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 of the lower extremity defects. Muscle flaps are especially useful in upper leg and knee defects. In this study, we presented the medial gastrocnemius flap and PRP(Platelet-Rich-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 period. Medial gastrocnemius flap is extremely useful in knee defects. Adding PRP on the flap increases flap viability. In order to reduce the length of hospital stay, especially during periods such as a pandemic, it is necessary to use safe flaps, such as muscle flaps, in the reconstruction of the lower limbs.

Keywords: gastrocnemius flap, prp, lower limb defects, knee defects

PRP, platelet rich plasma

Lower extremity defects are common, and they are due to high-energy trauma or occur after ablative tumor extirpation. Approximately 55% of lower limb traumas occur due to traffic accidents.¹ Surgeons should be familiar with the reconstructive methods of the lower extremity. Among the lower extremity regions, the thigh and upper leg have higher vascularity and there are more available local soft tissues for reconstruction.² Options for lower extremity reconstruction must provide adequate coverage for exposed bone, muscle, joints, and tendons while maximizing function and providing acceptable contour for fitting shoes.³ For the coverage of exposed muscle or fascia, a split-thickness or full-thickness skin graft can be used for a satisfactory outcome. The knee and distal leg regions are more challenging.⁴

The gastrocnemius muscle flap is safe and frequently used in upper 1/3 of leg and knee defects. The relatively low donor site morbidity increases its frequency of use in patients with weak muscle strength.⁵ In this study, we presented our case where we performed a gastrocnemius muscle flap and PRP(Platelet-Rich-Plasma) application to a 30-year-old patient with a defect in the medial knee after a traffic accident.

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 the supine position, the incision was started 2–3cm posterior of the medial border of the tibia. The incision was continued from 5–6cm inferior of popliteal to 8–10cm proximal to the ankle. Skin and subcutaneous tissue were elevated. The fascia of the gastrocnemius muscle was excised from the superficial posterior part. The avascular plane between the gastrocnemius and soleus was reached by blunt dissection. The plantaris muscle between the muscles was preserved. The median raphe between the lateral and medial muscle parts was seen in 1/3 of the proximal leg. The course of the sural nerve was seen, and the nerve was preserved. The flap was dissected from distal to proximal. Approximately 1cm of Achilles tendon from the distal was cut with cautery and included in the flap (Figure 3). The flap was elevated from the median raphe level to proximal. Dissection was continued bluntly as the sural nerve passed proximally between the two heads. The flap was elevated (Figure 4) and inset on the defect. Blood was collected from the patient, and PRP was obtained by the method used by Orhan et al.,⁶ Approximately 1ml of PRP was applied to the flap (Figure 5). Flap and other parts were covered with a partial thickness skin graft. The donor site of the flap was closed primarily, and a hemovac drain was placed (Figure 6). Wound dressing was done. The operation was terminated by splinting the leg.

Figure 1 Preoperative view. 

Figure 2 Medial knee after debridement.

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

Figure 4 Separation of the flap from the distal part.

Figure 5 After inset, PRP application to 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 the 4th postoperative month (Figure 7).

Figure 7 Postoperative 4th month.

Lower extremity defects occur as a result of trauma, tumor, and chronic diseases.⁷ Due to the thin skin and non-expandable soft tissues, reconstruction of even small defects of the lower extremity can be challenging.³ According to the location, size, bone, tendon, and other structures exposed, the reconstruction options vary from secondary healing to free flap.^8,9 Muscle flaps are the most preferred in the upper 1/3 of the leg and knee defects.¹⁰ In medial knee defects especially, the medial gastrocnemius muscle flap is used due to the high rotation arc.¹¹

The gastrocnemius muscle flap was first described in 1977 by McCraw et al.¹² The gastrocnemius muscle has two heads; medial and lateral. Each head has its own neurovascular pedicle.¹³ Pedicles start at the knee level from the popliteal fossa. They enter through the proximal bellies of muscles and move distally across the muscles. The flap is classified as Mathes and Nahai Type 1.¹⁴ Thanks to this unique blood supply, the flap is detached from the distal and can cover defects in the proximal.¹⁴ Since the medial head is longer than lateral head and it lacks soft tissue interposition, it can cover more distant defects than the lateral head.⁵ Donor site morbidity is generally not seen in the postoperative long term. Kramer-de Quervain et al. conducted a gait analysis in the postoperative period and stated that no donor site morbidity was observed.¹⁵ While minor complications, such as wound healing and infection, are seen after the operation, usually major complications, such as a partial or total flap loss, are not seen.^16,17

In our case, the wounds were closed with grafts to decrease the length of hospital stay in the pandemic process, but the graft became a failure due to the exposed tissue in the medial knee. The medial gastrocnemius muscle flap has been preferred due to its advantages already mentioned. Obtaining PRP and applying PRP to the flap was done in accordance with the studies of Orhan et al.,⁶ No complications 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.

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.

None.

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The authors have no conflicts of interest to declare.

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