Extended Medial Gastrocnemius Rotational Flap for Treatment of Mid Tibia Chronic Osteomyelitis

Background: The mid-tibia region is a challenging reconstructive region given the paucity of soft tissue options and local muscle flaps available for reconstruction. A free-tissue transfer may not be an option in all cases due to patient comorbid conditions, personal preferences or operative resources availability. An extended medial gastrocnemius rotational flap may provide a safe, versatile and effective treatment option in the mid tibia region.

 

Methods: In this case series 5 patients with chronic osteomyelitis of the middle tibia region were treated with extended medial gastrocnemius rotational flap. In 2 cases original injury was a gunshot wound and in 3 cases it was an open fractures that never healed. Delay in treatment ranged from 10 to 30 years. Patients on average have undergone over 10 surgical procedures to treat their chronically infected, draining and non-healing mid tibia wounds. In addition to surgical procedures patients have be treated by systemic multi antimicrobial regiments on average 7 times in a hospital setting and an outpatient setting.

 

Results: All patients underwent staged-procedures with wide debridement of infected field along with collection of cultures and pathological specimens to rule out malignance. Orthopedic surgery service provided evaluation and stabilization of the tibia with external fixation. The initial treatment included an irrigating WoundVac therapy with 0.125% Dakin’s solution for 5 days and systemic broad spectrum antimicrobial therapy. Infection disease consult was initiated to assist with antimicrobial therapy.

During the second stage medial gastrocnemius rotational flap was disinserted from Achilles tendon and rotated to the established defect. Given the location and size of the defect the facial layers of the muscle on both sides were scored using the cautery every 1-1.5 cm in longitudinal and horizontal direction of the muscle fibers. Scoring increased the size of the muscle coverage by 50% allowing further distal tibia defect coverage. The muscle flap was covered with split thickness skin grafts and WoundVac as a bolster dressing.

At the 1 year follow up all patients remained infection free, have not required further hospitalizations or antimicrobial therapies. Given a significant bone loss during the debridement procedure 2 of the patients underwent bone grafting under the flap without complications.

 

Conclusion: In summary, this case series demonstrates that extended gastrocnemius flap in selected group of patients can be used to treat middle portion of the tibia defect. A systematic multidisciplinary team approach provides the ideal treatment option for these complex chronic lower extremity wounds.