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REVERSED SURAL NEUROVASCULAR FASCIO-CUTANEOUS FLAP FOR RECONSTRUCTION OF SOFT-TISSUE DEFECTS IN ANKLE AND FOOT

Objective To evaluate clinical significance of reversed sural neurovascular fasciocutaneous flap for reconstruction of softtissue defects in ankle and foot. Methods From July 1994 to December 2002, 52 cases of soft-tissuedefects in the ankle and foot were reconstructed by use of reversed sural neurovascular fascio-cutaneous flap, including 47 cases of traumatic defects, 3 cases of chronic ulcer and 2 cases of tumors. The flap area ranged from 4 cm×6 cm to 10 cm×21 cm. Results The flaps survived in 48 cases; the distal part necrosed and secondary free-skin graft were further conducted in 4 cases. All soft-tissue defects were repaired and their accompanied bone and tendon exposurehealed. Forty-six cases were followed-up for 5 months to 48 months, the color and texture of the flaps were excellent and 2point discrimination was 11-17 mm(14 mm on average).The functions of ankle joints were good.Conclusion The reversedsural neurovascular fascio-cutaneous flap is convenient in design and dissection. Its use can retained and replace vascular anostomosed flaps to certain degrees.

腓腸神經營養血管皮瓣修復足踝部軟組織缺損

總結腓腸神經營養血管皮瓣修復足、踝部軟組織缺損的臨床效果。 方法 2003 年3 月－2006 年7 月，應用腓腸神經營養血管皮瓣修復足、踝部軟組織缺損18 例，其中男10 例，女8 例；年齡6 ～ 52 歲。皮帶、車鏈絞傷15 例，砸傷3 例。合并踝關節、跗骨、跖骨骨折脫位5 例，跟踺缺損2 例，感染5 例。軟組織缺損8 cm ×6 cm ～ 17 cm× 8 cm。行急診手術8 例；擇期手術10 例。同時行關節和骨折內固定5 例，置管持續沖洗2 例，跟腱修復2 例。 結果 18 例皮瓣均成活。15 例傷口Ⅰ期愈合；1 例皮瓣邊緣表層壞死，經換藥、植皮后愈合；2 例傷口感染，換藥后愈合。患者獲隨訪8 個月～ 3 年，皮瓣外形、色澤、質地良好，踝關節功能滿意。背屈18 ～ 20°，跖屈30 ～ 35°。 結 論 腓腸神經營養血管皮瓣血運良好，操作簡便、安全，可有效修復足、踝部軟組織缺損。

內踝上皮支皮瓣修復足踝部皮膚軟組織缺損

REPAIR OF DEEP WOUNDS OF THE FOOT AND ANKLE

Objective To summarize the clinical effects of the repairing methods for deep wounds of the foot and ankle. Methods From March 2002 to June 2006, 49 patients with skin and deep tissue defects of the foot and ankle underwent the repairing treatment. Of them, 36 were males and 13 were females, aged 16 to 67 years( 39 years on average). The causes of injuries included mangled injury in 24 cases, high fall injury in 9 cases, cut injury in 7 cases, malignant soft tissue tumor in 5 cases, decubital ulcer in 2 cases, and electric burn in 2 cases. Of the 49 cases, 19 were in left side and 30 in right side. The defect size of skin ranged from 3 cm×2 cm to 20 cm×15 cm and deep tissue injuries were accompanied by defects of tendon and ligament in 24 cases, by damage of joint in 12 cases, and by bone defect in 9 cases, and 35 of them had infections, and 2 of them had diabetes of stage 2. The time between the injury and surgery ranged from 4 hours to 1 year.The wounds were repaired separately by local flap(3 cm×3 cm to 6 cm×4 cm) in 15 cases, local island flap(8 cm×5 cm to 12 cm×7 cm) in 25 cases, free flap(15 cm×11 cm to 24 cm×17 cm) in 4 cases, and cross leg flap(5 cm×4 cm to 8 cm×6 cm) in 5 cases. In 24 cases of defects of tendon and ligament, 15 underwent the reconstruction in one-stage operations,9 in two-satge operation.In 9 cases accompanied by bone defect, twostage bone grafting (12-64 g) was given after wound healed. Results All of the 49 flaps survived. Fortysix healed by the first intention and 3 with distal edge necrosis healed after skin grafting. Two patients with sinus formation healed after 68 months of dressing change. All the cases were followed up 6 months to 3 years, and all the flaps were well developed, the functions of the foot and ankle were satisfactory. Conclusion It can get an excellent result of appearance and function recovery repairing deep wounds of the foot and ankle with proper flaps in earlier time.

FREE VASCULARIZED POPLITEAL ARTERY CUTANEOUS BRANCH FLAP FOR REPAIR OF WOUND ON FOOT AND ANKLE

ObjectiveTo investigate the feasibility and effectiveness of free popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle by anatomical observation and clinical application. MethodsLatex was poured into the blood vessels of 8 cadavers, then perforator vessel of posterolateral upper calf was dissected, and the popliteal artery cutaneous branch flap was designed with a pedicle of 2.5 cm in length; the lateral tarsal artery of the foot was dissected, could be freed to 6 cm in length; the diameter of these vessels was measured, and the number of the accompanying veins was counted. Between March 2010 and January 2013, 13 cases of foot and ankle wounds were repaired with popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein. The size of flaps ranged from 6.0 cm×4.0 cm to 7.5 cm×5.5 cm. There were 11 males and 2 females, aged from 41 to 65 years (mean, 47.3 years). The causes of injury included traffic accident in 8 cases, crushing in 4 cases, and twist by machine in 1 case. The size of wounds, ranged from 5.0 cm×3.5 cm to 7.0 cm×5.0 cm. The donor sites were sutured directly. ResultsAccording to anatomical observation, the popliteal artery cutaneous branch flap was designed by using the lateral popliteal artery perforator for shaft. The vessel of the pedicle perforator flaps from the popliteal artery cutaneous branch flap matched well with the lateral tarsal artery. Clinical results: vascular crisis occurred in 2 flaps, which survived after symptomatic treatment; the other flaps survived, with primary healing of wound and incision at donor site. The patients were all followed up 5-18 months (mean, 11 months). The flap had normal color and good elasticity. Second stage operation was performed to make the flap thinner in 3 female patients because of bulky flaps. The remaining patients had no obvious fat flap. According to American Orthopaedic Foot and Ankle Society (AOFAS) score for evaluation of the ankle function at 6 months after operation, the results were excellent in 7 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 92.3%. ConclusionFree popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle is simple and effective. The donor site is hidden.

REPAIR OF SMALL AND MEDIUM-SIZED SOFT TISSUE DEFECT IN ANKLE WITH SURAL NEUROCUTANEOUSVASCULAR FLAP PEDICLED ON MAIN PERFORATING BRANCH OF PERONEAL ARTERY

Objective To investigate the operative techniques and cl inical results of sural neurocutaneous vascular flap pedicled on the relatively higher and main perforating branch of peroneal artery in repairing small and medium-sized soft tissue defects in ankle. Methods From July 2004 to February 2007, 14 patients (9 males and 5 females, aged 19-53 years) withsmall and medium-sized soft tissue defects in ankle were treated, including 4 cases of skin necrosis caused by surgery for achilles tendon rupture, 3 soft tissue defects due to car accident, 2 crush injury due to fall ing heavy objects, 2 chronical infectious ulcer, 2 skin necrosis cuased by surgery for calcaneus fracture and 1 melanoma resection in heel. Ranging from 4 cm × 2 cm to 9 cm × 5 cm and combing with exposure of either tendon or bone, the defects were in ankle areas (12 cases) and weight-bearing heel (2 cases). The time from injury to hospital ization was 12 days to 13 months, except 3 cases of emergency hospital ization. After thorough debridement, the sural neurocutaneous vascular flaps (13 cm × 5 cm - 36 cm × 6 cm ) pedicled on the perforating branch of peroneal artery was harvested to repair the defects. The donor sites were sutured directly. Results Postoperatively all the flaps survived, and all the donor sites and wounds healed by first intention. Over a 7-23 month follow-up period, the texture, appearance and color of the flaps in all cases were good, with two-point discrimination of 7-12 mm.The function of ankle obtained satisfactory recovery with normal in-shoe gait. Conclusion With a rel iable blood supply, simple operative procedure, sound repair of wound and satisfactory recovery of l imb function, the sural neurocutaneous vascular flap pedicled on the relatively higher and main perforating branch of peroneal artery is appl icable for the repair of small and medium-sized defects in the ankle and weight-bearing area of heel, especially for patients who have no satisfactory perforating branch in lower position.

Anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap for foot and ankle defect

ObjectiveTo investigate the clinical application of the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap in repair of foot and ankle defects.MethodsBetween October 2014 and October 2018, 18 cases with foot and ankle defects were treated. There were 12 males and 6 females with an average age of 32.8 years (range, 8-56 years). There were 11 cases of traffic accident injuries, 3 cases of falling from height injuries, and 4 cases of heavy objects injuries. The wound was at the dorsum of the foot in 9 cases, the heel in 4 cases, the lateral malleolus in 5 cases. The time from injury to flap repair was 7-34 days (mean, 19 days). The size of wound ranged from 6.0 cm×2.5 cm to 11.0 cm×6.0 cm. The foot and ankle defects were repaired with the peroneal artery terminal perforator propeller flap in size of 6 cm×3 cm-18 cm×7 cm, which donor site was repaired with the anterior tibial artery perforator propeller flap in size of 8 cm×3 cm-16 cm×6 cm.ResultsOne patient had a hemorrhagic swelling in the peroneal artery terminal perforator propeller flap, and survived after symptomatic treatment. All recipient and donor sites healed by first intention. Eighteen patients were followed up 6-15 months (mean, 12.5 months). At last follow-up, the shape, color, texture, and thickness of the flaps in the donor sites were similar with those in the recipient sites. There were only linear scars on the donor sites. The two-point discrimination of the peroneal artery terminal perforator propeller flap ranged from 10 to 12 mm (mean, 11 mm). According to American Orthopaedic Foot and Ankle Society (AOFAS) score criteria, the results were excellent in 15 cases and good in 3 cases, with an excellent and good rate of 100%.ConclusionThe foot and ankle defects can be repaired with the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap. The procedure is not sacrificing the main vessel and can avoid the skin grafting and obtain the good ankle function.

股前外側皮瓣游離移植修復足踝部大面積皮膚軟組織缺損

目的 總結股前外側皮瓣修復足踝部大面積皮膚軟組織缺損的臨床應用效果。 方法 2007 年1 月－2010 年12 月，采用股前外側皮瓣修復30 例足踝部大面積皮膚軟組織缺損。男18 例，女12 例；年齡18 ～ 55 歲，平均36 歲。外傷19 例，燒傷4 例，慢性感染創面7 例。病程9 h ～ 8 個月。缺損部位：小腿下1/3 及跟腱區8 例，外踝及足背外側區10 例，內踝及足背內側區5 例，足跟及足底7 例。創面均伴血管、骨及肌腱外露。創面缺損范圍20 cm × 14 cm ～ 23 cm ×21 cm。皮瓣切取范圍為22 cm × 16 cm ～ 25 cm × 23 cm。供區游離植皮修復。 結果 術后5 ～ 7 d 3 例皮瓣邊緣出現部分壞死，予以加強換藥后成活；其余皮瓣及供區植皮均順利成活，創面均Ⅰ期愈合。患者均獲隨訪，隨訪時間6 ～ 36 個月，平均18 個月。皮瓣耐磨，無局部潰爛，其中27 例恢復保護性感覺。但皮瓣外形臃腫，12 例于術后1 年行二次手術皮瓣修整后，外形滿意。 結論 股前外側皮瓣具有切取范圍大、血管口徑粗、部位隱蔽等特點，是修復足踝部大面積皮膚軟組織缺損的有效方法之一。

PROGRESS AND MAIN POINTS IN TREATMENT OF ACUTE FOOT AND ANKLE INJURIES

Objective To give a review and commentary on the treatment of acute foot and ankle injuries. Methods Based on the treatment experience and recent l iterature, a commentary on acute foot and ankle injuries were given, included the basic and cl inical research results, evaluation before operation, and treatment methods of the soft tissue and bone injuries. Results The treatment of acute foot and ankle injuries is still a hot point in orthopaedic surgery. Operative and non-operative treatment of fresh Achilles tendon rupture can achieve satisfactory results, and early weight-bearing do not increase the re-rupture rate. The time delay between first debridement and injury within 24 hours does not increase the infection rate. For the treatment of severe ankle fractures, attentions should be paid to the cartilage injury, and anatomic reduction, good real ignment, and the congruity recovery are very important. The treatment determination of calcaneal fractures depends on the fully understanding injury mechanisms, classifications, and treatment method. Talus fractures should try to be treated by experienced surgeons. Operation and fixation methods of Lisfranc injury depends on different injury types. Conclusion Acute foot and ankle injuries are common in cl inical, to achieve a satisfactory result in evaluation and treatment, it is important to have a fully evaluation of the injury type, and choose the best operation time and suitable treatment methods, as well as to fully understand the biomechanical characteristics of different regions.

REPAIR OF ANKLE SKIN AND SOFT TISSUE DEFECT WITH FREE SUPERFICIAL ILIAC CIRCUMFLEX ARTERY PERFORATOR FLAP

ObjectiveTo investigate the effectiveness of free superficial iliac circumflex artery perforator flap for repair of foot skin and soft tissue defect. MethodsBetween January 2010 and December 2015, 16 patients with ankle skin and soft tissue defect were treated. There were 13 males and 3 females with an average age of 32 years (range, 5-56 years). The causes included traffic accident injury in 8 cases, machinery injury in 3 cases, falling injury in 3 cases, and electrically injury in 2 cases. The time from injury to hospital was 1 to 6 hours (mean, 3.5 hours). The wound sites included foot dorsum skin defect in 6 cases, ankle skin defect in 5 cases, the back foot and ankle skin defect in 5 cases. The skin defect size ranged 5 cm×4 cm to 16 cm×7 cm. All patients had tendon exposure, and 8 patients had fracture. An emergency repair was performed in 6 cases, and selective surgery in 10 cases. The free iliac circumflex artery perforators flap was used to repair defect; the flap size was 6 cm×5 cm to 17 cm×8 cm, and the flap thickness was 0.4 to 1.1 cm (mean, 0.8 cm). ResultsThe flaps survived in the other 15 patients with primary healing of wounds except 1 patient because the iliac circumflex artery was too small to provide good blood supply, who underwent repair with local skin flap. Incision at donor site healed by first intention. The 15 cases were followed up 6-24 months (mean, 13 months). The appearance of the foot was satisfactory, and the flap had good texture without bulky flaps. ConclusionFree iliac circumflex artery perforators flap is one of ideal flaps in repair of skin defect of the foot and ankle because of hidden donor site, reliable blood supply, less injury to donor site, and full use of the flap.