Using Medial Gastrocnemius Muscle Flap and PRP (Platelet-Rich-Plasma) in Medial Knee Defect

MOJ Clinical & Medical Case Reports

Case Report Open Access Using medial gastrocnemius muscle flap and PRP (Platelet-Rich-Plasma) in medial knee defect

Abstract Volume 10 Issue 4 - 2020 Lower extremity defects can occur due to many reasons, such as a tumor, gunshot wound, and traffic accident. Many different methods have been described in the reconstruction Burak Ergün Tatar, Can Uslu, Caner Gelbal, of the lower extremity defects. Muscle flaps are especially useful in upper leg and knee Tevfik Balıkcı, Mehmet Erdem defects. In this study, we presented the medial gastrocnemius flap and PRP(Platelet-Rich- Department of Plastic Surgery, University of Health Sciences, Turkey Plasma) application to the 30 years old patient who had an open wound in the upper leg and knee as a result of a traffic accident. No problems were encountered in the postoperative Correspondence: Mehmet Erdem, Department of Plastic period. Medial gastrocnemius flap is extremely useful in knee defects. Adding PRP on the Surgery, University of Health Sciences, Bagcılar Training and flap increases flap viability. In order to reduce the length of hospital stay, especially during Research Hospital, Turkey, Tel +90 537 735 45 90, periods such as a pandemic, it is necessary to use safe flaps, such as muscle flaps, in the +90 212 440 40 00, Email reconstruction of the lower limbs. Received: August 02, 2020 | Published: August 17, 2020 Keywords: gastrocnemius flap, prp, lower limb defects, knee defects

Abbreviations: PRP, platelet rich plasma the supine position, the incision was started 2–3cm posterior of the medial border of the tibia. The incision was continued from 5–6cm Introduction inferior of popliteal to 8–10cm proximal to the ankle. Skin and subcutaneous tissue were elevated. The fascia of the gastrocnemius Lower extremity defects are common, and they are due to high- muscle was excised from the superficial posterior part. The avascular energy trauma or occur after ablative tumor extirpation. Approximately 1 plane between the gastrocnemius and soleus was reached by blunt 55% of lower limb traumas occur due to traffic accidents. Surgeons dissection. The plantaris muscle between the muscles was preserved. should be familiar with the reconstructive methods of the lower The median raphe between the lateral and medial muscle parts was extremity. Among the lower extremity regions, the thigh and upper seen in 1/3 of the proximal leg. The course of the sural nerve was leg have higher vascularity and there are more available local soft 2 seen, and the nerve was preserved. The flap was dissected from distal tissues for reconstruction. Options for lower extremity reconstruction to proximal. Approximately 1cm of Achilles tendon from the distal must provide adequate coverage for exposed bone, muscle, joints, and was cut with cautery and included in the flap (Figure 3). The flap was tendons while maximizing function and providing acceptable contour 3 elevated from the median raphe level to proximal. Dissection was for fitting shoes. For the coverage of exposed muscle or fascia, a split- continued bluntly as the sural nerve passed proximally between the thickness or full-thickness skin graft can be used for a satisfactory 4 two heads. The flap was elevated (Figure 4) and inset on the defect. outcome. The knee and distal leg regions are more challenging. Blood was collected from the patient, and PRP was obtained by the The gastrocnemius muscle flap is safe and frequently used in upper method used by Orhan et al.,6 Approximately 1ml of PRP was applied 1/3 of leg and knee defects. The relatively low donor site morbidity to the flap (Figure 5). Flap and other parts were covered with a partial increases its frequency of use in patients with weak muscle strength.5 In thickness skin graft. The donor site of the flap was closed primarily, this study, we presented our case where we performed a gastrocnemius and a hemovac drain was placed (Figure 6). Wound dressing was muscle flap and PRP(Platelet-Rich-Plasma) application to a 30-year- done. The operation was terminated by splinting the leg. old patient with a defect in the medial knee after a traffic accident. Case report A 30-year-old male patient applied to our emergency department with a traffic accident. An open wound was found on the anterior of the right thigh, medial of the knee, and anterior of the tibia. No fracture was detected in the X-ray. The patient was hospitalized. Debridement was performed after antibiotherapy, and vacuum assistant therapy was applied. He was taken to the operating theater after the wound swab culture was negative. All wounds were grafted. The patient was discharged with oral antibiotherapy. After one week, grafts on the anterior of the crus and the medial knee were failures. A gastrocnemius muscle flap was planned for the patient. Under general anesthesia, fail grafts were debrided in the right medial knee and the anterior of the crus. After debridement, the wound on the anterior of the crus was graftable, but the exposed tissues were found medial and inferior to the knee (Figure 1-2). In Figure 1 Preoperative view.

Submit Manuscript | http://medcraveonline.com MOJ Clin Med Case Rep. 2020;10(4):103‒106. 103 ©2020 Tatar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Using medial gastrocnemius muscle flap and PRP (Platelet-Rich-Plasma) in medial knee defect ©2020 Tatar et al. 104

Figure 2 Medial knee after debridement.

Figure 5 After inset, PRP application to flap.

Figure 3 Medial gastrocnemius muscle (Blue skin marker: 1 cm Achilles tendon included in flap).

Figure 6 Partial thickness skin graft covering of the flap. When the fluid from the drain was less than 20ml (Postoperative day 2), the drain was removed. On the 5th postoperative day, wound dressing was opened. The grafts were intact. Oral antibiotherapy was continued for one week. The patient was routinely called for controls. No complication was encountered in the wound or while walking in Figure 4 Separation of the flap from the distal part. the 4th postoperative month (Figure 7).

Citation: Tatar BE, Uslu C, Gelbal C, et al. Using medial gastrocnemius muscle flap and PRP (Platelet-Rich-Plasma) in medial knee defect.MOJ Clin Med Case Rep. 2020;10(4):103‒106. DOI: 10.15406/mojcr.2020.10.00354 Copyright: Using medial gastrocnemius muscle flap and PRP (Platelet-Rich-Plasma) in medial knee defect ©2020 Tatar et al. 105

were observed in our patient in the postoperative period. No donor site morbidity was observed. We also think that the PRP applied increases flap viability. The priority of healthcare professionals should be to discharge patients and enable them to return home in good health, especially in times of a pandemic. Therefore, it is more appropriate to select safer flaps in the reconstruction of tissue defects. Conclusion The gastrocnemius flap is a handy and safe flap that is often used to close defects in the upper 1/3 of the leg and around the knee. Acknowledgments None. Funding None. Conflicts of interest The authors have no conflicts of interest to declare. References 1. Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower Figure 7 Postoperative 4th month. extremity injuries among US high school athletes. Academic Emerg Med. 2007;14(7): 641–645. Discussion 2. Lambers K, Ootes D, Ring D. Incidence of patients with lower extremity Lower extremity defects occur as a result of trauma, tumor, and injuries presenting to US emergency departments by anatomic region, 7 disease category, and age. Clinical Orthopaedics and Related Research®. chronic diseases. Due to the thin skin and non-expandable soft 2012;470(1): 284–290. tissues, reconstruction of even small defects of the lower extremity can be challenging.3 According to the location, size, bone, tendon, 3. AlMugaren FM, Pak CJ, Suh HP, et al. Best Local Flaps for Lower and other structures exposed, the reconstruction options vary from Extremity Reconstruction. Plastic and Reconstructive Surgery Global secondary healing to free flap.8,9 Muscle flaps are the most preferred Open. 2020;8(4). in the upper 1/3 of the leg and knee defects.10 In medial knee defects 4. Francel TJ, Vander Kolk CA, Hoopes JE, et al. Microvascular soft–tissue especially, the medial gastrocnemius muscle flap is used due to the transplantation for reconstruction of acute open tibial fractures: timing high rotation arc.11 of coverage and long–term functional results. Plastic and reconstructive surgery. 1992;89(3):478–487. The gastrocnemius muscle flap was first described in 1977 by McCraw et al.12 The gastrocnemius muscle has two heads; medial 5. Walton Z, Armstrong M, Traven S, et al. Pedicled rotational medial and 13 lateral gastrocnemius flaps: surgical technique. JAAOS–Journal of the and lateral. Each head has its own neurovascular pedicle. Pedicles American Academy of Orthopaedic Surgeons. 2017;25(11):744–751. start at the knee level from the popliteal fossa. They enter through the proximal bellies of muscles and move distally across the muscles. The 6. Orhan E, Uysal AÇ, Başer E, et al. The effect of intradermal administration flap is classified as Mathes and Nahai Type 141. Thanks to this unique of inactive platelet–rich plasma on flap viability in rats. Acta Cirurgica blood supply, the flap is detached from the distal and can cover defects Brasileira. 2017; 32(4): 280–286. in the proximal.14 Since the medial head is longer than lateral head 7. Soltanian H, Garcia RM, Hollenbeck ST. Current concepts in lower and it lacks soft tissue interposition, it can cover more distant defects extremity reconstruction. Plastic and reconstructive surgery 2015; than the lateral head.5 Donor site morbidity is generally not seen in 136(6):815e–829e. the postoperative long term. Kramer-de Quervain et al. conducted a 8. Mendieta M, Cabrera R, Siu A, et al. Perforator propeller flaps for gait analysis in the postoperative period and stated that no donor site the coverage of middle and distal leg soft–tissue defects. Plastic and morbidity was observed.15 While minor complications, such as wound Reconstructive Surgery Global Open. 2018; 6(5):e1759. healing and infection, are seen after the operation, usually major 16,17 9. Reddy V, Stevenson TR. MOC–PS (SM) CME article: lower extremity complications, such as a partial or total flap loss, are not seen. reconstruction. Plastic and Reconstructive Surgery. 2008; 121(4): 1–7. In our case, the wounds were closed with grafts to decrease the 10. Grotting JC, Vasconez LO. Regional blood supply and the selection of length of hospital stay in the pandemic process, but the graft became flaps for reconstruction.Clinics in plastic surgery. 1986; 13(4): 581–593. a failure due to the exposed tissue in the medial knee. The medial gastrocnemius muscle flap has been preferred due to its advantages 11. El–Shazly M, Kamal A. Practical guidelines for getting the most out of the gastrocnemius muscle flap units: a presented algorithm for the best already mentioned. Obtaining PRP and applying PRP to the flap was flap choice.European Journal of Plastic Surgery. 2012;35(8):589–594. done in accordance with the studies of Orhan et al.,6 No complications

12. McCRAW JB, Fishman JH, Sharzer LA. The versatile gastrocnemius 15. Kramers–de Quervain IA, Lüuffer JM, Küch K, et al. Functional donor– myocutaneous flap. Plastic and reconstructive Surgery. 1978; 62(1):15– site morbidity during level and uphill gait after a gastrocnemius or soleus 23. muscle–flap procedure.JBJS . 2001;83(2):239–246. 13. Tsetsonis CH, Kaxira OS, Laoulakos DH, Set al. The arterial 16. Buchner M, Zeifang F, Bernd L. Medial gastrocnemius muscle flap in communication between the gastrocnemius muscle heads: a fresh limb–sparing surgery of malignant bone tumors of the proximal tibia: cadaveric study and clinical implications. Plastic and reconstructive mid–term results in 25 patients. Annals of plastic surgery. 2003;51(3): surgery. 2000;105(1): 94–98. 266–272. 14. Panse N, Bhadgale R, Karanjkar A, et al. The reach of the Gastrocnemius 17. Anract P, Missenard G, Jeanrot C, et al. Knee reconstruction with Musculocutaneous flap: how high is high? World Journal of Plastic prosthesis and muscle flap after total arthrectomy. Clinical Orthopaedics Surgery. 2018; 7(3):319. and Related Research. (1976–2007) 2001; 384: 208–216.