ORIGINAL RESEARCH PAPER

SOFT TISSUE COVERAGE OF MIDDLE-THIRD LEG DEFECTS – MUSCLE FLAPS VERSUS PERFORATOR BASED FASCIO-CUTANEOUS FLAPS

Dr Kunal Sanyal Assistant Professor, Dept. Of General Surgery, Midnapore M C&H. Paschim Medinipur

Dr Amit Roy Associate Professor, Dept. Of General Surgery, N.R.S M C&H. Kolkata.

Dr Santanu Suba Assistant Professor, Dept. Of Plastic and Reconstructive Surgery, MC&H .Kolkata

Dr Shubhrojyoti Roy

Senior Resident Surgeon, Department of General Surgery, R.G.Kar MC&H Kolkata

Dr Suman Das*Assistant Professor, Department of General Surgery, R.G.Kar MC&H Kolkata *Corresponding Author

INTRODUCTIONOne of the challenging areas in plastic and reconstructive surgery is the closure of soft tissue defects in the middle third of the leg. This is frequently encountered due to rise in the incidence of trauma, burn, infection, fracture, vascular diseases and tumor ablation. As because tibia is subcutaneously placed in leg, these causes lead to frequent exposure of the underlying bone. It is a difcult task to nd appropriate soft tissue coverage without any functional deformities and donor site morbidity.

Many techniques are available for this purpose but each one has its own limitations. Many advances have been made in the management of soft tissue defects of the leg. In leg, practically all the potential muscle transfers are located in posterior compartment. Most of the time they are intact after an anterior injury and are available. Moreover, all the muscles of deep and supercial posterior compartment participate in planter exion of foot. So, raising of one muscle does not lead to important functional impairment.

Traditionally, there were soleus muscle ap (whole soleus or hemi-soleus), gastrocnemius (whole or hemi) muscle aps. Usually the muscle alone is transposed, which leaves a relatively insignicant donor site contour deformity in contrast to use of myocutaneous aps which result in a large skin-grafted, mid-calf region. Distant aps like micro-vascular free aps, cross leg aps are also used.

Newer methods of perforator based fascio-cutaneous aps including the propeller aps, which consist of skin, sub-cutaneous tissue and deep fascia give promising results. Blood supply for the fascio-cutaneous aps in leg comes from:

1. septo-cutaneous perforators that arise froma. posteriortibial artery-medially,b. anteriortibial artery –antero-laterallyc. peroneal artery –postero-laterally

2. musculo-cutaneous perforators coming through both gastrocnemius.

The perforators are consistently positioned in the leg, so pre-operative surface marking after routine hand held Doppler study can be done.

Propeller ap is a pedicled, islanded fascio-cutaneous ap that rotates

like two blades of a propeller around a single perforator, is useful in covering defects in the middle third of theleg.

MATERIALS AND METHODSIt was a prospective study. The place of study was department of Plastic and Reconstructive surgery, Medical College &Hospital, Kolkata.

Sample size – 20.

Inclusion criteria - all the patients with middle third leg defects attending the plastic and reconstructive surgery OPD at medical college, Kolkata and also the patients referred from orthopedics surgery and general surgery department who gave consent were included.

Exclusion criteria – those patients who were unt for operating procedures on medical or anesthetic grounds and who did not give consent for including in the study were excluded.

Sample design - Each patient was studied individually with particular attention to history taking, clinical examination and the inclusion and exclusion criteria. They were investigated thoroughly and after getting pre-anesthetic tness, they were taken for study. They were explained about the operative procedure and only after getting their consent, they were considered.

Parameters studied –Ÿ Size of thedefectŸ Type of ap chosen - muscle aps/perforator based fascio

cutaneousapsŸ Name of the apŸ Measurement of length and width of theapŸ OperatingtimeŸ Post-operative ap colorchangeŸ Post-operative ap temperaturemonitoringŸ Doppler evolution of theapŸ Necrosis of theapŸ SecondaryprocedureŸ Duration of hospitalstayŸ Donor site morbidity

INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

General Surgery

Volume - 9 | Issue - 6 | June - 2020 | PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

ABSTRACTIntroduction: The best technique in the management of soft tissue defects of the leg depends on some factors as the location of the defect in leg, injury extension, viability of tissues, circulatory conditions and reconstructive techniques One of the best options for regional reconstruction of .middle-third of leg is the use of muscle aps. Another option is perforator based fascio-cutaneous aps that is less invasive than the muscle aps .In this study we compared both the techniques of Soft tissue coverage of leg defects.Material and methods: A total of 20 Patients meeting inclusion criteria were selected into 2 groups. Patients undergoing reconstruction of middle-third of leg defects by use of muscle aps and fascio-cutaneous aps.Results: In perforator based fascio-cutaneous ap coverage more time was needed.Conclusion: Perforator based fasciocutaneous aps should be the rst preference in considering the soft tissue coverage of middle-third leg defects.

KEYWORDSMiddle-Third Leg Defects, Muscle Flaps, Perforator Based Fascio-Cutaneous Flaps.

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Volume - 9 | Issue - 6 | June - 2020

Study tools –a. Historyb. Clinicalexaminationc. Operative records

Study techniques The patients were selected as of inclusion criteria, who required reconstruction of middle third of leg region. The choice between delayed and immediate coverage depended on local condition of the wound, exposure of vital structure and general condition of the patient.

A routine hand held Doppler study was performed to mark the vascular axis of the ap. Planning in reverse was done to mark the ap. Donor site was closed primarily in cases of small defects and skin grafting was done in cases of large defects.

Post-operative ap monitoring was done by periodical clinical assessment and with the help of hand held Doppler, and secondary intervention was done if required.

Follow up for ap survival, early and left wound complications of both the ap and donor site and their aesthetic outcome were noted.

Subjects have been categorized based on outcome variables. Simple frequencies and percentages have been calculated for statistical analysis based on the nature of data. Histograms, pie chart, frequency distribution tables and other statistical tools were used through Microsoft Excel software.

RESULT AND ANALYSISThe detailed result and analysis of the performed study is as follows:

Table 1: Types of flaps taken

Medial hemisoleus muscle ap is the main workhorse ap for covering the soft tissue defects with exposed bone in middle-two-third of the leg, while posterior tibial artery perforator based fascio cutaneous aps are commonly chosen fascio-cutaneous aps alongwithperoneal artery perforator ap.

Table 2: Operating time:

The operating time ranged from 50 minutes to 85 minutes with 70 minutes in average. In perforator based fascio-cutaneous ap coverage more time was needed.

Table 3: Post op Flap complications:

PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

No Percentage

1. Med. Hemisoleusms. Flap 8 40

2. Med. Gastro. Myocut. ap 2 10

3. PTA Perforator ap 6 30

4. Peroneal Artery Perf.Flap 1 5

5. Saphenous ap 2 10

6. Cross legap 1 5

Time No Percentage

Up to 60 min. 8 40

More than60min. 12 60

International Journal of Scientific Research 23

Complications No PercentageNo Complication 10 50Collection under ap 5 25Marginal Congestion 2 10Necrosis 3 15

Two patients post-operatively had collection under ap and in ve patients the ap had congestion at the margins. Two patients had total necrosis and one patient had partial necrosis of the ap.

Table 4: Requirement of Flap Debridement.

The necrosed ap in 3 cases required debridement.

Table 5: Duration of Post-op. Hospital Stay

The average hospital stay period was 7 to 12 days. The patients who developed total or partial necrosis had to stay longer.

Table 6: Conspicuous scar in donor site.

The skin grafted area in the donor sites gave rise to conspicuous scar

DISCUSSION.In the eld of reconstructive surgery, not a day goes by without a skin ap being used. The earliest description of skin aps was by Sushruta in 600 bc. Tagliacozzi in 1597 described a random pattern ap from the medial aspect of the upper arm to reconstruction of the nose. Despite extensive studies of the blood supply to the skin by Manchot in 1889 and Salmon in 1936, most of the reconstructions during World War I

1and II were by tube pedicles. In 1973, MacGregor & Morgan classied 2 skin aps into axial and random pattern aps. Ponten highlighted the

value of fascia in augmenting the blood supply to the skin. The most common muscle flap used to cover the mid third leg is soleus muscle flap. It was initially used as pedicled ap by Ger and later by Mathes

3 8 and Nahai . Gastrocnemius Flap is another type I muscle ap used to cover the defect over middle third of leg

4Cormack & Lamberty in classied fasciocutaneous aps into three major types, differentiated by the origin of the circulation to their “fascial plexus. ” Their type A ap had multiple “fascial feeders ” or perforators that did not require specic identication, reminiscent of the random skin ap. Type B aps contained a large, solitary septocutaneous perforator. The type C ap relied on multiple and usually diminutive segmental septocutaneous branches, so that elevation of these aps almost always necessitated inclusion of the source vessel with the ap in order to maintain their complete integrity.

5Mathes & Nahai's later classication of fasciocutaneous aps was also subcategorized on the basis of the type of deep fascial perforator, thus

4being very similar to Cormack & Lamberty's tripartite system of aps.

6Nakajima et al expanded the subtypes of fasciocutaneous aps into six forms, each based on a distinctly different perforator of the deep fascia. Most had been previously described, e.g. their type I “direct cutaneous

10 aps” were identical to the axial aps of McGregor & Morgan . The 4type II “direct septocutaneous aps” were identical to Cormack &

9Lamberty's type B fasciocutaneous aps, and the type V “septocutaneous perforator aps” would be the same as the latter's type C. The type VI “musculocutaneous perforator aps” resembled traditional myocutaneous aps. The remaining two types of aps

6hypothesized by Nakajima et al, based on a “direct cutaneous branch of muscular vessel ” (IV) and “perforating cutaneous branch of a muscular vessel ” (III), were without question.

The posterior tibial artery perforator has septocutaneous, musculocutaneous, and periosteocutaneous perforators as described

7 8by Koshima et al in 1992. Apart from these perforators, there are vessels that supply the Achilles tendon and also perforate to supply the skin. These are called “tendinocutaneous perforators

Aetiology of middle third leg defect were studied, which included mostly road trafc accidents in 55% (11 out of 20) patients, and of infective aetiology in 30% (6 out of 20) patients, and in others i.e. 15% (3 out of 20 patients ), the defect was the result of tumor resection.

Cross Leg flaps remain a useful and highly reliable tool for the reconstruction of difcult wounds of the leg. It offers the possibility of

11salvaging limbs that are otherwise non reconstructable. Hamilton rst introduced the cross leg ap in 1854

The study was conducted in 20 patients over 2 years in Medical College and Hospital, Kolkata.

The mean age of the patients was 48.4 years.

Out of the 20 patients, 14(70%) were male and 6(30%) were female patients. As males are more outgoing by profession, they are more vulnerable to road accidents. Awareness of road safety measures is to be increased among these groups.

The selection of aps were on random basis. In road trafc accident patients, both the muscle aps and perforator based fascio- cutaneous aps were used. We used muscle ap or myocutaneous ap in 7 out of 11(63·7%) of post road trafc accident patients, and perforator based fascio- cutaneous aps in 4 out of 11(36·3%) post road trafc accident patients. In patients with infective aetiology, mostly fascio- cutaneous aps were done in 80% (4 out of 5) patients. Defects after tumor excision were covered with both muscle aps and fascio- cutaneous aps.

The defect length was mostly within 5cm in 65% (13 out of 20) patients. One post road trafc accident patient with a bigger 10cmx4cm defect had to be treated with cross leg ap coverage as this patient had injury over the calf muscles and local soft tissues for fasciocutaneous ap was not available. Another patient with 7cmx4cm defect was treated with fascio- cutaneous aps. Other patients with defect length of upto 6cm and width upto 3cm or 4cm were given both muscle ap and fascio cutaneous ap.

The operating time was 70minutes on average. In case of perforator based fascio- cutaneous ap, dissection of the perforator and skin grafting over donor site took some extra time. The mean operating time for muscle ap coverage was 57minutes and in fascio-cutaneous ap coverage, the mean time was 77minutes. One patient with cross leg ap coverage needed a second stage detachment of ap.

Donor site in patients in whom a muscle ap was taken, were closed primarily whereas in patients where either myocutaneous ap or fascio cutaneous ap were taken, had undergone split thickness skin grafting coverage.

Sec. Procedures No Percentage

Debridement Required 3 15

No Debridement 17 85

Total 20 100

No Percentage

Up to 10 days 14 70

More than10 days 6 30

No Percentage

Present 12 60

NotPresent 8 40

Volume - 9 | Issue - 6 | June - 2020 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

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Post-operatively two patients with medial hemisoleus muscle ap developed ap necrosis, where secondary procedures of debridement had to be done. One patient with myocutaneous ap coverage developed partial necrosis whereas no such complications were seen in cases of perforator based fascio cutaneous aps. Post-operative collection developed in ve cases which had to be drained and in two cases the ap showed congestion in the margins where few marginal stiches had to be removed.

The average post- operative hospital stay period was 7-12 days in cases of fascio- cutaneous aps and 7-11 days in cases of muscle aps. Only the patients in whom partial or complete ap necrosis occurred had to stay for a longer time.

Flap survival in perforator based fascio-cutaneous aps(posterior tibial artery perforator, peroneal artery perforator, saphenous ap and cross leg ap) was 100% (10 out of 10)

Most major limb injuries were historically treated with amputations and the patient was destined to die of infection. Renements and improved knowledge of plastic surgery has since then helped limb salvage. The goals of reconstruction are to restore or maintain function, coverage of defects and open wounds in leg to give patient a healed wound and to let them resume their life, ambulate and go back to work while preventing amputation. The focus in recent times has been ideal tissue selection to achieve optimal functional and cosmetic results as well as reduced donor site morbidity. The standard method of reconstruction of soft tissue defects in middle third of leg is soleus muscle ap. The soleus muscle being the prime ankle planter exor and stabilizer of the ankle, cannot be sacriced without signicant morbidity. The availability and better understanding of the vascular anatomy of the leg, it's interrelation with muscle groups and lower morbidity has motivated the use of perforator based fascio-cutaneous aps. The application of perforator based aps for mid leg reconstruction has many advantages as the main artery and underlying muscles are preserved and it has the thickness, texture and pigmentation of the sites that has been lost, replacing with the 'like with like' principle. The study also showed good results with no failure rates in cases of coverage with perforator based fascio-cutaneous aps.

CONCLUSIONIn our study, all the perforator based fascio-cutaneous aps survived and provided good coverage of the defect in middle-third of the leg without any functional deformities of the patient. So the perforator based fascio-cutaneous aps should be the rst preference in considering the soft tissue coverage of middle-third leg defects

Source of Support: Nil; Conflict of Interest: None

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