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CASE REPORT Table of Contents  
Ahead of print publication
Intraosseous muscle transfer: Pseudotumour of the knee

1 Department of Radiology, Kettering General Hospital, Kettering, UK
2 Department of Musculoskeletal Imaging, Royal Orthopaedic Hospital, Birmingham, UK

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Date of Submission22-Feb-2020
Date of Decision26-Apr-2020
Date of Acceptance03-May-2020


Muscle transfers and flaps to cover defects have been used in orthopaedics for over a century. We present a case of a 49-year-old female who had surgery many years ago and was referred as a presumed tumour.

Keywords: Knee, muscle, transfer

How to cite this URL:
Thaker S, Azzopardi C, Almeer G, Davies A M, Botchu R. Intraosseous muscle transfer: Pseudotumour of the knee. Hamdan Med J [Epub ahead of print] [cited 2020 Sep 25]. Available from: http://www.hamdanjournal.org/preprintarticle.asp?id=289738

  Introduction Top

Muscle transfers and flaps are used to cover defects due to various pathologies, especially around the knee, for about a century.[1],[2],[3] We present a case of 49-year-old female who had surgery many years ago and was referred as a presumed tumour.

  Case Report Top

A 49-year-old female presented with a 3-month history of non-specific left posterior knee pain. She has had some surgical intervention 14 years ago in abroad. The patient, unfortunately, was unable to give us details of her previous surgery. She, however, described a traumatic event leading to surgery. She had an X-ray that demonstrated a well-defined geographic lesion with sclerotic margins involving the left posterolateral aspect of the proximal tibia [Figure 1]. There was no associated periosteal reaction. Proximal tibiofibular articulation was intact. Overall, the appearance is of a non-aggressive proximal tibial lesion. She had a magnetic resonance imaging (MRI) to evaluate this further. Corresponding to radiographic lytic bony lesion within the lateral aspect of the proximal tibia, The MRI signal of the lesion was isointense to muscle on all sequences [Figure 2], [Figure 3], [Figure 4]. There was no bone marrow oedema or periosteal reaction. Axial and sagittal [Figure 3] images depict lateral gastrocnemius invaginating into the proximal tibial defect with myofibrillar pattern confirmed on T1-weighted [Figure 4] and T2 fat-suppressed [Figure 4]b coronal image. The appearance was typical of a pedicled lateral gastrocnemius transposition flap. There was no lateral gastrocnemius oedema or collection. The graft was healthy without any local complications. She was managed symptomatically.
Figure 1: Anteroposterior (a) and lateral (b) knee radiographs demonstrating well-defined, sclerotic marginated lesion in the lateral proximal tibia. No overt sinister or neoplastic feature or significant osteoarthritis

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Figure 2: Axial STIR (a) and graphical (b) representation showing pedicled lateral gastrocnemius muscle into proximal tibial defect. No oedema in transposed muscle flap or surrounding bone or soft tissue

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Figure 3: Sagittal STIR (a) and graphical (b) representation illustrating pedicled lateral gastrocnemius muscle into proximal tibial defect

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Figure 4: T1-weighted (a) and T2 fat-suppressed (b) coronal images demonstrating sclerotic marginated proximal lateral tibial defect without sinister bony features

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  Discussion Top

The concept of using local muscle flap to cover the lower extremity defects is about a century old. In the 1970s, Barfod and Pers[4] had successfully demonstrated the use of rotating pedicled gastrocnemius muscle flap to cover the defects around the knee.[4] Since then, it is used to cover defects around the knee, popliteal fossa, distal thigh, and proximal tibia because of its reliable blood supply, its ability to be easily surgically harvested, low recipient site complications and rare donor site morbidity.[5]

A gastrocnemius muscle transfer is a relatively simple surgical procedure and has proven invaluable in the patient management of large osseous defects. In addition, gastrocnemius transposition flaps do not jeopardise local neoplasm control when used as a part of limb salvage procedures for primary bone tumour around the knee.[6] Even though various pedicled muscle flaps are used by plastic surgeons and orthopaedics worldwide, imaging literature of them is surprisingly scarce.

Post-operatively, it is a standard radiology practice to obtain plain radiographs of the knee providing cost-effective primary imaging with a scant ionising radiation to the site. Radiographs help excluding fractures, arthritis, tumour recurrence and other joint-related pathologies and further triage and assess need of an MRI. MRI essentially acts as a problem-solving tool when presented with unreliable surgical history, as in this case, differentiating between possible sinister pathology such as osteomyelitis, low-grade site-specific neoplasms such as aneurysm bone cyst, giant cell tumour or aggressive bony neoplasms such as sarcoma.[7],[8] MRI is particularly helpful when a radiologist is posed with the dilemma of tumour recurrence and whether to biopsy the lesion or not. Understanding the appearances of transposition muscle flap can aid in clinching the diagnosis and avoid invasive management even with inconclusive surgical history.

In addition to differentiating appearances of the muscle flaps from more sinister bony neoplasms, complications following gastrocnemius transposition muscle graft can also be detected, clinically, in most cases; however, imaging may assist in confirming suspected complications. Specific gastrocnemius muscle flap-related complications include peroneal nerve palsy, gastrocnemius muscle oedema due to obstructed venous and lymphatic backflow, flap necrosis and residual and recurrent infection with or without fistula formation.[9]

In conclusion, the use of gastrocnemius muscle transposition flap in the lower limb reconstruction is occasionally performed. Therefore, the musculoskeletal radiologist should remain aware of its healthy and abnormal appearances. The paucity of clinical information in this case highlights the important role of the radiologist in identifying a non-touch lesion and thus avoiding any invasive procedures. The radiologist should therefore be aware of the radiological appearances of this type of surgery.

Informed consent was obtained from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zeis M. Progress in the therapy of open injuries of the knee joint. Zentralbl Chir 1960;85:1202-14.  Back to cited text no. 1
Stark WJ. The use of pedicled muscle flaps in the surgical treatment of chronic osteomyelitis resulting from compound fractures. J Bone Joint Surg Am 1946;28:343-50.  Back to cited text no. 2
Schulten MW. A method of muscle grafting femur via plastic surgery in females. Zentralbl Chir 1897;20:566-70. (original article in Swedish).  Back to cited text no. 3
Barfod B, Pers M. Gastrocnemius-plasty for primary closure of compound injuries of the knee. J Bone Joint Surg Br 1970;52:124-7.  Back to cited text no. 4
Feldman JJ, Cohen BE, May JW Jr. The medial gastrocnemius myocutaneous flap. Plast Reconstr Surg 1978;61:531-9.  Back to cited text no. 5
Malawer MM, Price WM. Gastrocnemius transposition flap in conjunction with limb-sparing surgery for primary bone sarcomas around the knee. Plast Reconstr Surg 1984;73:741-50.  Back to cited text no. 6
Stacy GS, Heck RK, Peabody TD, Dixon LB. Neoplastic and tumorlike lesions detected on MR imaging of the knee in patients with suspected internal derangement: Part I, intraosseous entities. AJR Am J Roentgenol 2002;178:589-94.  Back to cited text no. 7
Stacy GS, Heck RK, Peabody TD, Dixon LB. Neoplastic and tumorlike lesions detected on MR imaging of the knee in patients with suspected internal derangement: Part 2, articular and juxtaarticular entities. AJR Am J Roentgenol 2002;178:595-9.  Back to cited text no. 8
Daigeler A, Drücke D, Tatar K, Homann HH, Goertz O, Tilkorn D, et al. The pedicled gastrocnemius muscle flap: A review of 218 cases. Plast Reconstr Surg 2009;123:250-7.  Back to cited text no. 9

Correspondence Address:
Rajesh Botchu,
Department of Musculoskeletal Radiology, The Royal Orthopedic Hospital, Bristol Road South, Northfield, Birmingham
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HMJ.HMJ_21_20


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


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