Limb salvage surgery with a multidisciplinary approach is the standard of care when treating sarcomas confined to the limbs.1 Patients treated this way are afforded significantly greater mobility with lower energy expenditure when compared with patients treated with amputation,2 and long-term cost-utility analysis shows that limb salvage yields lower costs and higher utility when compared with amputation.3
Although coverage of midlateral femur defects is well documented with various flaps, this can be difficult in patients with significant damage to the soft tissues and vasculature typically used to accomplish this. Thus, the standard regional and even free flap approaches may be precluded. Flaps that use the lateral gastrocnemius are typically used alone or in combination with the medial gastrocnemius for coverage of defects of the upper tibia, the knee joint, and the popliteal fossa.4 However, we report a case of a lateral gastrocnemius myocutaneous flap used to cover exposed orthopedic hardware of the midlateral femur, 14 cm above the joint line of the knee.
The patient is a 62-year-old male veteran with a history of a liposarcoma of the right thigh. He underwent limb salvage surgery that involved rectus abdominis free flap reconstruction in 2003 and was subsequently treated with radiation therapy in 2004. Pathologic fracture of his irradiated distal femur was treated with retrograde intramedullary nailing in 2007. Infection of this orthopedic hardware required complete hardware removal in 2011 (Fig. 1A). Advised by numerous surgeons to undergo an above-knee amputation of his seemingly unsalvageable limb, the patient presented to the Veterans Affairs San Diego Healthcare System for creative limb salvage options.
Initial treatment by the orthopedic surgery team in February 2012 involved distal femoral resection and implantation of antibiotic-impregnated femoral and tibial cement spacers. To avoid disturbing the rectus abdominis free flap, access incisions to the midlateral femur were made in lieu of the standard medial parapatellar approach for planned hardware implantation. The plastic surgery team then took the patient to surgery for the first of 3 stages of lateral gastrocnemius myocutaneous flap elevation in March 2012. Incisions extending beyond the edges of the muscle belly and incorporating distal perforators were made along with the overlying fasciocutaneous component as an en bloc type of dissection.
The patient underwent the second stage of flap elevation in April 2012. The previous incisions were opened, and the flap was further elevated along with its lateral sural artery pedicle while maintaining the sural nerve in its anatomic position. By this time, roughly 75% of the lateral gastrocnemius muscle belly was circumferentially elevated, and its skin paddle was extended to within 8 cm of the lateral malleolus.
The third stage of flap elevation was performed after distal femoral replacement and total knee arthroplasty by the orthopedics team in May 2012 (Fig. 1B). The final size of the defect measured approximately 5-cm wide × 12-cm long × 5-cm deep, where the orthopedic megaprosthesis remained exposed. The islanded flap was carefully rotated and inset into the midlateral femur defect while protecting the pedicle (Fig. 2). The newly inset lateral gastrocnemius myocutaneous flap was then sutured into place with the aid of advancement flaps of the suprapatellar tissue (3-cm wide × 6-cm long) and the upper lateral thigh tissue (2-cm wide × 8-cm long). Intraoperative pencil-tip Doppler confirmed the meticulously dissected pedicle, as well as the dorsalis pedis and posterior tibial artery pulses throughout the operation.
The patient remained in the on-campus skilled nursing facility of the Veterans Affairs for 1 month after his final surgery, where he was treated with intravenous antibiotics, optimized nutritionally, and rehabilitated with physical therapy. After discharge, the patient had excellent healing at both recipient and donor sites (Fig. 3) and was able to walk comfortably but cautiously without pain or assistive devices for the first time in years.
Coverage of wounds of the midlateral femur in the context of severe soft tissue loss, previous reconstruction, irradiation, and failed orthopedic hardware presents a complex problem with limited solutions. Regional flaps (eg, rectus femoris, vastus lateralis, tensor fascia latae) and free flaps (eg, rectus abdominis, latissimus dorsi, anterolateral thigh) that are typically used to cover defects in this region may simply be unavailable, as was the case with our patient. To date, there are no cases describing the exclusive use of a lateral gastrocnemius myocutaneous flap to cover exposed orthopedic hardware of the midlateral femur. Reviewing both old and new literature on flap reconstruction of the lower extremity and the utility of the delay phenomena provides insight into the novelty of using this flap in such a fashion.
In 1978, McCraw et al5 described the use of the versatile gastrocnemius myocutaneous flap to cover soft tissue defects of the upper tibia, the knee joint, and the popliteal fossa. The range of rotation of this flap, as demonstrated by the authors, enabled coverage of small complex wounds to these lower regions.
In 1981, Sanders and O’Neill6 described 8 cases in which the gastrocnemius myocutaneous flap was used to cover exposed knee prostheses. Three of these cases used a lateral gastrocnemius myocutaneous flap: 1 used in conjunction with a medial gastrocnemius myocutaneous flap, and 2 used exclusively. The authors showed that the medial head of the gastrocnemius was more amenable to covering larger and more proximal defects when compared with the lateral head because of the medial head’s larger size and length and its greater mobility. Although more easily accessible, the lateral head was described as being restricted in mobility by the lateral popliteal nerve (ie, common peroneal nerve) passing over the muscle’s pedicle.
In 1984, Malawer and Price7 described 10 cases in which malignant bone tumors of the knee joint underwent limb-sparing surgery and gastrocnemius flap transposition. Three of these cases used a lateral gastrocnemius transposition flap: 1 used in conjunction with a medial gastrocnemius transposition flap to cover the distal femur, and 2 used exclusively to cover the proximal fibula. The authors determined that the medial head was best suited for coverage of proximal tibia and distal femur defects, whereas the lateral head was best suited for coverage of defects of the proximal fibula.
In 2007, Chim et al8 reviewed 10 cases of local muscle flaps for knee megaprosthesis coverage after limb salvage surgery for various types of sarcomas in the distal femur or the proximal tibia. Three of these cases used a lateral gastrocnemius transposition flap: 1 in conjunction with a medial gastrocnemius transposition flap to cover the proximal tibia, 1 in conjunction with a medial gastrocnemius transposition flap to cover the distal femur, and 1 in conjunction with a gracilis transposition flap to cover the distal femur.
The abovementioned articles demonstrate a wealth of instances in which the medial gastrocnemius covered various defects of the tibia, the knee joint, and the distal femur but conversely demonstrate the relative paucity of instances in which the lateral gastrocnemius covered similar defects. On the basis of the current data, the lateral gastrocnemius myocutaneous flap would seem to have limited applications, especially by itself.
Given the size and the location of our patient’s defect in the midlateral femur and the patient’s complicated history of previously used flaps, few options were left for us to treat his irradiated, infected, and scarred wound bed. Although another free flap may have been possible, we felt that this option would have required disrupting the vasculature of his leg with yet another deep dissection and complex anastomosis on a limb already at tremendous risk for being unsalvageable.
We believe that the success of our patient’s extended lateral gastrocnemius myocutaneous flap was aided by using the delay technique (Fig. 4), which McFarlane et al9 described as providing decreased risk for pedicle flap necrosis via conditioning of flap tissues to survive a state of hypoxia when raised. Although the exact molecular mechanism of this conditioning has yet to be elucidated, a number of studies by Lineaweaver et al10 identified vascular endothelial growth factor as a key cytokine responsible for flap tissue survival after surgical delay.11 With the skin of the posterior calf reliably perfused by fascial perforators originating from multiple angiosomes,12–14 the delay phenomena allowed us to safely lengthen the skin paddle and extend the arc of rotation of the patient’s lateral gastrocnemius myocutaneous flap by de novo arborization of the lateral sural artery pedicle. Moreover, this method allowed the flap’s viability to be closely monitored while the patient’s infection was cleared, nutrition was optimized, and struggles with compliance were addressed before finally committing the flap to inset.
In our review of the literature, this is the first reported case of an extended lateral gastrocnemius myocutaneous flap used to cover exposed orthopedic hardware of the midlateral femur. Although the medial gastrocnemius has been used to cover extremely high defects of the midmedial femur,15 we were able to use the lateral gastrocnemius to cover a midlateral femur defect 14 cm above the joint line of the knee.
Our experience shows that the lateral gastrocnemius myocutaneous flap can be elevated to heights previously not reported to cover extremely complex wounds. By choosing to use a regional flap rather than a risky and technically difficult free flap, options higher up on the reconstructive ladder were saved to cover any soft tissue defects that the patient may acquire in the future while still providing lasting coverage for a defect that would have otherwise required limb amputation.
The case presented demonstrates the use of an extended lateral gastrocnemius myocutaneous flap to cover a large defect of the midlateral femur and illustrates the creative collaborations needed with our orthopedic surgery colleagues to successfully plan combined surgical interventions and rehabilitate our mutual patient. However, more research into the reproducibility of the extended lateral gastrocnemius myocutaneous flap is necessary. The impact of factors such as duration of delay, proximity of pedicle origin, and management of patient comorbidities on the length, the perfusion, and the adherence of this particular flap remains unknown.
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