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with exposed bone present in the leg. In all cases, a proximally-based hemisoleus flap was used. All patients
were between 15–65 years of age. Depending upon the position of the defect and ease of rotation, either
the medial or lateral hemisoleus was used to cover the defects. In 7 patients with large defects, both the
hemi-gastrocnemius and hemisoleus flap were used.
l Results: Most of the patients studied (52.5%) had defects in the middle third of their leg. A further
12(30%) patients had defects over the upper part of the lower third of the leg and 7(17.5%) cases involved
large defects exposing bones comprising both the middle and lower thirds of the leg. All the flaps survived
well except 5 which developed partial skin graft loss, and 1 where complete flap loss was observed. Out
of 5 patients who developed partial graft loss, 3 patients achieved complete healing by regular dressings
and 2 required regrafting. The patient who developed complete flap loss required below knee
amputation. No donor site morbidity was observed, except minimal depression in the posterior leg.
l Conclusion: Due to a high degree of reliability, versatility, minimal donor site morbidity, less operating
time, low cost and good functional gain, this procedure is highly suitable for the treatment of complex
middle and lower leg defects.
l Declaration of interest: There were no external sources of funding for this study.The authors have no
S
evere lower limb traumas are common fractured and osteomyelitic lower leg bone remains a I. Ahmad,I MS,
among victims of road accidents. The difficult task. In these cases, muscle flaps are a good MCh(Plast Surg),
Associate Professor;
relatively unprotected anteromedial option to cover these defects in order to combat S. Akhtar,1 MS,
portion of the tibia is at risk of bone infection and to provide good vascularity to the MCh(Plast Surg), Senior
exposure following trauma. Because of exposed area of bone for better healing. In addition, Resident;
complexity of the defect, soft tissue coverage remains the muscle flap provides bulk to the bony defect. E. Rashidi,1 MS,
MCh(Plast Surg), Senior
a challenge to plastic surgeons. The use of local skin Local muscle flaps were first reported by Stark4 and
Resident;
flaps and fasciocutaneous flaps may become limited have become an established procedure for the soft M.F. Khurram,1 MS,
especially if their pedicles come within the zone of tissue coverage of pretibial skin defects, especially MCh(Plast Surg), Assistant
injury. Cross leg flaps may be another option but is when associated with osteomyelitis.5 Mathes et al. Professor;
difficult to use in the presence of fixators, with 3 described the proximally-based soleus muscle flap,6 1 Post-Graduate
Department of Burns,
weeks immobilisation being an additional problem. which has been used for the soft tissue coverage of Plastic and
Free flaps may be a good solution,1 yet they are not the middle third of the leg. It has also been widely Reconstructive Surgery,
available in all centres and have a higher rate of fail- employed for the treatment of chronic osteomyelitis Jawaharlal Nehru Medical
ure.2 of the leg bones.4,6,7 College, Aligarh Muslim
University, India.
Parrett and Pribaz3 described the changing trend of To further investigate the use of the proximally-
Email: drsohaibakhtar@
lower extremity trauma management from microv- based soleus muscle flap for the treatment of com- gmail.com
ascular to local flaps, skin grafting and vacuum- plex wounds of the lower legs, this study aimed to
assisted closure. According to the authors, microvas- treat specifically patients with defects in the middle
cular free-tissue transfer increases the ability to close and lower third of the leg using the hemisoleus mus-
wounds, transfer vascularised bone, and prevent cle flap. In cases involving large soft defects, both
amputation, yet remains a complex, invasive proce- hemisoleus and hemi-gastrocnemius flaps were used.
dure with significant complication rates, donor site The study also strived to determine the rate of flap
morbidity, and failure rates. survival, donor morbidity and functional outcomes
Reconstruction of the soft tissue defect of exposed, of the patients receiving surgery.
s
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3
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References
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2 Yajima, H., Tamai, S.,
Mizumoto, S. et al.Vascular
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473–478. Fig 1a. Defect involving the lower and Fig 1b Hemisoleous and hemi- Fig 1c. Post op. day 7. Skin graft
3 Parrett, M.B., Pribaz, J.J. middle third of the leg.The lateral gastrocnemius flap raised. Relaxing well taken.
Lower Extremity incision approach was used for raising incision given over the hemisoleus
Reconstruction, Rev Med
Clin Condes 2010; 21: 1, 66 both hemi-gastrocnemius and to advance more distally and cover
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4 Stark, W.J. The use of shown in the figure).
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5 Ger, R. The management
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6 Mathes, S.J., Nahai F. (eds).
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Louis, Mosby, 1982. Fig 2a. Defect over middle and lower third of leg. Fig 2b. Post op photograph after applying hemigastro-
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1594–1597 [in Japanese].
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8 Tobin, G.R. Hemisoleus fasciocutaneous flaps,12 and muscle flaps.6 Random lateral approach required dissection of an additional
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1985; 76: 1, 87–96. of cross-leg flaps has been limited by the difficulty of common peroneal nerve is always present. The most
9 Barclay, T.L., Cardos, E., immobilising both legs for 3 weeks, joint stiffness, difficult dissection involved cases of large wound
Sharpe, D.T. Cross leg and concern about donor site cosmetic deformity in size, long standing and severe cases of trauma. Addi-
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10 May, J.W., Gallico, G.G., anaesthetic risk. insufficient in some cases; atrophy of the muscle was
Lukash, F.N. Microvascular
transfer of free tissue for In this study, we have successfully used the proxi- significant in these type of defects.
closure of bone wounds of mally-based hemisoleus flap for the coverage of soft Pu,15 in his series of four patients with an extensive
the distal lower extremity. tissue defects over the middle and distal lower leg. mid-tibial wound of the leg, successfully used the
N Engl J Med 1982; 306: 5,
253–257. Along with the hemisoleus muscle, we have used combined medial gastrocnemius and medial hemi-
11 Tolhurst, D.E., Haeseker, gastrocnemius in some cases with large soft tissue soleus muscle flaps for soft-tissue reconstruction.
B., Zeeman, R.J. The defects. Importantly, proximally-based hemisoleus Limb salvage was achieved in all four patients during
development of
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12 Akhtar, S., Hameed, A. Other groups have previously explored the grafting coverage using the proximally-based medial hemiso-
Versatility of the sural potential of the hemisoleus muscle flap. leus muscle flap, demonstrating positive results.
fasciocutaneous flap in the Fatih et al13 studied the arterial blood supply of the In our study, 7 patients suffered from large defects
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13 Fathi, M., Hassanzad
Azar, M., Arab Kheradmand, ply of the soleus was critical for harvesting the soleus hemisoleus and hemi-gastrocnemius flap was used
A., Shahidi, S. Anatomy of muscle flap. Furthermore, Ata-ul-Haq et al14 conclud- to cover the exposed bone, where a medial incision
arterial supply of the soleus ed in their study that the hemisoleus muscle flap was was used to harvest medial hemisoleus and hemi-
muscle. Acta Med Iran 2011;
49: 4, 237–240. a valuable local option for soft tissue coverage of gastrocnemius muscle.
14 Ata-ul-Haq, Tarar, M.N., middle third of lower leg for preserving the function Recently, there has been a movement towards
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