Distally based sural artery flap: a workhorse to cover the soft tissue defects of lower 1/3 Tibia and Foot

To present our experience of soft tissue cover of lower one third of tibia and foot, treated by an Orthopaedic Surgeon without any special training and reliability of this flap. Eleven patients, ten males and one female, with soft tissue defect of lower one third tibia and foot requiring soft tissue cover were treated from March 1999 to February 2004. The flap was outlined at the posterior aspect of junction of upper and middle 1/3 leg. The pivot point of the pedicle was at least 5cm i.e., 3 fingers" breadth above the lateral mallelous to allow anastomosis with the peroneal artery. Skin incision was started along the line in which the fascial pedicle would be taken. The subdermal layer was dissected to expose the sural nerve, accompanying superficial sural vessels and short saphenous vein. The subcutaneous fascial pedicle was elevated, with a width of 2cm to include the nerve and these vessels. At the proximal margin of the flap, the nerve and the vessels were ligated and severed. The skin island was elevated with the deep fascia. The donor site defect was closed directly when the flap was less than 3cm wide. A larger donor site defect along with the pedicle was covered with a split thickness skin graft. All flaps except one survived. Most flaps showed slight venous congestion which cleared in a few days. There was no loss of split skin graft. Distally based Sural artery flap remains the choice for reconstruction of soft tissue defects of lower 1/3 tibia and foot. The dissection is easy, quicker and can be done by an Orthopaedic surgeon without any special training

Correction of adult foot deformities by ilizarov ring fixator

To evaluate the efficacy of Ilizarov ring fixator in treating adult Foot Deformities. Descriptive Study from May 2003 to Dec. 2005. Orthopaedics Unit II at Civil Hospital, Karachi. Fourteen patients, three females and eleven males, were treated with the Ilizarov ring fixator. The ages of the patients ranged from 14 to 55 years [mean 19.4 years]. The deformities included were post-polio residual deformities, neglected and relapsed club feet, rocker bottom deformity, post-burn contractures, and neurotropic feet with myelomeningocele, post-traumatic and leg length discrepancy. The correction of the deformities was carried out with osteotomy in 13 feet and without osteotomy in one foot. The osteotomies used included triple arthrodesis in eight feet, U-Osteotomy in two feet, V-Osteotomy in two feet and supra-malleolar osteotomy in one patient. Tibial lengthening was done simultaneously in two patients. Ankle arthrodesis was done in one patient. Ilizarov ring fixator was applied for a total duration of 10 to 24 weeks [mean 16 weeks]. The mean post-operative follow-up was 18 months [range 12-26 months]. Plantigrade foot was achieved in all the cases at the time of Ilizarov ring fixator removal, and the gait improved. All the patients were satisfied with the outcome, except one in which the deformity recurred in a neurotropic foot. Pin tract injection was noticed in all the cases, from time to time. Ankle subluxation occured in one patient in which ankle arthrodesis was done. Incomplete osteotomy was noticed in one patient. Our study concludes that Ilizarov ring fixator allows simultaneous correction of severe deformities of the adult foot, with reduced risk of cutaneous and neuro vascular complications and avoiding the shortening of the foot

Fractures of patella

Patella, the largest sesamoid bone in the human body with its subcutaneous location is more vulnerable to injuries. The stress distribution gets disturbed if the articular surface of the patella becomes incongruous. Most of the patellar fractures occur as a result of a combination of direct or indirect trauma. Transverse, vertical and polar fractures without comminution are either due to stress or due to powerful quadriceps contraction against resistance. Good history, thorough clinical examination and high quality radiographs are mandatory for accurate diagnosis. A number of management approaches are recommended including immobilizing, excision and repair, and internal fixation. Complication of patellar fracture include infection, loss of fixation, knee stiffness and post traumatic osteoarthritis

Immobilization of cross-leg flap by external fixator

This is a study of 34 patients having Gustilo type III i.e. open fracture with soft tissue defect that cannot be filled by simpler methods like partial thickness skin grafting but requires cross leg flap with stabilization. In this study, stabilization was done with a relatively new method i.e. by an external fixator which allows easy access to the flap and readjustment if necessary together with early mobilization. The flap grafts were accepted in all cases. Age [minimum 3 years] and site [exposed heel, dorsum of foot, exposed tibia] are not a restriction for the use of external fixator. Complications were minimum and easily treated e.g. pin-tract infection [17.65%], joints stiffness [20.59%, etc. this flap was used for 24 tibial fractures out of which 21 united giving a nonunion rate of 12.50%. We feel that management of cross-leg flap with external fixator is simpler and gives better results