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The Repair of Lower Leg, Ankle and Foot Soft Tissue Defects

目的　评价不同皮瓣、肌皮瓣修复小腿及足踝部皮肤软组织缺损的效果，探讨小腿及足踝部皮肤软组织缺损的理想修复方法。 方法　2002年6月－2010年1月，应用15种皮瓣、肌皮瓣修复128例（138处）小腿及足踝部皮肤软组织缺损。其中小腿中上段21处，小腿中下段45处，内外踝及足跟部43处，足背及前足29处。主要应用最多的皮瓣有腓肠神经营养血管皮瓣、腓肠肌内外侧头肌皮瓣、腓浅神经营养血管皮瓣和足底内侧皮瓣。修复软组织缺损范围5 cm×4 cm～23 cm×14 cm。 结果　术后135处创面Ⅰ期愈合，皮瓣完全成活；2处皮瓣部分坏死，经二次手术植皮修复；1例游离股前外侧皮瓣修复小腿中下段软组织缺损，皮瓣完全坏死，后改取对侧腓肠神经营养血管交腿皮瓣修复成活。腓肠神经营养血管皮瓣应用例数最多，成活率高，吻合血管的游离皮瓣坏死率较高。术后患者均获随访1～10年，平均23个月，皮瓣均成活良好, 无溃疡、渗液等。 结论　正确认识并选择皮瓣、肌皮瓣修复小腿及足踝部皮肤软组织缺损可提高皮瓣成活率，恢复肢体良好功能，腓肠神经营养血管皮瓣是一种修复小腿及足踝部软组织缺损的理想皮瓣。

腓肠神经营养血管蒂逆行岛状皮瓣修复足踝部深度烧伤

Clinical study on treatment of chronic infection of foot and ankle with lower extremity ischemic diseases by tibial transverse transport combined with antibiotic embedded bone cement

ObjectiveTo study the effectiveness of tibial transverse transport combined with the antibiotics embedded bone cement in the treatment of chronic infection of foot and ankle with lower extremity ischemic diseases.MethodsA retrospective analysis was performed on 28 patients with ischemic diseases of lower extremities associated with chronic foot and ankle infection who were treated with tibial transverse transport combined with antibiotic bone cement between August 2015 and October 2019. There were 22 males and 6 females, with an average age of 65.6 years (range, 41-86 years). There were 25 cases of diabetic foot, 2 cases of arteriosclerosis obliterans, and 1 case of thromboangiitis obliterans. The course of infection ranged from 1 to 27 years, with an average of 14.9 years. The healing condition and time of foot and ankle in all patients were recorded and compared, and the Wagner grading and WIFi (W: lower extremity wound classification; I: ischemic classification; Fi: foot infection classification) grading were compared before and at last follow-up.ResultsThe wound surface of 1 diabetic foot patient improved at 111 days after operation, without purulent secretion, and lost follow-up. The remaining 27 cases were followed up 5 to 21 months (mean, 8.4 months). There was no necrosis in the tibial osteotomy incision and the local flap. After operation, 21 cases showed needle reaction of external fixator, but the needle infection gradually improved after the corresponding treatment. Among the 24 patients with diabetic foot, 1 died of multiple organ failure due to pulmonary infection. Acute lower extremity vascular embolism occurred in 1 case, and the foot was amputated due to acute gangrene. In the remaining 22 cases, the wound healing time of foot and ankle was 2.5-11.0 months (mean, 4.6 months). At last follow-up, Wagner grading and WIFi grading of the patients were significantly improved when compared with those before operation (P<0.05). One patient with thromboangiitis obliterans had foot and ankle healing at 6 months after operation. Two patients with lower extremity arteriosclerosis obliterans had foot and ankle healing at 16 and 18 months after operation, respectively.ConclusionTibial transverse transport combined with the antibiotics embedded bone cement is effective in treating chronic infection of foot and ankle with lower extremity ischemic diseases.

逆行隐神经皮瓣交腿移位修复难治足踝部创面

目的 总结采用逆行隐神经皮瓣交腿移位修复难治足踝部创面的方法及疗效。 方法 2005 年9 月－2010 年11 月，采用逆行隐神经皮瓣交腿移位修复9 例难治足踝部创面。男8 例，女1 例；年龄17 ～ 47 岁，平均34.5 岁。交通事故伤5 例，重物压砸伤3 例；伤后至入院时间为2 h ～ 6 个月。脉管炎1 例，病程18 个月。缺损部位：踝部4 例，足跟部3 例，前足2 例。缺损范围为6 cm × 5 cm ～ 17 cm × 11 cm。术中皮瓣切取范围为8 cm × 6 cm ～ 16 cm × 10 cm，术后3 ～ 5 周行皮瓣断蒂。供区游离植皮修复。 结果 1 例感染创面术后4 d 发生局限感染，经换药处理后愈合，皮瓣成活；其余交腿皮瓣及供区植皮均顺利成活，创面Ⅰ期愈合。患者均获随访，随访时间6 ～ 34 个月，平均16 个月。皮瓣质地优良，无溃疡发生。术后22 个月皮瓣两点辨别觉为8 ～ 10 mm，均恢复保护性感觉。足踝均能负重行走，踝关节活动范围：背伸8 ～ 20°，跖屈10 ～ 35°。供区术后足背内侧感觉支配区麻木感范围随时间延长缩小。 结论 逆行隐神经皮瓣切取简便，厚薄适度，不损伤知名血管，术后可恢复皮瓣感觉，有效防止皮瓣再破溃，是修复足踝部创面的较好方法之 一。

内踝上皮支皮瓣修复足踝部皮肤软组织缺损

Application of perforator propeller flap of lower limb in the treatment of foot and ankle defect in children

Objective To investigate the effectiveness of perforator propeller flap of lower limb in the treatment of foot and ankle defect in children. Methods The clinical data of 28 children with foot and ankle defect treated with perforator propeller flap of lower limb between January 2018 and January 2021 were retrospectively analyzed. There were 18 boys and 10 girls with an average age of 7.3 years (range, 6-14 years). There were 8 cases of traffic accident injury and 20 cases of chronic infection wound. The disease duration was 2-4 months, with an average of 2.8 months. After thorough debridement, the residual wound size ranged from 5 cm×4 cm to 9 cm×5 cm. Repairing was performed after 7-28 days of the infection in control. According to the location, size, and shape of the wound, the perforating vessels were located by ultrasonic Doppler, and the perforator propeller flap (area ranged from 6 cm×5 cm to 11 cm×6 cm) was designed and harvested to repair the wound. Flap transfer combined with free split-thickness skin graft covered the wound in 2 cases. The donor site was sutured directly (22 cases) or repaired with skin graft (6 cases). Results Twenty-six flaps survived, of which 20 cases were in primary healing, and 6 cases had epidermal necrosis at the end of small paddle, which healed after dressing change. Necrosis occurred in 2 cases due to venous crisis which healed after anterolateral femoral flap free transplantation. Primary wound healing was achieved in donor site. All 28 children were followed up 6-24 months (mean, 10.5 months). The texture, shape, and motor function of the lower limb was satisfactory. At last follow-up, the American Orthopaedic Foot and Ankle Association (AOFAS) score was 89.8±8.0, which was significantly different from the preoperative score (79.6±10.4) (t=−11.205, P<0.001); 20 cases were excellent, 6 cases were good, and 2 cases were poor, and the excellent and good rate was 92.8%. ConclusionThe perforator propeller flap of lower limb in children has its own characteristics. It is a reliable method to repair the foot and ankle defect in children.

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.

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.

Reconstruction of the donor area of distally based sural flap with relaying lateral gastrocnemius artery perforator propeller flap

Objective To investigate the clinical application of relaying lateral gastrocnemius artery perforator flap in reconstruction of the donor defect after distally sural flap transferring. Methods Between January 2014 and January 2016, 12 cases with foot and ankle defects were treated. There were 10 males and 2 females with an average age of 23.4 years (mean, 14-52 years). The injury was caused by motorcycle accident in 7 cases and traffic accident in 5 cases. The injury located at left limb in 7 cases and right limb in 5 cases. The size of soft tissue ranged from 10 cm×4 cm to 12 cm×6 cm. The disease duration was 2-84 hours (mean, 26.2 hours). The foot and ankle defects were reconstructed by distally sural flaps, then the flap donor sites were reconstructed with relaying lateral gastrocnemius artery perforator flap at the same stage. The size of distally sural flap ranged from 11 cm×5 cm to 13 cm×7 cm. The size of relaying flap ranged from 7 cm×4 cm to 10 cm×6 cm. Results All flaps survived uneventfully. All recipient sites and donor sites healed smoothly. No vascular crisis, wound dehiscence, or evident swelling occurred. All patients were followed up 6-14 months (mean, 12.4 months) with satisfied esthetic and functional results in recipient and donor sites. There were only linear scar on the donor sites. The color and contour was satisfying, the function of calf and foot were not affected. Conclusion The relaying lateral gastrocnemius artery perforator flap combined with distally sural flap is an idea choice to reconstruct foot and ankle defect, which can avoid donor site skin grafting, minimize donor site morbidity.

腓肠神经营养血管皮瓣修复足踝部软组织缺损

总结腓肠神经营养血管皮瓣修复足、踝部软组织缺损的临床效果。 方法 2003 年3 月－2006 年7 月，应用腓肠神经营养血管皮瓣修复足、踝部软组织缺损18 例，其中男10 例，女8 例；年龄6 ～ 52 岁。皮带、车链绞伤15 例，砸伤3 例。合并踝关节、跗骨、跖骨骨折脱位5 例，跟踺缺损2 例，感染5 例。软组织缺损8 cm ×6 cm ～ 17 cm× 8 cm。行急诊手术8 例；择期手术10 例。同时行关节和骨折内固定5 例，置管持续冲洗2 例，跟腱修复2 例。 结果 18 例皮瓣均成活。15 例伤口Ⅰ期愈合；1 例皮瓣边缘表层坏死，经换药、植皮后愈合；2 例伤口感染，换药后愈合。患者获随访8 个月～ 3 年，皮瓣外形、色泽、质地良好，踝关节功能满意。背屈18 ～ 20°，跖屈30 ～ 35°。 结 论 腓肠神经营养血管皮瓣血运良好，操作简便、安全，可有效修复足、踝部软组织缺损。