Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 9-11

Leg ulcer in postgastrocnemius flap patient: A case report


1 Department of Surgery, Federal Teaching Hospital, Ido-Ekiti, Nigeria
2 Department of Plastic Surgery, National Orthopaedic Hospital, Enugu, Nigeria

Date of Web Publication10-Aug-2018

Correspondence Address:
Dr. Yusuf O Abdullahi
C/o Surgery Department, Federal Teaching Hospital, Ido-Ekiti
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_10_17

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  Abstract 

Leg ulcer is a common cause of morbidity and source of social and economic distress, especially among the young and middle aged people. It often results from or associated with venous insufficiency, for which a number of theories have been implicated. Limb elevation and compression bandaging have thus become cornerstones in the management of most leg ulcers. We report a case of a 50-year-old man with leg ulcer and a previous history of ipsilateral gastrocnemius flap. We propose the hypothesis of muscle pump failure as a cause of the leg ulcer.

Keywords: Gastrocnemius flap, leg ulcer, muscle pump


How to cite this article:
Abdullahi YO, Onah II. Leg ulcer in postgastrocnemius flap patient: A case report. Nigerian J Plast Surg 2018;14:9-11

How to cite this URL:
Abdullahi YO, Onah II. Leg ulcer in postgastrocnemius flap patient: A case report. Nigerian J Plast Surg [serial online] 2018 [cited 2018 Oct 16];14:9-11. Available from: http://www.njps.org/text.asp?2018/14/1/9/238816


  Introduction Top


Chronic leg ulcer affects between 1.9% and 3.1% of the population.[1],[2] It may results from a number of causes. Chronic venous insufficiency is the most common etiology, accounting for about 60% of leg ulcers in one study.[3] Over 70% of these patients have impaired calf muscle pump.[4] Loss of calf muscle bulk resulting from atrophy is suspected to lead to decrease venous return and consequent chronic venous insufficiency.[5] Here, we present a case of a patient who developed leg ulcer 11 years following both heads gastrocnemius muscle flap of the ipsilateral leg. We consider that this patient may provide a basis for an association between venous leg ulcer and previous gastrocnemius muscle flap.


  Case history Top


Mr. E.R. was a 50-year-old trader who first presented to the National Orthopaedic Hospital Enugu (NOHE) in April 2005 with wound, swelling, and deformity of the proximal right leg and inability to bear weight with the leg following a gunshot injury, 24 h to presentation. There was associated bleeding, no dizziness nor loss of consciousness. No injury to other parts of the body. A diagnosis of open right proximal tibiofibular fracture secondary to gunshot injury was made after a detailed clinical examination. Distal neurovascular status was normal.

He was worked up for surgery. X-ray of the right leg which showed right tibia-plateau fracture. Wound biopsy and microcopy culture and sensitivity; complete blood count; electrolyte urea and creatinine; and urinalysis results were essentially normal. He had initial serial wound debridement and subsequent flap cover with both heads of gastrocnemius muscle and immediate split thickness skin grafting. Intraoperative findings of an open proximal tibia fracture with soft tissue defect of 8 × 6 × 6 cm on the anteriomedial aspect of proximal third of the right leg [Figure 1]. Size of dead space obviates the use of single-head gastrocnemius flap. Surgical approach was via a posterior leg lazy “S” incision. Both heads of gastrocnemius muscle were detached from the Achilles tendon and transposed through subcutaneous tunnels to fill the defect. Donor site was closed directly and harvested split thickness skin graft was laid on the muscle flaps [Figure 2]. He had good flap survival and graft take [Figure 3], and was subsequently discharged.
Figure 1: Proximal right leg wound

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Figure 2: Both heads gastrocnemius flap inset

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Figure 3: Healed proximal right leg wound post gastrocnemius flap

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A period of 11 years later, patient re-presented with a 7-month history of right leg ulcer which followed a ruptured blister and was progressively increasing in size. There was prior history of right leg swelling and itching. A 10 × 12-cm ulcer at distal third of medial leg with sloppy edge and unhealthy granulation tissue in its floor was found on examination. Surrounding skin was hyperpigmented with pedal edema up to the shin [[Figure 4] and [Figure 5]]. No clinical feature is suggestive of venous incompetence. Right lower limb Doppler ultrasound confirmed competent leg veins. Other investigations were essentially normal. A diagnosis of chronic leg ulcer secondary to suspected muscle pump failure due to prior gastrocnemius flap was made.
Figure 4: Distal right leg ulcer

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Figure 5: Right leg proximal scar and a distal ulcer

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Patient was commenced on a weekly multilayered compression bandaging, with a contact layer of povidone-iodine gauze dressing. He also had analgesics, vitamin A, C and E. He had sustained decrease in wound size and marked wound bed improvement [Figure 6]. Residual wound was subsequently grafted with split thickness skin graft, and take was 100%. Patient is presently on follow-up with compression stockings.
Figure 6: Residual right leg ulcer post serial compression therapy

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  Discussion Top


The use of both heads of gastrocnemius muscle in reconstruction of proximal leg defect is uncommon. Salibian and Anzel[6] reported the use of both heads of gastrocnemius flap in 1983 in salvage of an infected total knee prosthesis also Mamloukakis et al.[7] use both heads of gastrocnemius muscle flap for coverage of an expose upper third of the tibia. However, there is no documentation of a leg ulcer as a sequela of gastrocnemius muscle flap.

Normal venous circulation depends on a normal central pump (the heart), a venous pressure gradient, a normal calf muscle pump, and normal vein structures with intact valves. The contraction of the gastrocnemius and soleus muscle expel more than 60% of venous blood into the popliteal vein. Araki et al.[8] demonstrated the significance of a failing calf pump in patients with venous insufficiency progressing to ulceration.

Venous hypertension triggers a number of microcirculatory events which result in leg ulcer and other skin manifestations seen in chronic venous insufficiency of the lower limbs. Patient presents usually with heaviness in the legs; swelling; mild pain relieved by elevation; ulcer located commonly at the “gaiter” region; stasis dermatitis; and lipodermatosclerosis.

Compression therapy is the cornerstone of venous leg ulcer treatment and has been demonstrated to improve healing rates in patients with existing ulcers. The aim is to achieve healing by improving venous return and tissue edema.[9] The two main principles underpinning how compression therapy works are (1) creation of an enclosed system that allows internal pressures to be evenly distributed in the leg; (2) variation of interface pressures according to limb shape and tension of bandage applied. Healing rate of ulcer depends on the ulcer size. Patient with calf muscle pump failure should be maintained on lifelong compression hosiery thereafter.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lees TA, Lamber D. Prevalence of lower limb ulceration in an urban health district. Br J Surg 1992;79:1032-4.  Back to cited text no. 1
    
2.
Barclay KL, Granby T, Elton PJ. The prevalence of leg ulcers in hospitals. Hosp Med 1998;59:850.  Back to cited text no. 2
    
3.
Baker SR, Stacey MC, Jopp-Mckay AG, Hoskin SE, Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg 1991;78:864-7.  Back to cited text no. 3
    
4.
Kan M, Delis K. Haemodynamic effect of supervised calf muscle exercise in patient with venous leg ulceration: A prospective controlled study. Arch Surg 2001;136:1364-9.  Back to cited text no. 4
    
5.
Broderick BJ, Dessus S, Grace PA, Olaighin G. Technique for the computation of lower leg muscle bulk from magnetic resonance images. Med Eng Phys 2010;32:926-33.  Back to cited text no. 5
    
6.
Salibian AH, Anzel SH. Salvage of an infected total knee prosthesis with medial and lateral gastrocnemius muscle flaps. A case report. J Bone Joint Surg Am 1983;65:681-4.  Back to cited text no. 6
    
7.
Mamloukakis SC, Assimomitis CM, Tsetsonis CH, Strianos SD, Kokkalis GA. Gastrocnemius muscle flap of both heads on single vascular pedicle. Scand J Plast Reconstr Surg Hand Surg 2006;40:120-3.  Back to cited text no. 7
    
8.
Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC et al. The significance of calf muscle pump function in venous ulceration. J Vasc Surg 1994;20:872-9.  Back to cited text no. 8
    
9.
Kramer SA. Compression wraps for venous ulcer healing: A review. J Vasc Nurs 1999;17:89-97.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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