Reconstruction of complete knee extensor mechanism loss with gastrocnemius flaps

Surgical Treatment of Bone Sarcoma

Bone sarcomas are rare primary malignant mesenchymal bone tumors. The three main entities are osteosarcoma, chondrosarcoma, and Ewing sarcoma. While prognosis has improved for affected patients over the past decades, bone sarcomas are still critical conditions that require an interdisciplinary diagnostic and therapeutic approach. While radiotherapy plays a role especially in Ewing sarcoma and chemotherapy in Ewing sarcoma and osteosarcoma, surgery remains the main pillar of treatment in all three entities. After complete tumor resection, the created bone defects need to be reconstructed. Possible strategies are implantation of allografts or autografts including vascularized bone grafts (e.g., of the fibula). Around the knee joint, rotationplasty can be performed or, as an alternative, the implantation of (expandable) megaprostheses can be performed. Challenges still associated with the implantation of foreign materials are aseptic loosening and infection. Future improvements may come with advances in 3D printing of individualized resection blades/implants, thus also securing safe tumor resection margins while at the same time shortening the required surgical time. Faster osseointegration and lower infection rates may possibly be achieved through more elaborate implant surface structures.

Patella cryo-free technique with recycled frozen autograft reconstruction preserves extensor mechanism for proximal tibial malignancy

BACKGROUNDS

We designed a patella cryo-free method to protect patella from cryoinjury during recycled frozen bone-prosthesis-composite reconstruction for proximal tibial malignancy. This study aimed to use animal model to ensure safety and efficacy of this method and reported our clinical outcomes.

METHODS

Six swine proximal tibias along with patella and patellar tendon were harvested and dived into group A (n = 3, traditional patella freezing) and group B (n = 3, patella cryo-free). Temperature curve measurement, histological analysis, and TUNEL assay were performed in both groups. Clinically, we retrospectively reviewed 23 patients with proximal tibia malignant bone tumor (13: traditional patella freezing method; 10: patella cryo-free method). The clinical and functional outcomes were reported and compared in both groups.

RESULTS

Temperature curve of the group B showed that ideal therapeutic temperature (<-60°C) required to kill tumor cells can be achieved in the proximal tibia while the innocent patella can be kept in room temperature at all time. Histological analysis showed better preservation of the cartilage tissue in patella of group B. TUNEL assay showed significantly more apoptotic cells in the frozen tibia of both groups and frozen patella of group A. When reviewing our clinical results, less complication of the patella as well as better functional preservation were found in patients subjecting to patella cryo-free method. No local recurrence was observed in either group.

CONCLUSION

Patellar cryo-free technique could protect patella from cryoinjury during freezing and therefore preserve more extensor functions for patients with proximal tibial malignant bone tumors.

Reconstruction of massive knee defects with extensor mechanism deficiency through concurrent anterolateral thigh flap and autogenous hamstring tendon: A report of two cases

Reconstruction of an infected knee joint with a large defect and extensor mechanism deficiency is challenging. In this study, we aim to describe a one-stage reconstruction surgery and provide its surgical outcome. Two patients had patellar open fracture and subsequent septic arthritis; in addition, a large soft tissue defect, loss of patella, and shortening of the patellar tendon were observed. The semitendinosus-gracilis tendon formed a loop to stabilize the patella. A free or supercharged reverse pedicle myocutaneous anterolateral thigh flap with fascial extension is designed to fill the defect and eradicate the infection. Mean clinical follow-up was 18 months. Although some limitation in the knee range of motion was observed, the dynamometer showed only partial loss in peak concentric power and eccentric power. We developed an innovative surgical procedure to alleviate infection and reconstruct a complex knee defect with extensor mechanism deficiency; this procedure resulted in favorable clinical outcomes.

The results of patellar stainless steel wire extensor mechanism reconstruction in proximal tibial tumour excision mega-prosthesis surgeries for proximal tibial sarcomas

BACKGROUND

Extensor mechanism function after a proximal tibial tumour excision is the major determining factor for the limb function. However, problems of extensor lag, delayed healing and poor functional outcomes exist with the previous methods of its reconstruction. We describe a novel technique of using a patellar stainless steel (SS) wire to reconstruct the extensor apparatus of the knee in non-porous coated implants and examine the functional outcome and associated complications.

METHODS

This was a retrospective analytical interventional study. Twenty-six patients operated between 2011 and 2019 were included. Extensor lag measured at 6 months and 12 months postoperative, total range of motion at 12 months and Musculoskeletal Tumor Society (MSTS) score at the final visit were retrieved. Complications that occurred during the follow up period were noted. Patellar position was measured using comparative patellar-position-ratio.

RESULTS

Mean extensor lag at 6 months was 18.5° which improved to 8.7° at 12 months. Patellar malposition and deep infection were found to be the causes of poor functional outcome. A patellar-position-ratio between 0.9 and 1.1 led to a well-functioning extensor apparatus. Four patients underwent above-knee amputations. Deep infection and amputations reduced the MSTS score. An SS wire give way after 6 months did not affect the extensor power. A medial gastrocnemius flap reduced the infection rates.

CONCLUSION

Patellar SS wiring is an effective technique for reconstructing the knee extensor apparatus following a proximal tibial tumour excision mega-prosthesis. Proper position of the SS wire prevents wire-related complications. For a well-functioning extensor apparatus, use of a gastrocnemius flap cover intra-operatively is pertinent along with lack of infection for a pain-free, stable and mobile limb.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair

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Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures.

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Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week.

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Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult.

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Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D.

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For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

[Emergency coverage of post-traumatic losses of cutaneous substances of the anterior face of the knee using proximally based sural fasciocutaneous flap: about 4 cases of articular wounds]

Our study reports 4 cases of male patients with wounds on the anterior face of the knee loosing cutaneous substance after motorcycle accident. The patients had undergone surgery involving the debridement and the application of four proximally based sural fasciocutaneous flaps since 2012. The average age of patients ranged from 28 to 42 years. The highest loss of cutaneous substance measured 14 x 10 cm. The average pedicle length was 14 cm. The post-operative suites were uneventful with a satisfactory wound healing. From a functional point of view the knee and the ankle were completely mobile. This study shows the effectiveness and reliability of proximally based sural fasciocutaneous flap in the coverage of post-traumatic losses of cutaneous substances of the anterior face of the knee, and allows for limit the indications for heads of the gastrocnemius muscle flaps.

Single-stage quadriceps tendon reconstruction with gastrocnemius fascia and knee soft tissue defect reconstruction with medial gastrocnemius flap-A case report

INTRODUCTION

Quadriceps tendon rupture, although uncommon, is associated with knee joint instability and requires surgical repair. A variety of methods including allografts, synthetic grafts and autologous tendons are used for tendon reconstruction. This work is reported in line with the SCARE criteria (Agha et al., 2018) for case report publication.

PRESENTATION OF CASE

A new method of simultaneous quadriceps tendon reconstruction and soft tissue knee reconstruction in a 38-year-old male patient following trauma to his knee and subsequent multiple surgeries and wound infections. In a single-stage procedure, gastrocnemius muscle fascia was used for quadriceps tendon reconstruction and medial head of the gastrocnemius muscle flap with split-thickness skin graft was used to cover the soft tissue defect on the anterior aspect of the knee following previous post-operative soft tissue infections and subsequent skin necrosis.

DISCUSSION

The only way to maintain the vitality of the patella was to reconstruct the defect with well-vascularized tissue so we decided to use the medial gastrocnemius muscle flap. To obtain good quality tissue for the quadriceps tendon reconstruction, we decided to use the gastrocnemius muscle fascia to minimise the morbidity of the donor region and to reduce the duration of surgery.

CONCLUSION

Postoperatively, the patient had an excellent cosmetic outcome with full active extension and limited flexion of the knee joint caused by the preoperative condition. To our knowledge, quadriceps tendon reconstruction using the gastrocnemius muscle fascia has never been reported in English literature and is as valuable as already known reconstruction methods using other tendons or fascia.

The Medial Sural Artery Perforator Flap: The First Choice for Soft-Tissue Reconstruction About the Knee

BACKGROUND

The gastrocnemius muscle flap may be considered the first choice in many cases of soft-tissue reconstruction about the knee. Limited arc of rotation and reach of the flap as well as unsightly muscle bulk are major disadvantages and were the impetus to look for a local alternative. The aim of this study is to present a consecutive series of patients with a reconstruction about the knee involving the medial sural artery perforator flap (MSAPF).

METHODS

A consecutive series of 17 cases of defect reconstructions about the knee using the MSAPF is described, with an emphasis on early postoperative complications.

RESULTS

No major flap-related complications occurred except 1 case of tip necrosis that healed uneventfully after excision and secondary suture. Two patients with direct donor-site closure had a minor complication that required no revision, and 2 had partial skin-graft loss.

CONCLUSIONS

In summary, use of this pedicled perforator flap represents a reliable technique for soft-tissue reconstruction about the knee with an acceptable complication rate and optimal contour reconstruction without the need for a skin graft and secondary debulking procedures. The range of motion associated with the MSAPF in comparison to the range associated with the gastrocnemius muscle flap is increased so that more proximal and lateral defects can be covered.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Site Infections after Tissue Flaps Performed in Low- and Middle-Human Development Index Countries: A Systematic Review

BACKGROUND

Surgical site infections (SSIs) affect the safety of surgical care and are particularly problematic and prevalent in low and middle Human Development Index Countries (LMHDICs).

METHODS

We performed a systematic review of the existing literature on SSIs after tissue flap procedures in LMHDICs through the PubMed, Ovid, and Web of Science databases. Of the 405 abstracts identified, 79 were selected for full text review, and 30 studies met inclusion criteria for analysis.

RESULTS

In the pooled analysis, the SSI rate was 5.8 infections per 100 flap procedures (95% confidence interval [CI] 2%-10%, range: 0-40%). The most common indication for tissue flap was pilonidal sinus repair, which had a pooled SSI rate of 5.6 infections per 100 flap procedures (95% CI 2%-10%, range: 0-15%). No fatalities from an infection were noted. The reporting of infection epidemiology, prevention, and treatment was poor, with few studies reporting antibiotic agent use (37%), responsible pathogens (13%), infection comorbidities (13%), or time to infection (7%); none reported cost.

CONCLUSIONS

Our review highlights the need for more work to develop standardized hospital-based reporting for surgical outcomes and complications, as well as future studies by large, multi-national groups to establish baseline incidence rates for SSIs and best practice guidelines to monitor SSI rates.

Patellar tendon reconstruction using an extended gastrocnemius flap following cryogenic injury to the knee

Cryogenic thermal necrosis after knee surgery is rare. We describe a patient who presented with an anterior knee soft tissue defect in conjunction with an extensor mechanism deficiency secondary to a cold thermal injury after an anterior cruciate ligament reconstruction. We treated the patient with a single stage surgical procedure combining patellar tendon reconstruction and soft tissue coverage utilizing the superficial portion of the patient's vascularized Achilles tendon attached to a medial gastrocnemius flap. The patient returned to unrestricted activities and has demonstrated this through a five year follow-up.

Medial Gastrocnemius Flap for Reconstruction of the Extensor Mechanism of the Knee Following High-Energy Trauma. A minimum 5 year follow-up

INTRODUCTION

The purpose of this study was to assess the medium-term results of reconstruction of the extensor mechanism using the medial gastrocnemius while also providing soft tissue coverage.

MATERIALS AND METHODS

This retrospective review consisted of a consecutive series of four patients (age 28-40 years) with complex high energy traumatic injuries to lower extremity including both soft tissue loss and disruption of the knee extensor mechanism. The medial gastrocnemius rotational flap was used to reconstruct the patellar tendon and restore soft tissue coverage simultaneously. Range of motion and extensor lag; functional recovery was judged by return to work and sports activity. Validated measures included the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and the modified Cincinnati Score.

RESULTS

At the final follow up was 61.5 (57-66) months after reconstruction, the mean SF 12 physical component score ranged from 21.7 to 56.8 with a median of 55.3; the mental component from 42.8 to 60.7 with a median of 58.6. The KSS knee score ranged from 50 to 78 with a median of 68; the function score from 65 to 90 with a median of 85. The Oxford knee score ranged from 22 to 45 with a median of 33.5. The KOOS ranged from 28 to 82.7 with a median of 73.7 and the modified Cincinnati score from 38 to 82 with a median of 76.5. Knee range of motion ranged from 0 to 120°. Of the four patients three returned to working fulltime in their profession and returned to sports, including mountain biking and fitness training.

CONCLUSIONS

For severe traumatic knee injuries with the combination of soft tissue defects and disruption of the extensor mechanism, the medial gastrocnemius flap provides an excellent reconstructive option to address both problems simultaneously. The results of this small case series support the use of this limb salvage technique.

Management of Pipkin Type-III Femoral Head Fracture and Ipsilateral Open Floating Knee with Extensor Apparatus Injury: A Case Report

CASE

A twenty-eight-year-old man presented with a Pipkin type-III femoral head fracture and open floating knee injury. Initially debridement was performed, during which the extensor apparatus could not be salvaged. The top priority in management of the floating knee was achievement of adequate soft-tissue coverage followed by skeletal stabilization as staged procedures. Because the femoral head was split, dislocated, comminuted, and deemed nonreconstructible, arthroplasty was considered the best option. The extensor mechanism damage was addressed by reconstruction using an iliotibial tract flap.

CONCLUSION

This case report is presented for its uniqueness, the management protocol, and the difficulties encountered during the multistage treatment.

Reconstruction of segmental defects of Achilles tendon: Is it a must in infected complex defects?

Loss of Achilles tendon combined with overlying soft tissue loss is a challenging problem. Multiple techniques like tendon graft with coverage by soft tissue flap or composite flaps have been used. All these options are technically demanding. Reports do exist whereby muscle flaps bridging the defect used as cover in course of time could transmit the tendon force across the defect. We are presenting a case where a free gracilis muscle flap used to cover the soft tissue defect at the Achilles tendon at 2 years follow up provided stable cover and produced active function of the Achilles tendon allowing the patient to stand tip toe. Mechanism of its action has been analysed by MRI and M-mode ultrasound. While in primary Achilles tendon injury reconstruction is still the recommended option, in complex situations mere filling of the gap with the flap without formal reconstruction of the tendon could give good functional outcome. This technique can be used in demanding situations.

Knee extensor loss and proximal tibial soft tissue defect managed successfully with simultaneous medial gastrocnemius flap, saphenous fasciocutaneous flap and medial hemisoleus flap: a case report

INTRODUCTION

Open fractures of the proximal tibia often pose serious challenges to the treating orthopedic surgeon. Management of these complex injuries becomes difficult if they are associated with damage to the extensor mechanism and an exposed knee joint. The scenario becomes more difficult to manage when the soft tissue defect extends to the middle third of the leg. We report a case where we used an extended medial gastrocnemius flap in combination with a saphenous artery fasciocutaneous flap and a medial hemisoleus flap for treatment of an infected proximal tibia fracture with loss of the extensor mechanism and soft tissue defect. To the best of our knowledge, combined use of these three flaps for the management of such injuries has not been reported elsewhere to date.

CASE PRESENTATION

A 28-year-old Indian man presented to our Out-patient Department with complaints of pain and pus discharge from his left proximal leg for four weeks. He had sustained an open fracture of his left proximal tibia in a road traffic accident five weeks ago and had been operated on elsewhere. He had a stiff, painful knee with an infected wound of 4×4cm over the proximal third of his leg exposing infected, necrotic patellar tendon. He was successfully managed with debridement and simultaneously elevated flaps as described.

CONCLUSIONS

This procedure avoids the donor site morbidity associated with free flaps harvested from sites distant from the site of injury, and also does not need the expertise of microvascular reconstruction. To the best of our knowledge, this is also the first report of the combined use of three local flaps for knee extensor reconstruction and soft tissue coverage around the knee.

Isolated ischaemic contracture of medial head of gastrocnemius

A 47-year-old woman presented with a disabling fixed flexion deformity of the knee and an equinus deformity of the ankle following treatment in a cast for a minor flexion deformity following a tibial plateau fracture. Two years later, the cause was identified as an isolated ischaemic contracture involving the medial head of gastrocnemius. She made a good recovery following extensive corrective surgery and rehabilitation.

Experience of using local flaps to cover open lower limb injuries at an Indian trauma center

Background:

Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons.

Materials and Methods:

We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included.

Results:

There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 × 2 to 30 × 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery.

Conclusion:

Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.

[Extended lateral gastrocnemius transposition flap for reconstruction of open knee extensor disruption]

We describe a modified technique to reconstruct a damaged knee extensor mechanism after infected patellar fracture. After resection of infected soft tissue and quadriceps tendon a compound suprapatellar defect existed. Due to compromised tissue on the medial aspect of the calf, we used this flap, which consists of the lateral gastrocnemius muscle with parts of the adjacent Achilles tendon. After a follow-up period of several months the range of movement is 0-0-120°.

Lateral gastrocnemius flap cover for distal thigh soft tissue loss

BACKGROUND

The gastrocnemius muscle flap has been used extensively for cover around the knee. However, the use of the lateral gastrocnemius for cover of the distal thigh has not been well described.

METHODS

The lateral gastrocnemius flap was used in eight patients from October 2004 to February 2009 for cover of the distal thigh proximal to the knee joint. We included patients who had soft tissue loss secondary to trauma and infection and who required soft tissue cover in the distal lateral thigh (>8 cm proximal to the joint line). The average age of the patients was 40 years (21-64 years). Four patients had soft tissue loss secondary to trauma, two had loss secondary to chronic infection, and two patients had soft tissue loss after surgical infection.

RESULTS

All patients had resolution of infection at final follow-up. The average area of soft tissue cover achieved was 14 × 9 cm. The maximal proximal extent reached with lateral gastrocnemius flap from the joint line was 17 cm (8-17 cm) measured in full knee extension. There were two complications. One patient developed a common peroneal palsy and infection, which recovered after re-exploration. Another patient developed a sinus, which resolved after removal of a loose screw.

CONCLUSION

The lateral gastrocnemius muscle flap is effective in the cover of the lateral distal thigh.