The gastrocnemius with soleus bi-muscle flap

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1 The British Association of Plastic Surgeons (2004) 57, The gastrocnemius with soleus bi-muscle flap Ikuo Hyodo a, *, Bin Nakayama b, Mitsuru Takahashi c, Kazuhiro Toriyama d, Yuzuru Kamei d, Shuhei Torii d a Department of Head and Neck Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya , Japan b Department of Plastic and Reconstructive Surgery, School of Medicine, Tottori University, 36-1 Nishi-machi, Yonago , Japan c Department of Orthopaedic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimo-nagakubo Nagaizumi-cho, Sunto-gun , Japan d Department of Plastic and Reconstructive Surgery, School of Medicine, Nagoya University, 65 Tsurumai, Syouwa-ku, Nagoya , Japan Received 12 December 2002; accepted 21 October 2003 KEYWORDS Leg; Gastrocnemius muscle flap; Perforator Summary The gastrocnemius muscle flap is often insufficient in volume and arc of rotation for coverage of a large soft tissue defect of the knee and the upper third of the leg. Therefore we developed a new concept of the flap which combines soleus and gastrocnemius muscles, named the gastrocnemius with soleus bi-muscle flap. In 16 cadavers we studied the location and number of perforators, which penetrate the gastrocnemius muscle through the soleus muscle. In all cases perforators were found in the distal half of the gastrocnemius muscle. Angiography in one fresh cadaver confirmed that the soleus muscle could receive the reversed flow from the gastrocnemius muscle perforators. We subsequently treated a patient with exposed proximal tibia with this flap. This flap is useful to cover a large soft tissue defect of the knee and the upper third of the leg. Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. The gastrocnemius muscle flap is often used to cover soft tissue defects of the knee and the upper third of the leg, because of the ease of harvesting and its reliability. 1 4 However, in cases where there is a large soft tissue defect of the knee and upper third of the leg, the gastrocnemius muscle flap is often insufficient in volume and length. To overcome these limitations, an anatomic investigation of the location and number of perforators *Corresponding author. Tel.: þ ; fax: þ address: ihyodo@aichi-cc.jp between the soleus and the gastrocnemius muscles was conducted and a muscle flap combining the soleus and gastrocnemius muscles was developed. This flap was used clinically to reconstruct soft tissue defects. Method The locations and numbers of perforating vessels which penetrated the lateral and medial gastrocnemius muscles from the soleus muscle were measured in eight cadavers, 16 legs. The vertical S /$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 78 I. Hyodo et al. Figure 1 The positions of the perforators penetrating the lateral and medial heads of the gastrocnemius muscle from the soleus muscle were measured as a ratio using the distance between the fibula head and the perforating points and the distance between fibula head and lateral malleolus, and the ratio using the distance between the center of gastrocnemius muscles and the perforating points and the distance between the center of gastrocnemius muscles and lateral border of muscles. All perforators were marked on 16 cadavers. There was a high frequency of perforators on the margin. In all cases perforators was found distal half of the gastrocnemius muscle. Figure 2 (A) Perforators penetrating from soleus muscle to the lateral and medical heads gastrocnemius muscle. The gastrocnemius muscle was excluded and the soleus muscle remained. (B) Perforator penetrating from the soleus muscle to the gastrocnemius muscle. location of all perforators was expressed as a ratio of the distance between the fibula head and the perforating points and the distance between fibula head and lateral malleolus. The horizontal location of all perforators was expressed as a ratio of the

3 The gastrocnemius with soleus bi-muscle flap 79 Figure 3 Angiography done in a fresh cadaver via the lateral sural artery after the soleus and gastrocnemius muscles were raised, confirmed that reversed flow could be seen from the external margin of the lateral head of the soleus muscle (underlined). distance between the mid-line of the gastrocnemius muscles and the perforating points and the distance between the mid-line of the gastrocnemius muscles and lateral border of the lateral head or medial head. In addition, angiography was conducted on one fresh cadaver; the injection was made with leadoxide gelatin mixture via the lateral sural artery after raising the lateral, medial gastrocnemius and soleus muscles. Radiographic images were taken. 5 Results The numbers of perforators connecting gastrocnemius and soleus ranged from three to 11 per leg on the medial head of the gastrocnemius muscle, with an average of 5.9. On the lateral head, the numbers of perforators also ranged from three to 11, with an average of 7.0. While the locations of perforators were variable, we could always find perforators in the distal half of the gastrocnemius muscle (Fig. 1). The positions of the perforators on 16 legs are all marked in Fig. 2. On the lateral and medial heads, there was a high frequency of perforators at the margin of the muscle belly (on the medial head in 13 of 16 legs (82%), and on the lateral head in all legs). The diameter of the perforators at the margin of the muscle belly averaged 0.94 mm on the medial head and 0.92 mm on the lateral head. The diameter of perforators found in locations other than at the margin averaged 0.69 mm on the medial head and 0.75 mm on the lateral head (Table 1). The results of the angiogram done on a fresh cadaver via the lateral sural artery before raising the soleus and medial and lateral gastrocnemius muscles confirmed that the perforators of the soleus muscle accommodated reverse flow as they entered the external margin of the lateral head (Fig. 3). Surgical technique After investigating the relevant anatomy in cadavers the certainty of having a few perforators in the distal half of the gastrocnemius muscle was confirmed. The high frequency of perforators at the margin of the muscle belly also seemed reliable. We concluded that this flap should be raised to the distal half gastrocnemius muscle with its underlying soleus muscle without the need for direct observation of the perforators (Fig. 4). Clinical case The patient was a 10-year-old girl with osteosarcoma of the left tibia. Previously she had been treated with systemic neo-adjuvant chemotherapy, local radiation therapy and surgery as well as Table 1 Numbers of perforators Distal half Diameter of perforators (mm) Margin perforators (mm) Medial head 3 11 (5.9) a 2 5 (3.2) a 0.69 b 0.94 b lateral head 3 11 (7.0) a 2 6 (3.8) a 0.75 b 0.92 b a Mean numbers of perforators. b Mean diameter of perforators.

4 80 I. Hyodo et al. adjuvant chemotherapy postoperatively. In the first operation wide resection of the tumour was performed and the proximal anterior tibial artery and vein was resected. The reconstruction involved knee arthrodesis by intramedually fixation, heattreated tibia grafting (for 15 min at 70 8C) 6 and a pedicled fibular flap transfer. About one month after discharge from hospital, local necrosis in the upper third of the tibia was seen along with a subcutaneous abscess (Fig. 5). The damaged and dead tissue was debrided. A large soft tissue defect remained and heat-treated bone was exposed. In this case, there were no appropriate recipient vessels for a free flap. Because the volume of the gastrocnemius muscle flap alone would have been insufficient to cover the defect the gastrocnemius with soleus bi-muscle flap was raised in which a necessary amount of soleus muscle was added to the medial gastrocnemius muscle. The postoperative course was uneventful and in the 2 years since surgery the local condition has remained stable (Fig. 6). Discussion Figure 4 (A,B) Harvesting the gastrocnemius muscle (G) include soleus muscle (S). The soleus muscle is a bipenniform muscle with a central intramuscular septum with a mixed blood supply. The proximal portion of the soleus muscle is supplied by three vessels: posterior tibial artery, peroneal artery, and branches from the popliteal artery. The distal two thirds are supplied by the posterior tibial and peroneal arteries. The soleus muscle blood supply is segmental; however, an axial intramuscular vascular pattern is found frequently in the distal lateral muscle and occasionally in the distal medial muscle. The posterior tibial artery supplies the medial segment of the muscle and is the main blood supply to the distal soleus muscle. 7,8 From our investigation of cadavers, in the perforators between the soleus and gastrocnemius muscles, arteries with segmental and axial patterns within the soleus muscle penetrate the gastrocnemius muscle. The location of the perforators between the soleus and the gastrocnemius muscle is varied, but in our series a perforator always existed in the distal half of the gastrocnemius muscle. To observe the blood supply in the soleus muscle part of the flap when raising the bi-muscle flap, we injected contrast medium into the sural artery of a fresh cadaver and observed the contrast in the soleus muscle having passed through the perforators penetrating between the soleus muscle and the gastrocnemius muscle. This showed the flow

5 The gastrocnemius with soleus bi-muscle flap 81 Figure 5 (A,B) Preoperative view. At the upper third of the tibia heat-treated bone was exposed. spreading out from the gastrocnemius muscle to the soleus muscle. In our clinical case as well, the blood supply of the soleus muscle part of the raised flap was good and not congestive. In the fasciocutaneous flap and the musculocutaneous flap vascular territories spreading to the neighbouring territory are well known as the dynamic territory, 9 but there have been no reports such as this on the creation of a bi-muscle flap. Using the perforators between the soleus and the gastrocnemius muscle, we created a new concept of flap, which adds the soleus muscle to the gastrocnemius muscle flap with retrograde blood flow through its extent. In future, were the vascular territory between neighbouring muscles to be clearly identified, there would be further possibilities for development of new bi-muscle flaps. Because the gastrocnemius with soleus bimuscle flap uses two muscles of the calf, morbidity will not be low in patients. The plantar flexion can be achieved even with one of the calf muscles. Our clinical case underwent arthrodesis of the knee joint with the intramedually fixation, and uses a long leg brace. This flap provides enough volume and length to repair large defects of the upper third of the leg and knee joint, and we believe that this flap is useful to reconstruct such lesions.

6 82 I. Hyodo et al. Acknowledgements We thank Yasuo Sugiura Professor of the Department of Anatomy at Nagoya University, for their valuable support in providing the anatomic specimens. References 1. Aiache AE. A gastrocnemius muscle flap to fill an osteomyelitic hole in the femur. Br J Plast Surg 1978;31: Morris AM. A gastrocnemius muscrocutaneous flap. Br J Plast Surg 1978;31: Meller I, Ariche A, Sagi A. The role of the gastrocnemius muscle flap in limb-sparing surgery for bone sarcoma of the distal femur: a proposed classification of muscle transfers. Plast Reconstr Surg 1997;99: Greenberg B, LaRossa D, Lotke PA, Murphy JP, Noone RB. Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap. Plast Reconstr Surg 1989;83: Rees MJ, Taylor GI. A simplified lead oxide cadaver injection technique. Plast Reconstr Surg 1986;77: Nakanisi K, Sato K, Sato T, et al. Preservation of bone morphogenetic protein in heat-treated bone. J Jpn Orthop Assoc 1992;66: Sadasivan KK, Ogden JT, Albright JA. Anatomic variations of the soleus muscle. Orthopedics 1991;14: Tobin GR. Hemisoleus and reversed hemisoleus flap. Plast Reconstr Surg 1985;76: Cormack GC, Lamberty BGH. The arterial of skin flaps, 2nd ed. Churchill Livingstone; p Figure 6 Postoperative view, 2 years after surgery.