B.

C, D. Left: The nerve to the gracilis is dissected proximally for several centimeters and the vascular pedicle tied deep to the adductor longus. Additional length can be obtained by ligating multiple muscular branches. Right: The separate and mobilized muscle with the tied minor pedicles and the long major pedicle and proximal nerve.

PLATE XVIII-3

A. A long, unstable, chronically draining wound extends from the tibial tubercle to the medial aspect of the ankle.

B. The gracilis muscle is oriented in an upside-down fashion, with the vascular pedicle coming off the superficial medial side of the muscle.

C. The scar tissue and underlying chronically infected bone have been removed, creating a long fusiform defect into which the muscle will be inserted.

D. The gracilis muscle has been placed in the incisional defect and covered with a split-thickness skin graft. The artery from the gracilis has been repaired in an end-to-side fashion to the posterior tibial vessels and the vein in the end-to-end manner with one of the venae comitantes. The superficial saphenous system could also be used to drain the muscle.

Clinical Cases

CASE 1

A 61-year-old mechanic had suffered from a draining sinus tract from osteomyelitis for 18 years.

FIG. 18-01. Draining sinus tract on leg.

FIG. 18-02. The gracilis donor site is outlined on the contralateral thigh, with the main medial circumflex arterial pedicle entering medially into the proximal muscle.

FIG. 18-03. Through a longitudinal incision, the muscle is harvested from distal to proximal. The muscle is retracted posteriorly.

FIG. 18-04. Muscle is elevated to isolate major proximal pedicle.

FIG. 18-05. Accessory pedicles to the distal muscle must be ligated.

FIG. 18-06. The debrided recipient site and the isolated gracilis transplant.

FIG. 18-07. The donor defect can be easily closed with minimal morbidity.

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