[Reconstruction of forefoot skin defect with island flap pedicled with lateral tarsal artery]

OBJECTIVE

To investigate the therapeutic effect of island flap pedicled with lateral tarsal artery for forefoot skin defect.

METHODS

From March 2007 to January 2009, 12 cases with forefoot skin defects were treated by reversed island flap pedicled with lateral tarsal artery.

RESULTS

All the flaps survived completely with a followed-up period of 8-22 months, 13 months in average. The flaps and skin grafts had soft texture and a similar color as the surrounding skin. The flaps had a suitable thickness with deep pain sensation. Shallow touch and pain sensation recovered in the skin graft and within 1-2 cm of the flap edge, which was graded as S1-S2. There was no problem in shoes-wearing and walking. No flap ulcer happened.

CONCLUSION

Island flap pedicled with lateral tarsal artery is suitable for forefoot skin defect, leaving less morbidity to donor site.

Primary internal fixation and soft-tissue reconstruction in the treatment for an open Lisfranc fracture-dislocation

The importance of anatomical reduction for improved outcome has been recognised in the management of Lisfranc injuries. Operative fixation is indicated in case of dislocation or unstable ligamentous injury, because discongruity of the Lisfranc joint can lead to deleterious functional outcome. Screws are the recommended method of fixation of the medial en middle column, and K-wires are used for stabilisation of the unstable lateral column. Primary arthrodesis can provide advantages in pure ligamentous injury. In the management of complex open Lisfranc fractures, external fixation with K-wires can be used, but often results in a high percentage of arc deformities and functional limitations. In recent years, there is a progressive change from external to internal fixation in primary stabilisation of open fractures. This case report describes the treatment for a grade III open Lisfranc fracture-dislocation by use of primary internal fixation and soft-tissue reconstruction.

[Clinical application of the free superficial peroneal artery perforator flap]

OBJECTIVE

To investigate the applied anatomy of the superficial peroneal artery perforator flap and report the clinical results of repairing the soft tissue defects with free perforator flaps.

METHODS

15 fresh cadavers were injected with a modified lead oxide-gelatin mixture for three-dimensional visualization reconstruction using a 16-slice spiral computed tomography scanner and specialized software (Materiaise's interactive medical image control system, MIMICS). The origin, course and distribution of the superficial peroneal artery perforator in the anterolateral leg region were observed. Clinically 6 cases with hand defects and 6 cases with feet defects were treated with free superficial peroneal artery perforator flap transplantation. The defect size ranged from 3.0 cm x 4.5 cm to 5.0 cm x 11.0 cm.

RESULTS

The diameter of the superficial peroneal artery is (1.2 +/- 0.3) mm at its origin from the anterior tibial artery 5 cm below the fibula head. It is (5.6 +/- 1.8) cm in length. This artery is truly anastomosed with other perforators to form the chain of superficial peroneal nerve accessory artery. The superficial peroneal artery perforators [outer diameter (0.7 +/- 0.2) mm] with a vein are in the anterolateral leg region, supplying the skin in proximal-middle region. All the 12 cases were treated successfully. The clinical results were satisfactory after 3-12 months of following-up.

CONCLUSIONS

The superficial peroneal artery perforator flap has constantly, reliable blood supply, and good texture. It is a good option for repairing soft-tissue defect with free transfer.

[Application of pedicle reducing tension flap in the distally-based pedicle flap operation]

OBJECTIVE

To explore the effectiveness of reducing tension method on the survival and appearance of distally-based pedicle flap.

METHODS

Between October 2009 and February 2011, 27 cases of defect of extremity skin and soft tissue were repaired with distally-based pedicle flap through reducing tension flap method. There were 19 males and 8 females with an average age of 31.5 years (range, 17-58 years). Defects were caused by traffic accident in 14 cases, by machine in 9 cases, by surgical infection in 3 cases, and by tumor excision in 1 case. The locations were the distal tibia in 7 cases, the ankle-joint in 12 cases, the foot in 5 cases, the palm in 2 cases, and the dorsum of hand in 1 case. The time from injury to hospitalization was 1-19 hours with an average of 10 hours. The size of defect ranged from 5.2 cm x 3.8 cm to 14.0 cm x 5.8 cm. The size of distally-based pedicle flap ranged from 5.5 cm x 4.5 cm to 14.5 cm x 6.5 cm. The donor sites were sutured directly in 6 cases and were repaired with skin grafting in 21 cases.

RESULTS

All reducing tension flaps survived. Partial necrosis occurred in the distally-based pedicle flap in 3 cases at 7 days after operation, which was cured after dressing change and skin grafting in 1 case, after excision of necrosis skin edge and direct suture in 2 cases. The other flaps survived and wounds achieved primary healing. The incisions at donor sites healed by first intention and skin grafting survived. Twenty-six cases were followed up 6-12 months (mean, 7.5 months). The appearance and texture of the flaps were good.

CONCLUSION

Pedicle reducing tension flap could promote the survival and the appearance of distally-based pedicle flap.

Injuries of the tarsometatarsal joints: treatment and outcome

Between January 2005 and May 2009, a total of 26 patients, 21 males and 5 females, were admitted for treatment of Lisfranc lesion. All patients were radiologically evaluated and classified according to the criteria proposed by Myerson: 5 (19.2%) patients had a type A injury, 2 patients (7.7%) presented with a type B1 injury, 17 (65.4%) sustained the most common type B2 injury and 1 (3.8%) patient suffered from a type C1 and C2 injury. Taking radiological and clinical findings in account, fifteen patients were elected for operative treatment and eleven patients were treated conservatively. According to type of fracture we established three groups; in group I metatarsal fracture was found in fourteen (53.9%) patients, group II with phalangeal fracture in three (11.5%) cases, whereas in group III nine (34.6%) patients sustained combined metatarsal, navicular and, most commonly, a cuneiform fracture. Using the American Orthopedic Foot and Ankle Society (AOFAS) midfoot scoring scale and SF-36 questionnaire, the functional outcome was assessed. The mean value for age distribution was 42.7 +/- 13.2 years and the mean follow up was 27.9 +/- 12.4 months. A p value < 0.005 was regarded as statistically significant for the analysis of the results. We found by means of SF 36 questionnaire a statistically significant difference in the role limitation due to existence of pain (p = 0.04) and poor general health (p = 0.013) in the group of patients that sustained combined foot fracture. The purpose of this study is to assess the treatment of Lisfranc injuries in our patients, according to SF36 and AOFAS criteria, clinical outcome was evaluated. In the group I the mean AOFAS score was 74.0 +/- 9.1 and in the group II it reached 72.0 +/- 5.2 signifying fair outcome! Poor outcome was present in the group III with mean AOFAS score 67.1 +/- 9.0. All unstable injuries require surgery. Clinical outcome is highly dependent on the restoration of normal anatomic alignment.

[Application of free posterior tibial artery perforator flap for skin defect on the dorsum of hand or foot]

OBJECTIVE

To summarize the technique and therapeutic effect of free posterior tibial artery perforator (PTP) flap for skin defect on the dorsum of hand or foot.

METHODS

The lower leg was divided into 6 sections equally from the level of tibial tuberosity to the connection of medial and lateral malleolus. The free PTP flap was designed along the inner edge of tibia within the proximal section 2 and 3. The flap was harvested with 2-3 bundles of the saphenous nerve included. The size of skin defects on the dorsum of hand or foot ranged from 3.0 cm x 7.5 cm to 6.0 cm x 12.0 cm.

RESULTS

From Jan. 2009 to Dec. 2010, 11 cases were treated with free PTP flaps. All the flaps survived completely. The follow-up period ranged from 3 to 10 months. The flaps had good color and texture. Two point discrimination recovered to 7-10 mm, leaving linear scar at the donor site. The appearance and function of the hand or foot was satisfactory.

CONCLUSIONS

The free PTP flap is thin with good sensation, leaving less morbidity at donor site. The posterior tibial artery can be reserved. It is an ideal method for skin defect on the dorsum of hand or foot.

Distally based superficial sural artery flap for foot and ankle reconstruction in children

BACKGROUND

Wheel spoke injury of the ankle and foot is very common in children and its reconstruction is challenging. Reverse sural artery flap is very useful to cover these defects. Free tissue transfer is an option in children which needs a micro-vascular expertise, expensive equipment and long operating time.

METHODS

Sixteen cases with ankle and foot defects were operated during a period of 18 months at the Children Hospital and Institute of Child Health Lahore. The efficacy of sural artery flap for the coverage of these defects was evaluated.

RESULTS

Sixteen children presented with defects of foot and ankle, 62.5% were male and 37.5% were female. Their age ranged from 2-13 years. All patients had trauma to the foot, most of them having wheel spoke injury. Some had roadside accidents and glass injury. Fascio-cutaneous flaps were used in 9 patients and fascia only flap in 7 patients with split thickness skin graft. Flaps were used to cover tendoachilles, malleoli, dorsum of foot, calcaneus, amputation stump and to reconstruct heel. Fifteen flaps survived whereas one necrosed. There was loss of skin graft in two cases of adipofascial flaps. Mean follow-up was 6 months.

CONCLUSION

Sural artery flap is quick and safe with wide arc of rotation and minimal donor site morbidity and it does not sacrifice major extremity vessel.

Advances in intramedullary nail fixation in foot and ankle surgery

Tibiotalocalcaneal arthrodesis for the treatment of complex foot and ankle deformities are extremely challenging cases. Technological advances in intramedullary nail fixation have improved the biomechanical properties of available fixation constructs in recent years. Nails designed specifically to accommodate hindfoot anatomy, advancement in the understanding of optimal screw orientation, fixed angle technology, the availability of spiral blade screws, and features designed to achieve compression across the arthrodesis site have provided the foot and ankle surgeon with a greater armamentarium for performing tibiotalocalneal arthrodesis. Although advances may help to improve clinical results, small sample sizes and the low-level evidence of study designs limit the evaluation of how these advances affect clinical outcomes.

[Application of V-Y flap pedicled with superior malleolus cutaneous branch for small skin defect at the dorsal side of foot]

OBJECTIVE

To investigate the therapeutic effect of V-Y flap pedicled with superior malleolus cutaneous branch for small skin defect at the dorsal side of foot.

METHODS

From Aug. 2008 to Aug. 2010, 9 cases with skin defects at the dorsal side of feet were treated by V-Y flaps pedicled with superior malleolus cutaneous branch. The flap size ranged from 6.0 cm x 5.5 cm to 12.0 cm x 6.5 cm. The defects at the donor sites were closed directly.

RESULTS

All flaps survived completely. 9 cases were followed up for 6-12 months after operation. The flaps had good texture and color match. The 2-point discrimination distance at the flap was 10-14 mm. The function of ankle was normal.

CONCLUSIONS

The V-Y flap pedicled with superior malleolus cutaneous branch is ideal for the treatment of small skin defect at the dorsal side of foot.

[The choice of the treatment and surgical intervention for patients with fractures and dislocation fractures of front and middle parts of the foot]

For the period from 2004 till 2009 142 patients were observed in our clinic. We were able to follow up 53 of the 74 patients in the main group and 49 of the 68 ones in the control group for 12 months. The majority of injuries were located in the front area of foot; most of them were dislocation fractures. It was shown that the frequency of isolated stable and unstable traumas was roughly equal. Multiple injuries were generally unstable. We designed a simple convenient classification of fractures and dislocation fractures in front and middle parts of the foot. An original algorithm is proposed for the treatment and choice of operating methods based on our classification and ensuring satisfactory results in the majority of cases. Relief incisions outside projection of the surgical intervention field make it possible to close the operating wounds and avoid extension of their edges, prevent enlargement of edema, and avoid severe pyoinfectious complications in the early postoperative period. Overall, we achieved reduction of their frequency to 1% compared with 10% in the control group. The frequency of late complications was 9.44% versus 42.85% in controls.

Can an ankle-foot orthosis change hearts and minds?

The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population.

Partial foot amputations in the combat wounded

Throughout the current conflicts in Afghanistan and Iraq, there have been more than 1100 combat-related major limb amputations, with approximately 80% involving the lower extremity. There is, however, a paucity of data regarding the number of amputations below the level of the ankle. Although not as common, partial foot amputations, in the appropriate setting, offer a way to improve function and decrease energy consumption when compared to proximal amputations. Sound surgical tenets are prerequisite for successful outcomes when performing a distal amputation. Maintaining a robust soft tissue envelope allowing for tension-free wound closure is paramount in determining the feasibility of a partial foot amputation. Careful consideration of tendon balancing is also of utmost importance in avoiding common complications of contracture and deformity. Partial foot amputations present a viable surgical option for successful outcomes and maximization of patient function in the combat injured when certain criteria are met.

[Surgical treatment of tarsometatarsal joints injury]

OBJECTIVE

To summmarize the clinical experience of open reduction and internal fixation for the treatment of tarsometatarsal joint injury ane evaluate the effects of operative treatment to tarsometatarsal joint injury.

METHODS

From March to July in 2009,9 patients with tarsometatarsal joint injury were treated by open reduction and internal fixation included 7 males and 2 females with an average age of 33.5 years old ranging from 20 to 47 years. According to Quenu-Kuss classification, there were 5 cases of type A, 3 of type B, 1 of type C. All patients were treated by cannulated screws and Kirschner wires through 1 to 2 microtubule straight incision on dorsum of foot. The foot function were assessed by American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score.

RESULTS

All patients were followed up for 5 to 12 months with an average of 8 months. Complications concluded 1 case with infection, 1 case with post-traumatic arthritis. The failure of Kirschner wires was not discovered in 9 cases. According to AOFAS system,the total scores increased from preoperative (15.5 +/- 4.2) to postoperative (92.0 +/- 5.2) (t = -45.95, P < 0.01). The results were excellent in 7 cases, good in 1, and poor in 1.

CONCLUSION

Open reduction and internal fixation for the reatment of tarsometatarsal joint injury should have satisfying results.

Long-term follow-up on microsurgical free-tissue transfer in foot and ankle reconstruction

BACKGROUND

We have previously reported on the efficacy of free-tissue transfer in ankle and foot reconstruction with a mean follow-up period of 3.7 years (9 months-7.5 years) postoperatively. This study will evaluate the long-term results of free-tissue transfer performed for soft tissue defect coverage, diabetic foot salvage and the treatment of chronic osteomyelitis in 38 patients.

METHODS

The long-term efficacy of free-tissue transfer for foot and ankle reconstruction was evaluated in a retrospective study among patients operated during a period of 5 years (January 1992-December 1996); 38 were available for follow-up. Indications for reconstruction included acute wounds with soft tissue defects, diabetic foot ulcers, and chronic osteomyelitis.

RESULTS

At a mean follow-up of 12 years, there were no major complications in the soft tissue defect group. Among the diabetic patients, two patients had recurrent ulcerations of the forefoot which were detected early and treated conservatively. In the osteomyelitis group, however, there were no recurrences of the foot infection.

CONCLUSIONS

The free-tissue transfer provided an excellent method of soft tissue reconstruction with a very minimal long-term complication rate, and a very high rate of success in the treatment of diabetic foot ulcers and chronic osteomyelitis.

Distally based sural lesser saphenous neuro-veno-adipo-fascial (NVAF) flap for reconstruction in the foot: lessons learned

We report nine cases in which the neuro-veno-adipo-fascial (NVAF) flap was used to perform reconstruction of foot wounds over a 7-year period. Complications occurred in five (56%) patients. One patient suffered total loss of the flap and four experienced partial loss of the NVAF flap. Complications are to be expected with the use of the NVAF flap for foot wounds, but in most cases the flap is salvageable. The NVAF flap is an option in foot reconstruction when free tissue transfer is not available, contraindicated due to patient factors or when a prior free flap has failed.

[Analysis of the vacuum sealing drainage technique combined with sural neurovascular pedicle fascio-cutaneous flap to repair deep wounds in the foot near the ankle joint with exposed bone and tendons]

OBJECTIVE

To evaluate the practical method of vacuum sealing drainage (VSD) technique combined with sural neurovascular pedicle fasciocutaneous flap to repair deep wounds in the foot near the ankle joint with exposed bone and tendons.

METHODS

From January 2006 to January 2009, 79 patients with deep wounds in the foot near the ankle joint with exposed bone and tendons were treated by VSD technique combined with sural neurovascular pedicle fasciocutaneous flap including 58 males and 21 females with an average age of 34 years old ranging from 7 to 59 years. There were 17 cases in low 1/3 part of leg and achilles tendon, 28 in lateral malleolus and lateral dorsum of foot, 21 in medial malleolus and medial dorsum of foot, 13 in heel and pelma. Firstly the wounds were debrided and cultivated by using VSD technique, then the soft tissue defections were repaired with sural neurovascular pedicle fasciocutaneous flap.

RESULTS

The area of flap was from 6 cm x 5 cm to 18 cm x 15 cm; All patients stayed in hospital for 14 to 30 days, 18 days in average. Living flaps of all patients were followed-up from 6 months to 3 years, the flaps of 2 patients were mostly necrotic, 3 were necrotic, 5 cases appeared obstacle of venous back streaming. The others survived with no infections.

CONCLUSION

The wound would become fresh and clean as soon as possible with VSD. The sural neurovascular pedicle fasciocutaneous flap could provide a good covering for the exposed wound. Therefore the wound healed faster with friction resistance and fine appearance. The time of hospitalization were greatly shortened after combined application.

[Surgical treatment of tarsometatarsal joint complex injury]

OBJECTIVE

To report the outcome of surgical treatment of tarsometatarsal joint complex injury.

METHODS

In the period from January 2003 to December 2008, 167 cases of closed tarsometatarsal joint injury were treated, including 35 cases of tarsometatarsal joint complex injury. Diagnosis was made by X-ray examination or/and CT scan. Either close or open reduction was performed and followed by internal fixation with screw or/and plate. X-ray examination was done in the regular follow-up and functional evaluation was carried out by AOFAS midfoot score system.

RESULTS

In this series 135 cases got a mean follow-up of 48 months, ranging from 12 to 75 months. Therein the 26 cases of tarsometatarsal joint complex injury had a mean postoperative AOFAS midfoot score of 67 (ranging from 48 to 75), and secondary post-traumatic arthritis in 16 cases, 12 of which had arthrodesis as a result of severe pain. The 109 cases of pure tarsometatarsal joint injury had a mean postoperative AOFAS midfoot score of 82 (ranging from 70 to 95), and secondary post-traumatic arthritis in 17 cases, only 5 of which had arthrodesis finally. Those cases of pure tarsometatarsal joint injury treated by close reduction and internal fixation with percutaneous screw got a mean postoperative AOFAS midfoot score of 87 (ranging from 82 to 95), demonstrating a significant deference (t = 2.651, P < 0.05) when compared with that of metatarsal joint complex injury.

CONCLUSION

The tarsometatarsal joint complex injury has a prognosis inferior to that of the pure tarsometatarsal joint injury, and the keys to its successful treatment are appropriate diagnosis, anatomical reduction and secure fixation of all the components of the complex.

[Application of modified superficial peroneal neuro-fasciocutaneous flap in repairing soft tissue defect of forefoot]

OBJECTIVE

To investigate the operative procedures and clinical outcomes of the modified superficial peroneal neuro-fasciocutaneous flap in repairing soft tissue defect of forefoot.

METHODS

From May 2006 to May 2009, 5 male patients (aged 40-63 years) with soft tissue defect of forefoot were treated with the modified superficial peroneal neuro-fasciocutaneous flap. Tendons and bones were exposed in all cases. Defect was caused by object crash (4 cases) and traffic accident (1 case). The sizes of soft tissue defects of forefoot were 4 cm x 2 cm-8 cm x 4 cm. Rotating point of the modified superficial peroneal neuro-fasciocutaneous flap pedicled with the peripheral vessels network of ankle joint was at the level of tibiotalar joint. The flaps ranging from 5 cm x 4 cm to 10 cm x 6 cm were adopted to repair soft tissue defects of forefoot. The donor sites were either sutured directly or covered with intermediate split thickness skin grafts.

RESULTS

All flaps survived and all wounds healed by first intention. Skin graft at donor site survived completely in all cases. All patients were followed up 6-18 months (mean 11 months). The appearance, texture, and function of the flap were satisfactory. There was a protective sensibility in all flaps without abrasion or ulceration, and the two-point discrimination of the flaps was 10-13 mm. The walking pattern was normal. No obvious discomfort was observed at the skin-graft donor sites.

CONCLUSION

With reliable blood supply, no sacrifice of vascular trunks, favorable texture, and thickness, the modified superficial peroneal neuro-fasciocutaneous flap pedicled with the peripheral vessels network of ankle joint is useful to repair skin soft tissue defect of the forefoot.

Soft tissue management of war wounds to the foot and ankle

This article details the experiences of United States military reconstructive surgeons in the soft tissue management of war wounds of the foot and ankle resulting from the conflicts in Iraq and Afghanistan. War wounds from this conflict are commonly caused by blast and fragmentation, and are characteristically extensive, heterogeneous, and severe. Multiple serial débridement episodes are routinely necessary because of deterioration of the wounds over time, which is in contrast to civilian trauma wherein fewer débridement episodes are generally required. Wound therapy adjuncts, such as subatmospheric wound dressing and synthetic dermal replacement, have been used extensively with favorable results. Pedicled flaps, such as the distally based sural neurofasciocutaneous flap, are reliable, and avoid the risks and technical demands associated with microsurgery. Free tissue transfer, such as the anterolateral thigh flap, the latissimus dorsi muscle flap, and the rectus abdominis muscle flap, are powerful reconstructive tools, and have been extensively used in the reconstruction of war wounds of the foot and ankle.