A Gustilo Type 3B Open Tibial Fracture Treated with a Proximal Flexor Hallucis Longus Flap: A Case Report.
ABSTRACT: In the treatment of Gustilo Type 3B open tibial fractures, it is important to perform soft tissue reconstruction and bone reconstruction simultaneously. Gastrocnemius muscle and soleus muscle flaps are generally used as rotational flaps for the tibia. The distal third of the tibia can often not be covered with the gastrocnemius muscle and soleus muscle flaps. Treatment distal to the distal third of the tibia is difficult because fewer flap options are available. In the present report, we describe our experience with a Gustilo Type 3B open tibial fracture treated by gastrocnemius muscle and soleus muscle flaps, along with an additional proximally based flexor hallucis longus flap, which is a rare procedure.The participant was a 17-year-old male who injured his left tibia in a motorcycle traffic accident. Physical examination revealed a wound of 13 cm × 7 cm extending from the medial lower leg to the posterior aspect, with extensive skin loss. There was no nerve or vascular injury. The tibia was exposed, with detachment of the periosteum. The radiograph revealed a tibial shaft fracture. The AO/OTA classification was 42-A3.3, and it was classified as a Gustilo-Anderson Type 3B fracture. Gastrocnemius muscle and soleus muscle flaps were lifted in the area of the soft-tissue defect and then, placed over the tibia. Despite this, the distal portion of the tibia remained uncovered. Therefore, a flexor hallucis longus flap was lifted and placed over the distal portion of the tibia. On day 7 after the injury, the external fixation device was removed and the tibial shaft was fixated with two Ender nails (4.5 mm in diameter). The clinical course was satisfactory, and the skin graft and flap were successful. Bone union was achieved without infection, and the resulting range of motion was normal.For the treatment of Gustilo-Anderson Type 3B open tibial fractures, early treatment of the soft-tissue defect is vital. We surgically treated a Gustilo-Anderson Type 3B open tibial fracture with gastrocnemius muscle and soleus muscle flaps, along with an additional proximally based flexor hallucis longus flap, which is a rare procedure. In the event of a soft-tissue defect in the distal third of the tibia, the use of a proximally based flexor hallucis longus flap is an effective surgical approach.
Project description:The ideal reconstruction of lower limb defects should replace like with like and minimize morbidity to the donor site, achieving the best possible esthetic and functional outcome. The goal is to obtain stable healing and to resume daily life in an efficient manner. Although the classical local flaps such as gastrocnemius, soleus muscle flap, and the reverse sural flap have allowed to achieve those goals, perforator flaps are now added on to the armamentarium in lower extremity reconstruction using local flaps. A perforator-based local flap, such as a propeller or keystone flap, has made reconstruction efficient while further reducing donor-site morbidity. This article aims to provide a useful review of the best available local flaps for lower limb defects.
Project description:Inferiorly based gastrocnemius muscle flaps have been successfully used to cover soft tissue defects of the middle third of the leg. This is done especially in older patients or patients with major complications where operative time should be limited. We aimed to determine the gastrocnemius muscle length that can be safely used for preparing inferiorly based muscle flaps.<b>Methods: </b>We performed angiographies and dissection to investigate the numbers and distribution of the communicating arterial branches between the medial and lateral heads of the gastrocnemius muscle, and the perforating arterial branches of the medial sural artery from the soleus to the gastrocnemius muscles on 18 legs of preserved cadavers.<br><br><b>Results: </b>The lengths of the gastrocnemius heads were approximately 10?cm, and the communicating arterial branches of the gastrocnemius muscle also were located at approximately 10?cm from the gastrocnemius head. The perforating arterial branches from the soleus muscle to the gastrocnemius muscle were also located at approximately 10?cm from the gastrocnemius head.<br><br><b>Conclusions: </b>Communicating arterial branches of the gastrocnemius muscle were found in all cadavers. To the best of our knowledge, no other study has focused on investigating the perforating arterial branches that supply the gastrocnemius from the soleus muscle. Our study indicates that the entire gastrocnemius muscle can be safely used in reconstruction surgeries.
Project description:To describe the epidemiology of sport-related open fractures from one centre's adult patient population over a 15-year period.A retrospective review of a prospectively-collected database was performed: The database contained information all sport-related open fractures, sustained from 1995 to 2009 in the Edinburgh, Mid and East Lothian Populations.Over the 15-year period, there were 85 fractures recorded in 84 patients. The annual incidence of open sport-related fractures was 0.01 per 1000 population. The mean age at injury was 29.2 years (range 15-67). There were 70 (83%) males and 14 females (17%). The 6 most common sports were soccer (n = 19, 22%), rugby (n = 9, 11%), cycling (n = 8, 9%), hockey (n = 8, 9%); horse riding (n = 6, 7%) and skiing (n = 6, 7%). The five most common anatomical locations were finger phalanges (n = 30, 35%); tibial diaphysis (n = 19, 23%); forearm (n = 12, 14%); ankle (n = 7, 8%) and metacarpals (n = 5, 6%). The mean injury severity score was 7.02. According to the Gustilo-Anderson classification system, 45 (53%) fractures were grade 1; 28 (33%) fractures were grade 2; 8 (9%) fractures were grade 3a; and 4 (5%) fractures were grade 3b. Out of the total number of fractures, 7 (8%) required plastic surgical intervention as part of management. The types of flaps used were split skin graft (n = 4), fasciocutaneous flaps (n = 2); and adipofascial flap (n = 1).We analysed the epidemiology of open fractures secondary to sport in one centre over a 15-year period. Soccer and rugby were the most common causative sports while fractures of the finger phalanx and of the tibial diaphysis were the most common sites. Open fractures are uncommon in sport; however, when they are sustained they usually occur on muddy sport fields or forest tracks and therefore must be treated appropriately. It is important that clinicians and sports therapists have knowledge of these injuries, in order to ensure they are managed optimally.
Project description:Adhesion of the flexor hallucis longus (FHL) muscle to the distal tibia can occur after distal tibial fracture, distal fibular fracture, low tibial osteotomy, soft-tissue injury at the posterior ankle, subclinical compartment syndrome of the distal deep posterior compartment of the leg, or Volkmann contracture after deep posterior compartment syndrome of the leg. The purpose of this Technical Note is to report the endoscopic approach of FHL muscle adhesiolysis. It is indicated in patients with symptomatic adhesion of the FHL muscle and contraindicated if there is entrapment of the FHL muscle or tendon in the fracture callus or if there is extensive fibrosis and contracture of the FHL muscle as a result of Volkmann contracture after deep posterior compartment syndrome of the leg.
Project description:Gustilo Grade IIIB and IIIC open fractures of the lower extremity often involve complex wounds requiring bony fixation and soft tissue reconstruction. We present a case of a 32 year-old male who suffered a traumatic Gustilo Grade IIIB open fracture of the tibia and fibula with an extensive soft tissue defect. Reconstruction was first attempted with a turbocharged anterolateral thigh flap that failed due to venous thrombosis. Due to vascular injury, limited reconstructive options were available from the ipsilateral leg. Limb salvage was subsequently achieved with a chimeric cross-leg latissimus dorsi-serratus anterior (LD-SA) free flap based off the contralateral healthy leg, using the serratus for pedicle bridge coverage so that the latissimus could be fully used for defect coverage. Though not extensively described in the literature, this flap is a versatile reconstructive option for limb salvage in patients with Gustilo IIIB or IIIC injuries to the lower extremity.
Project description:Covering soft tissue defects remains challenging for orthopaedic surgeons, especially those in resource-challenged facilities. Covering tissue defects follow a plan from simple to complex: primary closure, local flap, area flap, pedicle flap, and free flap. I will limit my discussion to the role of latter two. At the district-level hospital in Vietnam, pedicle flaps are generally more useful, so I will discuss free flaps only briefly. The choices of pedicle flaps include: kite flap, posterior interosseous flap, radial flap (Chinese flap), neurocutaneous flap, anterolateral thigh fasciocutaneous flap, gastrocnemius flap, sural flap, posterior leg flaps; we typically use a free flap with the latissimus dorsi. Soft tissue coverage with pedicle flaps has many advantages: reliability, relatively easy harvest, and good blood supply. Free flaps with microanastomosis have an important place in covering difficult medium- or large-sized soft tissue defects but also require more instruments and more highly trained surgeons.
Project description:AIMS:To investigate differential muscle atrophy during bed-rest, the impact of a high-intensity concentric-eccentric (flywheel) resistance exercise countermeasure and muscle recovery after bed-rest. METHODS:Twenty-five healthy male subjects underwent 90 dayshead-down tilt bed-rest. Volume of individual lower-limb muscles was measured via MRI before, twice during and four times up to 1 year after bed-rest. Subjects were either inactive (n=16) or performed flywheel exercise every third day of bed-rest (n=9). Functional performance was assessed via countermovement jump. RESULTS:On 'intent-to-treat' analysis, flywheel prevented atrophy in the vasti (p<0.001) and reduced atrophy in the hip adductor/extensor adductor magnus (p=0.001) and ankle dorsiflexors/toe flexors (soleus (p<0.001), gastrocnemius medialis (p<0.001), gastrocnemius lateralis (p=0.02), and tibialis posterior with flexor digitorum longus (p=0.04)). Flywheel exercise was not effective for the hamstrings, gracilis, sartorius, peroneals and anterior tibial muscles. Muscle atrophy in vasti, soleus, gastrocnemius medialis, gastrocnemius lateralis and adductor magnus correlated with losses in countermovement jump performance. Muscle volume recovered within 90 days after bed-rest, however long-term after bed-rest, the inactive subjects only showed significantly increased muscle volume versus prebed-rest in a number of muscles including soleus (+4.3%), gastrocnemius medialis (+3.9%) and semimembranosus (+4.3%). This was not associated with greater countermovement jump performance. CONCLUSION:The exercise countermeasure was effective in preventing or reducing atrophy in the vasti, adductor magnus and ankle dorsiflexors/toe flexors but not the hamstrings, medial thigh muscles or peroneals and dorsiflexor muscles. TRIAL REGISTRATION NUMBER:NCT00311571; results.
Project description:The success of devices delivering functional electrical stimulation (FES) has been hindered by complications related to implants including skin breakdown and subsequent wound dehiscence. Our hypothesis was that a vascularized muscle flap along the dorsal surface of an epimysial electrode would prevent skin breakdown during FES therapy to treat atrophy of the gastrocnemius muscle during peripheral nerve injury. Resection of a tibial nerve segment with subsequent electrode implantation on the dorsal surfaces of the gastrocnemius muscle was performed on ten Lewis rats. In five rats, the biceps femoris (BF) muscle was dissected and placed along the dorsal surface of the electrode (Flap group). The other five animals did not undergo flap placement (No Flap group). All animals were treated with daily FES therapy for 2 weeks and degree of immune response and skin breakdown were evaluated. The postoperative course of one animal in the No Flap group was complicated by complete wound dehiscence requiring euthanasia of the animal on postoperative day 4. The remaining 4 No Flap animals showed evidence of ulceration at the implant by postoperative day 7. The 5 animals in the Flap group did not have ulcerative lesions. Excised tissue at postoperative day 14 examined by histology and in vivo Imaging System (IVIS) showed decreased implant-induced inflammation in the Flap group. Expression of specific markers for local foreign body response were also decreased in the Flap group.
Project description:BACKGROUND:The tibialis anterior flap is an underused flap, mainly because it is not an expendable muscle and is small in size. AIM:To study the use of the tibialis anterior muscle flap for longitudinal middle third tibial defects. MATERIALS AND METHODS:We have analysed the use of tibialis anterior flap in five patients by the function preservation technique. RESULTS AND CONCLUSION:Function preservation techniques used in the harvesting of this flap will be able to cover narrow and linear defects on middle third of tibia comfortably. Size and pliability of the muscle must be assessed before initiation of harvesting of the flap. Flap harvesting is initiated by a saggital split incision to preserve maximum blood supply to the muscle. Transverse incisions may be employed to obtain the desired reach of the flap. This flap is a simple alternative for linear wounds with small transverse dimensions on middle third of the leg, where the tibialis anterior muscle is uninjured.
Project description:We compare comprehensive quantitative profiling of lipids at the molecular level from skeletal muscle tissues (gastrocnemius and soleus) of Zucker diabetic fatty rats and Zucker lean control rats during treadmill exercise by nanoflow liquid chromatography-tandem mass spectrometry. Because type II diabetes is caused by decreased insulin sensitivity due to excess lipids accumulated in skeletal muscle tissue, lipidomic analysis of muscle tissues under treadmill exercise can help unveil the mechanism of lipid-associated insulin resistance. In total, 314 lipid species, including phospholipids, sphingolipids, ceramides, diacylglycerols (DAGs), and triacylglycerols (TAGs), were analyzed to examine diabetes-related lipid species and responses to treadmill exercise. Most lysophospholipid levels increased with diabetes. While DAG levels (10 from the gastrocnemius and 13 from the soleus) were >3-fold higher in diabetic rats, levels of most of these decreased after exercise in soleus but not in gastrocnemius. Levels of 5 highly abundant TAGs (52:1 and 54:3 in the gastrocnemius and 48:2, 50:2, and 52:4 in the soleus) displaying 2-fold increases in diabetic rats decreased after exercise in the soleus but not in the gastrocnemius in most cases. Thus, aerobic exercise has a stronger influence on lipid levels in the soleus than in the gastrocnemius in type 2 diabetic rats.