Leg Reconstruction: Proximal Third

Clinical Presentation

An 11-year-old White male sustained a significant crush and avulsion injury to his right upper leg as a result of a motor vehicle accident. He had extensive full-thickness skin loss over the proximal third of his leg with the exposed underlying tibia measuring 7 × 2 cm. The soft tissue wound was debrided by the trauma service and his surgical care was then transferred to the plastic surgery service for definitive soft tissue reconstruction ( Fig. 43.1 ). Soft tissue coverage was planned after definitive debridement.

Operative Plan and Special Considerations for Reconstruction

For this relatively large soft tissue wound with the exposed tibia in the proximal third of the leg, a classic local muscle flap, such as a medial gastrocnemius muscle flap, can be selected to cover the exposed tibia. The medial gastrocnemius muscle is a type I muscle flap and receives a blood supply primarily from the medial sural artery off the popliteal artery. The rest of the wound can be closed by an adjacent skin rearrangement and a split-thickness skin graft as a one-stage reconstruction. Because of significant crushing injury to the adjacent skin, any perforator-based skin flaps would not be an option. In addition, a distant flap, such as a reversed anterolateral thigh perforator flap, would not reach the proximal tibial location.

Operative Procedures

Under general anesthesia with the patient in the supine position, the right proximal tibial wound was debrided and unhealthy looking and traumatized skin was excised. All colonized tissues were sharply removed. The open wound appeared to be fresh and clean after a definitive debridement performed by the plastic surgery service ( Fig. 43.2 ).

The proposed incision for exposure of the distal medial gastrocnemius muscle was marked and the flap dissection was performed under tourniquet control ( Fig. 43.3 ). The skin incision was made through the skin, subcutaneous tissues, and fascia to expose the medial gastrocnemius muscle. In the proximal third of the leg, the medial surface of the medial gastrocnemius muscle was easily separated from the soleus muscle. The plantaris tendon was visualized between the gastrocnemius muscle and the underlying soleus muscle. The dissection went distally along the medial boarder of the medial gastrocnemius until its tendon joined the Achilles tendon. The tendon of the muscle was divided several centimeters distal to the muscle belly and the medial half of the gastrocnemius muscle was dissected from distal to proximal direction along the raphe between the medial and lateral gastrocnemius muscle bellies. During the flap dissection, the lessor saphenous vein and sural nerve were visualized and protected. Once the medial gastrocnemius muscle was elevated adequately, it was rotated medially to cover the exposed upper tibia. The flap was temporarily inset into the wound and the entire exposed upper tibial was completely covered. One drain was placed under the flap and another in the donor site.

The flap was approximated with the adjacent subcutaneous tissue with several interrupted half-buried 3-0 Monocryl sutures. Additional local skin rearrangements were done for some portions of wound closure and the rest of the wound including the muscle flap was covered with split-thickness skin grafts. Split-thickness skin grafts were harvested with a dermatome from the right lateral thigh and meshed to 1:1.5 ratio. The incision for the flap exposure was closed in two layers and all skin grafts were secured with skin staples ( Fig. 43.4 ).