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

ABSTRACT

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.