DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Open mid tibial fracture of left lower extremity with soft tissue defect and exposed bone.
POSTOPERATIVE DIAGNOSIS: Open mid tibial fracture of left lower extremity with soft tissue defect and exposed bone.
OPERATION PERFORMED: Delayed reconstruction of open left mid tibial fracture with soleus muscle flap and application of split thickness skin graft to 50 sq cm.
SURGEON: John Doe, MD
ANESTHESIA: General with epidural catheter placement.
ESTIMATED BLOOD LOSS: 125 mL.
OPERATIVE FINDINGS: A soleus muscle flap was raised via medial approach. The patient was noted to have a previous split thickness skin graft to the medial mid tibia. This was joined with the donor site incision, and the distal two to three muscular perforators at the posterior tibia were ligated. A muscular perforator at the mid tibia was preserved as were of proximal branches of the posterior tibial and popliteal arteries as well as peroneal. A full muscle harvest was accomplished and preservation of the gastroc muscle bellies and Achilles tendon was noted. A drain was placed in the donor site and brought out through a separate stab incision in the distal posteromedial ankle.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating table following placement of an epidural catheter and induction of general anesthesia. The left lower extremity was prepped and draped in a standard surgical fashion. An incision, approximately 2 cm medial to the medial border of the tibia, was then made and joined with the pre-existing split thickness skin graft site on the medial mid tibia. The incision was carried down through the skin and subcutaneous tissue to the level of fascia, which was incised. The medial gastrocnemius muscle belly was identified and elevated off the soleus. The soleus was then elevated off the medial tibial border. Underlying this, the posterior tibial artery, vein, and nerve were identified as were muscular branches from these to the distal third of the soleus. These were ligated between hemoclips and divided.
Great care was made in elevating the distal gastrocnemius muscle belly and Achilles tendon off the soleus. The distal soleus insertion was then divided under direct vision and dissection carried out from a distal to proximal direction. Along the way, as was mentioned, muscular perforators of the distal posterior tibia to the soleus were divided between hemoclips at the mid tibia. An additional perforator was identified and preserved, and this was the point of our rotation.
Also, along the way, the sural nerve was identified and also preserved. The defect was then inspected prior to placement of our incision. The wound bed was curetted with a bony curette, and a bone biopsy was obtained at the fracture site with the use of bony curette. These were sent to microbiology and pathology to rule out an osteomyelitis. Additional tissue cultures were sent of the wound margin and sent to microbiology for Gram stain culture and sensitivity. The wound bed itself was then irrigated with 2 liters of antibiotic solution of polymyxin and bacitracin.
At this point, the patient was given a dose of IV Ancef, and following appropriate period of time, the left lower extremity was exsanguinated with the use of an Esmarch bandage, and a tourniquet was insufflated to 250 mmHg. Total ischemia time for elevation of the flap was 100 minutes. The flap was successfully rotated. The tourniquet was then taken down and the donor site inspected for hemostasis achieved with use of Bovie cautery. A #15 round Blake drain was placed in a subgastroc pocket and brought out through a separate stab incision in the distal posterior medial ankle. This drain was then secured with a 4-0 nylon suture. The donor site was then reapproximated with interrupted 3-0 Vicryl at the level of the fascia followed by interrupted 0 Vicryl in the deep dermis and a running subcuticular suture of 4-0 Monocryl.
The intervening skin bridge between the anterior mid tibial defect and the donor site was then joined with incision to allow our muscle flap to be inset without undue tension. There was more than adequate reach to the lateral tibia and complete coverage of our bony defect. Inset was then accomplished with 3-0 mattress sutures pledgeted with Xeroform. The muscle belly upon inset appeared to be bright red with no evidence of venous congestion. A split thickness skin graft measuring 1/1200th of an inch was then harvested from the left anterolateral thigh and meshed in a 1:1.5 ratio. The skin graft was then inset with a running suture of 4-0 chromic. A Xeroform bacitracin dressing was then applied. The patient was placed in a knee immobilizer with a window through the mid tibial defect and soleus flap. He was successfully extubated and brought to the recovery room in stable condition.
PLAN: The patient is to be admitted for strict bed rest, IV hydration, pain management, and appropriate antibiotic therapy.
