Reyad, K., Setta, H. (2018). Reconstruction of Lower One Third Leg Defects in Single Vessel Lower Limb by Medial Hemisoleus Muscle Flap Based on Distal Posterior Tibial Artery Perforators. The Egyptian Journal of Plastic and Reconstructive Surgery, 42(2), 291-297. doi: 10.21608/ejprs.2018.79714
Khaled A Reyad; Hany Saad Setta. "Reconstruction of Lower One Third Leg Defects in Single Vessel Lower Limb by Medial Hemisoleus Muscle Flap Based on Distal Posterior Tibial Artery Perforators". The Egyptian Journal of Plastic and Reconstructive Surgery, 42, 2, 2018, 291-297. doi: 10.21608/ejprs.2018.79714
Reyad, K., Setta, H. (2018). 'Reconstruction of Lower One Third Leg Defects in Single Vessel Lower Limb by Medial Hemisoleus Muscle Flap Based on Distal Posterior Tibial Artery Perforators', The Egyptian Journal of Plastic and Reconstructive Surgery, 42(2), pp. 291-297. doi: 10.21608/ejprs.2018.79714
Reyad, K., Setta, H. Reconstruction of Lower One Third Leg Defects in Single Vessel Lower Limb by Medial Hemisoleus Muscle Flap Based on Distal Posterior Tibial Artery Perforators. The Egyptian Journal of Plastic and Reconstructive Surgery, 2018; 42(2): 291-297. doi: 10.21608/ejprs.2018.79714
Reconstruction of Lower One Third Leg Defects in Single Vessel Lower Limb by Medial Hemisoleus Muscle Flap Based on Distal Posterior Tibial Artery Perforators
The Departments of Plastic & Reconstructive Surgery, Faculty of Medicine, Ain Shams University, Egypt
Abstract
Background: Crushing injuries of the lower 1/3 of the lower limb always represent a challenge for reconstruction. Reconstructive options diminish with the injury of one or more of the major vessels of the lower limb. This is a revisit of distally based medial hemi-soleus muscle flap as a valuable option in such reconstruction. Patients and Methods: 16 patients with skin loss over lower one third of leg of various causes had pre-operative duplex done to detect affection of anterior tibial and/or peroneal vessels and confirm patency of the posterior tibial vessels. CT angiography was done for confirmation. In case of one or two vessels affection, sparing the posterior tibial artery, the defects in the distal one third of the leg were reconstructed by distally based hemi-soleus muscle flap; based on the distal perforators of the medial head of the soleus muscle from the posterior tibial artery. Results: The flap survived completely in twelve cases with total loss in one patient, partial loss in two case and local recurrence of the excised tumour in one case. Conclusion: The distally based medial hemi-soleus muscle flap is a very good option in reconstruction of problematic lower one third skin defects especially that associated with vascular injury other than the posterior tibial vessels.
INTRODUCTION High energy leg injuries usually result in soft tissue losses and skin defects and are usually accompanied with bony fractures or even bony defects. These injuries may be severe enough to be associated with major leg vessel injuries rendering reconstructive options limited. The lower one third skin defects of leg usually represents a reconstructive challenge and the role of local skin flaps and distally based fasciocutaneous flaps may be limited especially if their vascular pedicles fall within the zone of injury. Free flaps are the golden operation in reconstruction [1] of these defects but it may not be applicable in vascular compromised limbs as those suffering injury of one or two large 291 vessels from the three major vessels supplying the lower limb (Posterior tibial, Anterior tibial and Peroneal vessels). Perforator flaps [2,3] based on either direct or indirect perforator may be useful especially in small defects but has tedious dissection and partial flap loss rate at 11.3%. Cross leg flaps are another option but it may render impossible if the patient has another proximal femur or pelvic fractures or even if they have external fixator to leg bones with difficult flap inset, with local flap necrosis of 40% [4]. Distally based neuro-vascular sural flap is used with local flap necrosis rate of 21% [5]. The reversed flow hemi-soleus flap with sacrifice of the posterior tibial artery to be included within the flap was described by Guyron [6]. However the flap did not gain much popularity because it has the great disadvantage of sacrificing major leg blood vessel [6,7,8]. The distally based Soleus muscle flap based on the distal perforators of the posterior tibial was introduced by Townsend [9] and later on by Fayman et al., [10], is a good option in reconstruction of lower one third leg defects in vascular compromised leg (one or two vessels injury) owing to the following advantages; no disruption of major blood vessels, stable coverage and profound circulation that is able to supply the underlying bone with blood especially bone grafts or osteomyelic bone after less than radical excision. So our aim in this study is to re-evaluate the reliability of the distally based hemi-soleus muscle flap in the reconstruction of lower third leg defects in vascular compromised cases where only the posterior tibial artery is always preserved. PATIENTS AND METHODS The study was compiled from a retrospective chart review of sixteen patients in a two year period (September 2014 till July 2016) at the Plastic and Reconstructive Surgical Departments in Ain Shams University and Alzayton Hospitals. These patients suffered from lower one third skin defects of leg with injury of one or more leg vessels sparing the posterior tibial vessels. The defects were due to one of the following causes; post traumatic, post tumour excision or osteomyelitis and unstable scar. The injured vessels in these patients were either the anterior tibial alone, peroneal alone or both the anterior tibial and the peroneal vessels. All patients underwent reconstruction of the skin defects by distally based medial hemi-soleus muscle flaps based on distal posterior tibial perforators arising from the posterior tibial artery distally and directly entering the medial side of the soleus muscle. These perforators were identified intraoperatively and preserved. Patients had early debridement and careful assessment of the injured leg vascular tree. That was done routinely using Duplex ultrasound and in case of confirmed vascular injury by the duplex, CT angiography is done to confirm the findings and confirm the level of vessel interruption. The integrity of the posterior tibial vessels till distal leg was confirmed before proceeding to the flap coverage. Operative procedure: The technique described by Townsend [9] then Fayman [10] was done. Incision was done 2cm posterior to the medial border of the tibia then the gastrocnemius muscle was encountered and bluntly dissected from the underlying soleus muscle owing to the natural plane between them except at the beginning of the tendo-achillis where sharp dissection is the role. The vascular pedicle of the soleus muscle is explored to confirm adequacy and location of the distal perforators of the posterior tibial artery, also preservation of the blood supply to the lateral portion of the muscle coming through the proximal vascular pedicles that shared to a limited part in the supply to the muscle distally as the medial and lateral portions of the muscle are proven to be not a watershed level concerning its vascularity [10]. After pedicle adequacy confirmation, the flap is dissected from the deep muscles of the 292 Vol. 42, No. 2 / Reconstruction of Lower One Third Leg Defects back of the leg and splitting of the soleus muscle ensue along its natural plain if available, harvesting the medial hemi-soleus as needed to reach the defect safely without tension. Extreme care during dissection was taken to avoid injury of the major vessels as the legs were already suffering one or two vessel injury. RESULTS Sixteen patients shared in this study; fourteen males and two female with ages ranging from 12 to 54 years, suffering from skin defects in the lower one third of the leg (pretibial in fourteen cases and tendoachilis in two cases). They suffered also from major leg vessel disruption either anterior tibial or peroneal or both as detected by the pre-operative duplex and proven by CT lower limb arterial angiography. Ten patients suffer from anterior tibial vessels injury alone, four patients suffered from peroneal vessels injury and two patient suffered from both anterior tibial and peroneal vessels injury. The causes of the skin defects were due to trauma in most of cases (14 cases), osteomyelitis and unstable scar (one case) or post tumour excision (one case). The average presentation of patients ranged from 4 to 183 days. In all patients distally based medial hemi-soleus muscle flap based were used without sacrifice of the posterior tibial vessels. Twelve flaps healed well (75%) (Figs. 1,2), one flap suffered total loss due to ischemia (6%) (Fig. 3), three flaps suffered venous congestion and partial loss (distal one centimetre) (19%) (Fig. 4). One of the three flaps that suffered venous congestion; local recurrence from the tumour excised before occurred with partial loss of the flap. All surviving flaps underwent grafting on the seventh day except for flaps that suffered congestion and partial loss, underwent grafting after 21 days. All patients had excellent take of the skin graft. Two patients needed further operation in the form of bone grafting to the tibia after one month. Table (1) summarizes the data of the patients. Fig. (1): 43 years old male with post traumatic defect of the distal one third of the tibia that resulted after a period of negligence in osteomyelitis. A- After radical debridement of the chronic osteomyelitis, B- The resultant defect was reconstructed using distally based medial hemi-soleus muscle flap, C- after one week. D- Followed by skin grafting. (A) (B) (C) (D) Egypt, J. Plast. Reconstr. Surg., July 2018 293 Fig. (2): 37 years old male A- with post traumatic unstable scar over the tendoachilis that was presented 50 days following the trauma. B- He underwent excision of the scar and resurfacing by distally based medial hemi-soleus muscle flap. C- Followed by its skin grafting. Fig. (3): 55 years old, heavy smoker male with A- Post traumatic pretibial skin defect with injury to the anterior tibial vessels, first free rectus muscle flap was done to cover the whole defect, but total loss of the free flap occurred so another option was done. B- That was reconstructed by distally based medial soleus suffering ischemia and eventually total loss. (A) (B) (C) Fig. (4): 12 years old male with. A- Sarcoma of the lower tibia with local invasion of the skin. B- The patient underwent radical excision of the bone and external freezing followed by its reinsertion as a bone graft fixed by k wires. C- The resultant defect was reconstructed by distally based medial hemi-soleus that suffered congestion and partial loss about less than one centimetre. D- Two months later the flap was infiltrated with local recurrence of the tumour. (A) (B) (C) (D) (A) (B) 294 1 2 3 4 5 Defect Location and size Distal one third of tibia, total surface area of the defect 87cm2 Distal one third of tibia. total surface area of the defect 98cm2 Tendo-achilis. total surface area of the defect 46 cm2 Distal one third of tibia. total surface area of the defect 54cm2 Distal one third of tibia. total surface area of the defect 43cm2 Case number Age 12 43 37 33 15 Gender Male Male Male Male Male Cause Post sarcoma excision of the tibia with bone freezing and application as bone graft then fixation by k wires Osteomyelitis following internal fixation of fracture tibia with skin necrosis Post-traumatic unstable scar with tendo-achilis exposure Post traumatic skin loss over the distal tibia Post traumatic defect pretibial lower one third Duration (days) 21 183 50 7 150 Associated conditions Sarcoma metastasis in the lung Seavy smoker No Heavy smoker No Both the anterior tibial and peroneal vessels were ligated in the procedure of sarcoma excision Anterior tibial Anterior tibial Peroneal vessels Anterior tibial Vessel affected Result The flap healed well but venous congestion with partial flap loss about one cm followed by local recurrence occurred in the distal part of the tibia Flap healed well Flap healed well Partial loss followed by dressings Flap healed well 18 8 7 21 7 Period before graft (days) Need for another procedures No No No No Needed bone grafting after one month Excellent Excellent Excellent Excellent Excellent Graft healing Disruption of the distal part of the flap due to venous congestion followed bylocal recurrence of sarcoma in the distal part of the flap and general metastasis in the lungs,the patient died five months later No Haematoma underneath the flap that was evacuated with no further sequel Partial loss of the flap No Complication (s) Table (1): Data of patients in the study. Vol. 42, No. 2 / Reconstruction of Lower One Third Leg Defects Egypt, J. Plast. Reconstr. Surg., July 2018 295 Defect Location and size Distal one third of tibia.total surface area of the defect 33cm2 Distal one third of tibia.total surface area of the defect 87cm2 Distal one third of tibia, free rectus flap was donefollowed by complete loss. total surface area of the efect 120cm2 Tendoachilis total surface area of the defect 40cm2 Distal one third of tibia. total surface area of the defect 34cm2 Distal one third of tibia. total surface area ofthe defect 56cm2 6 7 8 9 10 11 Case number Age 54 19 55 42 33 27 Gender Female Male Male Female Male Male Cause Post traumatic defect pretibial lower one third Post traumatic skin loss over the distal tibia Post traumatic skin loss over the distal tibia Post traumatic skin loss over the tendo achilis Post traumatic defect pretibial lower one third Post traumatic defect pretibial lower one third Duration (days) 100 4 4 21 2 10 Associated conditions NO Smoker Diabe tic, heavy smoker No No No Anterior tibial Peroneal vessels Anterior tibial vessels Peroneal vessels Anterior tibial vessels Both the anterior tibialand peroneal vessels injury Vessel affected Result Flap healed well Flap healed well Flap suffered severe ischemia and loss of the whole flap Flap suffered venous congestion and partial loss about one cm Flap healed well Flap healed well 7 7 No 17 9 7 Period before graft (days) Need for another procedures No No Coverage by cross leg flap No Another skin grafting operation No Excellent Excellent No Good with partial loss of the skin graft that left to heal by secondary intention Infection occurred with more than 70% loss of the skin graft followed by re-grafting Excellent graft take Graft healing No No Total loss of the flap Flap congestion with partial loss of the flap Loss of the skin graft No Complication (s) Table (1): Continued Defect Location and size Distal one third of tibia. total surface area of the defect 72cm2 Distal one third of tibia. total surface area of the defect 64cm2 Distal one third of tibia.total surface area of the efect 54cm2 Distal one third of tibia. total surface area of the defect 52cm2 Distal one third of tibia. total surface area of the defect 70cm2 12 13 14 15 16 Case number Age 14 23 52 54 22 Gender Male Male Male Male Male Cause Post traumatic defect pretibial lower one third Post traumatic defect pretibial lower one third Post traumatic defect pretibial lower one third Post traumatic defect pretibial lower one third Post traumatic defect pretibial lower one third Duration (days) 11 2 4 3 12 Associated conditions No Heavy smoker No No No Anterior tibial vessels Peroneal vessels Anterior ti bial vessels Anterior tibial vessels Anterior tibial vessels Vessel affected Result Flap healed well Flap healed well Flap healed well Flap healed well Flap healed well 7 8 8 7 8 Period before graft (days) Need for another procedures No No No No No Excellent graft take Partial loss of the skin graft then left to heal by secondary intention Excellent graft take Excellent graft take Excellent graft take Graft healing No No No No No Complication (s) Table (1): Continued 296 Vol. 42, No. 2 / Reconstruction of Lower One Third Leg Defects DISCUSSION The skin defects of the lower one third of the leg are considered one of the challenging defects due to skin tightness and subcutaneous nature of the bones and tendons. An added problem is injury of one or more of the major vessels of the leg, as this makes the free flaps option more difficult. So here comes the necessity of coverage by regional flap without sacrificing a major blood supply of the leg. The distally based hemi-soleus muscle flap has these criteriae and also the advantage of neither major function loss occurs after flap harvest, nor donor site morbidity. Also it has the advantage of increasing the blood supply to the underlying bone; promoting bone salvage in chronic osteomyelitis [11,12,13] attributing to its robust blood supply from the feeding perforators of the distal posterior tibial artery, the venous plexus [9], and also keeping the lateral part of the flap preserved allowing for its additional blood supply from the proximal pedicles through the significant vascular communications between the medial and lateral portions of the muscle [10]. In our study sixteen cases with skin defects of the lower one third of the leg were reconstructed by distally based medial hemi-soleus muscle flaps where 75% healed completely. Conclusion: The distally based medial hemisoleus is a reliable flap for reconstruction of problematic lower one third defects in vascular compromised lower limbs as those suffering from injury to the anterior tibial and/or peroneal vessels; provided that the posterior tibial vessels are preserved. It provides reliable coverage concerning the vascularity and even can treat conditions as osteomyelitis in tibia by its robust blood supply.