use restorative procedures to cover the bone or joints and prevent infection. There are several methods for repairing damaged areas, one of which is the use of the gastrocnemius flap technique (9). The gastrocnemius flap is the primary muscle flap used in the reconstruction of the upper third of the leg (10).

In this technique, the medial and lateral head of the gastrocnemius muscle is removed to reconstruct the tissue defects of the proximal tibial region (9, 10). Typically, the removal of the lateral head is performed less in reconstructive surgeries due to size, movement limitation, and risk of damage to the peroneal nerve (11).

According to the study of Walton et al (10) removing one head of the muscle does not lead to dysfunction in patients (9, 10), but due to the presence of compensatory vessels and the use of long and wide muscles, this technique has become an effective and practical technique for repairing defects (9).

The suitability of the gastrocnemius flap technique has been investigated and confirmed in various studies. For example, in a study, Mayoly et al. used the gastrocnemius flap technique to reconstruct knee defects in injured patients following trauma, tumors, and knee replacements. All patients had a uncomplicated recovery after 15 days (6).

Shahzad et al. (2016) investigated the results of the gastrocnemius flap technique on 139 patients with soft tissue defects in the leg. The results after 6 weeks showed that more than 95% of the patients achieved their remission (3).

The health of the blood vessels of the gastrocnemius muscle is necessary to perform the gastrocnemius flap. For this reason, it is recommended to perform arteriography before using the flap. Patients who need gastrocnemius flap with complications such as active infection, repair of popliteal artery, and popliteal anorism will suffer from a disorder in the recovery process after the flap due to insufficient blood supply to the muscle(5). Therefore, according to medical science, the use of gastrocnemius flap is considered a contraindication for these patients. will be Nevertheless, in the present study, the gastrocnemius flap procedure was performed in a patient with popliteal artery injury without any complications, and the results were successful

The use of the gastrocnemius muscle flap to cover soft tissue defects of the knee can be successful even in patients with popliteal artery injury. It is suggested to carry out more research in order to know the factors affecting the success of this technique and finally to add the gastrocnemius flap as a Selective technique in people with leg tissue defects along with popliteal artery injury.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

SSI:

Surgical site infection

MHGMF

Medial hemi Gastrocnemius Myocutaneous Flap

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

MB collected the information and wrote the report. SM assisted with the writing of the report and collected x-rays. MB and SM had the initial idea for the report and is guarantor. All authors read and approved the final manuscript.

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No competing interests reported.

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Gastrocnemius Myocutaneous Flap for Coverage of Knee Defects in the injuries of popliteal artery: A clinical case report

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Abstract

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Introduction

Case Presentation

Treatment

Discussion

Conclusions

Consent

Abbreviations

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References

Additional Declarations

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