iprs000007 10.3205/iprs000007 urn:nbn:de:0183-iprs0000078 Research Article Der gestielte Gastroknemiusmuskellappen zur Behandlung von Weichteilproblemen am Knie – Indikation, Durchführung und Resultate Moebius Moebius Boris B Dr. med.

Evang. Krankenhaus Hubertus, Spanische Allee 10-14; D-14129 Berlin, GermanyEvang. Krankenhaus Hubertus, Berlin, Germany

moebius@ekh-berlin.de author Scheller Scheller Eike Eric EE

Evang. Krankenhaus Hubertus, Berlin, Germany

author German Medical Science GMS Publishing House

Düsseldorf

610 gastrocnemius muscle flap soft tissue damage of the knee prosthesis infections Gastrocnemiuslappen Weichteildefekt am Kniegelenk Protheseninfektion Knieprothese 2012010920160310 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution License. You are free: to Share - to copy, distribute and transmit the work, provided the original author and source are credited. Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen. Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden. 2193-8091 1 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW GMS Interdiscip Plast Reconstr Surg DGPW 07 20160309ISSN added Bei einer Zunahme von endoprothetischen Gelenkersatz am Kniegelenk kommt es aufgrund der hohen Rate an Weichteilproblemen (von der Wundheilungsstörung bis hin zum tiefen Wundinfekt) auch zu einer Zunahme an kritischen Wunden im Bereich des Kniegelenks. In der Literat</PlainText></TextGroup>ur wird eine allgemeine Weichteilkomplikationsrate von bis zu 20&#37; <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, in 5&#37; <TextLink reference="3"></TextLink> sogar mit freiliegendem Knochen beschrieben. Diese stellen mittlerweile ein immer gewichtiger werdendes Problem f&#252;r den behandelnden Chirurgen dar. Bei einer notwendigen suffizienten Weichteilbedeckung von Knochen, Sehnen und prothetischem Material bleibt in speziellen F&#228;llen nur der Ausweg einen gestielten Muskellappen zu verwenden. Hierf&#252;r ist der M. Gastrocnemius hervorragend geeignet. Es handelt sich um ein aufwendiges Verfahren, welches mit einer hohen Komplikationsrate vergesellschaftet ist. Durch dieses Verfahren kann jedoch ein sicherer Weichteilverschluss erreicht werden und damit die Funktion der Prothese und die Extremit&#228;t des Patienten gerettet werden. Zwischen 8&#47;2004 und 3&#47;2011 wurden in unserem Haus 23 Patienten mit einem Gastrocnemiusschwenklappen nach Knieprothesen- oder Kniearthrodeseninfekt mit konsekutivem Weichteilschaden behandelt. Insgesamt lag die Ausheilungsrate der Knieinfekte mit stabilen Weichteilverh&#228;ltnissen bei fast 87&#37;. Die Revisionsrate mit Lappenhebungen und Nahtrevisionen sowohl der Empf&#228;nger, wie auch der Entnahmestelle lag jedoch bei fast 35&#37; mit langwierigen konservativen oder erneuten operativen Behandlungen.</Pgraph></Abstract> <Abstract language="en" linked="yes"><Pgraph>With the increase of endoprosthetic knee replacements, there is also an increase of critical wounds to the knee due to a high incidence of soft tissue problems (ranging from wound healing defects to severe wound infections). The literature describes a general rate of soft tissue complications of up to 20&#37; <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, with 5&#37; <TextLink reference="3"></TextLink> involving exposed bone. These complications are an increasingly important problem for surgeons. Since sufficient coverage of bones, tendons and prosthetic material with soft tissue is a necessity, the use of a pediculated muscle flap is the only solution in some cases. The gastrocnemius muscle is very useful for this purpose. It is an elaborate procedure which is associated with a high rate of complications. However, this procedure can establish a secure coverage with soft tissue, and the function of the prosthesis and the patient&#8217;s extremity can be saved. We have treated 23 patients with a gastrocnemius rotation flap after knee prosthesis or knee arthrodesis infection with consecutive soft tissue damage at our hospital from 8&#47;2004 through 3&#47;2011. The overall rate of healing of the knee infections with stable soft tissue status is almost 87&#37;. The revision rate with lifting of the flap and revision of the sutures at the point of insertion as well as the point of extraction was about 35&#37; with long-term conservative or additional surgical treatments.</Pgraph></Abstract> <TextBlock linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>Wound healing defects and associated soft tissue damages are becoming more important in the orthopedic practice. This is due to the significant increase of prosthesis implantations <TextLink reference="4"></TextLink>, including knee prosthesis implantations and the demographic development of society. The demands on a long lifetime of the prostheses are consistently increasing due to the increasing life expectancy of the patients receiving prostheses. Standardizations in endoprosthetics, increased experience of surgeons and the further development of prostheses has led to the consistent improvement of long-term results and lifetime of artificial joints <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink> so that prostheses are implanted and replaced in younger patients as well. A secure and stable coverage with soft tissue is a basic requirement for good short-term and long-term results regarding the prosthesis. Without a sufficient coverage with vital soft tissue with a good blood supply, primary implant healing and primary wound healing are not possible. The risks of infection of the prosthesis and reduced capacity of the new joint exist. This is especially important for the knee because there is little soft tissue coverage in general which contributes to the increased risk for wound healing defects due to the surgical wound leading to a reduced blood supply. Transcutaneous measurements of oxygenation have shown that the level of oxygenation near the surgical scar necessary for wound healing is only reached after two to three days <TextLink reference="7"></TextLink>&#91;. Besides the negative impact of the surgery itself on the primary wound healing, various other exogenous factors play a role in wound healing. The most important factors are rheumatoid arthritis, diabetes, long-term cortisone intake, malnutrition, nicotine use, hypothyroidism and existing multiple scars in the area of the surgery <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>, <TextLink reference="10"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Material and methods"> <MainHeadline>Material and methods</MainHeadline><Pgraph>Laing et al. <TextLink reference="11"></TextLink> have described five stages of soft tissue defects after knee endoprosthetics 1992: </Pgraph><Pgraph><UnorderedList><ListItem level="1">Stage 0: Redness near the wound without wound dehiscence or development of necrosis </ListItem><ListItem level="1">Stage 1: Only superficial skin necrosis or tension blisters, deeper layers not affected; no fistula </ListItem><ListItem level="1">Stage 2: Extensive skin necrosis with fistula towards the knee, deeper layers of tissue not affected </ListItem><ListItem level="1">Stage 3: Joint fistula with dehiscence of deeper layers; a small part of the joint prosthesis is visible </ListItem><ListItem level="1">Stage 4 : Widespread tissue necrosis with wound dehiscence and visible prosthesis </ListItem></UnorderedList></Pgraph><Pgraph>For stages 0 and 1, a conservative treatment with fixation of the knee and bed rest for the patient is favoured and the soft tissue damage usually heals well without surgical treatment. For stage 2 and above, surgical measures are preferred. In stage 2, the superficial skin necrosis should be removed and temporary soft tissue coverage and vac-therapy should occur. A swab should be submitted for an antibiogram for subsequent antibiotic therapy. Permanent soft tissue coverage can occur in the case of asepsis. Depending on size, a split-skin (MESH-graft) or full-skin graft can be chosen. </Pgraph><Pgraph>For soft tissue damage of stage 3 (Figure 1 <ImgLink imgNo="1" imgType="figure"/>), a muscle flap is necessary, because the deeper damages cannot be treated with mere skin transplants <TextLink reference="12"></TextLink>. The benefits of muscle flaps, e.g. a gastrocnemius rotation flap, are evident: because the muscle flap is supplied with blood, it can be placed on infected wounds; this leads to a sign<TextGroup><PlainText>ifica</PlainText></TextGroup>nt improvement of wound healing. This is due to secure soft tissue coverage of possibly exposed bone and prosthetic material. It is also due to the transportation of immunocompetent cells to the site of infection with the normal blood supply which leads to an improvement of wound healing and defence against infection <TextLink reference="13"></TextLink>. For this stage, the elevation and use of one gastrocnemius muscle belly, medial or lateral, is sufficient (Figure 2 <ImgLink imgNo="2" imgType="figure"/>). </Pgraph><Pgraph>The lateral gastrocnemius muscle flap plasty was first described by Barford and Pers <TextLink reference="14"></TextLink> and the medial gast<TextGroup><PlainText>rocn</PlainText></TextGroup>emius muscle flap plasty was first described by Ger <TextLink reference="15"></TextLink>. The localisation of the damage dictates which muscle belly should be used. The medial head is often longer and wider than the lateral head which is why it is usually used. Due to separate blood supply through the Aa. surales medialis and laterialis, the elevation of an isolated flap <TextLink reference="16"></TextLink> and the coverage of almost the entire knee (Figure 3 <ImgLink imgNo="3" imgType="figure"/>) is possible. The muscle belly should be lifted without a skin graft because this could cause problems with the closure of the skin near the location of extraction. For the dermal closure of the implanted muscle flap, split-skin (MESH-graft) with a thickness of 0.3 to 0.5 mm should be used. The muscular aponeurosis and parts of the fascia of the muscle should be removed, so that it can heal well (Figure 4 <ImgLink imgNo="4" imgType="figure"/>).</Pgraph><Pgraph>In case of stage 4 soft tissue damage, both bellies of the gastrocnemius muscle can be used. An area of up to <TextGroup><PlainText>60 square</PlainText></TextGroup> centimetres can be covered this way <TextLink reference="17"></TextLink>. The muscle coverage with split-skin (MESH-graft) is also indic<TextGroup><PlainText>ate</PlainText></TextGroup>d (Figure 5 <ImgLink imgNo="5" imgType="figure"/>, Figure 6 <ImgLink imgNo="6" imgType="figure"/>, Figure 7 <ImgLink imgNo="7" imgType="figure"/>, Figure 8 <ImgLink imgNo="8" imgType="figure"/>, Figure 9 <ImgLink imgNo="9" imgType="figure"/>). </Pgraph><Pgraph>If there is an intact suralis muscle, the expected muscular deficit regarding plantar flexion is remarkably small <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink> and there is little aesthetic defect involved with muscle flap plasty <TextLink reference="20"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Results"> <MainHeadline>Results</MainHeadline><Pgraph>We treated 23 patients between 8&#47;2004 and 3&#47;2011 with a gastrocnemius muscle flap. 16 patients were treated for stage 3 soft tissue damage and seven patients were treated for stage 4 soft tissue damage. Accordingly, 16 patients received one-headed muscle flaps and seven patients received two-headed muscle-flaps with split-skin grafts from the ipsilateral thigh. Out of 23 patients, eight patients had to undergo surgery once more. Dehiscence or necrosis at the split-skin graft occurred in three patients, and this required repeated split-skin grafts. One patient experienced dehiscence near the extraction point of the muscle which was successfully treated with split-skin graft after vac-therapy. Four patients experienced recurring infection of the prosthesis with development of a fistula and large soft tissue destruction which was successfully treated with elaborate surgical measures in one case. The extremity could not be saved in three cases, and this resulted in above-knee amputation.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>Due to the increasing number of implantation of knee endoprostheses and the associated number of soft tissue damages, a standardized procedure for the treatment of these complications is necessary. In the case of deep soft tissue damages with fistulas reaching the prosthesis or exposing the prosthesis, the gastrocnemius muscle flap is a good method for secure coverage of the prost<TextGroup><PlainText>hesi</PlainText></TextGroup>s with well-perfused tissue. Despite the high rate of complications of almost 35&#37; which required at least another surgery, the amputation of the extremity could be avoided for 87&#37; of the treated patients. This method of soft tissue reconstruction is a necessary skill for surgeons involved with the implantation of knee endoprostheses.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Bruner S</RefAuthor> <RefAuthor>Jester A</RefAuthor> <RefAuthor>Sauerbier M</RefAuthor> <RefAuthor>Germann G</RefAuthor> <RefTitle>Use of a cross-over fistula for simultaneus microsurgical tissue transfer and restoration of blood flow to the lower extremity</RefTitle> <RefYear>2004</RefYear> <RefJournal>Microsurgery</RefJournal> <RefPage>114-7</RefPage> <RefTotal>Bruner S, Jester A, Sauerbier M, Germann G. Use of a cross-over fistula for simultaneus microsurgical tissue transfer and restoration of blood flow to the lower extremity. Microsurgery. 2004;24(2):114-7. DOI: 10.1002&#47;micr.20005</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1002&#47;micr.20005</RefLink> </Reference> <Reference refNo="2"> <RefAuthor>Gerwin M</RefAuthor> <RefAuthor>Rothaus KO</RefAuthor> <RefAuthor>Windsor RE</RefAuthor> <RefAuthor>Brause BD</RefAuthor> <RefAuthor>Insall JN</RefAuthor> <RefTitle>Gastrocnemius muscle flap coverage of exposed or infected knee prothesis</RefTitle> <RefYear>1993</RefYear> <RefJournal>Clin Orthop Relat Res</RefJournal> <RefPage>64-70</RefPage> <RefTotal>Gerwin M, Rothaus KO, Windsor RE, Brause BD, Insall JN. Gastrocnemius muscle flap coverage of exposed or infected knee prothesis. Clin Orthop Relat Res. 1993;286:64-70.</RefTotal> </Reference> <Reference refNo="3"> <RefAuthor>Johnson DP</RefAuthor> <RefAuthor>Bannister GC</RefAuthor> <RefTitle>The outcome of infected arthroplasty of the knee</RefTitle> <RefYear>1986</RefYear> <RefJournal>J Bone Joint Surg Br</RefJournal> <RefPage>289-91</RefPage> <RefTotal>Johnson DP, Bannister GC. The outcome of infected arthroplasty of the knee. J Bone Joint Surg Br. 1986;68(2):289-91.</RefTotal> </Reference> <Reference refNo="4"> <RefAuthor>BARMER GEK</RefAuthor> <RefTitle></RefTitle> <RefYear>2010</RefYear> <RefBookTitle>3,5 Milliarden Euro f&#252;r neue Knie- und H&#252;ftgelenke. Report Krankenhaus</RefBookTitle> <RefPage></RefPage> <RefTotal>BARMER GEK. 3,5 Milliarden Euro f&#252;r neue Knie- und H&#252;ftgelenke. Report Krankenhaus. Berlin; Juli 2010.</RefTotal> </Reference> <Reference refNo="5"> <RefAuthor>K&#246;nig A</RefAuthor> <RefAuthor>Kirschner S</RefAuthor> <RefTitle>Langzeitergebnisse in der Knieendoprothetik.</RefTitle> <RefYear>2003</RefYear> <RefJournal>Orthop&#228;de</RefJournal> <RefPage>516-26</RefPage> <RefTotal>K&#246;nig A, Kirschner S. Langzeitergebnisse in der Knieendoprothetik &#91;Long-term results in total knee arthroplasty&#93;. Orthop&#228;de. 2003;32(6):516-26.</RefTotal> </Reference> <Reference refNo="6"> <RefAuthor>Erler K</RefAuthor> <RefAuthor>Neumann U</RefAuthor> <RefAuthor>Anders C</RefAuthor> <RefAuthor>Venbrocks RA</RefAuthor> <RefAuthor>Babisch J</RefAuthor> <RefAuthor>Pieper KS</RefAuthor> <RefAuthor>Scholle HC</RefAuthor> <RefAuthor>Br&#252;ckner L</RefAuthor> <RefTitle>Nachuntersuchungsergebnisse mittels EMG-Mapping &#8211; 5 Jahre nach Knieprothesenimplantation</RefTitle> <RefYear>2003</RefYear> <RefJournal>Z Ortop Ihre Grenzgeb</RefJournal> <RefPage>48-53</RefPage> <RefTotal>Erler K, Neumann U, Anders C, Venbrocks RA, Babisch J, Pieper KS, Scholle HC, Br&#252;ckner L. Nachuntersuchungsergebnisse mittels EMG-Mapping &#8211; 5 Jahre nach Knieprothesenimplantation &#91;5-Year Follow-up Study of Total Knee Arthroplasty by Means of EMG Mapping&#93;. Z Ortop Ihre Grenzgeb. 2003;141(1):48-53. DOI: 10.1055&#47;s-2003-37304</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1055&#47;s-2003-37304</RefLink> </Reference> <Reference refNo="7"> <RefAuthor>Johnson DP</RefAuthor> <RefTitle>The effect of continuous passive motion on woundhealing and joint mobility after knee arthroplasty</RefTitle> <RefYear>1990</RefYear> <RefJournal>J Bone Joint Surg Am</RefJournal> <RefPage>421-6</RefPage> <RefTotal>Johnson DP. The effect of continuous passive motion on woundhealing and joint mobility after knee arthroplasty. J Bone Joint Surg Am. 1990;72(3):421-6.</RefTotal> </Reference> <Reference refNo="8"> <RefAuthor>Casanova D</RefAuthor> <RefAuthor>Huard O</RefAuthor> <RefAuthor>Zalta R</RefAuthor> <RefAuthor>Bardot J</RefAuthor> <RefAuthor>Magalon G</RefAuthor> <RefTitle>Management of wounds of exposed or infected knee prostheses</RefTitle> <RefYear>2001</RefYear> <RefJournal>Scand J Plast Reconstr Surg Hand Surg</RefJournal> <RefPage>71-7</RefPage> <RefTotal>Casanova D, Huard O, Zalta R, Bardot J, Magalon G. Management of wounds of exposed or infected knee prostheses. Scand J Plast Reconstr Surg Hand Surg. 2001;35(1):71-7. DOI: 10.1080&#47;02844310151032637</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1080&#47;02844310151032637</RefLink> </Reference> <Reference refNo="9"> <RefAuthor>Nahabedian MY</RefAuthor> <RefAuthor>Orlando JC</RefAuthor> <RefAuthor>Delanois RE</RefAuthor> <RefAuthor>Mont MA</RefAuthor> <RefAuthor>Hungerford DS</RefAuthor> <RefTitle>Salvage procedures for complex soft tissue defects of the knee</RefTitle> <RefYear>1998</RefYear> <RefJournal>Clin Orthop Relat Res</RefJournal> <RefPage>119-24</RefPage> <RefTotal>Nahabedian MY, Orlando JC, Delanois RE, Mont MA, Hungerford DS. Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res. 1998;356:119-24. DOI: 10.1097&#47;00003086-199811000-00017</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1097&#47;00003086-199811000-00017</RefLink> </Reference> <Reference refNo="10"> <RefAuthor>Ries MD</RefAuthor> <RefTitle>Skin nerosis after total knee arthroplasty</RefTitle> <RefYear>2002</RefYear> <RefJournal>J Arthroplasty</RefJournal> <RefPage>75-7</RefPage> <RefTotal>Ries MD. Skin nerosis after total knee arthroplasty. J Arthroplasty. 2002;17(4 Suppl 1):75-7. DOI: 10.1054&#47;arth.2002.32452</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1054&#47;arth.2002.32452</RefLink> </Reference> <Reference refNo="11"> <RefAuthor>Laing JH</RefAuthor> <RefAuthor>Hancock K</RefAuthor> <RefAuthor>Harrison DH</RefAuthor> <RefTitle>The exposed total knee replacement prosthesis: a new classification and treatment algorithm</RefTitle> <RefYear>1992</RefYear> <RefJournal>Br J Plast Surg</RefJournal> <RefPage>66-9</RefPage> <RefTotal>Laing JH, Hancock K, Harrison DH. The exposed total knee replacement prosthesis: a new classification and treatment algorithm. Br J Plast Surg. 1992;45(1):66-9. DOI: 10.1016&#47;0007-1226(92)90120-M</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1016&#47;0007-1226(92)90120-M</RefLink> </Reference> <Reference refNo="12"> <RefAuthor>Hallock GG</RefAuthor> <RefTitle>Salvage of total knee arthroplasty with local fasciocutaneous flaps</RefTitle> <RefYear>1990</RefYear> <RefJournal>J Bone Joint Surg Am</RefJournal> <RefPage>1236-9</RefPage> <RefTotal>Hallock GG. Salvage of total knee arthroplasty with local fasciocutaneous flaps. J Bone Joint Surg Am. 1990;72(8):1236-9.</RefTotal> </Reference> <Reference refNo="13"> <RefAuthor>Mathes SJ</RefAuthor> <RefAuthor>Alpert BS</RefAuthor> <RefAuthor>Chang N</RefAuthor> <RefTitle>Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlations</RefTitle> <RefYear>1982</RefYear> <RefJournal>Plast Reconstr Surg</RefJournal> <RefPage>815-29</RefPage> <RefTotal>Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlations. Plast Reconstr Surg. 1982;69(5):815-29. DOI: 10.1097&#47;00006534-198205000-00018</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1097&#47;00006534-198205000-00018</RefLink> </Reference> <Reference refNo="14"> <RefAuthor>Barfod B</RefAuthor> <RefAuthor>Pers M</RefAuthor> <RefTitle>Gastrocnemius plasty for primary closure of compound injuries of the knee</RefTitle> <RefYear>1970</RefYear> <RefJournal>J Bone Joint Surg</RefJournal> <RefPage>124-7</RefPage> <RefTotal>Barfod B, Pers M. Gastrocnemius plasty for primary closure of compound injuries of the knee. J Bone Joint Surg. 1970;52(1):124-7.</RefTotal> </Reference> <Reference refNo="15"> <RefAuthor>Ger R</RefAuthor> <RefTitle>The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg</RefTitle> <RefYear>1971</RefYear> <RefJournal>J Trauma</RefJournal> <RefPage>502-11</RefPage> <RefTotal>Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions of the leg. J Trauma. 1971;11(6):502-11. DOI: 10.1097&#47;00005373-197106000-00007</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1097&#47;00005373-197106000-00007</RefLink> </Reference> <Reference refNo="16"> <RefAuthor>McCraw JB</RefAuthor> <RefAuthor>Dibbel DG</RefAuthor> <RefAuthor>Carraway JH</RefAuthor> <RefTitle>Clinical definition of independent myocutaneous vascular territories</RefTitle> <RefYear>1977</RefYear> <RefJournal>Plast Reconstr Surg</RefJournal> <RefPage>341-52</RefPage> <RefTotal>McCraw JB, Dibbel DG, Carraway JH. Clinical definition of independent myocutaneous vascular territories. Plast Reconstr Surg. 1977;60(3):341-52.</RefTotal> </Reference> <Reference refNo="17"> <RefAuthor>Li Z</RefAuthor> <RefAuthor>Liu K</RefAuthor> <RefAuthor>Lin Y</RefAuthor> <RefAuthor>Li L</RefAuthor> <RefTitle>Lateral sural cutaneous artery island flap in the treatment of soft tissue defects at the knee</RefTitle> <RefYear>1990</RefYear> <RefJournal>Br J Plast Surg</RefJournal> <RefPage>546-50</RefPage> <RefTotal>Li Z, Liu K, Lin Y, Li L. Lateral sural cutaneous artery island flap in the treatment of soft tissue defects at the knee. Br J Plast Surg. 1990;43(5):546-50. DOI: 10.1016&#47;0007-1226(90)90118-J</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.1016&#47;0007-1226(90)90118-J</RefLink> </Reference> <Reference refNo="18"> <RefAuthor>Markhede G</RefAuthor> <RefAuthor>Nistor L</RefAuthor> <RefTitle>Strength of plantar flexion and function after resection of various parts of the triceps surae muscle</RefTitle> <RefYear>1979</RefYear> <RefJournal>Acta Orthop Scand</RefJournal> <RefPage>693-7</RefPage> <RefTotal>Markhede G, Nistor L. Strength of plantar flexion and function after resection of various parts of the triceps surae muscle. Acta Orthop Scand. 1979;50(6):693-7. DOI: 10.3109&#47;17453677908991295</RefTotal> <RefLink>http:&#47;&#47;dx.doi.org&#47;10.3109&#47;17453677908991295</RefLink> </Reference> <Reference refNo="19"> <RefAuthor>Murray MP</RefAuthor> <RefAuthor>Guten GN</RefAuthor> <RefAuthor>Sepic SB</RefAuthor> <RefAuthor></RefAuthor> <RefTitle>Function of the triceps surae during gait; compensatory mechanism for unilateral los</RefTitle> <RefYear>1978</RefYear> <RefJournal>J Bone Joint Surg Am</RefJournal> <RefPage>473-6</RefPage> <RefTotal>Murray MP, Guten GN, Sepic SB, et al. Function of the triceps surae during gait; compensatory mechanism for unilateral los. J Bone Joint Surg Am. 1978;60(4):473-6.</RefTotal> </Reference> <Reference refNo="20"> <RefAuthor>Mathes SJ</RefAuthor> <RefAuthor>Nahai F</RefAuthor> <RefTitle></RefTitle> <RefYear>1997</RefYear> <RefBookTitle>Reconstructive Surgery: Principles, Anatomy and Technique</RefBookTitle> <RefPage></RefPage> <RefTotal>Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy and Technique. London&#47;New York: Churchill Livingstone; 1997.</RefTotal> </Reference> </References> <Media> <Tables> <NoOfTables>0</NoOfTables> </Tables> <Figures> <Figure format="png" height="344" width="581"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Stage 3 soft tissue damage according to Laing</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="347" width="568"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: Prepared medial head of the gastrocnemius muscle</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="373" width="564"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Figure 3: Inserted gastrocnemius</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="420" width="564"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Figure 4: About three months after surgery</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="436" width="565"> <MediaNo>5</MediaNo> <MediaID>5</MediaID> <Caption><Pgraph><Mark1>Figure 5: Stage 4 soft tissue damaged according to Laing</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="568" width="331"> <MediaNo>6</MediaNo> <MediaID>6</MediaID> <Caption><Pgraph><Mark1>Figure 6: After preparation of both muscle heads</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="329" width="562"> <MediaNo>7</MediaNo> <MediaID>7</MediaID> <Caption><Pgraph><Mark1>Figure 7: After both muscle heads were pulled through</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="394" width="566"> <MediaNo>8</MediaNo> <MediaID>8</MediaID> <Caption><Pgraph><Mark1>Figure 8: After fixation of both muscle heads</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="421" width="562"> <MediaNo>9</MediaNo> <MediaID>9</MediaID> <Caption><Pgraph><Mark1>Figure 9: After split-skin graft on the gastrocnemius flap plasty</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>9</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>