Anatomic design of a sensate plantar flap

To date, full-thickness skin ulcers of the heel of the foot are still difficult wounds to cover. Many choices of coverage are available, but few provide long-term coverage due to bone exposure, deficient sensibility, and subsequent breakdown. An advancement flap based on the medial plantar artery with sensory nerve branches is presented with long-term follow-up. This flap is available and expendable, with an excellent are of rotation. Reliable circulation and sensibility are the key factors for successful reconstruction.

[The reverse medial plantar island flap: anatomy and clinical applications]

A new flap, the reverse medial planter island flap based on the distal end of the medial plantar artery (MPA) is introduced. It is found that the MPA is connected with the plantar profund artery via the first plantar metatarsal artery or the big lateral branch of the MPA, joining the common digital artery that comes from the arch of the plantar artery. This flap was used in 3 cases of electric injury with satisfactory results. It suggests that the reverse medial plantar island flap is an ideal flap for reconstruction of the defects in the weight-bearing area of the forefoot.

Classification and reconstructive options in foot plantar skin avulsion injuries

Between 1989 and 1994, 28 patients who had plantar avulsion injuries were treated. Patient ages averaged 30 years (range 7 to 62 years). Length of follow-up averaged 20 months. Five patients (18 percent) were classified as having suprafascial avulsions, where the shearing plane was limited to the superficial subcutaneous layer, leaving the deeper subcutaneous fat. Twenty-three patients (82 percent) were classified as having subfascial avulsions, where the stripping force extended deep into the plantar aponeurosis. For the suprafascial avulsions, defatting these flaps and replacing them with full-thickness skin grafts was the treatment of choice. For the subfascial group, the avulsions with proximally based flaps (4 patients) that were well nourished by mediolaterally orientated neurovascular bundles could be treated by sewing the avulsed flaps tension-free back to their former positions. For the subfascial group with distally based flaps (19 patients), the avulsed flaps were supplied by anteroposteriorly orientated vascular plexuses that were compromised. Primary revascularization of the soft tissue should be considered whenever possible. Among them, 10 patients attempted microvascular salvage. Only 3 patients succeeded with revascularization. In the remaining 16 patients, the avulsed flaps went on to partial or complete necrosis, and these required secondary reconstruction with free muscle flaps for heel defects.

Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps

Twenty one patients underwent reconstruction of the weight-bearing portion of the foot with 22 free flap transfers: 12 free flaps were skin-grafted muscle flaps and 10 were fasciocutaneous flaps. Twelve flaps were reinnervated by nerve coaptation (n = 10) or an 'onlay' nerve graft (n = 2). Follow-up ranged from 1.5 to 7 years (mean 38.5 months). Five flaps (23%) developed full thickness ulcers that required surgical treatment. All ulcers occurred in patients who had an underlying neuropathy. Most complications occurred early in the series. No significant difference was found in the incidence of complications and functional outcome between fasciocutaneous and skin-grafted muscle flaps. There was no significant difference between reinnervated and non-innervated flaps. Both fasciocutaneous and skin-grafted muscle flaps, whether reinnervated or non-innervated, can be successfully used for weight-bearing foot reconstruction. Neither type of flap should be considered permanent in the presence of peripheral neuropathy. Appropriate selection of patients, extensive education about foot care and frequent follow-up visits are essential to maintain a healthy, intact flap and reconstructed foot.

The external oblique muscle free flap

To date, the external oblique muscle has been considered to have a purely segmental vascular supply and therefore has been used surgically only as a pedicled flap. To better define the vascular anatomy and nerve supply of the muscle, we performed arterial injection studies and dissected the nerves that entered the muscle in 35 human cadavers. We found that in addition to the segmental arteries, one or two large branches of the deep circumflex iliac artery contributed significantly to the blood supply of the external oblique muscle in 33 of the 35 cadavers. We also found that the lateral cutaneous branches of the intercostal nerves entered and supplied the muscle near its origin from the rib in a strictly segmental pattern. These anatomic findings enabled us to transplant the external oblique muscle successfully as a free flap based on the deep circumflex iliac vessels in six patients. The muscle flap is thin, pliable, and can be combined with an iliac bone or an abdominal skin transplant. Its vascular pedicle is long (mean 12 cm) and of adequate diameter for microvascular repair. The donor scar of the flap is inconspicuously situated along the inguinal ligament and the iliac crest. Finally, since the muscle has a multiple nerve supply, it has the potential to provide several functional units at the recipient site when transplanted as a functional free flap.

Complications when using the cannulated 3.5 mm screw system

Five patients with breakage of instrumentation when using the cannulated 3.5 mm screw system for fracture fixation are reported. Four 1.25 mm guide wires were sheared off by the cannulated drill and one 3.5 mm cannulated tap sleeve fractured. This article presents potential dangers when using the cannulated 3.5 mm screw system for general fracture care.

Magnetic resonance imaging of severe frostbite injuries

Frostbite injury causes damage by direct ice crystal formation at the cellular level with cellular dehydration and microvascular occlusion. Acute treatment is well defined with rapid tissue rewarming. Definitive surgical therapy is usually delayed until a clear level of demarcation is seen. Technium (Tc)-99 bone scanning has become the standard imaging study employed within the first several days to assess tissue perfusion and viability. We present 2 patients with severe frostbite injury in which magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were compared to Tc-99 bone scans. MRI/MRA appears to be superior to bone scanning by allowing direct visualization of occluded vessels, imaging of surrounding tissues, and by showing a more clear-cut line of demarcation of ischemic tissue. MRI/MRA may also allow early intervention in cases of severe frostbite, thus preventing secondary infection and increased cost.

Distally based sural island flap for foot and ankle reconstruction

The distally based sural island flap is vascularized by the cutaneous perforating branches of the peroneal artery. Three variants of this flap were used for reconstruction of 19 patients with defects in the ankle and in both dorsal and plantar surfaces of the foot. Four adipofascial sural flaps were used to cover the exposed Achilles tendons. Twelve fasciocutaneous sural flaps were used to resurface defects in the ankle region as well as in the non-weight-bearing area of the heel. Another four sural flaps, innervated by the lateral sural cutaneous nerve, were used to resurface the weight-bearing areas of the heel. The advantage of this flap is a constant and reliable blood supply without sacrifice of major arteries or sensory nerves. It also has the potential for reinnervation and can be performed in a single stage without microsurgery.

[Spontaneous liver rupture after thrombolytic therapy with streptokinase]

Two months after an osteosynthesis of a Maisonneuve-fracture a 45-year-old patient developed a thrombosis of the deep veins on the side of the fracture. Subsequent to two days of lysis with Streptokinase a rupture of the liver occurred and was treated by hemihepatectomy. A traumatic event or a tumor could be excluded as reason for the rupture. Therefore a rupture of the liver due to the application of Streptokinase has to be assumed.

[Microsurgical restoration of foot tissue defects]

From 1984 to 1994, 236 different types of traumatic defects of foot were repaired by microsurgical tissue grafting. They included simple cutaneous flap in 187 and composite flap in 49. Among the 236 different tissue flaps, vascularized flap was used in 97 and pedicled flap in 139. The 4 fore-foot and 6 heel defects were repaired by composite skeleted cutaneous grafts with scapula and vascularized febula respectively. After the follow-up from 1 to 10 years, all the grafted tissues were survived and healed well. The functions were satisfactory, and 186 patients had resumed their original works. The key to good function following repair was to maintaion the integrity of foot structures and the sensation of the sole and heel.

Lateral calcaneal artery flap for coverage of a posterior heel defect in a child

The lateral calcaneal artery fasciocutaneous transpositional flap is utilized for coverage in a case presentation of a 6-year-old child with an insensate posterior heel defect. The procedural technique and 32-month follow-up is described. Advocacy of this flap, for this patient, and potential detriments of alternative coverage options are discussed.

Arthroscopy of the foot and ankle in the athlete

Ankle arthroscopy has evolved over the past decade to address many acute and chronic injuries in the athlete. Although similar outcomes are reported with established open procedures, arthroscopic intervention confers the advantages of decreased postoperative morbidity and earlier return to sports activity. Arthroscopic procedures for the foot are evolving; however, most are considered investigational at this time.

The fate of lower extremities with failed free flaps

This study reviews the outcome of patients with failed free flaps to lower extremities. The failure rate was 10 percent (41 of 413 flaps) over a 13-year period. Trauma patients (83 percent of all patients) had a failure rate of 11 percent, while nontrauma patients had a failure rate of 6.7 percent. The most common cause of failure was venous thrombosis (34 percent). Eight of 36 patients (22 percent) went on to amputation after the failed free flap; all were trauma patients. Patients with tibia-fibula fractures had a 35 percent amputation rate (6 of 17 patients) after a failed free flap. Seventy-eight percent of the patients (28 of 36) had salvage of their extremities by split-thickness skin graft, local flaps, or a second free flap. Long-term follow-up was available in 24 of 36 patients (67 percent), 20 of whom were salvaged without amputation. Of the patients whose limbs were salvaged, none had undergone an amputation at a mean follow-up of 6.2 years. All were ambulating, but 7 (35 percent) had intermittent wound breakdown. Despite an initial free-flap loss, the majority of extremities can be salvaged with subsequent procedures. However, on long-term follow-up, a large percentage of patients continue to have wound problems.

The distally based superficial sural flap for reconstruction of the lower leg and foot

We describe our experience with the use of distally based superficial sural flaps for coverage of defects in the lower leg and foot in 21 patients. In 18 patients the flap was successfully transferred, in 2 cases partial necrosis of the flap occurred and 1 flap failed completely. In 18 cases the flap was used as a fasciocutaneous flap and in 3 cases as a fascial flap only. The advantages of this flap are: easy and quick dissection, hence saving operating time, minimal morbidity of donor site and preservation of major arteries of the leg. Although the flap was described as reliable for covering defects around the ankle joint, we have been able to cover defects of the dorsum of the foot distally and up to the mid-third of the tibia proximally.

The bipedicled flap on the lower leg, a valuable old method? Its indications and limitations in 12 cases

Covering defects of the lower leg is still an exceptional problem when tendons or bone are exposed within small defects, particularly in the malleolar region. We present 12 cases of successful wound closure on the lower leg with the versatile bipedicled flap. We had a low incidence of minor complications, whether it was used as a cutaneous, fasciocutaneous, or myo-fasciocutaneous flap, in some cases also based on underlying perforators to guarantee perfusion of the flap. If it is limited to selected indications and patients, the bipedicled flap may be a reliable alternative to other, more sophisticated methods of tissue transfer.

The use of bone grafts in the management of nonunions

Nonunions can be frustrating complication for the lower extremity surgeon. The cessation of bone healing requires an understanding of its etiology before it may be treated appropriately. This article will review nonunions and, in the context of this special issue, discuss the role of bone grafts in their treatment.

[Repair of skin defects on the anterior portion of the foot with reversed dorsalis pedis flap]

Based on anatomical observations of the course of skin arteries and venous drainage of the reversed dorsalis pedis flap in 30 adult cadaversmretrograde dorsalis pedis flaps have been performed on six patients to repair their skin defects on the anterior portion of the foot. All the flaps survived without severe swelling or any necrosis. Clinical applications indicated that the blood supply and venous drainage of the flap were satisfactory. The advantages and key points of the operation were discussed in this paper.