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Objective:To investigate the efficacy of the nutrient vessel of medial and lateral sural subcutaneous nerve chimeric tissue flap based on posterior perforating branch of peroneal artery to repair the composite tissue defect in the Achilles tendon area.Methods:From January 2016 to June 2021, 12 patients suffering from infectious wound with defect of Achilles tendon were treated in the Department of Trauma and Microscopic Orthopaedics, 988th Hospital of the Joint Logistics Support Force of PLA. The area of soft tissue defect around Achilles tendon was 2.5 cm× 4.5 cm-8.0 cm×12.5 cm, and the length of the defect of Achilles tendon was 3.0-7.0 cm. The defect around the Achilles tendon were repaired with the nutrient vessel of medial and lateral sural subcutaneous nerve chimeric Achilles tendon flap (ATF) and the posterior perforating branch of peroneal artery was used as the vessel of blood supply. The size of flap was 3.0 cm×5.0 cm-9.0 cm×13.0 cm, and the size of the ATF was 3.0 cm×4.0 cm-3.0 cm×8.0 cm. The donor sites were sutured directly (8 cases) or repaired with skin graft (4 cases). External fixation were put on for 6 weeks after surgery. Then the external fixation was removed and the functional exercise gradually started. Outpatient clinic follow-ups were carried out regularly. Thermann Achilles tendon function assessment system was used to evaluate the last follow-up.Results:The chimeric ATF was harvested and the blood supply of each flap was good during the operation. There was no vascular crisis after surgery. The flaps survived smoothly and the wound achieved grade A healing. All patients were entered follow-up that lasted for 10-24 months. There was good appearance of flaps with minor bloating, and the colour of flaps was similar to the skin around the receiving site. The texture was soft with normal function of the lower legs and ankle. Tendon function was evaluated by Thermann Achilles tendon function assessment system, the result were 8 cases in excellent and 4 cases in good.Conclusion:The nutrient vessel of medial and lateral sural subcutaneous nerve chimeric tissue flap based on posterior perforating branch of peroneal artery can accurately repair a composite tissue defect in the Achilles tendon area, and it is one of the effective methods for the repair of a composite soft tissue wound with Achilles tendon defect.
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Objective:To explore a surgical technique and treatment outcomes of the segmentle bridging reconstruction for severed fingers with single segmentle defect by using the free second toe bone-joint composite tissue combined with the great toe flap.Methods:From June 2010 to September 2017, 5 patients suffered from severed segmental defect of finger were treated. According to the defects of bone-joints, blood vessels, nerves, tendons and other soft tissues, the reconstruction surgery was designed to create a Flow-through bridging composite flap pedicled with the first dorsal metatarsal artery or the plantar artery. The blood vessles carried by the pedicle were anastomosed with the vessels in the finger to restore the blood supply to the distal finger while having the defected finger segment reconstructed. A Flow-through bridging composite flap was created by taking the second toe bone-joint composite tissue combined with a C-shaped or half-moon shaped flap from the fibular side of the great toe. Skin graft, retrograde lateral tarsal flap or free perforator flaps were used in 3 cases to repair the donor sites of the great and second toes. Iliac strip was implanted in 2 cases for toe salvage. Kirschner wires were removed 4-6 weeks after surgery followed by functional exercise.Results:All of the 5 reconstructed distal segments of the fingers survived with the healing of fractures in 8-12 week after surgery. The postoperative follow-up lasted 6-36 months and all the patients had the follow-ups at the outpatient clinic. It was found that the maximum flexion of the reconstructed interphalangel joint was 60 degrees together with dorsiflezion. According to the evaluation standard of the reconstructed function for thumb and finger issued by the Hand Surgery Society of the Chinese Medical Association, 3 fingers were in excellent and 2 in good. No obviouse affect on walking was found in all the patients.Conclusion:The free second toe joint composite tissue together with the great toe flap can be used to bridge the single segmental defect of a finger. It restores the blood supply to as well as the appearance of the distal finger, helps the recovery of the reconstructed distal finger. It is an ideal technique in the treatment of a severed distal segment of the finger.
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Objective:To investigate the surgical method and clinical effect of free medial plantar flap (MPF) combined with anterolateral thigh flap (ALTF) in repair of large soft tissue defect in the weight bearing area of sole.Methods:From April, 2017 to August, 2019, 8 patients with large soft tissue defects in plantar weight bearing area were repaired by free MPF combined with ALTF. Four patients had the defects located in the hindfoot and the surrounding area, 3 in the forefoot and 1 in the whole foot. A tandem flap made of free MPF combined with ALTF was used to repair the heel in 5 patients and repair the plantar forefoot in 3 patients. The size of defects ranged from 15.0 cm×10.0 cm to 26.0 cm×22.0 cm. The size of the MPF ranged from 6.0 cm×5.0 cm to 8.0 cm×6.5 cm. The donor sites repaired with full thickness skin graft. The size of ALTF ranged from 15.0 cm×7.0 cm to 27.0 cm×11.0 cm. Two donor sites were sutured directly, and the other 6 were repaired by full-thickness abdominal skin graft. The patients entered follow-up at outpatient clinic and via WeChat for 9 to 18 months.Results:All the 8 tandem flaps and the donor grafts survived. Only 1 ALTF had a distal necrosis and healed after change of dressing. All the flaps had good elasticity and good texture. All the recipient area of MPF achieved sensation recovery of pain and touch. But the ALTF only partially recovered tactile sensation. The weight-bearing and walking function were good. At the last follow-up, all patients were evaluated by Maryland foot score, of which 4 patients were excellent, 3 were good, and 1 was fair.Conclusion:The free MPF combined with ALTF is one of the ideal methods for the repair of plantar soft tissue defect in the weight bearing area of sole. It can better restore the foot weight-bearing and walking function with good clinical effect.
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Objective To investigate the clinical effect of lateral supramalleolar perforator flap with the rotation point down on the repair of forefoot soft tissue defect.Methods From January,2016 to June,2017,23 cases (15 males and 8 females) of forefoot soft tissue defect were repaired by lateral supramalleolar perforator flap with the rotation point down.The age ranged from 8 to 67 (mean,42.9) years.The soft tissue defects were located far from the tarsometatarsal joint of the foot and the areas were 4.0 cm×4.0 cm-8.0 cm×12.0 cm.The areas of flap stitched directly or take blade thick skin repair on the thigh.All cases were followed-up by telephone or Internet,outpatient visit and home visit.Results Twenty-one cases survived successfully.Small area necrosis occurred at the distal end of the flap in 1 case,and healed after changing treatment.In the other cases,tension blister appeared at the distal end of the flap.After cut off some surgical stitches,the flap survived.All cases were followed-up from 6 to 12 months.The shape of flaps were not bloated and had good textures.The walking of affected limbs had no significant effect,and the functional recovery was satisfactory.Conclusion The lateral supramalleolar perforator flap is easy to cut and the perforator of flap is constant,which is a appropriate flap to repair the soft tissue defect of the forefoot.
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To explore the method and effect of repairing the soft tissue defect of the lateral heel with the retrograde lateral supramalleolar flap pedicled with the end perforator of peroneal artery. Methods From May, 2015 to February, 2018, 16 cases of lateral calcaneal soft tissue defect were repaired with the retrograde lateral supramalleolar flap pedicled with the end perforator of peroneal artery.All wounds were treated with one-stage dilata-tion and VSD to control infection. In cases of chronic calcaneal bone infection, the bone defect formed after extensive resection of infected bone was temporarily filled with antibiotic bone cement. The area of soft tissue defect on the lat-eral heel was 3.0 cm×2.0 cm-8.0 cm×5.0 cm, and the area of flaps was 3.5 cm×2.5 cm-8.5 cm×5.5 cm. The small donor area of the flap was sutured directly, and the larger area was repaired by skin grafting. Patients with chronic calcaneal bone infection underwent bone cement removal and autogenous bone transplantation after inducing mem-brane formation 6 to 8 weeks after flap transplantation. All cases were followed-up, including 7 cases outpatient fol-low-up and 9 telephone follow-up. Results All the 16 flaps survived smoothly. The donor and recipient areas of the flaps healed primarily. All cases were followed-up for 3 to 13 months. The flaps had good shape, no swelling, similar color to heel skin and no pigmentation.Ankle flexion and extension were not restricted.Four cases with chron-ic osteomyelitis of calcaneus healed well after second-stage bone grafting, with an average healing time of 8.5 months. Conclusion The retrograde lateral supramalleolar flap with the end perforator of peroneal artery is an ideal method for repairing the soft tissue defect on the lateral heel with simple operation and reliable blood supply.
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Objective To explore the clinical efficacy of secondary posterior internal fixation after transoral anterior atlantoaxial release under 3D operative microscopy for treatment of irreducible atlantoaxial dislocation.Methods From January 2014 to May 2016,12 patients with irreducible atlantoaxial dislocation were treated with secondary posterior internal fixation after transoral anterior atlantoaxial release under 3D operative microscopy in our hospital.They were 7 males and 5 females,with an average age of 37.1 years (from 25 to 54 years).The efficacy was analyzed in terms of their visual analogue scale (VAS),Japanese Orthopaedic Association (JOA) scoring,improvement rate of neurological function,American Spinal Injury Association (ASIA) grading,atlas-dens interval (ADI),space available for the cord (SAC) and cervicomedullary angle (CMA) before and one year after operation.Results The patients were followed up for more than one year.All the atlantoaxial joints obtained anatomic reduction.Their preoperative values of VAS (5.73 ± 1.36 points),JOA score (9.03 ± 2.12 points),ADI (8.34 ± 1.12 mm),SAC (9.53 ± 0.69 mm) and CMA (121.23°±4.32°) were significantly improved one year after operation (1.21 ±0.63 points,14.32±2.51 points,2.83 ± 0.36 mm,14.23 ± 1.22 mm and 153.53° ± 9.25°, respectively) (P ＜0.05).The improvement rate of neurological function increased gradually with the postoperative time,reaching 94.14％ ±5.11％ one year after operation.The postoperative ASIA grading was significantly improved too one year after operation (P ＜ 0.05).Conclusion Secondary posterior internal fixation after transoral anterior atlantoaxial release under 3D operative microscopy may lead to fine clinical efficacy one year after operation for patients with irreducible atlantoaxial dislocation.
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Objective To explore the clinical effect of repairing the large area of soft tissue defect of the calf by the retrograde anterolateral thigh flap with single high cutaneous perforator. Methods From January, 2014 to July, 2017, 9 cases of large area of soft tissue defects were repaired by the retrograde anterolateral thigh flap with sin-gle high cutaneous perforator.There were 7 males and 2 females, aged 24-48 years.Soft tissue defects area of the calf was 10.0 cm×7.0 cm to 35.0 cm×15.0 cm, including skin grafting and skin stretch to repair the area. The perforating point of the high cutaneous artery branches was designed at the proximal end of the flap, which was used as the single nutrient vessel of the flap. The rotation point of the flap was moved upward to the proximal thigh, which not only in-creased the blood supply of the flap, but also made the flap repair range to the distal calf. The flap range was 15.0 cm×10.0 cm to 22.0 cm×12.0 cm. Results All flaps were cut smoothly, and no vascular crisis occurred. All flaps survived smoothly.All patients were followed-up for 6-12 months. The appearance of flaps was plump, slightly bloat-ed, and their color was similar to the recipient area. The texture was soft, and no active disorder in the donor site. Conclusion The retrograde anterolateral thigh flap with single high cutaneous perforator can be designed at a high rotation point.By increasing the number and caliber of the anastomotic branch between the pedicle and lateral superi-or genicular artery, the blood supply and reflux of flap can be improved, and the survival rate is not affected. Com-pared with the traditional anterolateral thigh flap, it has great advantages.
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Objective To investigate the clinical effect of the chimeric flap based on the perforator of the posterior tibial artery for reconstruction of bone and skin defect in extremities.Methods From March,2007 to June,2013,the legs of the patients with bone nonunion,bone defect and skin soft tissue defect in extremities accepted digital subtraction angiography to find the larger perforators in the upper middle section of posterior tibia1 artery.Color doppler flow imaging (CDFI) was used to track branches and directions of the larger perforators and to look for the perforators which gave off secondary branches respectively to the skin and periosteum.According to the length of bone defect and the area of skin defect,the composite flap with the bone flap and skin flap was designed and cut out.It was based on the right single perforator of the posterior tibial artery which was chosen.The free composite flap was called the chimeric flap based on the perforator of the posterior tibial artery and repaired bone and skin defect in extremities.The size of osseous flaps ranged from 1.5 cm × 0.6 cm × 0.4 cm to 4.0 cm × 2.0 cm × 1.0 cm,and the size of cutaneous flaps of total 17 cases ranged from 2.0 cm × 2.0 cm to 7.0 cm × 6.0 cm.Results Followed-up for 3 to 18 months,all osseous flaps and cutaneous flaps survived,and all donor sites healed well.Nine cases of all cutaneous flaps were flat with the surrounding tissue and others bloated,but they were flat with the surrounding tissue after second phase to fat plastic.The fracture line disappeared and bone healed well at the time of 3-6 months after operation of bone graft to repair bone defect.According to the related evaluation criteria made by the Chinese Medical Association,the results of 10 cases of hand trauma patients were excellent in 7 cases,good in 2 cases,may in 1 case.Seven cases of lower leg and foot trauma patients could walk with load without pain.Conclusion Application of the chimeric flap based on the perforator of the posterior tibia1 artery is an ideal method to repair the small pieces of bone defect with skin soft tissue defect caused by various reasons in extremities.Because this kind of surgery doesn't sacrifice known vessels with minimal donor site morbidity,and healing time of the bone graft is short and the bone is not easy to absorb.