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Eur J Plast Surg (1992) 15:261-263

Do local transposition flaps of the lower leg endanger leg function and vascular supply?

New aspects in the coverage of soft tissue defects

W. Jungwir th 1, C. Papp 1 and A. Koller 2

University Clinic of Plastic and Reconstructive Surgery and 2 Department of Sports Medicine, University of Innsbruck, Austria

Summary. Postoperat ive clinical examina t ion and isok- inetic diagnosis were per formed in 18 cases of muscle t ranspos i t ion flaps in the lower extremity out of a group of 40 pat ients treated in this way. We measured post- operat ive func t ion in add i t ion to venous backflow and arterial supply. In pat ients who had no postoperat ive physical therapy, results of the dynamomet r i c examina- t ion showed a signif icant difference between the heal thy and the operated leg. Despite this, 89% were unrestr ic ted in their abili ty to walk, and all pat ients re turned to their former occupat ions. There was no func t iona l restr ict ion by using muscu la r t ranspos i t ion flaps for defect coverage in the lower extremity. To achieve complete muscle reha- bi l i tat ion, pos topera t ive physical therapy is necessary.

Key words: Transpos i t ion muscle flaps - Func t iona l ex- a m i n a t i o n - Lower leg - Soft tissue defects - Chronic osteomyelit is

Unt i l recently, large soft tissue defects of the lower leg had to be treated with tube pedicle flaps and cross-leg flaps [6]. Wi th the in t roduc t ion of local muscle t ranspo- sition, described by Ger [1], and later by M c G r a w et al. [4], s ignificant therapeut ic progress was made. These techniques have cons iderably shor tened the du ra t ion and, consequent ly , the costs of hospi ta l iza t ion; they are an integral par t of rou t ine reconstruct ive surgery. A n aspect of these procedures, which has no t been previous- ly studied, is the func t iona l impa i rmen t [8] and circula- tory changes which may occur in the affected lower leg after muscle flap t ransposi t ion .

Patients and methods

From 1980 to 1988, a total of 40 patients received 46 transposition flaps on the lower leg. Of these, seven patients were not included in the follow-up examination because they were confined to bed,

Correspondence to: Dr. W. Jungwirth, EMCO-Private Clinic, Mar- tin Hell-Strasse 2-4, A-5422 Bad Duerrnberg/Salzburg, Austria

while the other 15 patients were not available for examination. To find out the side effects of local muscle transposition, 18 patients without serious secondary injuries on the lower leg were followed up. At the time of surgery, the patients' mean age was 44 years. The youngest was four years old and the oldest 85 years.

Of the 40 patients, 89% had sustained a third degree open fracture of the lower leg, while in 11%, chronic osteomyelitis caused the defect. On average, the soft tissue defects had a surface area of 35 cm 2.

Due to the lengthy anamnesis involved with chronic osteomyeli- tis, there was a 5.5 year (50th percentile) interval between occur- rence of the lesion and surgery. Hospitalization in our department averaged 20 days.

Defects were reconstructed by means of local transposition of proximally pedicled muscle flaps. The surgical technique is essen- tially that of McGraw and Mathes et al. [2, 3, 5]. In the preparation of these muscles, especially the soleus muscle, special care was taken to protect the venous drainage system. Whenever possible, neither the greater saphenous vein nor the branches in the upper third draining from the muscle into the deep veins were damaged. It is especially important for the distal third of the transposed muscle to be elevated atraumatically in order to guarantee arterio- venous flow all the way to the tip of the muscle, because even small lesions can cause peripheral muscle necrosis.

In 25 cases, the medial head of the gastrocnemius muscle (m.) was transposed; in six, the soleus m.; in six, the tibialis anterior m. [7]; and in nine cases, other muscles of the lower leg. These included the extensor hallucis longus m., the flexor hallucis longus m. and the peroneus longus m. (Table 1).

In all patients, the soft tissue defects were reconstructed during one hospital stay. In one case, a postoperative hematoma had to be evacuated, and in another case, a partial flap necrosis was de- brided. No other complications, such as venous thromboses of the leg, were observed. Low dose heparin was administered to all patients preoperatively.

The follow-up period averaged 4.7 years with a minimum of one year.

Table 1. Muscle flap transpositions on the lower leg

Muscles used Number of cases

Gastrocnemius medialis m. 25 Soleus m. 6 Tibialis anterior m. 7 Other muscles 9

262

120

100

80

E 6 0

z 4 0

20.

i i

I I

,'~ ad ~ r,.d ~" -r: z a.: ~ ~:d I-~ toe Ld o-'~ J Jd

Patients healthy leg

• operated leg

-120

100

40

-20

I - 0

Fig. 2. Test results of isokinetic examination for plantar flexion in the healthy and in the operated leg. In most cases, we found a significant difference in strength. In patients with postoperative physical training, there were similar results for both legs. Despite a sufficient function for everyday demands, five patients have been unable to perform a complete series of exercises in the operated leg with the dynamometer

A maximum exertion test was performed five times and an endurance test ten times. The test results were evaluated on-line with the C.D.R.C. computer. The readings were shown graphically and as a numerical value in Newton meters (Nwtm) (Fig. 2).

Fig. I a-c. Isokinetic dynamometer

Patients underwent clinical postoperative assessment paying particular attention to the following points : • The quality and stability of the soft tissue cover, • any recurrence of osteomyelitis and a clinical and radiological examination of fracture stability, • signs of venous insufficiency or restricted arterial blood supply, and • ability to walk and participate in sports. In order to ensure objective results, all patients were examined with the isokinetic diagnostic system "Cybex" (Cybex, Smithtown Ave., Ronkonkoma, N.Y., USA) (Fig. I a-c). This device permits optimal muscle function during movement by applying variable resistance. Plantar and dorsiflexion of the ankle of the operated and the healthy leg were measured with a series of exercises.

Results

O n cl inical fo l low-up examina t ion , none o f the pa t ien t s h a d a recur rence o f os teomyel i t i s . The soft t issue cover was in tac t in all cases. F rac tu re s were r ad io log ica l ly sta- ble.

The o p e r a t e d leg d id no t increase in c i rcumference, . no r was there any n o c t u r n a l swell ing ind ica t ing an ab- sence o f venous insufficiency. W i t h the excep t ion o f one pa t i en t wi th a Stage 2 i m p a i r m e n t in a r te r ia l c i rcu la t ion , the vascu la r i ty o f the o p e r a t e d legs was normal . There were no t roph ic d isorders .

Cl inical ly , 89% o f the pa t ien t s h a d no res t r ic t ions in their ab i l i ty to walk , and 33% en joyed spor t s such as h iking, ski ing and cycling. The wa lk ing abi l i ty o f pa - t ients wi th i m p a i r e d ar te r ia l c i rcu la t ion was l imi ted to 1,000 m. Al l pa t i en t s r e tu rned to thei r f o rmer occupa- t ions.

E v a l u a t i o n o f the tests wi th the i sokine t ic d i agnos t i c sys tem showed the fo l lowing resul ts : A m a x i m u m exer- t ion test r epea ted five t imes resul ted in a m e a n o f 23.6 N w t m for p l a n t a r f lexion on the in ju red side. The hea l thy side ach ieved a m e a n o f 67.6 N w t m . The maxi - m u m exer t ion in dors i f l ex ion was 4.6 N w t m on the in- j u r e d and 20.1 N w t m on the hea l thy side. The endu rance tests r epea ted ten t imes p r o d u c e d values o f 13.7 N w t m (p lan ta r ) and 1.7 N w t m (dorsa l ) on the o p e r a t e d side and 45.8 N w t m (p lan ta r ) as well as 14 N w t m (dorsif lex- ion) for the hea l thy leg. The difference be tween the hea l thy and the o p e r a t e d leg is s ta t i s t ica l ly s igni f icant b o t h for m a x i m u m exer t ion and endu rance (p < 0 . 0 0 1 ; t-test).

263

Case report

A 63-year-old male patient sustained an open gunshot wound in the distal portion of the right lower leg during World War II. Since 1945, he had recurrent osteomyelitis. Numerous attempts at surgical treatment over the past 45 years were unsuccessful. On admission, he presented with a 5 cm x 5 cm pretibial ulcer with exposure of the tibia. After resection of the ulcer and tangential chiseling the tibia, the defect was covered with a soleus flap and mesh graft. Histological examination revealed a precancerous state. After a hospital stay of ten days, the patient underwent out-clinic physical therapy. On a four year follow-up there has been no recur- rence. He enjoys unrestricted cycling, and cross-country and down- hill skiing. The dynamometric examination shows a small differ- ence (7 Nwtm) between the healthy and the operated leg.

Discussion

Our experience shows that, when correct ly indicated, the pedicled muscle flap is valuable in the t rea tment o f soft tissue defects o f the lower leg. To find ou t side effects o f local muscle flap t ransposi t ion, we excluded patients with severe secondary injuries o f the lower leg. Dur ing the fol low-up period, there was no recurrence o f osteo- myelitis, soft tissue defects or refractures. The absence o f venous insufficiency is ascribed to careful surgical technique. The short hospi tal izat ion and rapid postoper- ative mobi l izat ion are the reason for the minimal func- t ional impai rment o f the opera ted extremity. Clinically, the absence o f individual muscles in the lower leg had no negative effects. All patients were fully reintegrated into society.

Compar i son o f the results o f clinical and dynamomet - ric examinat ion b rough t a definite discrepancy to light: dynamomet r i c examinat ion showed the opera ted ex- t remity to be significantly weakened. More precise an- amnesis, however, revealed that in several cases, physical therapy was able to increase the strength o f the injured lower leg muscula ture to tha t o f the heal thy leg. In the absence o f a need in increased individual performance, the muscula ture o f the opera ted lower leg remained

clearly weakened. In these cases, the values for the heal thy leg were also lower.

Conclusion

Local t ransposi t ion o f pedicled muscle flaps on the lower leg is risk-free. As long as there are no secondary inju- ries, a lmost complete rehabil i tat ion can be expected. The loss o f funct ion in a muscle o f the lower leg is insignifi- cant for everyday demands. Objective dynamomet r i c ex- aminat ion, however, shows a definite drop in perfor- mance in the opera ted leg. With special training, this can be increased to the level o f the heal thy leg. Physical training seems to be the key to better dynamomet r i c funct ion o f the opera ted leg.

Whenever possible, postoperat ive physical therapy should be performed. Muscle t ransposi t ion endangers neither the venous nor arterial circulat ion o f the affected lower leg.

References

1. Ger R (1971) The technique of muscle transposition in the opera- tive treatment of traumatic and ulcerative lesions of the leg. J Trauma 11 : 502-510

2. Mathes S J, Nahai F (1982) Clinical applications for muscle and musculocutaneous flaps. Mosby, St Louis Toronto London

3. Mathes SJ, McGraw JB, Vasconez LO (1974) Muscle transposi- tion flaps for coverage of lower extremity defects. Anatomical Considerations. Surg Clin North Am 54:1337

4. McGraw JB, Fishman JH, Sharzer LA (1978) The versatile gas- trocnemius myocutaneous flap. Plast Reconstr Surg 62:15 23

5. McGraw JB, Arnold PG (1986) McGraw's and Arnold's atlas of muscle and musculocutaneous flaps. Hampton Press, Norfolk

6. Morris A (1978) Gastrocnemius musculocutaneous flap. Br J Plast Surg 31:216-219

7. Papp Ch, Maurer H (1988) Der Musculus tibialis anterior als distal gestielter osteomuscul/irer Transpositionslappen. Chirurg 59:61(~613

8. Tolhurst DE (1980) "Skin and bone": the use of muscle flaps to cover exposed bone. Br J Plast Surg 33:99 114