Efficacy of medial plantar flap combined with medial foot flap for repairing weight-bearing area defects of the foot / 中华创伤杂志

Objective:To investigate the clinical effect of combining medial plantar flap with medial foot flap for repairing weight-bearing area defects of the foot.Methods:A retrospective case series study was used to analyze the clinical data of 12 patients with weight-bearing area defects of the foot, who were admitted to the Affiliated Hospital of Zunyi Medical University from March 2020 to March 2022. There were 9 males and 3 females, with the age of 27-62 years [(39.3±8.7)years]. There were 4 patients with palm defects and 8 with heel defects. The defect area ranged from 10 cm×8 cm to 13 cm×12 cm. The cutting area of skin flap ranged from 11 cm×8 cm to 14 cm×13 cm. A total of 5 patients were treated with free flaps (4 patients with palm and 1 with heel defects) and 7 with pedicled flaps (all with heel defects). The flap donor areas were repaired with skin grafting. The flap survival was observed after surgery. At the last follow-up, the appearance, texture, and two point discrimination of the flap were recorded; the foot function was evaluated by Maryland foot function score; the sensory function of the reconstructed skin flap was evaluated by testing the two-point discrimination using a bipedal gauge.Results:The patients were followed up for 6-24 months [(11.8±5.3)months], and all the flaps survived. At the last follow-up, the flaps were free of any swelling and ulceration, with good texture and no sliding. The Maryland foot function score was (92.8±7.2)points at the last follow-up, which was significantly higher than the preoperative (36.6±6.1)points ( P<0.01), being excellent in 9 patients and good in 3. The two-point discrimination of the reconstructed flap was (17.8±5.7)mm at the last follow-up, and there was no significant difference compared with the contralateral (16.3±5.1)mm ( P>0.05). The sensation of the flap returned to normal. There were residual scars in the flap donor area after skin grafting, but no significant impact on foot movement. Conclusion:The medial plantar flap combined with medial foot flap has a large cutting area and good texture, meets the functional requirements, and achieves good postoperative sense recovery, making it a good choice for the repair of weight-bearing area defects of the foot.

Feasibility of MRI assisting early diagnosis of midfoot ligament and tendon injuries / 中华全科医师杂志

Objective:To explore the feasibility of MRI to assist the early diagnosis of midfoot tendon and ligament injuries.Methods:Fifty-two patients with midfoot ligament and tendon injuries who visited Beijing Jishuitan Hospital from September 2016 to December 2021 were enrolled in the study, and 20 healthy volunteers were recruited as controls. All participants underwent mid foot coronal (short axis), sagittal, and axial (long axis) MRI T1 weighted imaging and proton fat suppression sequence examination. The MRI images were evaluated by 2 senior radiologists independently.Results:The consistency of the two radiologists in diagnosis of tendons, ligaments, bones, and soft tissues were good ( κ=0.916, 0.896, and 0.893, respectively). The tendons and ligaments of the midfoot in 20 healthy volunteers (40 feet) showed uniform bands of varying thickness with slightly low signal intensity; the anterior tibial tendon showed a thin line shape, the posterior tibial tendon showed a slightly thick band with uniform low signal intensity, and the calcaneonavicular ligament showed a thin line-like low signal intensity running in different directions. In 52 patients with midfoot tendon and ligament injuries, 18 had anterior tibial tendon injuries, 20 had posterior tibial tendon injuries, and 14 had calcaneonavicular ligament injuries. The injured tendon or ligament was characterized by uneven thickness, blurred edges, and continuous interruption on T1WI sequence, uneven enhancement of signal in the tendon or ligament running area on PD-FS sequence, accumulation of fluid in the tendon sheath, and partial tearing. The partial tear showed discontinuity and thickening of tendons, while the complete tear showed that the tendons were interrupted and retracted, the fiber structure disappeared and was filled with liquid, and the surrounding soft tissue edema was present. Conclusion:MRI can clearly display the course and anatomical structure of the attachment end of the midfoot tendon and ligament, which may assist in early diagnosis of midfoot tendon and ligament injuries.

Fracturas de la base del quinto metatarsiano: ¿es útil mi tornillo de esponjosa con rosca parcial? Experiencia de 10 años / Fractures of the base of the fifth metatarsal bone: is my partially-threaded cancellous screw useful? 10-year experience

OBJETIVO Evaluar el resultado quirúrgico de fracturas de las zonas 2 y 3 de la base del quinto metatarsiano usando tornillos de esponjosa de diámetro de 4,0 mm con rosca parcial. MATERIALES Y MÉTODOS Evaluación retrospectiva de pacientes operados entre 2010 a 2019. Incluimos todos los casos sintetizados con este dispositivo con seguimiento mínimo de tresmeses, y excluimos casos operados con otros dispositivos y seguimiento menor a tres meses. Evaluamos la consolidació n y la presencia de complicaciones. Determinamos el largo del tornillo, el diámetro del canal endomedular, la distancia entre el borde proximal de la tuberosidad y la fractura, y la distancia de paso de la rosca sobre el rasgo de la fractura en radiografías anteroposterior (AP) y oblicua del pie. RESULTADOS Evaluamos 39 casos, y la muestra tenía una edad promedio de 27 años, y predominio del sexo masculino. El largo de tornillo más usado fue el de 45 mm, y los diámetros promedios del canal endomedular medidos en las radiografías AP y oblicua fueron de 4,6 mm y 3,96 mm, respectivamente. La distancia del borde de la tuberosidad hasta la fractura fue de 25,8 mm, y la distancia de paso de la rosca sobre el rasgo de la fractura fue en promedio de 24 mm. Hubo 100% de consolidación, en un promedio de 9,4 semanas, y 3 casos de retardo de consolidación, 2 de retroceso de tornillo, 1 de rosca intrafoco, y 1 de fractura cortical superior. No hubo retiros de tornillos a la fecha. DISCUSION No existe consenso respecto al tornillo ideal. La literatura internacional recomienda dispositivos intramedulares de diámetro de al menos 4,5 mm. Existen pocos reportes del uso de tornillos de diámetro de 4,0 mm. CONCLUSIONES El tornillo de esponjosa de diámetro de 4,0 mm con rosca parcial es una alternativa eficaz, segura y con baja tasa de complicaciones para el manejo de estas fracturas en nuestra población.

OBJETIVE To evaluate the surgical result of zone-2 and -3 fractures of the base of the fifth metatarsal bone using partially-threaded cancellous screws with a diameter of 4.0 mm. MATERIALS AND METHODS A retrospective evaluation of patients submitted to surgery between 2010 and 2019. We included all of the cases synthesized with this device with a minimum follow-up of three months, and excluded the cases operated on with other devices and follow-up shorter than three months. We evaluated the consolidation and the presence of complications, and determined, screw length, diameter of the endomedullary canal, the distance between the proximal edge of tuberosity and the fracture, and thread pitch over the fracture line on anteroposterior (AP) and oblique radiographs. RESULTS We evaluated 39 cases, and the sample had an average age of 27 years and male predominance. The most used screw length was 45 mm, and the average diameters of the medullary canal measured on the AP and oblique radiographs were of 4.6 mm and 3.96 mm respectively. The distance from the edge of the tuberosity to the fracture was of 25.8 mm, and the thread pitch over the fracture line was on average 24 mm. The rate of consolidation was of 100%, occurring in an average of 9.4 weeks, and there were 3 cases of consolidation delay, 2 of screw recoil, 1 of intrafocus thread, and 1 of superior cortex fracture. To date, there have been no cases of screw removal. DISCUSSION There is no consensus regarding the ideal screw. The international literature recommends intramedullary devices with a diameter of at least 4.5 mm. There are few reports of the use of screws with 4.0 mm in diameter. CONCLUSIONS The partially-threaded cancellous screw with a diameter of 4.0 mm is an effective and safe option, with a low complication rate for the management of these fractures.

Negative pressure wound therapy combined with a retrograde sural neurovascular flap for repair of foot and ankle wounds / 中国基层医药

Objective:To investigate the efficacy of negative pressure wound therapy (NPWT) combined with a retrograde sural neurovascular flap for the repair of foot and ankle wounds.Methods:Eighty-eight patients with foot and ankle wounds who received treatment in Shandong Wendeng Osteopathic Hospital from July 2019 to January 2020 were included in this study. They were randomly assigned to undergo either NPWT combined with retrograde sural neurovascular flap repair (observation group, n = 44) or retrograde sural neurovascular flap repair alone (control group, n = 44). Clinical efficacy, flap survival, wound healing, and postoperative ankle function scores were compared between the two groups. Results:Total response rate was significantly higher in the observation group than in the control group [97.73% (43/44) vs. 81.82% (36/44), χ2 = 6.07, P = 0.014]. Flap survival rate was significantly higher in the observation group than in the control group [100.00% (44/44) vs. 86.36% (38/44), χ2 = 4.47, P = 0.034]. Wound healing rate was significantly higher in the observation group than in the control group [97.73% (43/44) vs. 79.55% (35/44), χ2 = 7.22, P = 0.007]. Half a year after surgery, pain score, gait score, foot and ankle swelling score, range of motion of the tibiotalar joint, range of motion of the ankle joint were (1.81 ± 0.45) points, (1.40 ± 0.41) points, (1.98 ± 0.38) points, (0.41 ± 0.35) points, and (0.84 ± 0.51) points, respectively in the observation group, which were significantly lower than those in the control group ( t = 2.63, 2.62, 2.15, 2.09, 2.02, all P < 0.05). Conclusion:NPWT combined with a retrograde sural neurovascular flap greatly increases flap survival rate and wound healing rate and improves the ankle function of patients with foot and ankle wounds.

Transplanted low-set perforating branch propeller flap of fibular artery for repairing calcaneal soft tissue defects / 中华创伤杂志

Objective:To investigate the clinical efficacy of low-set perforating branch propeller flap of fibular artery for repairing calcaneal soft tissue defects.Methods:A retrospective case series study was conducted on 28 patients with calcaneal soft tissue defects admitted to 920th Hospital of Joint Logistics Support Force of PLA from January 2013 to December 2019. There were 19 males and 9 females，aged 13-69 years［（33.8±13.7）years］. The size of soft tissue defects ranged from 5 cm×2 cm to 18 cm×12 cm，and the size of flaps ranged from 12 cm×4 cm to 24 cm×10 cm. The soft tissue defects were repaired with the low-set fibular artery perforator propeller flap after emergency debridement or flap transplantation at the second stage after debridement according to the wound surface conditions. The survival of the flap，wound healing at the recipient and donor sites and complications were recorded. The function of the affected ankle was assessed according to American Orthopedic Foot and Ankle Society（AOFAS）ankle-hindfoot score before operation and at the final follow-up. The degree of satisfaction of flap appearance was assessed by Thankappan flap appearance satisfaction score at the final follow-up.Results:All patients were followed up for 2-40 months［（17.4±5.9）months］. All flaps survived and wounds at both donor and recipient sites were healed well，with satisfactory color and texture of the flaps，without thinning operation performed. Three patients experienced numbness on both sides of the incision at donor sites within 1 week after operation and returned to normal on their own about 2 months after operation，with all flaps restoring partial light pain sensation 1 year after operation. No complications occurred such as blood flow disorder of the affected limb or compartment syndrome. The AOFAS ankle-hindfoot score was 56-95 points［（82.3±15.2）points］at the final follow-up，significantly higher than the preoperative score of 17-68 points［（35.7±13.4）points］（ P<0.01）. The results were excellent in 21 patients，good in 5 and fair in 2，with excellent and good rate of 93%.The appearance satisfaction score was 4-10 points［（7.6±2.9）points］according to Thankappan flap appearance satisfaction score. The results were excellent in 6 patients，good in 15 and fair in 7，with the excellent and good rate of 75%. Conclusions:The low-set perforating branch propeller flap of fibular artery for reconstruction of calcaneal soft tissue defects has advantages of reliable blood supply and high survival rate of the flap as well as good restoration of the appearance and function of the affected limb.

Free peroneal artery perforator flap designed by vascular localization with three-dimensional CT angiography for repairing soft tissue defects of the dorsal forefoot / 中华创伤杂志

Objective:To investigate the surgical method and clinical effect of the free peroneal artery perforator flap designed by vascular localization with three-dimensional CT angiography（3D-CTA）in repairing soft tissue defects of the dorsal forefoot.Methods:A retrospective case series study was conducted to analyze the clinical data of 17 patients with soft tissue defects of the dorsal forefoot admitted to Hospital of the 80th Group Army of PLA from February 2015 to January 2019，including 11 males and 6 females，aged from 16 to 65 years［（39.2±9.7）years］. The area of soft tissue defects ranged from 3.0 cm×2.0 cm to 10.0 cm×7.0 cm，and the size of skin flap was from 3.5 cm×2.5 cm to 10.5 cm×7.5 cm. Preoperative 3D-CTA was performed to select the appropriate perforator vessels，and a personalized skin flap was designed according to the examination results and wound conditions. Of all，10 patients were repaired with the peroneal perforator flap at the first stage，and 7 patients grafted with peroneal perforator flap with wound expansion in the second stage. The perforator diameter，vertical distance from the starting point of the perforator to the tip of the lateral malleolus and horizontal distance from the starting point of the perforator to the outer edge of the lower leg were compared between preoperative 3D-CTA and actual intraoperative measurements. The survival of the flap and occurrence of the vascular crisis were observed after operation. The foot function was assessed with the American Orthopedic Foot and Ankle Society（AOFAS）ankle hindfoot score preoperatively and at postoperative 6 months. Six months after operation，effect of flap repair was evaluated by using flap satisfaction score and flap sensory function measured by the criteria established by British Medical Rresearch Council（BMRC）. Incision healing and motor function of the donor area were detected.Results:All patients were followed up for 6-12 months［（9.6±2.3）months］. There was no statistically significant differences in perforator diameter，vertical distance from the starting point of the perforator to the tip of the lateral malleolus and horizontal distance from the starting point of the perforator to the outer edge of the lower leg between preoperative 3D-CTA and actual intraoperative measurements（ P>0.05）. All flaps survived without vascular crisis. Six months after operation，a higher AOFAS ankle hindfoot score［（84.0±7.9）points］was found when compared to that preoperatively［（51.3±8.2）points］（P<0.05），with excellent results in 12 patients and good results in 5 patients. At 6 months after the operation，the thickness of the flap was flush with the surrounding skin，which did not affect the wearing of shoes；the thickness of the flap was level with the surrounding skin but did not affect the wearing of shoes. The repair effect was satisfactory with the flap satisfaction score of（8.7±2.3）points.Based on the criteria established by BMRC，the sensory function of the flap continued to improve，including 10 patients reaching the level of S 3-S 4 with the two-point discrimination of（10.2±2.0）mm and 7 patients reaching the level of S 2. All incisions at the donor area were healed well without obvious scar contracture or motion limitation. Conclusions:For soft tissue defects of the dorsal forefoot，3D-CTA assisted vascular localization is able to have individualized and precise design of peroneal artery perforator flap preoperatively to assist rapid and accurate skin flap cutting and accelerate defect healing and functional recovery in the dorsal foot. Moreover，the free peroneal artery perforator flap has advantages of high patients' satisfaction，with minor trauma on donar site or without damaging the main artery.

Efficacy of anteriorlateral thigh myocutaneous flap combined with sequential fibular flap for repairing complex tissue defects of the foot / 中华创伤杂志

Objective:To investigate the clinical effect of the anterolateral thigh myocutaneous flap combined with sequential fibular flap to repair complex tissue defects of the foot.Methods:A retrospective case series study was conducted to analyze the clinical data of 6 patients with complex tissue defects of the foot admitted to Ruihua Hospital of Soochow University from March 2017 to March 2019. There were 5 males and 1 females，aged 33-54 years［（41.4±10.2）years］. The area of the skin and soft tissue defects of the foot was from 12 cm×7 cm to 19 cm×9 cm. First metatarsal defect occurred in 3 patients，4-5th metatarsal defects in 2，and 4-5th metatarsal combined with lateral cuneiform and cuboid defects in 1. The length of bone defects was 6-14 cm，and partial extensor tendon defects were found in all patients. The anterolateral thigh myocutaneous flap was used to cover the wound in the first stage，and the sequential fibula flap was used to repair the complex bone defects. The myocutaneous flap survival，wound healing，fibular bone flap healing and donor site recovery were detected. The appearance and sensory recovery of myocutaneous flap and related complications were observed at the last follow-up. The foot function was evaluated by the Maryland foot function score before operation，at postoperative 1 month，at postoperative 6 months and at the last follow-up.Results:All patients were followed up for 9-33 months［（17.8±5.2）months］. All musculocutaneous flaps survived at postoperative 2 weeks. One patient sustained sinus tract formation due to partial necrosis of the residual metatarsal bone，which healed 3 weeks after re-debridement，while the wounds of other patients healed smoothly. The surgical incision healed two weeks after fibular flap surgery，with no signs of local infection. A small amount of callus formed between the transplanted fibula and the fractured end of the bone in the recipient area was observed 6 weeks after the fibular flap operation. Primary bone healing was found in all patients，with the fibular flap healing time of 12-18 weeks［（14.5±4.3）weeks］. The donor sites of the myocutaneous flap and fibular flap also showed primary healing with only linear scars left. Three patients had numbness in the lower and outer side of the donor sites of the thigh but were gradually recovered to the normal 6 months after the repair of the fibula. The joint function of the knee and ankle at the donor sites of the fibular flap recovered well. There showed slight swelling appearance of the flap，a protective feeling of the myocutaneous flap and sound healing of the bone flaps，at the last follow-up，with no complications such as resorption or osteomyelitis of the fibula flap. The Maryland foot function evaluation score was increased from（23.5±5.2）points preoperatively to（44.3±5.3）points at postoperative 1 month，（52.1±7.4）points at postoperative 6 months，and（84.5±11.1）points at the last follow-up（ P<0.05），with statistically significant difference at each time point after operation（ P<0.05）. The foot function was excellent in 3 patients，good in 2，and fair in 1. Conclusion:For complex tissue defects of the foot，the anterolateral femoral myocutaneous flap and subsequent fibular flap can effectively repair the wound of the foot，reduce the occurrence of serious infection-related complications，ensure the healing of bone defects，restore the shape of the foot，reduce the occurrence of serious infection-related complications and promote the functional recovery of the affected limb.

Free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve for repair of soft tissue defect in the foot and ankle / 中华创伤杂志

Objective:To investigate the efficacy of free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve for repair of soft tissue defect in the foot and ankle.Methods:A retrospective case series study was made on clinical data of 9 patients with soft tissue defect in the foot and ankle admitted to 80th Group Military Hospital from December 2017 to December 2019. There were 8 males and 1 females, with the age of 28-63 years [(47.3±12.3)years] and the body mass index (BMI) of 16.7-27.8 kg/m 2 [(23.9±3.9)kg/m 2]. The size of soft tissue defect ranged from 10 cm×6 cm to 20 cm×12 cm. All patients were treated with the free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve. After debridement or tumor resection, a thin sensate flap was harvested by intra-adipose tissue dissection between the superficial and deep fat layers. The size of flap ranged from 13 cm×8 cm and 13 cm×10 cm. The thickness of the defatted flap ranged from 3-6 mm. The distance from the anterosuperior iliac spine to the point where the lateral cutaneous branch of the subcostal nerve crossed the iliac crest ranged from 7.5-10.0 cm. The flap survival, complications, and reoperation were observed after operation. The sensory recovery of the flap was evaluated using Tinel sign and nine-grid method including monofilament touch perception, vibration perception, pinprick perception, temperature perception, and static two-point discrimination test. The joint range of motion, and shoewear and walking problems were recorded. At the last follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to assess the affected foot and ankle. The injury at the donor site was detected as well. Results:All patients were followed up for 6-35 months [(21.1±10.1)months]. All flaps survived without infection or tumor reoccurrence. One patient developed ulceration, then surplus skin on the reconstructed heel was resected. One patient underwent flap debulking and removal of internal fixation. One or more sensory modalities within the nine areas in each flap could be detected at postoperative 3-6 months. The monofilament touch, vibration, pinprick, and temperature perception were presented in almost all regions of each flap at postoperative 12 months. However, only one patient in one region was noted with the static two-point discrimination, in which the distance of the two points was set as 25 mm. The range of ankle motion was slightly limited in 2 patients who underwent osseoligamentous complex reconstruction. All patients were able to wear normal shoes and walk without pain. At the last follow-up, the AOFAS ankle-hindfoot score ranged from 78 to 97 points [(86.4±7.4)points], significantly improved from preoperative 10-70 points [(44.2±18.4)points] ( P<0.01). No patients complained of pain at the donor site, but the widening linear scar was noted. Conclusion:For medium-sized soft tissue defect of the foot and ankle, the free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve can be defatted with the requirement and has advantages in defect site appearance, sensory restoration, wearing ordinary shoes, painless walking, good functional recovery, and minimal donor site morbidity.

Efficacy of bilayer artificial dermis graft plus single layer dermal template for repair of lower extremity wounds with large area of exposed bone / 中华创伤杂志

Objective:To compare the efficacy of bilayer artificial dermis graft plus single layer dermal template and bilayer artificial dermis graft only in repairing lower extremity wounds with large area of exposed bone.Methods:A retrospective case-control study was conducted to analyze the clinical data of 34 patients with 37 wounds of the lower extremity involving large area of exposed bone admitted to Beijing Jishuitan Hospital from November 2009 to November 2020. There were 27 males and 7 females, aged 9-67 years [35.5(29, 45)years]. The exposed bone in the lower leg, ankle and foot was greater than 10 cm 2 in size (the shortest distance from edge to edge of bony exposure was more than 2 cm). At the first stage, the wounds were grafted with bilayer type artificial dermis only for 21 wounds of 20 patients in Group A, and grafted with bilayer type artificial dermis plus single layer dermal template for 16 wounds of 14 patients in Group B. At the second stage, the auto-skin graft was performed in the two groups. The wound healing rate was observed in all patients, and was compared between the two groups at 2 weeks and 2 months after the second stage operation. At the same time, the interval between first stage and second stage surgery was measured. The Vancouver Scar Scale (VSS) was used to evaluate the scar in the skin grafting area in the two groups at 5-6 months after the second stage operation. Results:All patients were followed up for 1 to 24 months [5(2, 7.5)months]. The total excellent and good wound healing rate in all patients was 81%(30/37) at 2 weeks and 97%(36/37) at 2 months. There was no significant difference between the Group A and Group B in the excellent and good wound healing rate at 2 weeks [(76%(16/21) vs. 88%(14/16)] and at 2 months [95%(20/21) vs. 100%(16/16)] ( P>0.05). In Group A, the bilayer artificial dermis was grafted into 4 wounds again to complete exposed bone coverage. However, all wounds in Group B were covered initially without re-grafting. The interval between the two-stage operation was 20(16, 21)days in Group A after the 4 patients who underwent secondary artificial dermal transplantation were excluded, showing no significant difference from 21(21, 23)days in Group B ( P>0.05). At 5-6 months after the second stage operation, the VSS score in Group B [(8.0±1.2)points] was significant less than that in Group A [(9.2±1.1)days] ( P<0.05). In the sub-index of VSS, the score of color and softness of scar in Group B [(2.0±0.6)points, (1.6±0.5)points] were significantly improved compared to those in Group A [(2.5±0.5)points, (2.2±0.7)points] ( P<0.05). Conclusions:The artificial dermis grafting is effective in treatment of lower extremity wounds with large area of exposed bone. However, the bilayer artificial dermis graft plus single layer dermal template can avoid artificial dermal re-graft in repair of large area of exposed bone, and the interval between two-stage operation is not significantly prolonged. Moerover, the color and texture of scar after skin grafting and wound repair efficiency and quality are improved.

Induced membrane technique combined with anterolateral thigh flap transfer for reconstruction of composite foot defect / 中华创伤杂志

Objective:To investigate the efficacy of induced membrane technique combined with anterolateral thigh flap transfer in treating composite foot defect.Methods:A retrospective case series study was performed for 7 patients with composite foot defect treated at 920th Hospital of Joint Logistic Support Force of PLA from February 2014 to December 2018. There were 5 males and 2 females, with the age of 20-73 years [(38.9±16.3)years]. The composite defect located at the forefoot in 5 patients, midfoot in 1, and hindfoot in 1. There were 9 metatarsal bone defects, 1 medial cuneiform bone defect, and 1 calcaneus bone defect. The size of soft tissue defect varied from 6 cm×5 cm to 70 cm×35 cm. At stage I, the anterolateral thigh flap transfer and vancomycin loaded cement implantation were performed. The flap survival and complications were recorded. At stage II, the cement was removed and autogenous bone was grafted into the induced membrane. The duration of two-stage operation, bone union time, and complications were recorded. The postoperative function was assessed using Maryland foot score system before operation and at the last follow-up and postoperative compications were documented.Results:All patients were followed up for 22-54 months [(33.8±9.7)months]. At stage I, flaps survived in all patients, and bulking of the flap was seen in 3 patients. One patient with calcaneus bone defect had repeated infection after operation, and received debridement. At stage II, 6 patients received bone grafting surgery. The duration of two-stage operation was 2-4 months [(2.8±0.9)months]. The bone union time was 3 and 7 months [(4.7±1.2)months]. At the last follow-up, the Maryland foot function score was 63-92 points [(82.1±8.7)points], significantly different from 0 point before operation ( P<0.01). The results were excellent in 1 patient, good in 5, and fair in 1. Except for one nonunion of metatarsal bone, all the other 8 sites were with bone union uneventfully. Conclusion:The induced membrane technique combined with anterolateral thigh flap transfer is an effective protocol for composite foot defect, which can well repair soft tissue and bone defect, and restore walking.

Efficacy of free anterolateral thigh perforater flap in repair of forefoot injuries combined with multiple tissue defect / 中华创伤杂志

Objective:To investigate the effect of free anterolateral thigh perforator flap in repair of forefoot injuries combined with multiple tissue defect.Methods:A retrospective case series study was conducted on 26 patients who suffered from forefoot injuries combined with multiple tissue defect admitted to 920th Hospital of Joint Logistic Support Force of PLA from January 2015 to December 2019. There were 21 males and 5 females, aged 15-61 years [(31.6±12.5)years]. The combined injuries were fracture in 10 patients, arsometatarsal joint dislocation in 3, bone defect in 9, tendon injury in 5, and ligament injury in 3. Management of multiple tissue defect of the forefeet: soft-tissue defect of the forefeet was resurfaced with free anterolateral thigh perforator flaps with the dimension of 6.0 cm×3.5 cm to 26.5 cm×10.0 cm; fracture was fixed by Kirschner wires; joint dislocation was treated by open reduction and Kirschner wires fixations; bone defect was reconstructed either by one-stage bone graft or by use of membrane-induced technique and secondary bone graft, according to the wound conditions; tendon injury of extensor digitorum longus was repaired by direct tendon suture or by tendon transfer; tarsometatarsal ligament injury was primarily sutured. The flap survival rate was observed within 2 weeks after operation. The fracture healing, bone-defect repair, foot appearance, and donor-site healing were detected at 1 month, 3 months, 6 months, 1 year post-operatively and at the last follow-up. The postoperative complications were recorded. The foot function was assessed using American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score before operation and at the final follow-up.Results:All patients were followed up for 6-36 months [(20.5±4.6)months]. All flaps survived uneventfully. The fracture healing and bone defect repair were acquired. The flap showed good texture, including primary flap thinning in 11 patients and secondarily thinning in 15 patients at 3-6 months postoperatively. The donor sites showed good healing, leaving only a linear scar. The flap venous crisis developed in 1 patient and survived after emergency vascular exploring. Local infection of flap occurred in 3 patients and was cured after further debridement and the use of sensitive antibiotics. The AOFAS ankle-hindfoot score was 54-94 points [(76.6±10.4)points] at the last follow-up, compared to preoperative 11-51 points [(27.2±11.3)points] ( P<0.01). The results were excellent in 5 patients, good in 11, and fair in 10, with the excellent and good rate of 62%. Conclusions:For forefoot injuries combined with multiple tissue defect, anterolateral thigh perforator flap transplantation with additional techniques to treat fractures, bone defect, tendon and ligament injuries can achieve satisfactory results in aesthetic appearance of the flap and donor site and foot function recovery.

Manifestations of different imaging methods of Lisfranc joint injury and their clinical significance / 中国基层医药

Objective:To investigate the manifestations of different imaging methods of Lisfranc joint injury and their classification, providing a theoretical basis for increasing the rate of diagnosis of Lisfranc joint injury.Methods:The clinical data of 238 patients with Lisfranc joint injury who received treatment in the First People's Hospital of Wenling from January 2017 to January 2020 were retrospectively analyzed. According to the different types of injury, the clinical data were classified into Myerson and Nunley-Vertullo types and then statistically analyzed. The features of X-ray, CT and MRI images of injured Lisfranc joint were observed.Results:Among the 238 patients, 175 had Lisfranc joint fracture and dislocation, with Myerson classification type I 18 patients, type II 149 patients, and type III 8 patients; 63 had Lisfranc joint injury or sprain, with Nunley-Vertullo classification type I 14 patients, type II 45 patients and type III 4 patients. Only X-ray examination was performed in 8 patients, only CT scan in 10 patients, and only MRI in 17 patients. Both X-ray examination and CT scan were performed in 172 patients, both X-ray examination and MRI in 13 patients, both CT scan and MRI in 13 patients, and all X-ray examination, CT scan and MRI in 5 patients. The correct rate of the first X-ray diagnosis was 85.35% (169/198). In 157 patients with Myerson-type Lisfranc joint injury, the correct rate of diagnosis was 92.36% (145/157). In 41 patients with Nunley-Vertullo-type Lisfranc joint injury, the correct rate of diagnosis was 65.85% (27/41). There was significant difference in the correct rate of diagnosis between Myerson-type and Nunley-Vertullo-type Lisfranc joint injury ( χ2 = 5.135, P = 0.024). CT scan examination invovled the basal part of M2 in 88.50% (177/200) of patients, the basal part of M2-M4 in 64.00% (128/200) of patients, and the lateral dislocation of M2 in 65.00% (130/200) of patients . Three-dimensional reconstructions revealed that 37.00% (74/200) of patients had dorsal dislocation or subluxation and 7.50% (14/200) of patients had metatarsal dislocation or subluxation. MRI examination revealed that six patients had grade I injury, showing abnormal but uninterrupted signal, 24 patients had grade II injury, showing partial rupture of ligament, and 18 patients had grade III injury, showing complete rupture of ligament (interrupted or absent ligament signal). Conclusion:Among the different imaging diagnostic methods of Lisfranc joint injury, X-ray examination may lead to missed diagnosis. For patients with highly suspected Lisfranc joint injury who are not confirmed to suffer from Lisfranc joint injury by X-ray examination, CT scan or MRI should be performed.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

Association between sex differences on foot health related to the quality of life in a sample of sedentary people

SUMMARY Sedentary (sitting) time may produce many anatomical and physiological consequences which are supposedly associated with a decreased quality of life (QoL) related to foot health. Accordingly, this study aimed to analyze the QoL impact on the overall health and the foot health among male and female sedentary people. A total of 312 participants with an age mean of 39.81 ± 15.40 years completed all phases of the study. In addition, self-reported data were registered. The participants' sedentary lifestyle was determined using the European Prospective Investigation into Cancer and Nutrition (EPIC) physical activity questionnaire. Furthermore, the scores obtained from the Portuguese version of the Foot Health Status Questionnaire were registered. Sedentary people in the equivalent metabolic energy had 301.09 ± 72.22 (min/week). In the first section, values were higher for foot pain and foot function and lower for general foot health and footwear. In the second section, values were higher for general health and vigor and lower for physical activity and social capacity. The differences between the sex groups of the study were statistically significant for footwear (P = 0.008), physical activity (P= 0.002), social capacity (P = 0.001) and vigor (P = 0.001) showing a worst QoL related to foot health in favor of male subjects in comparison with females. The rest of the domains did not show any statistically significant difference (P ≥ .01). The sedentary population evidenced a negative impact on the QoL related to foot health. This problem may be associated with this lifestyle, especially for males.

RESUMO O tempo sedentário (sentado) pode produzir muitas consequências anatômicas e fisiológicas que supostamente estão associadas a uma redução de qualidade de vida (QoL) relacionada à saúde do pé. Por conseguinte, o objetivo deste estudo foi analisar o impacto da QV sobre a saúde geral e a saúde do pé entre pessoas sedentárias masculinas e femininas. Uma amostra de 312 participantes com idade média de 39,81 ± 15,40 anos completou todas as fases do processo de estudo. Além disso, os dados autorrelatados foram registrados. O comportamento sedentário dos informantes foi determinado usando o questionário de prospecção prospectiva de câncer e nutrição (Epic). Além disso, os resultados obtidos com a versão em português do Questionário de Status de Saúde do Pé (PFHSQ) foram registrados. As pessoas sedentárias no equivalente de energia metabólica apresentaram 301,09 ± 72,22 (min/semana). Na primeira seção, os valores foram maiores para a dor no pé e função do pé e diminuíram a saúde e o calçado do pé geral. Na segunda seção, os valores foram maiores para saúde geral e vigor e menores para atividade física e capacidade social. As diferenças entre os grupos sexuais do estudo foram estatisticamente significativas para o calçado (P = 0,008), atividade física (P = 0,002), capacidade social (P = 0,001) e vigor (P = 0,001), mostrando uma pior QV relacionada à saúde do pé a favor dos sujeitos do sexo masculino em relação aos participantes sedentários femininos. O restante dos domínios não apresentou diferença estatisticamente significante (P ≥ 0,01). A população sedentária evidenciou um impacto negativo na QoL relacionada à saúde dos pés. Esse problema pode estar associado a este comportamento, especialmente no sexo masculino.

Síndrome do osso navicular acessório / Accessory navicular bone syndrome

O osso navicular acessório, do qual foram descritas três variantes, é frequentemente considerado uma variação anatômica normal.É uma anomalia congênita em que a tuberosidade do navicular se desenvolve a partir de um centro de ossificação secundário e tem uma incidência estimada entre 2% e 14% com maior incidência em mulheres sendo bilateral em 50-90% dos casos. Nosso objetivo foi relatar um caso e revisar a literatura acerca desta lesão incomum, utilizando-se da revisão do prontuário, registro fotográfico do método diagnóstico e revisão da literatura. Mulher de 59 anos com dor no lado medial do pé esquerdo há dois anos, com piora ao andar. Exame físico com testes específicos do tornozelo negativos, sem hematoma ou edema. Nega torção, trauma e cirurgias. A ressonância magnética demonstra osso navicular acessório tipo II e osso navicular, ambos com edema. Estes achados com quadro clínico são compatíveis com síndrome do osso navicular acessório. Este relato demonstra a dificuldade de diagnosticar essa lesão, pois seu o exame físico é inespecífico, podendo simular patologias mais complexas, necessitando de exames complementares para seu correto diagnóstico (AU)

The accessory navicular bone, of which three variants have been described, is often considered as a normal anatomic and roentgenographic variant. Is a congenital anomaly in which the tuberosity of the navicular bone develops from a secondary ossification center and it has an incidence estimated between 2% and 14% with higher incidence in women being bilateral in 50-90% of the cases. Our aim was to report a case and review the literature about this uncommon lesion. We carried out a review of medical records, photographic record of diagnostic method, and review from the literature. A 59 years old woman with pain in the medial side of the left foot for two years. Refers worsening with walking. Physical examination with specific ankle negative tests, without bruise or edema. Denies torsion, trauma and surgeries. Magnetic resonance imaging demonstrates type II accessory navicular bone with edema and navicular bone edema. These findings with clinical complaint are compatible with accessory navicular bone syndrome. This report demonstrates the difficulty of diagnosing this lesion, since its physical examination is non-specific, and it can simulate more complex pathologies, requiring complementary tests for its correct diagnosis (AU)

Clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of foot and ankle wounds / 中华烧伤杂志

Objective@#To investigate the clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of ankle and foot wounds.@*Methods@#From March 2014 to October 2018, 16 patients with foot and ankle injuries were admitted to our hospital and left large area of wounds on foot and ankle after emergency treatment. There were 13 males and 3 females, with age of 27 to 60 years. The area of the wounds ranged from 14 cm×10 cm to 40 cm×17 cm. The wounds were repaired with extra-long lateral femoral supercharged perforator flaps. The widths of flaps in 8 patients were longer than 8 cm, and the bilobed flaps were designed to repair the wounds. The area of the flaps ranged from 12 cm×5 cm to 40 cm×9 cm. During the operation, 54 perforators were detected, with an average of 3.2 perforators in each flap, and 36 source arteries of perforators were detected. The blood vessel trunk of 15 patients was descending branch of the lateral femoral circumflex artery, and their supercharged mode was anastomosis of the bulky perforator of descending branch of the lateral femoral circumflex artery with the oblique branch of the lateral femoral circumflex artery and/or medial femoral circumflex artery or the descending branch of superficial illiac circumflex artery. The blood vessel trunk of 1 patient was oblique branch of the lateral femoral circumflex artery, and the supercharged mode of the patient was anastomosis of the oblique branch of the lateral femoral circumflex artery with the bulky perforator of the descending branch of the lateral femoral circumflex artery. The wounds were covered with the flaps after supercharged blood vessel anastomosis, and blood vessels in the donor sites were anastomosed with those in the recipient sites. The donor site was sutured directly. The survival of the flap after the operation and healing time of the wound, and the flap condition, the two-point discrimination distance of flap in patients who were reconstructed with sensation, the recovery of the ankle function, and the appearance of the donor site during follow-up were recorded.@*Results@#A total of 17 flaps in 16 patients were designed, including 8 bilobed flaps and 9 non-lobulated flaps. Sixteen flaps in 15 patients survived. Vascular crisis occurred in the flap of one patient, and the flap survived when the vascular crisis was relieved by the second operation. The healing time of foot and ankle wounds ranged from 12 to 90 days. All the lateral femoral donor sites healed completely. During follow-up of 8 to 48 months, flaps in 2 patients were slightly bloated and were trimmed in 6 months after the operation. The other flaps were with good appearance, soft texture, good elasticity, and no rupture or ulceration. The two-point discrimination distances of flaps ranged from 7 to 16 mm in 8 patients who were reconstructed with sensation, and the other flaps recovered protective sensation. The flexion and extension function of ankle joint recovered well, and the walking function was not affected significantly. All donor sites formed linear scar, with no deep tissue infection such as osteomyelitis.@*Conclusions@#The application of extra-long lateral femoral supercharged perforator flaps to repair the large area of wounds in foot and ankle can significantly reduce damage to donor sites and has advantages of rich blood supply and good safety, thus it has satisfactory clinical effects.

Clinical analysis of free perforator flap for repairing soft tissue defects of the dorsum of foot / 中华整形外科杂志

Objective@#This study aims to analyze the outcome of free perforator flap for repairing soft tissue defects on the dorsum of foot.@*Methods@#Thirty-six patients with soft tissue defects on the dorsum of foot were treated at a single institution from March 2015 to September 2017. They were 20 males and 16 females, aged from 21 to 59 years old, with the mean age of 39.4 years. The causes of injury include crush injury (n=19), traffic injury (n=15), and electric injury (n=2). The injury site involves left foot (n=19) and right foot (n=17). The defect area of soft tissue was from 4.4 cm ×6.6 cm to 7.1 cm×16.2 cm in size. The vacuum sealing drainage dressing (VSD) was performed for all patients at the first stage of operation. The fracture and dislocated bone were fixed using Kirschner needle and plate screw. The ruptured tendon was repaired at the same time. The flap transplantation was performed at the second stage of operation. Twelve patients were treated with free anterolateral thigh perforator flap, 15 patients were treated with free sural artery perforator flap, and 9 were free peroneal perforator flap. The skin flap was from 4.9 cm× 7.2 cm to 7.9 cm × 17.8 cm in size.@*Results@#All 36 flaps survived. The wounds of both donor and recipient area primarily healed, without infection or skin necrosis. The venous crisis occurred in 1 patient of anterolateral thigh flap and 1 patient of free medial sural flap within 24 hours after surgery. Both flaps survived after stitches removed and blood cleaned. All patients were followed up for 6—22 months, with an mean follow-up period of 9.8 months. Except for the swollen anterolateral thigh perforator flap in 2 patients, the other patients were satisfied with the shape of flap and in wearing shoes. The sensation of flap was good, and the two-point discrimination was 11—16 mm. There was no obvious dysfunction occurred in the donor site.@*Conclusions@#The free anterolateral thigh perforator flap, free sural artery perforator flap and free peroneal perforator flap are suitable for repairing soft tissue defects on the dorsum of the foot. A reasonable surgical plan can help to obtain satisfactory clinical outcome.

Evaluation of podiatric disorders in a sample of children with intellectual disabilities: an analytical cross-sectional study

ABSTRACT BACKGROUND: Intellectual disabilities (IDs) usually derive from neurodevelopmental disabilities. They limit intellectual functioning and cause adaptive behaviors and orthopedic problems. These disabilities have harmful effects on health, everyday practical skills and social functioning, and they diminish quality of life. The goal of our research was to perform podiatric evaluations on schoolchildren with and without ID and ascertain their records of foot disorders. DESIGN AND SETTING: Analytical cross-sectional study conducted at a podiatric clinic in the city of Piedras Blancas, province of Asturias, Spain. METHODS: An analytical cross-sectional study on 82 schoolchildren affected by ID, compared with 117 healthy schoolchildren, was conducted at a podiatric clinic. Demographic data, clinical characteristics and measurements relating to podiatric examinations were recorded among the participants who completed all phases of the tool that was used in the study process. RESULTS: Almost 90% of the schoolchildren with and without ID presented foot disorders relating to smaller toes, nail disorders, flat feet or lower-limb alterations. CONCLUSIONS: The participants showed elevated prevalence of foot disorders. Podiatric evaluations are a significant means for preventing the appearance of medical conditions and/or foot problems, and they also improve general health.

Soft tissue reconstruction of foot and ankle defects with reverse sural fasciocutaneous flaps / Reconstrução do tecido mole de defeitos do pé e do tornozelo com retalhos fasciocutâneos surais de fluxo reverso

ABSTRACT Objective This study presents the results of 25 consecutive patients and evaluates the success of reverse sural fasciocuteneous flap (RSFF) on coverage of the foot and ankle region. Methods A total of 25 patients with soft tissue defects in the lower leg, foot, or ankle were treated with RSFF, from January 2010 to January 2017. In the evaluation of patients, the form prepared by the clinic was used and the following data were collected: age, follow-up, gender, etiology, defect size, complications, and patient satisfaction rates. Results Mean follow up time was 18 months. In all patients, the defects were fully covered. Three patients developed partial necrosis due to venous congestion. There was no complete flap loss in any of the patients. Patient satisfaction was excellent in all cases. Conclusion RSFF is quick, versatile, and easy to apply; it also provides safe soft tissue coverage, requires no microvascular repair, and provides an alternative to microsurgical reconstruction.

RESUMO Objetivo Este estudo apresenta os resultados de 25 pacientes consecutivos e avalia o sucesso do retalho fasciocutâneo sural de fluxo reverso (RFSR) na cobertura da região do pé e tornozelo. Métodos Foram analisados 25 pacientes com defeitos de partes moles na parte inferior da perna, pé ou tornozelo com RFSR, de janeiro de 2010 a janeiro de 2017. Na avaliação dos pacientes, o formulário preparado pela clínica foi usado e os seguintes dados foram coletados: idade, seguimento, sexo, etiologia, tamanho do defeito, complicações e grau de satisfação do paciente. Resultados O tempo médio de seguimento foi de 18 meses. Em todos os pacientes os defeitos foram totalmente cobertos. Três pacientes desenvolveram necrose parcial devido à congestão venosa. Não houve perda total do retalho. O grau de satisfação dos pacientes foi excelente em todos os casos. Conclusão O retalho fasciocutâneo sural reverso é rápido, versátil e fácil de aplicar. Além disso, fornece uma cobertura de tecidos moles segura, não requer reparo microvascular e é uma opção à reconstrução microcirúrgica.

Chopart Joint Fracture and Dislocation: A Report of Three Cases / 대한족부족관절학회지

Chopart joint fracture and dislocation are rare injuries compared with other joint injuries with various clinical manifestations. Moreover, there is a lack of knowledge of the radiological findings of the joints, and thus, the extent of joint ligament damage may be underestimated, leading to improper treatment. This paper reports three cases of Chopart joint injury and seeks to reconsider the importance of Chopart joint evaluation and treatment.